Overcoming Perceptions in the Emergency Department

I work as a Clinical Nurse Specialist in a community hospital emergency department. My most recent challenge has been ensuring we correct documentation problems on moderate sedation performed in the emergency department that were found as part of our annual Joint Commission self-survey.

Only one out of four procedures were documented thoroughly and accurately. Do I think we are taking short-cuts and harming patients? No. What I do think we're not doing isdue diligence in documenting the work we do and, if something bad were to happen, we have no way of proving before a jury that the work was performed to standard.

The problem is, the ER nurses don't see it that way and I am stymied in how to change this perception. Their first complaint was that the GI docs bring their patients down to do procedures at the end of their clinic day. "These aren't emergencies!" the nurses cry. They don't understand that these patients may not be emergencies, but these cases are urgent in that they drive the next diagnostic decision for that patient. They also don't understand budget constraints.

"If they keep their nurses past their standard working hours, they incur overtime which affects their budget. If there is somewhere else in the hospital that these procedures can be done without incurring overtime, doesn't it make sense to do the procedure there?" That just turned the conversation into complaints about how the ER nurses are dumped on and the hospital takes advantage of them.

I tried the approach that the nurse who is administering the sedation needs to "know" the patient and the best means of doing this was through documentation of the pre-sedation exam. "That's the physician's role," they asserted.

"You're right. It IS the physician's role," I agreed, "and there is nothing that says you can't ask the questions and review the patient's answers with the physician, especially if he or she is busy setting  up. If the physician has completed the pre-sedation paperwork, there is nothing that says you can't review it and tell the physician, 'Hey, you missed a spot over here.'" I am so frustrated that they can't see this is a teamwork and patient safety issue.

I spoke with my ED nurse manager and she doesn't know how to change this. This moderate sedation problem is just the tip of the iceberg in this department. It's like watching toddlers---everyone LOOKS like they're functioning as a team, but they're not. It's all parallel play: the techs are doing their own thing, the nurses are doing their own thing, and the physicians are doing their own thing. In the meantime, patients spend much more time in the ED than they need to, the physicians are not meeting benchmarks, and the nurses station looks like the Cantina in Star Wars.

The unfortunate thing is, I think I know how to fix this, but I only have the consultant role in this department. I've asked about the operationalized efficiency of an emergency department that sees patients within 30 minutes and I've been shut down. I've enquired about starting hourly rounding, bedside shift report, and bedside triage when census is low and I encounter extreme resistance from everyone, including the director.