I’ve clocked in 25 years (most of them in the ER) as a nurse and I can say with assuredness that this job is harder than ever. The total number of patients is greater, the medical needs are increasingly complex and the fuses (both of patients and staff) run much shorter on the powder keg that is your local emergency department (ED). I will reach the average age of US nurses this summer – 47 years old; I’ve seen a lot in this time. The good times are amazing and include saving lives, minimizing injury and developing lifelong friendships with both patients and colleagues. The bad times stay with me – the deaths, permanent disability and delivering dreadful news. The ugly though, is well, ugly! 7 to 9 hour waits to be seen by a doctor, 24+ hours waiting in the ED for admission beds and the bureaucracy of care delivery are three of the big items contributing to the explosive environment of the ED.
To this end, I’ve put together an insider’s guide for patients and families seeking emergency care:
Emergency or Not?
The most appropriate question to ask yourself is, “Am I having an issue that only an Emergency Department can address?” The American College of Emergency Physicians’ (ACEP) website offers resources to help you determine this. Click here for their Emergency 101 – Is it an Emergency?. This site also provides helpful information on when to activate the 911 system. The majority of ED visits do not result in the need for hospitalization. Of this group, many present with illnesses/injuries appropriate for primary care providers (PCPs), urgent care centers or fast-care clinics. Professionals (many with ED experience) staffing these venues know their limitations and when to refer to a higher level of care. Services at these sites include routine care for illnesses/injury, lab testing, x-rays and medication prescribing.
Be a Patient Patient
Most recent statistics show there are over 136 million patient visits to US emergency departments annually. This means unless you are having a stroke, heart attack or shot, you are going to wait to be seen. There are many additional factors contributing to your wait time including bed availability, illness severity of patients currently being treated, staffing, etc. It is a simple math problem in a 30-bed ED: 30 occupied ED rooms plus 30 patients in the waiting room equal a net of zero available beds. Each room that opens as patients are discharged or admitted receives the next sickest patient in this equation.
The Triage Nurse is your #1 Fan!
The first health professional you encounter in an ED is likely the triage nurse. Triage literally means to sort out. It is this nurse’s job to determine your “level of acuity” or how sick you are. Seasoned nurses concur that triage is the toughest ED assignment of all. The triage nurse often takes the brunt of the waiting room’s anger; this anger is almost always misplaced. This nurse is, in fact, assisting the nurse in charge in getting you back as quick as possible. S/he is your advocate in making this happen – so treat them well. It takes a significant amount of education and experience to perform theses duties. The Emergency Nurses Association recommends certification in emergency nursing (CEN) pediatric advanced life support (PALS), adult basic life support (BLS), advanced cardiac life support (ACLS) and trauma care (TNCC) for all triage nurses. These folks are experts in what they do and they deserve your respect.
Condition Changed Since Triage? – We want to know!
A condition can change over time; sometimes the change is good and other times it is not. It is important to communicate any change, at any point, to the people providing your care. Many of the things we do to get you better are influenced by the time in which they are done. Letting us know things like “I think I have a fever now”, “I lost feeling in my hand” or “I’m not sure what’s wrong but I suddenly feel much worse” raise signal flags that emergency staff are expert in reading. You are the most important member of the health care team and we want to hear from you!
Problems at the “Border”
ED visits continue to grow annually despite initiatives like the Affordable Care Act (ACA) of 2010. Patient hospitalizations are outpacing available patient beds; this worsens an already dangerous situation. The trickle-down effect is patients “boarding” in ED rooms until an admission bed opens. Each boarding patient takes away a treatment room for every ED patient in the waiting room. It is not unusual in my ED to see a 33% to 50% reduction in available ED treatment rooms by the time night shift ends. The simple math problem above becomes exponentially complicated in the face of ED boarding.
The Plane is NOT Going Down
It is important to know that despite the chaos, there is a very capable “captain” in authority; this person is the charge nurse. The charge nurse works like an air traffic controller landing patients and staff into the appropriate rooms and roles. Their job is control and command for the current shift. Higher level managers, including a nurse manager, chief physician and hospital nursing supervisors, are additional administrative resources but, the charge nurse is the sole person with the minute-to-minute operational view. S/he can typically address your concerns and meet your needs – just ask! An additional word of advice — Grandma always said, “You’ll catch more flies with honey than vinegar”; this proves true in the ED. Express your concerns in a respectful and kind manner. Showing your worry always gets a better (read quicker) response over showing your muscle. Threats of suing, accusations of incompetence or lashing out physically and/or verbally will not achieve what you desire.
EMS does not stand for Escape Medical Standstill
Coming to the ED via an ambulance does not mean you go straight to a treatment room. Misuse of EMS is a national problem in which people are using 911 for non-emergency medical transport, chronic medical problem treatment and even, transport to visit hospitalized loved ones. A nurse assesses all incoming ambulance arrivals. Patients are directed to the appropriate location based on this evaluation. The triage/waiting area is an appropriate destination for many patients.
Empty doesn’t mean Open
We look at historical patterns, future plans, seasonal spikes (like influenza) and variations in trauma volume to determine staffing needs and assignments. This is not unlike common core math; it is a guesstimate – kind of close but not exact. The who, what, where, how and why of patient volumes is complicated. Do not be surprised by empty rooms you may pass after a long wait on the way to your room. These rooms are likely unstaffed or reserved for specific types of patients (trauma, code blue, OB/Gyn, etc.). These rooms are put into play as additional staff arrive – typically during the “estimated” higher volume periods. They are taken out of play during traditionally slower periods.
Making the Wait Great (or at least a little better)
Many EDs now recognize that wait time can be productive time. Advanced practice providers (doctors, physician assistants and nurse practitioners) now participate in the triage or after-triage process by ordering lab tests, x-rays or other diagnostic studies. Brief medical screening exams enable these providers to determine what information will help in the diagnosis of your condition. This added service improves ED efficiency and provides additional information in determining who needs to be seen next. Studies show using providers in this manner improves patient satisfaction by getting you the information you need.
“It’s just another Manic…”
I bet you didn’t know that the 80s girl band The Bangles knew about the highest day for ED visits – that’s right, it’s Monday. Monday is the worst day to visit and the worst day to work when it comes to the number of patients. Most people assume weekends are the busiest but, who wants to ruin a perfectly good weekend with a trip to the hospital? Instead, patients wait and get sicker as they do. The patient log jams that ensue are not easily remedied and last into the next day. In general terms, the early birds do get the worms and the early patients get the rooms.
Overall, the message I hope to convey is: we care; we are frustrated by the current state of delayed emergency care delivery; we are actively working on solutions. Additionally, I hope the insights above and the comments below provide you with tools that make your next ED visit the best it can be.
Best Wishes for the Healthiest You!