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.

Escaping the Dead End Corridor

Even though I'm on leave, I still went in to work today. I had the doctor look at The Son's induration (it was healing), I physically signed out on leave, and I reviewed my email and action items. I compiled statistics and submitted the monthly Division Officer report because I wouldn't be back before the deadline. I fretted about sending one of the corpsmen to the ICU.

Ultimately, the corpsman I decided on was the result of my reading Marcus Buckingham's book, "Now, Discover Your Strengths." If this corpsman sees something that needs to be done, rather than finding a junior corpsman to take care of it, he simply does it himself. He knows a lot from his year on the floor, he has college experience, and he is older and dedicated to the Navy as a career. His strengths are his maturity, his ability to take initiative, and his clinical skills and expertise.

His weakness, as he relayed to me, is his inability to delegate. "It's just easier and faster to do it myself," he said.

I have identified two concepts here:

1. Many times it IS much easier to do it yourself. Picking up litter and answering the telephone are low-level tasks that require no additional training beyond common sense and commitment to teamwork.

2. You should always be training your replacement. There was no need for me to submit a report while on leave. I should have trained someone else to do it. I have to explain where to find the data for the reports and how to update the charts. I have to obtain permissions for the other person to be a contributor online. I have to show them how to review and respond to requests for additional information from higher-ups. I haven't done any of that and it's only a monthly report, so I also need to generate a "how-to" for my desktop reference, "Instant Division Officer Handbook - just add respirations."

I've shoved fistfuls of paper into this 3-inch binder and I haven't organized anything and I haven't made it easier for the next person to step into my shoes. When I first arrived here, I dutifully noted the heavily stenciled warning above the double doors: Dead End Corridor No Exit. I joke that the sign leading to my office is a self-fulfilling prophecy. Well, it will be if I don't start training my replacement now.