By MJ Brickey
In response to your article “Hospital authority discusses Emergency Department operations,” I read your article with anger and humor.
I am an experienced emergency department (ED) nurse myself and have worked in a number of locations and I can assure you four hours in a room of the ED is not that unusual. The national average from check-in to treatment can be as high as eight. Even in a “fast- track or clinic” setting, (the wait) within the ED is at least two hours.
There are a number of simple hard-core reasons for this and it has nothing to do with nurses doing a better job of communicating with patients about delays, although the hourly rounding which allows nurses to check in on a patient and informing of delays is the standard unless there are Pct’s (patient care tech), then it is every two hours with the Pct making them on the hour that the nurse does not. It still results in patients being seen each hour. As to informing patients when a doctor is going to come back in to see them, this is nearly impossible. Nurses do not have crystal balls hanging around their necks so that they can see the future. You may only have one physician and in some cases a mid-level (PA or NP) for additional help, to see those same 12-14 patients. The ED is just that ...for emergencies. Not common colds, sore throats, arthritic pain that you have had for months or years, it’s not for ingrown toe nails, or even toothaches. But because the public uses the ED or better known as the Emergency Department as a primary source of health care, we have ever increasing lengths of time for patients to be in the waiting room and in the patient treatment rooms. Because of this, those patients who really do need to be seen quickly may face serious delays in being treated while staff scramble to move patients to get them in. Also an important fact to remember, if there are no beds available for patients to be sent out of the ED then those patients must be kept in the ED until one becomes available. This includes ICU and well as medical-surgical patients.
Reasons for lack of bed space could range from no open beds to open beds but no staff to take care of them. As I understand it MRHC has reduced its staff to cut costs, thereby reducing available bed space. That need to hold those patients in the ED reduces available ED bed space to treat patients which exacerbates ED overcrowding.
Ask an ED nurse when was the last time you heard “Can you get me a warm blanket? Or can you turn off this light? Or is there a remote for the TV?” And the answer you get may be just minutes ago, but almost a certainty within that shift. We are not treating people and giving them what they need, it is what they want. Why? Because there is such a focus on that press gamey score that we are not focused on actual ED operations and the health care of our patients. The statement by Weldon Smith “hourly doesn't sound too good to me” was particularly interesting. Hourly rounding is the standard, and my guess is that he does not work with patients or in a busy ED.
Generally there is a 4-to-one ratio of patients to a nurse in the ED. Now if a cardiac arrest comes in that will tie up at least two nurses. a physician, a respiratory tech, a ED tech or two, in some hospital’s a pharmacist is also required. Let’s say that there has been a bad accident on U.S. Highway 69. I may have, say three-to-four patients with varying degrees of injury, everything from general body aches to multiple fractures, head injuries, and true shock symptoms; I have just tied up most of the ED staff to treat these patients. OK, now I have a true heart attack patient that needs to go to the cath lab immediately in one room, a severe respiratory patient that may need to have a tube placed so they can breathe in another; perhaps I have a teenager that has gotten into their parents medicine cabinet and because they cannot handle life anymore, has taken a unknown number of pain medication mixed with heart medication. Again I have just tied up most of the staff in addition to a number of other hospital personal to handle these true emergencies. Do you think the staff is going to be focused on running around informing of delays? No, and you would not either if that is your loved one that is dependent on the quick-thinking, motivated, educated, determined ED staff.
I also think perhaps there is a lack of understanding about triage and how it is used. Triage is a French word for sorting of injuries. It is one time that the more sick or hurt you are the faster you are supposed to be seen. So If 10 suspected heart attack patient come in and you’re there because your back hurts because you lifted something wrong, or you’re there for a migraine (you have a history of) then it is very possible you are going to be there awhile in the waiting room.
While it is not the national standard yet, one of the most common and best methods of triage is called the Emergency Severity Index (ESI). It provides five levels for categorization of patients in the ED. In a nutshell, a level 1 would be your cardiac arrest; 2 might be your significant shortness of breath; nausea, vomiting- abdominal pain might be a level 3; simple lacerations or sore throats and so on a level 4; and finally a level 5 would be things such as a medication refill, suture removal and so on. This system allows for both the seriousness of a patient condition and the number of resources needed to treat a patient turned into a number for prioritizing.
Folks, good, well-trained ED staff do not grow on trees; it requires significant commitment to patients, education, and a love for what they do to save you from life’s challenges. Its not to be a “sports commentator,” so that you know play by play what is going on in the ED. If you have to call to find out how busy the ED is... you probably do not need to go. If you think that you can call for an appointment ... you probably do not need to go. No, I am not making this up; people really do this! It is easy to blame the ED staff whether it is a nurse or the medical staff for a lack of customer service and expect huge improvement; it doesn’t cost money, but to effectively improve customer satisfaction requires a hospital and company-wide commitment and that does cost money.
As to a larger ED, yes I would also agree with that assessment. In addition I would also move the ICU (intensive care unit), cath lab, step down unit (it’s a unit between the usual med-surg. unit and the ICU) next door to any new emergency department. But remember you build it, they will come and that requires more staff. I can also offer some suggestions to help the bottleneck of ED to floor admissions, but that would take too long to put here.
I would also suggest education for the public as to what the ED is truly for and what it is not. Emergency department overcrowding is not new; it has no quick, magical fixes, and it is not going away anytime soon. If that ED is really seeing 28,000 and was designed for 12,000 then no matter how hard your nursing and medical staffs are (working), there will be long painful delays in being treated. So stop trying to pass the buck or making this political; it is not only a ED staff problem, it is a community problem. Why is the staff not being asked what they need do to help do the job? They are the best people to ask what improvements are needed.
Administration of any type will always look at numbers, and they will try to put it in a neat box with a bow on it, but that does not always reflect reality.
To the readers of this paper, the Emergency Department is not a clinic; it’s not the doctor’s office, and you are seen in the order you come through the door, but rather in order of severity of illness or injury, that’s how lives are saved. You want the best care you can get? Sure, who doesn’t, but it requires you to be responsible for making your doctor’s appointments, going to dialysis when scheduled, filling those prescriptions the doctor gives you, and being mindful of how the human body works. Your body takes time to heal , I said time… this does not mean every time you see the doctor you get an antibiotic; it does not mean that you get instantly better as soon as you take one dose of medication.
People in health care love to take care of patients, watch them get better, and live a happy joyful life. They are caring, loving people with families of their own; they have good and bad days just as we all do. Don’t curse at the staff, don’t threaten or otherwise belittle them when things don’t happen as fast or as well as you would like. Don’t come to the counter and demand to speak with a supervisor because you think you have been passed over or you been in the waiting room too long. Remember what triage really means when you consider this action. Above all, treat the ED staff with the same respect you demand for yourself; it will go a long way in making your stay as brief and unpleasant as possible.
A few good sources of information are the:
Emergency Nurses Association or ENA @ http://www.ena.org/Pages/default.aspx
Emergency Severity Index or ESI @ http://www.esitriage.org/
American College of Emergency Physicians @ http://www.acep.org/
CDC Study Illustrates Need for Solutions to ED Overcrowding @ http://www.newswise.com/articles/cdc-study-illustrates-need-for-solution-to-ed-overcrowding
A former McAlester resident