Try these strategies for better communication
When you’re managing a critical care patient in the emergency department (ED), poor communication between nursing units often is a problem, says Janice Piazza, RN, MSN, MBA, director of consulting services for VHA, a nationwide network of community-owned health care systems, and a former critical care nurse. Here, two critical care nurses give strategies to improve communication with critical care nurses:
• Agree on which orders will be initiated in the ED and which can wait until the patient gets to the intensive care unit (ICU).
There is often inconsistency in what tests, procedures, and administration of medications are done in the ED before the patient is transferred upstairs, says Piazza. She suggests completing a checklist of tasks to complete, depending on how long the patient is held in the ED.
• Verify admission orders before you bring a patient to the ICU.
In a busy ED, the patient’s physician may downgrade the acuity level of the patient, says Katherine Blee, RN, MSN, CAN, CCRN, nurse manager of the coronary care unit, medical intensive-care unit and surgical intensive care unit at Jerry L. Pettis Memorial VA Medical Center in Loma Linda, CA. For instance, a patient who first was assessed to require an ICU bed later may be given different admitting orders, she explains. As a result, the ED nurse gives a report based on the physician’s verbal indication for an ICU bed, and the patient is brought to the ICU room, only to have the nurses note that the admission orders actually were for the telemetry or medical/surgical unit, says Blee. To avoid this mix-up, Blee advises checking the admission orders.
However, she adds that there may be discrepancies between what the ED physician orders and what the admitting physician deems appropriate. "It is not uncommon for us to admit a patient to the ICU based on the ED physician’s orders, only to have the admitting physician reassess the patient on the unit and write transfer orders to a lower level of care," she says. To prevent this from happening, Blee suggests calling the admitting physician to verify the level of care required.
• Make sure your documentation is clear.
Good written communication can avoid a lot of frustration, says Piazza. "In this day of fragmented information and documentation systems, it’s often difficult to determine if orders have been completed," she says. For instance, you should clearly document medications given, time they were administered, what tests are completed, and what results are available, Piazza says.
Sometimes, specific blood work has been drawn, but it is not listed on the ED sheet, which leads to patient having duplicate blood work drawn, adds Blee. "Conversely, I have seen lab work that states on paper that they have been drawn, only to wait hours for results that never appear," she says. "A phone call to [the] lab indicates that the lab work was never sent to them."
• Give a thorough report to ICU nurses.
If you give report to the ICU nurse, Blee recommends making every effort to transport the patient upstairs. "The transporting nurse often is unfamiliar with the patient’s history and is unable to clarify concerns and questions," she says. Blee adds that a "thorough report" should include what labs were drawn, when they were sent, and what procedures were done. She also suggests passing on information as to which family members are present, and in cases such as head traumas or decreased level of consciousness, who the next of kin is. "Family members are comforted when they arrive on the unit and find that we are aware of what relationship they have with the patient," she says.
• Don’t bring the patient up to the ICU unless you are notified that the bed is ready.
Blee points to frequent instances where the patient is brought to the unit and the bed is not clean. "The transporting nurse, who was not the admitting ED nurse, states they were told by someone in the ED that the bed was ready," she says. "When pressed for names, often names cannot be recalled." This frustrating scenario can result in arguments while the patient still is on the gurney, she says. "This does not help the patient build a trusting relationship with the staff, especially when the patient is returned to the ED to wait until the room is cleaned," she notes. Blee adds that you should never leave a patient in the hallway or in a part of the unit without proper notification. "ICU nurses sometimes find ED patients parked on gurneys outside the units," she reports.
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