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Boarded patients may be overlooked: Make changes
David M. Solomon, RN, BSN, CEN, EMT-P, patient care coordinator in the ED at Catawba Valley Medical Center in Hickory, NC, says that usually, medications for boarded patients have to be ordered from the pharmacy.
"In our ED, this means someone has to walk to the pharmacy and pick those medications up," he says. "The medications then have to be verified with the orders and [Medication Administration Records]."
Solomon says that it has been his experience that by the time the ED nurse has evaluated a patient, contacted an admitting physician, received orders, and made the decision to hold the patient, the patient is already behind on his or her regularly scheduled medications.
When a patient is held in the ED, nurses must inform the pharmacy to ensure that the medications will be prepared and delivered, says Jenny Bosley, RN, MS, CEN, a clinical nurse specialist in the ED at Thomas Jefferson University Hospital in Philadelphia, PA.
The ED has two full-time pharmacists who can review orders, make recommendations for dosing and administration, and provide staff and patient education, she reports. "They work with the main pharmacy to order and obtain needed medications for the boarded inpatients," says Bosley.
The ED's automated medication dispenser has been set up to include individual labeled bins, adds Bosley. "A bin corresponds with each patient room, and can mimic the medication carts commonly found on an inpatient nursing unit," she says. "This ensures that the medications are secure and kept separated."
The ED pharmacist consistently monitors medication inventory, and makes adjustments, as needed, to specific inventory and/or par levels, says Bosley.
Request help from RNs
Bosley says that critical care pool nurses care for admitted patients in the ED if available. "If there is a nurse available to come to the ED, the pool nurse can care for them just as they would on an inpatient unit," she says. "This, in turn, frees up an ED nurse, who can then help at triage or assist another ED nurse."
When Portland-based Maine Medical Center's ED has more than three boarded patients, inpatients are "corralled" in the ambulatory section of the ED, says Kathleen L Wurgler, RN, BSN, an ED nurse. Float nurses care for these patients until they go upstairs, she adds.
"Satellite nursing units are opened up to meet the need of the boarded patients downstairs," says Wurgler. "This allows the flow of the ED to resume." (See related story, below, on using a Medication Administration Record.)
For more information on boarded ED patients, contact:
Mimic med/surg MAR practices
ED nurses at Catawba Valley Medical Center in Hickory, NC, implemented a new process for boarded patients that mimics what is done on the medical/surgical units, says David M. Solomon, RN, BSN, CEN, EMT-P, patient care coordinator in the ED.
"This includes the same schedule and documentation used on the med/surg units," he adds. "The ED charge nurses also watch to ensure the medication regimens are followed."
ED nurses use a Medication Administration Record (MAR) just as inpatient nurses do, says Solomon. "This is not something the ED commonly uses," he says. "The ED isn't used to this type of schedule. We normally work on what the patient needs in the moment."
The MAR involves the pharmacy, explains Solomon, and is a medication administration schedule used for patients who are going to be staying in the hospital for more than a few hours.
"The schedule ensures they routinely get the medications they have been prescribed, before and after hospital admission," says Solomon. "The ED doesn't deviate from a patient's normal medication regimen, or one that is created for their hospital stay based on their condition."
When the patient gets admitted, the MAR goes upstairs with the patient, says Solomon. "There is an easy transition after the patient's admission," he says. "The floor nurse only has to continue what we have already started, so it's less work on them."