What are the initial steps and guidelines for emergency room nurses to follow in critical care situations?

Emergency Room Nursing Guidelines for Critical Care Situations

Emergency room nurses must prioritize immediate airway management, continuous vital sign monitoring, and rapid patient assessment while maintaining constant visual contact with critically ill patients, with experienced charge nurses coordinating care through a structured pod-based or functional team model. 1

Initial Assessment and Core Competencies

Emergency room nurses responding to critical care situations must possess and immediately deploy six essential competencies 1:

• Infection control practices - First line of defense for both patient and staff safety 1
• Airway management - Including suctioning and artificial airway maintenance, as airway is always the first priority in any emergency 1, 2
• Vital signs and monitoring equipment - Continuous assessment of respiratory system, blood pressure, temperature, oxygen saturation, and urine output 1, 2
• Physical care activities - Patient turning, cleaning, and positioning (head of bed at 45° for mechanically ventilated patients to prevent ventilator-associated pneumonia) 1
• Foley catheter care and management of bodily wastes - With careful documentation of urinary output 1, 2
• Medication and nutrition delivery - Through enteral tubes and IV pumps when available 1

Staffing Structure and Team Organization

The Charge Nurse Role

The most experienced charge nurse should be identified immediately as they are best prepared to match patient needs with caregiver capabilities based on acuity and nurse experience levels. 1

The charge nurse has two primary organizational options 1:

Pod-Based Model (Recommended):

• Critical care nurses oversee a deliberately constructed "pod" of patients 1
• Each critical care nurse mentors non-critical care caregivers assigned to their pod 1
• Critical care nurses care for the most challenging patients while remaining available to assist non-critical care nurses 1
• Non-critical care nurses should be assigned no more than two critically ill patients 1
• Up to three non-critical care nurses work in collaboration with one critical care nurse 1

Functional Model (Alternative):

• Critical care nurses assigned to all patients for assessment and complex decision-making 1
• Other personnel assigned specific care functions (e.g., pharmacists for medication delivery, paramedics for airway maintenance) rather than comprehensive care for individual patients 1

A hybrid approach combining both models is also viable, with the critical care charge nurse providing oversight and working closely with the entire critical care team. 1

Environmental and Equipment Requirements

Patient Area Setup

Constant visual contact between nurse and patient must be maintained through large window openings or glass doors, while patients cannot see each other. 1

Essential equipment at bedside 1:

• Communication systems: telephone, intercom, manually triggered alarm system for immediate staff notification 1
• Administrative workstations per bed for patient files, monitoring, charts, imaging, and lab reports with paper backup 1
• Lockable storage cupboards with uniform arrangement of disposable materials, drugs, wound dressings, sampling equipment, intubation materials, and emergency drugs for easy identification in emergencies 1
• X-ray film viewer or digital imaging screen 1
• Monitoring equipment with outlets distributed on both sides of bed 1

Service outlets should be positioned 120-180 cm from the floor, with adequate access to the head of the bed for endotracheal intubation, resuscitation, and central venous catheterization. 1

Central Nursing Station

The administrative hub must contain 1:

• Satellite pharmacy with central lockable drawer for narcotics 1
• Computer terminals, telephone, intercom, and emergency call systems 1
• Optional visual display with access to individual patient monitoring and alarm recording 1
• Drug preparation area 1
• Satellite storage room for sterile and nonsterile clean material 1

Critical Care Interventions Priority

Hospitals must prioritize interventions that improve survival (without which death is likely), don't require extraordinarily expensive equipment, and can be implemented without consuming extensive resources. 1

Essential interventions to deliver 1:

• Basic mechanical ventilation modes 1
• Hemodynamic support with IV fluid resuscitation and vasopressors 1
• Antibiotic or disease-specific countermeasure therapy 1
• Prophylactic interventions: head of bed at 45° for ventilated patients and thromboembolism prophylaxis 1

Hospitals should stockpile sufficient equipment for IV fluid resuscitation and vasopressor administration for at least the first 48 hours without relying on external resources. 1

Documentation and Communication

Nurses must document carefully amidst apparent chaos, combining good assessment skills with knowledge of diagnosis, treatment, and appropriate nursing intervention. 2

Communication requirements 1, 3:

• Large wall clock and calendar visible to staff 1
• Multimedia access to internet and alternative nonverbal communication tools 1
• Clear, respectful, empathetic communication with patients despite the noisy, fast-paced environment 3
• Continuous observation and documentation of level of consciousness and neurological status 2

Patient-Nurse Relationship

An RN working bedside is crucial for establishing a patient-nurse relationship to meet the patient's physical, psychosocial, and relational needs. 4

Critical pitfall to avoid: The RN's focus on the patient decreases over time in emergency settings 4. When the RN communicates with the patient, the patient's physical needs are met to a greater extent 4, emphasizing the importance of maintaining active patient engagement throughout the care episode.

Triage and Resource Allocation

If there are limited hospital resources and many critically ill patients, triage decisions should be guided by the principle of seeking to help the greatest number of people survive the crisis. 1

This includes patients already receiving ICU care who are not casualties of the precipitating event 1.

Infection Control and Personal Protective Equipment

Hospitals should stockpile enough PPE to care for mass casualties for up to 48 hours, and all clinical staff should receive initial and periodic training on health care delivery using PPE. 1

Pre-event plans must augment usual airborne infection isolation capacity for critically ill victims of contagious pathogens 1.

Common Pitfalls

• Losing visual contact with patients - The physical environment must support constant observation 1
• Inadequate access to patient's head - Bedhead-against-wall layouts limit emergency access; freestanding arrangements with ceiling-mounted services are preferred 1
• Non-uniform equipment arrangement - Standardization is mandatory for easy identification in emergencies 1
• Decreased RN focus over time - Active communication and bedside presence must be maintained 4
• Ignoring fundamental care needs - While biomedical focus dominates, failure to meet basic needs has severe consequences 4