We Are The Champions

It seems no matter what the problem is in the hospital, the solution is to have the ER nurses take on one more responsibility. 

Electronic charting, for instance.  The patient's vital signs, height and weight doesn't transfer from the triage note to the flow sheet (where everything after triage is charted).  Solution?  Have IT or a representative from the software provider tweak the issue?  No.  Better to require the ER nurse before triaging the bleeding, moaning, puking, smothering, screaming and/or dying patient, to first click on the flow sheet option, open a flow sheet, apply it, save it, close it and then open the triage sheet by clicking on the electronic forms tab, triage sheet tab and then the go to sheet tab. 

A patient in a hospital in Chicago killed himself by drinking a cleaning substance which was left in a treatment room.  The solution?  Make sure noxious solutions are clearly marked as such?  Acknowledge the fact that, unless a patient exhibits suicidal tendencies, common sense dictates that we're simply not responsible for every single irrational thing anyone, anywhere might decide to do at any given time in any given place?  Realize some people are just too stupid to live? No.  Better to declare cleaning agents can no longer be kept in the treatment rooms, thereby creating a need for the ER nurses to go all the way to the clean utility area to get a spray bottle of solution to clean the rooms after patients leave, then go all the way back to the clean utility room to replace the bottle.  Hibiclens, alcohol, betadine, hydrogen peroxide?  Same thing.  Can't be kept in the rooms.  How did we ever keep from killing patients back in the day when we kept glass thermometers soaking in alcohol-based antiseptic in stainless steel trays with lift off lids in each treatment room?  How do we keep them from hanging themselves with the sheets on the beds, for instance?  Where does the responsibility of ER nurses stop?

ER doctors (whose salaries exceed ER nurses in our facility by in the neighborhood of nearly 10 times and rightly so considering the level of education and licensure required of them) can't seem to manage to a) sign the patient discharge instruction sheet or b) sign and document a diagnosis on their T-sheets.  The solution?  Discuss with the physicians the reimbursement issues involved with incomplete physician documentation?  Create a system whereby physicians are motivated to complete proper documentation such as not allowing them to work until said documentation is complete, as would be the case if a nurse were to do the same thing?  No.  Better to devise a new form for the ER nurses to be responsible to fill out at the discharge of every patient requiring her to go down a list, checking boxes indicating each form is accounted for and that the MD has signed his documents and written down a diagnosis.  If anything is missing, it will be the nurse's evaluation that suffers and she may miss out on her 2% annual raise, if the hospital happens to even give raises that year, which they often do not.

Somebody in the hospital is getting paid minimum wage to scan all the ER documents into the computer but can't quite manage to scan them in the correct order or even right side up in all cases.  The solution?  Counsel the persons responsible for scanning, impressing upon them the importance of legible scanned documents?  Explain to the entire hospital staff in an in-service if necessary that the upside down, scanned electronic documents can easily be turned right side up by clicking the rotate button on the pdf file viewer?  No.  Better to add to the ER nurses' responsibility that of ensuring each discharged patient's chart is placed in the correct scanning order and paper clipped, once before giving it to the ER doctor to sign and add his diagnosis to, and then a second time when received back from the doctor in a messy pile, paper clip missing.
 
Patients come to the hospital without a clue what medications they take, nor the dosages or frequencies.  The solution?   Public teaching regarding the necessity of the above data in order to provide safe care of the patient?  Requiring a family member to go home to retrieve the patient's medication bottles?  Refusing to render care in non-critical situations until somebody magically remembers or retrieves said data?  No.  Better to require the ER nurses to find out what pharmacy the patient uses and call them and waste their time looking up the medication lists of patients who don't care enough about their own health to notice what chemicals they put in their bodies.  Or call the patient's primary care provider's office and waste time they could be using to tend to the needs of responsible patients who actually make appointments and seek medical care in an appropriate setting.  Or, in the event the pharmacy and PCP's office are both closed or the patient orders medications from an insurance mail-order system, require the nurses to pull the information out of their asses.  Incomplete medication forms are unacceptable.

Some of the ER physicians are having difficulty mastering the task of ordering ER medications electronically.  The solution?  More and extensive teaching regarding the electronic ordering of meds to be done by IT with ER physicians?  Reworking the current system for the physician ordered medications?  No.  Better to require the ER nurses to learn to enter medication orders electronically (despite an aggressive taboo in the past regarding taking verbal med orders from physicians) which is to only be done in an emergency.  We all know how that's going to play out, now don't we?  After all,  we do work in the emergency room.  They're all emergencies, aren't they?  I mean, in somebody's eyes.

Besides, the ER physicians are busy.  They have every patient in the ER to see and there are several nurses to share the (growing list of) responsibilities assigned to them.  However, with the exception of a code situation, the doctor spends approximately 7 minutes with each patient and has an average of 2-3 orders per patient to put in electronically.  Otherwise, the medications need only be clicked "Continue" or "Discontinue" in the electronic medication list which was entered by the nurse while the patient was bleeding, moaning, puking, smothering, screaming or dying, incidentally (see the paragraph on electronic charting).  Otherwise, he has one T-sheet to fill out.  With a pen.  On real paper and not on a goddamned computer.  Like in the good, old days.  Is it really that difficult?

Meanwhile, the ER nurse has an extensive triage form full of medical history that hasn't carried over from the previous admissions due to yet another IT glitch, a medication form (including meds, dosages, frequencies, routes, last dose and time, doctor who prescribed and pharmacy filling the medication), a flow sheet including everything anybody in the ER or elsewhere has done for or to the patient during his/her stay in the ER,  a list of vital signs, a treatment sheet where things like blood cultures, etc are documented, transfer forms (okay, the MDs do 33% of this form, too), discharge education, a charge form and the new form where all the other forms are accounted for. 

In the interest of time I'll stop here but know that this is an incomplete list.