The ED at HMC has consistently performed and provided extraordinary care despite this unprecedented year. The teamwork among nurses, patients care techs, and physicians is apparent as they have achieved the highest patient satisfaction scores for an ED in the system. Attaining these scores was no easy feat and required consistent high-quality care with excellent communication. Hourly rounding was key to achieving this. The results were exceptional and presented as both a poster and podium presentation for AHS Research Day in 2020. 

During the pandemic, the team faced the unknown with poise and grace. When concerns regarding intubation were expressed. The team worked with a sister hospital to create a box to decrease exposure of the Covid-19 virus during intubation. The box was named as one of the top innovations of AHS for the pandemic. In addition, the team championed using the Lucas Device to reduce the number of people in the room during a code blue. Before the ICU received their Lucas Device, the ED did not hesitate to share theirs. ED team members also did not hesitate to float to the ICU and care for inpatients. This speaks to their commitment to the entire hospital. 

The existence of a unit-based shared governance (UBSG) council in the ED promotes nurse practice, education, utilization of evidence-based practice, and teamwork. It also provides a forum for nurses and other staff to discuss issues of patient care, safety, and work-life balance. Because this hospital is a primary stroke center, rapid initial diagnosis and treatment are essential. The system policy states a stretcher with a scale must be available for Code Stroke patients to not delay administration of weight-based tissue plasminogen activator (tPA). One of the first UBSG initiatives suggested by an ED nurse was to ensure that a stretcher with a scale is always available for stroke patients. An area outside of the computed topography (CT) room was cleared with signage that designated the stretcher for the exclusive use of stroke patients. This simple change helped decrease door to CT times, which is crucial for treatment. This example speaks to the collaboration of interdisciplinary professionals from nursing to radiology to improve the care of the patients served.

The team also received recognition for the Stroke care they provide earning the Golden Lobe Award. Despite the challenges faced, the ED continued to provide high-quality care with phenomenal door to balloon times for patients experiencing a myocardial infarction. Each case was flown to MMC within 90 minutes and resulted in positive patient outcomes. Coordinating care across the continuum also highlights the teamwork the ED displays. The ED staff comes into work every day unaware of the patients and medical conditions they may face. However, they continue to rise to the challenge and exceed expectations. The care they provide was even recognized on a nationally syndicated morning radio show. This would not have been possible without the teamwork they display on a daily basis.

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The Hackettstown Medical Center Emergency Department has been faced with several challenging situations in the past few years. The COVID-19 pandemic changed everything we knew for our entire professional and personal lives. One of the challenges of nursing care in the HMC ED is the lengthy boarding time for behavioral health patients that require inpatient admission. In an 11-bed ED, having two to three patients waiting for bed placement becomes a challenge, not only for space but to provide holistic and therapeutic care for the patient. With all patient visits in the ED increasing daily, it is imperative we keep all aspects of patient safety and humanity at the forefront. They are not simply a bed number or a diagnosis. In order to continue to care for all patients, it is essential to create a therapeutic environment. We worked extremely hard in the past few years to improve the conditions for patients who must wait in the ED for inpatient beds, whether it is another facility or even a medical bed assignment in HMC. Sometimes behavioral health patients will become disruptive, yelling from their rooms, or exhibiting attention-seeking behaviors when faced with long wait times. Truthfully, this can happen with any patient. Part of the unit culture is to be proactive with hourly rounding.

The nursing staff identified that we must especially create routines of normalcy in a chaotic environment for these patients. As nurses, we understand that many patients may need to be actively encouraged to perform activities of daily living. No person is meant to stay in a bed in a room for many hours, let alone up to one week. Due to COVID-19 restrictions, we have been boarding behavioral health inpatients for as long as seven to eight days. The days are long and monotonous with loud alarms, no windows, and only thirty-something channels of television. Stretchers are uncomfortable within hours and not designed for continued use for days. Hospital food and the standard ED snacks lose their luster very quickly. Patients cannot feel clean with just a washcloth and soap in the shared unit bathroom. Patients staying overnight are transferred to inpatient hospital beds to increase their comfort. Patients are encouraged to shower daily by the nurse. They are accompanied by an ED Tech who functions as a 1:1 sitter and maintains all patient safety and suicide precautions (if applicable). Security also assists with the routine to be sure that there is no issue with elopement while taking the patient from the ED to the inpatient unit to shower. Patients receive clean linens on their beds before they return. 

Recently, we had a challenging situation due to boarding three behavioral health patients waiting for transfer to an inpatient facility. Two of the patients were pediatric patients. It was during this time that several of the nurses identified that all of our standard measures alone would not be enough to meet the psychosocial and developmental needs of pediatric patients in the ED.

One patient, in particular, was considered extremely high-acuity for medical and psychiatric services. She had been restricting food intake at home and was very withdrawn, seemingly untrusting of the staff. Within the first day, all of her nurses, patient safety sitters, ED techs, and physician very quickly identified she would be at risk for further physical and mental health decompensation. Every nurse in the department took care of her in her 8-day stay before a bed was available for specialized services. Nurse-driven consultations with crisis, dietary, occupational, and physical therapy were all part of the daily routine in order to support her, knowing she would have a long length of stay in the ED. Even the patient sitters were involved with doing more than just the suicide precautions checks required. In the report, we discussed her particular dietary progress and any activities introduced by PT/OT, including drawing, Play-Doh, and exercises that she found enjoyable. In truth, we all found it therapeutic to sit and draw some pictures and join her for some of the activities. We even found ourselves in a little competition to see who could figure out which dietary creation would be what she would even attempt. Our patient sitters set up tables as if they were dining with her at a restaurant and making easy conversation. Although very reserved the first few days, it was extremely rewarding to see her smile and engage with us a little. It truly felt good to see her progress a small amount instead of potentially decompensating while waiting for services.

We also initiated the same interventions for the other pediatric patient and saw an incredible change in her behavior and made her stay less monotonous. By continuing to remember to treat others as we would like to be treated, we are able to minimize potential setbacks while making arrangements for definitive behavioral health care. We continue to remember that somewhere, each one of these patients is someone’s loved one. Sometimes the nursing care isn’t complex for these patients, however, it can be key in saving someone’s life. We’ve been faced with many challenges this year, but we identified many new resources to continue to make every patient’s hospitalization a little more pleasant. It has been a constant reminder that we must continue to meet each patient’s individualized needs to deliver care that is effective and meaningful for vulnerable patients.