Last week, I introduced the first of three main obstacles I've identified in my time as a Charge Nurse: Lack of staffing resources in the ED. If you missed that post, you should really check it out here to get some context. 

In this series, I'm discussing not only the challenges Charge Nurses face in our roles, but also the importance of maintaining a positive outlook in efforts to best keep up the morale of the rest of our teams. This next issue can be particularly difficult to tackle with a calm face, especially since it's all about the wellbeing of our patients. But, taking a second to breathe can help maintain relationships and ensure better outcomes for everyone involved. 

OBSTACLE #2: Barriers to facilitating flow for ED patients

All ED Charge Nurses have been there. You have an overfull department, a waiting room bursting at the seams, ambulances lining up in the bay, and that one sweet, sweet admission just about to go up and clear you a room.

Then it happens —  for some reason, the transfer up to the unit gets grounded, and will be staying in the ED. Perhaps it was a new admit from PACU taking that inpatient room, or the room isn’t clean, or the 30th consult has been added. All I know is in this moment, my blood pressure rises, and my hairline starts to recede at an accelerated rate.

I’m pretty sure we all do the same thing next: we push as much as professionally acceptable, then swallow our pride, and accept that the patient won’t be going upstairs. Facilitating flow and operations of the department is the main job of the ED Charge Nurse, and again this rapid flow algorithm is something that our inpatient colleagues, and maybe even house supervisors are not familiar with.

The sense of urgency is not always shared by the rest of the care team, and this is a unique challenge. There are barriers to giving report, sending the patient up, and pretty much all other steps in the process of physically admitting a patient. Trying to create space to care for our sickest in the department is a high-stakes task that can wear down even the calmest of ED nurses.

My best tactic for remaining positive in this situation is to continue to try calmly explaining the crucialness of getting THIS patient into a room. Even when the plan IS to get my patient up to a room, I still like to briefly explain why that’s so important to his or her outcome, and how thankful I am they’re making space for the patient.

Like all other issues, communication and teamwork here is key. Getting mad and upset at the inpatient unit, or house supervisor doesn’t work. First, it creates teamwork barriers for future situations, and secondly it does nothing to solve the current problem. This is where critical thinking comes into play. Pull a patient into the hallway, ask for a resource nurse, ask nurses with low acuity patients to flex up.

Sometimes we need to be flexible for just a bit to open up teamwork channels. I can say, when I work with people, they tend to help me later in the shift. Kind of a ‘you scratched my back now I will scratch yours,” approach.

What do you do when you encounter issues like this? We'd love to know!


Greg Brown

Written by Greg Brown

Greg Brown is an Assistant Nurse Manager at Providence. He has a passion for transforming emergency medicine and enhancing quality outcomes for patients.