As far as the original question of documentation, I try to document in the most friendly team-player manner when WR care is truly suboptimal that I’ve done my best and notified the appropriate parties. MOST WR care i do not make any special note about.
(1) We have some mini-rooms, fast-track rooms, or vertical-care space adjacent to the WR (pick your favorite terms). Most days we see a significant volume of fast-track style complaints in these rooms, and sometimes those patients then go back to the WR to wait for, say, an X-ray or a rapid strep. I personally have no issue with this, it speeds care, its not super risky, patients actually don’t mind a ton, etc. Granted I’d love double the rooms so everyone gets a room, but If you can peel some fast tracks out of the WR and see them in adjacent space, cool for you. Our PAs and MDs do this. We occasionally don’t have enough RNs to really staff these rooms, so occasionally we do things the RNs would normally do (hand people d/c paperwork, etc). I document NOTHING special on these charts. Our MD/PAs are empower to autonomously grab patients from the WR and see them in these spaces if things are backed up and they have high likelyhood of near immediate discharge based on the triage.
(2) As well, we have a host of med-exec approved triage-RN ordered labs / EKGs / plain films and they are told to be aggressive about ordering basic US or even non-con CT head for anti-coag head trauma from the WR (we speak via secured text, or in person, to order these and confirm we want them; sometimes we see the patient in the triage both for 60s to confirm). Is there theoretical liability with this? Sure. Does it also vastly speed care, and patients seem to like it? yes. Do patients sometimes get all of this done in the WR, and are ready to discharge? Sure. I am happy to go grab them, pull them into one of the vertical care spaces, and do the H&P part, go over the results that the kind triage RN ordered as part of the care team with me to expedite their care, and then explain the results and how I’d like to get them out of here with an Rx or whatever. When you frame it as clearly the system is crumbling but the RN and MD are working hard to get YOU THE PATIENT excellent care as quickly as possible even though you’re sitting in the WR… patients and families LIKE this.
For example, 80yo here with daughter b/c he tripped on the rug, clocked his forehead on the coffee table, has a lump and is on eliquis. He’s acting totally fine, has normal vitals, but they were concerned. Non-con head done from WR, negative, I pull patient and daughter back, confirm history, do neurological exam, then go over the thankfully negative CT scan (which was ordered bc the triage nurse was concerned about him, and talked to me in real time about getting it done ASAP! All the hospitals are SO crowded, we’ve really had to start hot-wiring the system to keep patients safe, you see?), and my recommendations re: concussion, symptoms to return for, etc.
Now, what you’ve noticed here is my WR is actually very high functioning. If Xrays are ordered in the WR? They get done. If labs are ordered? Phlebotomy does them. If CT is ordered? CT tech grabs the patient and does it. Is it always super fast? No the place is on fire! However, we and hospital leadership are 100% on the same page that WR care is sub-optimal, but barring doubling the size of our ED this week its going to happen, so we need to do WR care the best we can.
(3) The ones that I do occasional writing things down about… patients that are ESI 2, have concerning triage complaints, triage RN is begging to get them back, every room/hallway/closet is full, and you can’t get them back. Clearly at this point you’ve already escalated through admin whatever your process is for CODE DISASTER etc etc. I absolutely will go see these people in the WR, preferably pulling them into the triage booth or vertical room, or hallway. I absolutely order labs / imaging. I’ve put my own IVs in these people and drawn my own labs. The issue is if they need meds, does your hospital have nursing capacity to truly admin meds in the WR? I am fine hanging my own liter of NS on an IV poll in the WR. But I can’t pull Zosyn from the PYXIS, so you may need to negotiate with your Triage/resource RN to see if they can give a quick med.
Anyway, in this type of case I have written things like “triage RN alerted me to this patient, concerned about their presentation. Due to severe crowding, hospital on CODE DISASTER, every room/chair/hallway currently occupied and they could not be pulled out of the WR. As such I did go immediately and see the patient in the WR/triage booth; to expedite their care I have ordered labs, imaging, and medications for them. Patient understands the initial care plan. D/W triage and resource RN care plan.”
Usually we are good enough that once another 30-60min pass, if the diagnostics are looking bad, we can get them into a hallway chair at least. But when you are ordered a CT for likely perforated viscus in the WR and it shows free air… who knows what the “best” thing to write in the chart is? I figure the truth, without laying blame, and showing the care team is trying its best and did recognize the patient and did NOT “ignore” them in the WR is a reasonable thing to chart. I think the tone and context is important, and if you chose to write this type of context you should be collaborative and not finger pointing.
Have I literally run code strokes in the WR and pushed the patient to CT myself? Yes. Believe me no one in the WR complained about their wait for the rest of the shift… 🙂
