You Want Me on That Wall...

I am the gatekeeper; now, apparently, I am the timekeeper as well.

It has become the (marketing) rage to tout "Door to Doc" times in the ER under 30 minutes. Essentially, this means that you are GUARANTEED (Ha! Hahahahaha!) to see a provider in under 30 minutes from the time you walk into the department. I am frankly amazed that this declaration is not immediately followed by "....or your visit is free!". Assuming that the patient is one that actually pays the bill.

Rapid Door to Doc is not a new concept, just one the many stupid bandwagons that Suits (and other disguised boxes of hamsters) utilize when they worship at the Altar of Customer Service. It was being given a trial run along with copious billboard advertising at Utopia Medical Center before I left there 4 years ago. We had a fast-track, but the 30 minute "Door-to-Doc" was a bit of a joke. Under an hour, maybe; but unless you were really sick, had chest pain, were holding a severed extremity in triage or bleeding from your eyeballs in general did you have any hope of being placed in a room in under an hour. Never mind seeing the provider. We did much better on doing EKG's in under 5 minutes since we just did them in triage, although we then had to do a room to room search for a provider to initial it. Shouldn't that count? I thought so. Anyway, while the average ER employee would love to have every patient sitting in front of a doc within 30 minutes of hitting the door, in reality, it isn't practical and merely serves to set us up for failure.

I have been told that our Door-to-Doc times need to be 20 minutes, per Dr. Roboto, our medical director; this is the same individual who lacks adult social skills and has been the cause of 6 docs quitting in the last 1 1/2 years, but doesn't see this as attributable to his lack of leadership qualities. Naturally, the first thing to be looked at is NOT the registration process, but triage. It is not the fault of registration clerks that more idiot questions are added to the registration process on a daily basis; I feel badly that they have to ask really stupid questions such as "do you receive Black Lung benefits" and "if a monkey can climb a greased pole in 10 seconds, how much does a pound of butter weigh?, and "do you like cheese?". I get that these are very important to the kind of treatment patients receive. Really, I do. But registration generally takes at least 10 minutes if patients haven't been to our facility and if Helen is doing the registration. Subtract about 1/2 of that if anyone else is doing the job. To add to the mayhem, on weekends and after 5 PM there is only one registration clerk who must also register out-patients. However, Dr. Roboto now says that triage, not registration needs to be streamlined. The man is a rocket scientist I tell ya.

Naturally there are patients with complicated medical histories that are the exception, but by and large an experienced ER nurse should be able to triage quite rapidly; it takes organization and the ability to multitask. In our ER we are all very experienced; with the possible exception of Southern Cathy and Sherry who like to engage people in conversation about their kids, pets and past lives, most of us are very efficient.

To prove my point that the problem lies with the registration process, for the last week I have noted my triage time, as well as the time triage was completed. This has averaged 5-6 minutes for me; I can do a frequent flier dental paineur or migraineur in less than 4 minutes if they aren't on any other meds. After triage, the patient is registered unless it is someone who needs to go right back to a room; that time gets noted as well as the time the provider actually picks up the chart and enters the patient room.

Keep in mind that we are do not have electronic charting in our ER, and probably won't until the end of the present century, so that is a lot of time notation.

Five to six minutes worth of quality triage time. And if there are no other patients I triage them right in the treatment room and have the secretaries register them whenever. Right back to a room, how great is that?

Dr. Roboto doesn't think it's so great, but that is no surprise to me; anything that is actually, well, nursing is trivial; particularly if it requires any skill or concious thought other than blind order-following. A nursing assessment? Insignificant. Nursing process? Unimportant. Critical care skills? Inconsequential. Any nursing input at all? Trifling, unnecessary, worthless.

Roboto's actions scream contempt for nursing in a big way. No wonder nobody likes him. I think a couple of my co-workers have actually switched shifts so as not to work with him. I doubt his own mother can stand him; can't imagine how he can be married and have kids. But hey, he brings on a lot of his problems himself; who can take a man seriously who uses a pocket protector, never wears scrubs because he thinks they are unprofessional, has a fussy little circum-oral beard (door knockers?), talks to his clavicles, wears glasses attached to a little chain and wears a little teeny kid's backpack (probably filled with Fruit Roll-Ups, juice boxes, and jelly sandwiches with the crusts cut off). Also he lacks a sense of humor, which, to me is the worst offense. I am at my best and most passive aggressive self in his presence.

None of the other docs are committed to this lunacy, which is just as well; why put the extra pressure on people for the sake of another marketing ploy with unrealistic expectations? Sicker patients will always get seen as quickly as possible, most in well under the arbitrary 20 minute time frame.

Dear (fill in the blank), an Open Letter

Dear Parent who Smells Like an Ashtray:


Get real. When I ask you if your asthmatic child is exposed to second hand smoke at home and you reply no, please know that I think you are full of shit. You may claim to only smoke outside your home, but I will be needing a nebulizer treatment after spending three minutes in your presence. You reek, as does your child who is presently wheezing like an old Chevy.

It is your choice to improve your chances of developing lifelong respiratory ailments and/or lung cancer; it is not your child's. Grow the fu#k up.

And please refrain from the sob story about not being able to afford your child's inhaler, it just lacks authenticity when butts are over $5.00 per pack.

Yes, I know the irony is lost on you.

Disdainfully,

EDNurseasauras

Ya Gotta Use Bait

There has been some talk about how to increase (insurance having) patients at our ER; that is, without spending a ton of money. Marketing came up with a health fair to accomplish this.


Our recent weekend health fair (Mandatory Participation, haha!) took place on a beautiful Saturday; all of the components were in place. There were bike helmet fittings and $10 bike helmets available for purchase, what a deal. The usual giveaways that people love. Fingerprinting. Free bike inspections. Free car seat inspections. Drawings for free stuff. A farm stand with awesome looking fresh veggies for sale. Free vision checks and BP checks. FREE healthy turkey hotdog (Jennie-O, DELISH) and veggie burger lunch with all the fixin's, and a CRAZY rock climbing wall that was a useful babysitting device for one of the marketing divas. And the face painting was very popular with the little ones.

All of this good stuff in place right next to a playground where kids were involved in soccer and baseball. Yet, we had basically nobody attend. Why?

1. Poor advertising.

2. It was held IN BACK of the building where nobody goes. NOBODY. EVER.

The rock climbing wall was a crazy hit among the kids who did attend. I managed to sell 10 bike helmets. The bike inspection guy only did one bike inspection, and I think that was for one of the marketing people who felt bad and went home for her own bike.

Not one person from marketing asked those of us who lived and worked in the community for input on what might work to get people to attend. I just don't understand that.

You can bet that the first thing on the list for next year is have it OUT FRONT where people can see it.

Oh, and balloons. That was my idea. Balloons and much bigger writing on the sandwich boards that can be seen while driving.

What? Just 'Cause I Don't Drink the Koolaid?

A couple of weeks ago I was looking at the schedule and noticed that I had not received any charge pay for the entire month of Sept, and was apparently not in line for any in October. We are such a small shop that it is just "gimme" cash and is usually distributed equally among us. It is not a ton of money, but since they pay us through a peashooter anyway, an extra $20 or $30 a week at least pays for coffee or a manicure. Whatever.

I also noticed that SIC had received wayyyyyyyyyyy more of it than anyone.

It was a moment of WTF-ery that I felt deserved investigation. Since it was on a weekend and my boss wasn't around, I left a note.

The next day I got a call from Mikki. Apparently, at the last staff meeting my boss announced that charge pay would be withheld for anyone not up to date with competencies, a fact that was not shared with about half of our small staff. SIC sure got the memo, I observed; how convenient.

Our competencies are fairly useless, consisting of a monthly rhythm trip, like so:

So the idea is to identify the rhythm, count out the distance between each of the little teeny squares to determine the intervals and a whole bunch of other useless shit, then declare if/how it should be treated. Waste of time.

I hadn't done a single competency for the whole year; or the year before that. I think because I was in school, my boss sort of gave me a bye because I always do my certifications like BLS, ACLS, PALS, and TNCC. Now she was changing the rules of the game and drawing a line in the sand: if you want money, cough up the competencies.

Mikki knew I was a little pissed about this, not so much as holding charge pay hostage but how it was a big secret that seemed to benefit one or two people; she was practically hysterical. "Don't quit!", she begged, "you can copy mine, I just gave then to Sherry 'cause she hasn't done them either. Really, I mean it!".

As if I would quit over this. Or copy. I just didn't do 'em because I thought they were stupid. Sue me.

My contention is that surely, other knowledge might be more useful, such as inservices or competencies for stuff that we hardly ever see BUT MIGHT ACTUALLY NEED. Like what's in the delivery kit, how to prime the fluid warmer, or how to set up and maintain the IO (intraosseous) equipment (you really don't want to know what that is if you aren't medical, trust me). Other knowledge it might be good to know is specific to our unique facility such as a review of what to do with a deceased person after hours, or should we share our supply of lactated ringers with a local vet for use on a horse. Yes, we actually had a request for a case of IV fluid, unfortunately we only stock about 4 of that kind.

Did I break down and do competencies? Yep. We had 3 (THREE!) patients last Saturday night and I did every one of them, then stuffed them in the the boss's inbox which effectively pre-empted my written rant. Money talks and bullshit walks; OK, so I drank the Koolaid. If for no other reason than to prevent SIC from getting more $$ out of it.

Triage (defined)

Triage: a process of prioritizing patients based on the severity of their condition

Now I not only have to contend with patients who challenge my 30+ years of triage experience, now I am having to defend them to people I work with. In my small facility, there is a triage process as it pertains to the order in which patients are registered by the secretarial staff. In a perfect world, it would be first come first served. This would be followed by the ones with the biggest mouths, the most dramatic, or the most whiney.

ER patients and outpatients alike must register with the same secretarial staff. There are two until 5 PM, then there is only one. Helen, lord love her, is thorough but slllllllllllllllooooooooooooooowwwwwww. The lab and xray outpatients are sometimes bumped for registrations, appropriately, for patients who need to be seen in the ER sooner rather than later. Sometimes the docs are just antsy to see patients; sometimes we just want to get them in and out because we can.

Yesterday, I triaged a pale 6 year old with a head bump; he had vomited several times. Aside from a mildly elevated heart rate, he looked about as OK as he could. Still, I didn't feel I wanted him to sit in the waiting room while Helen registered several outpatients. As I exited the triage area, Helen intuited that I needed this child registered without delay and kicked the outpatient xray in front of her back to the waiting room.

Several minutes go by; Lee,the xray tech was in my face, abrupt and inappropriate as usual; "Do you ever think about how the patient might have felt? He was already seated. I know we are supposed to give preference to the ER patients, but do the outpatients always have to be bumped for every dental pain and boo-boo?"

Whoa, back off there. I waited for my blood to stop boiling, took a deep breath, calmly looked up as she loomed over me, then let her have it

"Lee, I understand your frustration. I am sure you got endless shit from the outpatient; not to mention it makes your numbers look bad, so I am sure there is a certain amount of self-preservation here. The reality is, it is my decision and mine alone when it comes to the order in which patients are registered; it is based on my clinical judgement. It is my license but more importantly it is based on doing what is right for patients who need care sooner rather than later, as well as common sense which you seem to be lacking today. Before you stick any more of your foot in your mouth you should know that this kid is head injured, pale and vomiting, which handily trumps your outpatient. That's all you need to know. Don't you ever question my clinical judgement again; you will lose, I assure you. Now get out and go fill in some forms or something".
She left sputtering but firmly in her place.

The Talker had heard the whole thing; "Wow", he said, "Well done".
Yeah, see definition.