Be alert for potential dangers: boarding, more invasive procedures
Emergency nursing practices might be unsafe
Have you inserted arterial or central lines, performed invasive pressure monitoring, or managed a mechanically ventilated patient in your ED recently? Invasive procedures such as these are being performed more often in EDs due to inpatients being boarded for long periods of time, which increases the potential for errors, warns Helen Sandkuhl, RN, MSN, CEN, TNS, FAEN, director of nursing for emergency and trauma services at Saint Louis (MO) University Hospital.
"Personnel caring for these patients may not be aware of practices that traditionally had ensured safety in preoperative settings," Sandkuhl says.
One example is medication labeling. "Solutions being placed in unlabeled basins during procedures can lead to medication errors and patient deaths," adds Sandkuhl. Also, patients might receive contrast media, when the order was to conduct the scan without it. "In busy settings where information may be scarce, wrong patients receiving contrast media can occur if two identifiers are not used," says Sandkuhl. "Renal failure is a possible result of this error."
To avoid these dangerous mistakes, Sandkuhl says to clarify verbal or written orders, and check lab values before sending patients for exams requiring contrast media.
Teresa Mancuso, RN, an ED nurse at Baptist Hospital of South Florida in Miami, says, "When an ICU patient boards in our department for long periods of time, patient-nurse ratio is compromised. The rest of the department must absorb the care of the ED patients. This can have a direct impact on a greater length of stay for our patients, adding to the boarding issue, overcrowding, and patients leaving without being seen or receiving treatment."
Risks increase
Tia Valentine, RN, CEN, clinical nurse educator for the ED at University of California San Diego Medical Center, says, "Numerous studies have demonstrated the importance of having the patient get to the proper unit at the proper time. This helps decrease morbidity and mortality. Maintaining an ICU- or CCU-level patient within the ED for an indefinite time does affect the end result of the patient."
More invasive procedures and complex treatments are being done in the ED at Tufts Medical Center in Boston, due to the level of acuity of boarded patients, says Alexandra Penzias, RN, MEd, MSN, CEN, clinical nurse educator in the Department of Emergency Medicine. "The number of patients who board defined as patients remaining in the ED longer than two hours beyond the decision to admit time is a major concern at our facility," says Penzias. "It is not uncommon for ED length of stay to exceed six hours."
Penzias points to research showing that the overall mortality of critically ill patients increases considerably when they remain in the ED longer than six hours.1 "As a result of this delay in disposition to an acute or critical care inpatient bed, ED nurses and physicians initiate ICU-level patient care management on these patients," says Penzias.
Safety is priority
Valentine reports that procedures such as bedside bronchoscopy, insertion of arterial, transvenous pacers or central venous pressure lines, and even ventriculostomy insertion are occurring on a more frequent basis.
"It may not even be uncommon in some EDs to have an intra-aortic balloon pump placed and maintained by a perfusionist, because of inability to move the patient to the CCU," adds Valentine.
These interventions might be new to ED nurses, says Valentine, but "it is the responsibility of the practicing nurse to make sure that the fundamental knowledge is present. Safety is a number one priority."
To better prepare nurses to care for critically ill patients, Tufts Medical Center implemented an ED Critical Care clinical excellence ladder. "This aims to match nurse competencies to patient characteristics, to achieve optimal outcomes," says Penzias.
During annual mandatory education days, ED nurses review the setup and management of arterial lines, central venous pressure and intracranial pressure monitoring, and initiation and management of patients requiring peritoneal dialysis.
Valentine notes that some ICU/CCUs have nurses that are specifically trained on procedures such as continuous venovenous hemodialysis. When a patient needs this procedure, these nurses are assigned to them. "This can also be used within the ED," suggests Valentine. "If the ED is boarding ICU-acuity patients, getting a CCU or ICU-trained nurse to come in and care for the patients within the ED may be an option." (See "Can you afford to add nurse to care for inpatients?" ED Nursing, April 2009.)
When a critical care patient is boarded in Baptist Hospital's ED, a critical care physician assumes care of the patient. "This practice allows for the ED physician to focus their care on other ED patients," says Mancuso. "The ED doctor remains close for sudden patient decompensation, but the intensivist will control the course of patient care." (See related stories on getting patients out of the ED quickly, below, and placing an arterial line, below.)
Reference
- Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007;35:1477-1483.
Sources
For more information on invasive procedures done in the ED, contact:
- Teresa Mancuso, RN, Emergency Department, Baptist Hospital of South Florida, Miami. Phone: (786) 596-1960. E-mail: [email protected].
- Alexandra Penzias, RN, M.Ed, MSN, CEN, Clinical Nurse Educator, Department of Emergency Medicine, Tufts Medical Center, Boston. Phone: (617) 636-5357. E-mail: [email protected].
- Helen Sandkuhl, RN, MSN, CEN, FAEN, Emergency Ser-vices, Saint Louis (MO) University Hospital. Phone: (314) 577-8774. E-mail: [email protected].
Get patients out of the ED quickly At Baptist Hospital of South Florida in Miami, ED nurses utilize triage-based care protocols to identify critical care patients quickly. "This facilitates quicker patient care, diagnosis, admission, transfer to inpatient areas, and thus, a shorter length of stay," says Teresa Mancuso, RN, an ED nurse at the hospital. "This process begins with the front-line triage." When there is no bed available, ED nurses use diagnostic, therapeutic, and management regimens for stable chest pain, pneumonia, asthma, renal colic, and headache. To get patients upstairs more quickly, phone report is used. "This is one strategy which allows us, the ED nurse, to quickly give report to the floor nurse and send the patient up within 30 minutes of receiving bed assignments," says Mancuso. "The floor nurse must be available to take report right away. If not, the resource nurse will." The ED resource nurses attend a staffing meeting twice daily to communicate specific patient needs, such as intensive care unit or telemetry. "In turn, staffing is increased specifically to meet these patient needs," says Mancuso. |
Placing an arterial line? You should check for this When placing an arterial line, make sure there are no bubbles in the line or transducer, says Tia Valentine, RN, CEN, clinical nurse educator for the ED at University of California San Diego Medical Center. "This can skew the data or dampen the waveform," Valentine says. Consider these other tips: Maintain the pressure bag at 300 mmHg. "This delivers 3 cc/hr under pressure, which prevents blood from backing up into the line and clotting," says Valentine. Be sure the dicrotic notch is present in an arterial line wave tracing. "If it is not present, consider catheter kinking or clotting," says Valentine. Make sure that the waveform correlates to the EKG waveform. "If it doesn't, this can mean there are some other medical issues looming that can result in a bad outcome," says Valentine. |
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content