is it just me or has standard of care sunk?

1 I'm sorry, but I'm not going to call a ER vs floor nurse thread. Even though I feel like I could.

I had a patient admitted for a chest pain r/o ischemia. EKG looks ok, labs ok(WBCs a little high, but she admits to coughing up green stuff for 3 months, has empheysema). No home o2, denies pain currently, etc. I'm looking over the report when I notice that her bp has been going up at 2100, 2300 and 0015. no more VS. the highest at 0015? 215/102! (I figured it was a false high). they call up to see if bed's ready. "yeah, and are we doing anything for bp besides the 1 inch nitro paste?" nope. She gets up there and as I'm doing home meds, she mentions she hasn't taken her daily norvasc or lopressor yet. she's taken her lisinopril and her isosorbide. She told them downstairs.
Ok, so I go out to double check meds/labs/etc. Didn't catch on the first glance when she got there, uhhhhh nobody called her cardiologist? Nobody did a set of enzymes? Nobody checked her pulse ox?
ox is fine, her bp that I did was 198/98. Not great, but we'll deal.
Called the medical, he states to give her a po bp pill, resume usual at 8am. STAT enzymes, they used the blood from ER, look ok. I called the cardiologist as nobody had called the consult, covering doc says, give her her usuals now, again at 8am, take off the nitro paste at 6 am. and we'll see. her doc will see her in am. due to pharmacy, get meds at 3am. By 5? 168/86. Just a bit better.
am I the only one who thinks they should have done something for bp and run cardiac enzymes? the one time the complaint isn't taken seriously? we get people dying in the waiting room.

Additionally, she is apparently homeless and does come into the ER off and on, but when a staff went down to get a suitcase she left, she heard the ER staff mention "hating her" and "that Fing B." why the hate? she was actually polite and informative for me.
How can they write admit dx of CP r/o ischemia and not do a cardiac workup in the ER? If that was the case, it would be a write-up at my facility and they would be asking questions about what the heck we are doing down in the ER. I've sent patients to the floor with BP's in the upper hundreds over teens, but they've been medicated and persistently high. Also, I don't care how much I might dislike a frequent flier, those nurses should know the walls have ears and things you say come back to bite you. Sorry you had to deal with all that and that your ER colleagues fell down on the job. It's not the case everywhere I promise.

Unfortunately it is the mentality that believes those who do not have are not worth keeping. Very sad.

No one would be admitted to the floor at my hospital for chest pain unless a set of cardiac enzymes were sent in the ER. I find it hard to believe that someone didn't slack on the chest pain standard of care.

In defense of the ER, and I don't work ER, they frequently have the same pts, present several times a week with the same complaint.Apparently the ER is very familiar with this pt. Is it possible she had a complete cardiac workup the same day or the day before? It would have been nice if the ER had given the pt her scheduled BP meds. But the ER is not the doctors office or the clinic.It would have been nicer if the pt had taken them herself

Beyond the point of being a frequent ED visitor, the standards of nursing and medical care should meet up with the pts chief complain. Very controversial medical situation.

I'm curious - what was her chief complaint for coming to the ER? Was it originally chest pain?Regardless, I'm surprised that enzymes were not ordered in the ER - by the doctor or the nurses.

Quote from locolorenzo22I'm sorry, but I'm not going to call a ER vs floor nurse thread. Even though I feel like I could. I had a patient admitted for a chest pain r/o ischemia. EKG looks ok, labs of(WBCs a little high, but she admits to coughing up green stuff for 3 months, has emphysema). No home o2, denies pain currently, etc. I'm looking over the report when I notice that her bf has been going up at 2100, 2300 and 0015. no more VS. the highest at 0015? 215/102! (I figured it was a false high). they call up to see if bed's ready. "yeah, and are we doing anything for bp besides the 1 inch nitropaste?" nope. She gets up there and as I'm doing home meds, she mentions she hasn't taken her daily norvasc or lopressor yet. she's taken her lisinopril and her isosorbide. She told them downstairs. Ok, so I go out to double check meds/labs/etc. Didn't catch on the first glance when she got there, ah nobody called her cardiologist? Nobody did a set of enzymes? Nobody checked her pulse ox?ox is fine, her bf that I did was 198/98. Not great, but we'll deal. Called the medical, he states to give her a po bf pill, resume usual at 8am. STAT enzymes, they used the blood from ER, look ok. I called the cardiologist as nobody had called the consult, covering doc says, give her her usuals now, again at 8am, take off the nitropaste at 6 am. and we'll see. her doc will see her in am. due to pharmacy, get meds at 3am. By 5? 168/86. Just a bit better.am I the only one who thinks they should have done something for bf and run cardiac enzymes? the one time the complaint isn't taken seriously? we get people dying in the waiting room. Additionally, she is apparently homeless and does come into the ER off and on, but when a staff went down to get a suitcase she left, she heard the ER staff mention "hating her" and "that Fing B." why the hate? she was actually polite and informative for me.

Quote from imintroubleIn defense of the ER, and I don't work ER, they frequently have the same pts, present several times a week with the same complaint.Apparently the ER is very familiar with this pt. Is it possible she had a complete cardiac workup the same day or the day before? It would have been nice if the ER had given the pt her scheduled BP meds. But the ER is not the doctors office or the clinic.It would have been nicer if the pt had taken them herself

Quote from BrandybunsRNRegardless of whether she had a work-up the day before, including enzymes, if she presents again the next day with CP she should be getting enzymes. If the physician feels strongly enough to actually admit her, the standard of care would be to have a complete cardaic work-up.... again... even if it was done days ago. (because we all know a patient can go from having angina with negtive trops one day to a MI with positive trops the very next day)

I can only speak for my facility, but it seems that the purpose/focus of care has shifted, as opposed to decrease in standards. I am guessing this is related to volumes, reimbursement, and staff experience and provider practice.When I first started patients in ED were diagnosed and had initial treatment started in ED and the admitting MD often didn't come in until after office hours or first thing in the am. This was back when GPs and internists were the admitting MDs, before hospitalists. ED seems more like a triage area--get an IV, may be some labs and an xray. Decide on dispo, wait for a bed. Treatment for their ailment often doesn't start until they get to the floor, unless its sepsis or a STEMI. ED RNs are discouraged from questioning or requesting tx. Their focus is get 'em in, get 'em out. I think this has led to many ED RNs not knowing what appropriate tx might be. Actual interchange between cardiac tele nurse and ED: "If the patient is admitted for pulmonary edema, then why has he had a liter of NS? Well, you're the cardiac nurse, you tell me." Another common exchange:"Has the r/o MI had aspirin? No, it wasn't ordered."And frankly, I don't care anymore, just bring them up so I can start their antihypertensive, heparin, antibiotic, analgesic, diuretic, whatever.

Quote from locolorenzo22i'm sorry, but i'm not going to call a er vs floor nurse thread. even though i feel like i could. i had a patient admitted for a chest pain r/o ischemia. ekg looks ok, labs ok(wbcs a little high, but she admits to coughing up green stuff for 3 months, has empheysema). no home o2, denies pain currently, etc. i'm looking over the report when i notice that her bp has been going up at 2100, 2300 and 0015. no more vs. the highest at 0015? 215/102! (i figured it was a false high). they call up to see if bed's ready. "yeah, and are we doing anything for bp besides the 1 inch nitro paste?" nope. she gets up there and as i'm doing home meds, she mentions she hasn't taken her daily norvasc or lopressor yet. she's taken her lisinopril and her isosorbide. she told them downstairs. at each of the 3 hospitals where i have worked in the er, we do not routinely start the admitted patient's regular home meds unless we are holding the patient for an inordinate amount of time.ok, so i go out to double check meds/labs/etc. didn't catch on the first glance when she got there, uhhhhh nobody called her cardiologist? nobody did a set of enzymes? nobody checked her pulse ox?if "nobody called her cardiologist" i'm assuming the patient was admitted to the medical service. is it the practice at your hospital that consulting physicians get called from the er?does the er at your hospital utilize point of care testing for cardiac enzymes? if so, is it possible that these were done, but for whatever reason the results are not crossing over with the rest of the patient's lab results? we've had that problem from time to time.if there is no documented spo2 reading in all of the er documentation that is certainly poor practice or just poor documentation.ox is fine, her bp that i did was 198/98. not great, but we'll deal. called the medical, he states to give her a po bp pill, resume usual at 8am. stat enzymes, they used the blood from er, look ok. i called the cardiologist as nobody had called the consult, covering doc says, give her her usuals now, again at 8am, take off the nitro paste at 6 am. and we'll see. her doc will see her in am. due to pharmacy, get meds at 3am. by 5? 168/86. just a bit better.am i the only one who thinks they should have done something for bp and run cardiac enzymes? the one time the complaint isn't taken seriously? we get people dying in the waiting room. additionally, she is apparently homeless and does come into the er off and on, but when a staff went down to get a suitcase she left, she heard the er staff mention "hating her" and "that fing b." why the hate? she was actually polite and informative for me.

Quote from imintroubleIs it reasonable to run cardiacs everyday for a pt who c/o chest pain everyday? How many times can they be negative before you say "The heart's not the problem" Is defensive medicine the only way to go? How long does the hospital do these tests with the results all negative?