Question

Scenario 1

John Hildebrand is emergency room charge nurse. During an evening shift, four victims come in from a major automobile accident. Two were critically injured, and two had minor injuries. All the other staff nurses were caring for these victims when a 55-year-old female came to the ER complaining of severe epigastric pain and some abdominal pain. John attended to this patient and, per protocol, gave her a GI cocktail (antacid, lidocaine, and phenobarbital [Donnatal]). Her pain level decreased shortly from 6 out of 10 to 3 out of 10. John also did an ECG to rule out any cardiac causes. Because her pain did not completely resolve, John and one of the physicians discussed possible causes. Although the patient did not present with any nausea, vomiting, or fever of any kind, her symptoms overall were vague. The doctor decided that blood work should be done “for the heck of it.” The patient was then sent home because she was stable and feeling a bit better. Thirty minutes later John called her with the results of her amylase and lipase levels and told her to go immediately to the ED. In the end, she had pancreatitis.

• 1.When an additional patient came into the ER, what choices did John have with regard to assigning a nurse the new patient?
• 2.What are the shift staffing issues in a busy ER?
• 3.Whose responsibility is it to make the staff assignments during the shift?
• 4.What decision-making strategies should be used when deciding who should take care of which patients in the ER?
• 5.How did the use of a clinical protocol help or hinder the care of the new patient with epigastric pain?

Scenario 2 Primary and specialty patient care in multispecialty outpatient clinical settings meets many of the characteristics of a complex adaptive system. Numerous agents (nurses) interact in a diverse social network (patients, physicians, therapists) that overlaps multiple systems (lab, specialty clinics, x-ray, social work) to provide care for patients who have a variety of health care issues. Care is often constrained by the time allowed for each appointment and the type of insurance a patient holds. Multiple referrals to specialists may occur without coordination by any one person, despite the fact that a patient may be assigned a primary health care provider. In complex systems such as multispecialty clinics, any disturbance in a positively reinforcing feedback loop may amplify in a “nonlinear” fashion throughout the system. Examples of a disturbance may include changes in a patient's insurance during the course of treatment and miscommunication between nurses and physicians, between physicians, or even the receptionist and the patient. The cascading effect of disturbances within the complex social network of staff and patients may result in unanticipated outcomes. For example, a new insurance carrier may cause the patient delay in treatment because referrals to specialists may require approval from the insurance company. Regardless of its pattern, the emergence of new insurance requirements results in new patterns of care as the appointment system and care providers adapt to new requirements. Complex systems are nonlinear and unpredictable. However, by altering or “tuning” system parameters, care coordination can lead to desired patient outcomes (Minas, 2005). For instance, if done correctly, adding a care coordinator to the system could facilitate timely and appropriate care for the patients. In the change of insurance example, the following system changes could make care more efficient and effective for all patients, whether or not insurance changes:

1.Assign each patient a medical home, which is a system of primary care that coordinates all the patient's health care needs (Kuraitis, 2007).

2.The care coordinator in the medical home takes a complete history upon initial entry into the clinic system and monitors patient's health each time a patient has an encounter with a care provider.

3.The care coordinator ensures that referral to specialists and requests for diagnostic tests and treatments are preapproved, if needed, by the insurance carrier.

4.The care coordinator ensures that all test results are communicated to the providers and to the patient and ensures that any needed follow-up takes place.

Answer 1

When an additional patient came into the ER, what choices did John have with regard to assigning a nurse the new patient?

Answer: When an additional patient come to emergency room then new patient can be assigned by a different nurse if available. This depend on availability of nurse also. Otherwise if there is another emergency then a patient can be shifted to the Emergency Department (ED) from Emergency Room(ER).

What are the shift staffing issues in a busy ER?

In a busy Emergency Room there are shift staffing issue due to stresses, shortage manpower, working overloads. There are stress due to critical environment. There is no chance for inaccuracy because of the life of patient is on stake. So in busy ER there are confusions about shift management.

Whose responsibility is it to make the staff assignments during the shift?

In hospital there a separate department can Vigil on assignments during the shifts of nursing staff. Otherwise this is the duty of superior physicians to make assignments for the nursing staff. Due to confusion there assignments can be mix up due to work load of incoming and outgoing patients. They have limited time for patient due to work overloads. So there should be an other department to time management and assign timely duties to nursing staff.

What decision-making strategies should be used when deciding who should take care of which patients in the ER?

Clinical reasoning,critical thinking and good judgement, previous experiences are the strategies which provide quality health services. The patient will come as usual but the key point is how to handle and provide them good sufficient service to them, so that there are minimum chances of the harm to anyone. A manager who handle these should be high on critical thinking. He have to take action and the accurate action within minimum to.e fraction because of criticalness of the Emergency Room Environment.