The state of health care -- with some ERs, ICUs, psych units and maternity wards filled to capacity -- is no surprise to RNs. Neither is the nursing shortage, which even has required some hospitals to temporarily close their doors to new admits house-wide. Registered nurses, for years, have been sounding the alarm that staffing cuts, reorganizations, deteriorating working conditions and other "bottom-line" measures would ultimately hurt patient care.

An Acute Case

One city where ER congestion is particularly acute is Las Vegas, NV, where health care corporations can't build or staff hospitals fast enough. For the past year, all but one of the nine emergency departments in the greater Las Vegas-area have been on divert status practically every day, prompting local health department officials to call the situation a public health crisis. The only ER that has not and cannot go on divert status to patients requiring a specified level of trauma care is the state's only level one trauma center, which is located in Las Vegas and serves southern Nevada and parts of Arizona, California and Utah.

Divert status means that an emergency department is temporarily shut down to ambulances, which then must transport patients to the next nearest facility capable of delivering care safely. If all the ERs are on divert, they must take turns accepting ambulance patients unless they are placed on "super divert."

As for walk-in patients, they are having even longer waits, because priority is given to ambulance cases. The Las Vegas Review-Journal reported that some waiting room patients have resorted to calling 911 in hopes of being seen sooner.

"For a few weeks this summer, the ERs had no place to divert to," said Nevada Nurses Association (NNA) member Cynthia Bunch, RN, a leading nurse and patient advocate who has been tracking the problem. "Ambulances have been unable to respond to other calls, because they're forced to wait sometimes two hours to give report to ER staff."

Having to wait is not the problem.

"The concern out there is that someone might die, because they can't get into an ER," said NNA member Diana Lombardo, MS, CCRN, a staff nurse at the level one trauma center, which never refuses trauma cases.

Compounding the ER glut is a shortage of ICU nurses and beds, which causes critically ill patients to be held in the ER for 24 hours or longer and forces surgical patients to remain in the recovery room up to 48 hours in some instances, Bunch said.

What makes the situation in Las Vegas even more frightening is that calls for emergency services are expected to rise even more once the flu season hits -- at a time when vaccine is reportedly in short supply and senior citizens flock to town for the winter.

An Acute Need

The issues surrounding the ER crisis in Las Vegas are complex, according to Bunch and Lombardo.

First, there are the demographics. For the past 10 years, an estimated 4,000 to 6,000 people a month move to the Las Vegas area to start a new life. Many are senior citizens, who are more apt to require emergency care.

Second, the area has been unable to keep up with the demand for hospital-based services.

"We're unique here," Bunch said. "We've built three new hospitals in the past four years when, in other parts of the country, hospitals have been shut down. In the last three months, we added 71 beds at one facility, 22 at another and 300 beds at a new hospital, and it's still not enough."

And then there is the nursing shortage, which has hit the area equally as hard:

• Eight Las Vegas-area hospitals are reporting a total of 500 nurse vacancies, particularly in the critical care and emergency nursing specialties.
• The local university and community college graduate only 200 nurses each year.
• Hospitals have high turnover rates among new nurses, with many choosing to leave after one year.
• Las Vegas has traditionally relied on traveling nurses to help staff hospitals. They, too, are increasingly in short supply.

"Nurses and NNA have been saying for at least five years that if hospitals didn't improve working conditions, there would be a shortage of emergency and critical care nurses," Bunch said. "You can't hire ER nurses, you have to grow them. Getting new grads to stay beyond a year is difficult, so the pool of nurses willing to become specialty nurses is really dwindling."

And finally, Bunch said there is no centralized body with the power to look into and solve the current and future emergency care needs of this rapidly growing area.

Crisis Management

Emergency Nurses Association President Benny Marett, MSN, RN, CEN, CNA, COHS-S, knows that what's happening in Las Vegas is not unique.

ERs all across the country are overflowing, in part, because of what Marett calls the "gatekeeper system."

"ER staff often must wait for a decision from managed care to determine whether a patient can be admitted at their hospital or sent to another," Marett said. For example, an 80-year-old comes in with a CVA. He can't be admitted right away, because the insurance company wants the ER staff to observe him for 24 hours to see if his condition improves.

Then there is the issue of ICUs and progressive care units either being full or short-staffed, so patients who should be admitted are kept on hold in ER beds, he said.

For example, the Albuquerque Journal reported that the city's ERs were on divert status for 732 hours during July and August and on "caution" -- which means that certain patients can't be seen because ICUs are full -- for a total of 2,749 hours.

Nurses Stat!

Nurses do have solutions to the shortage of specialty nurses.

One approach is to change the way nurses enter specialty practice. Traditionally, emergency and critical care nurses were required to have solid med-surg experience before they were given the opportunity to practice in the ER or ICU. But given the nursing shortage, emergency department heads are now rethinking whether that experience is indeed necessary.

"I think we do a lot of nurses a disfavor when we first throw them into areas where they don't want to work, like med-surg," Marett said. "Many new grads today are older, and they already have the level of maturity needed for emergency nursing. But they still need solid clinical skills."

Nurses say that the key to making a successful transition into emergency nursing is a strong mentoring program that is strongly backed by hospital management.

"What I think works are programs where seasoned ER nurses take new ER nurses for six or 12 weeks or longer, depending on the individual, and train them -- instead of just throwing them into the ER and seeing what happens," Marett said.

Nursing programs also need to change.

For example, there is only one university and one community college in the Las Vegas area that offer nursing programs, Lombardo said. Neither offers weekend classes and the university doesn't offer night classes to accommodate potential nursing students, who might need more flexible class schedules.

On the content side, Lombardo thinks that nursing programs could do a better job preparing students on the realities of health care today, like the workload.

Healing Las Vegas

In mid-September, American Medical Response (AMR), the Las Vegas-area ambulance service, investigated the ER crisis in the region and offered some recommendations. Among them were creating a "blue ribbon" committee to study and develop a plan of action to address the crisis and adopting a comprehensive recruitment campaign to address shortages in medical personnel, such as nurses.

Although Bunch agrees that a group needs to be formed to fix emergency care in the area, she's adamant that a permanent, centralized body also be created that will have the authority to implement strategies as needed.

She further plans to bring together professional nursing organizations in the region, like NNA, to ensure nursing's perspective is included in the discussion of emergency services improvements.

According to Lombardo and Bunch, other promising, community-initiated recommendations to help cure the current emergency care system are:

• Increasing beds at the region's mental care crisis center, so people who are inebriated can be monitored there instead of in the ER, as required by law.
• Setting up a triage system that would send non-seriously ill patients to urgent care facilities or clinics instead of to ERs.
• Creating a region-wide policy indicating when emergency departments are eligible for divert status. Currently, hospitals have differing policies.

As of press time, solving the emergency care crisis in the rapidly growing Las Vegas-area remains a front-burner issue within the community. In mid-October, the Las Vegas Review-Journal reported that the area's ambulance provider, AMR, might order paramedics to leave patients unattended in ERs and move on to their next call within 30 minutes -- whether hospital beds are available or not.

On a positive note, the Clark County Health District approved a measure Oct. 26 specifying that inebriated persons who don't need medical attention will be transported to an area detoxification center instead of to local hospitals, according to another Las Vegas Review-Journal report.

Nationwide, the healing of emergency and other health care services will take time, considering that health care experts also will have to figure out how to boost the number of registered nurses willing to be provide those vital services.

Susan Trossman is the senior reporter for The American Nurse.

A Scary Statistic

At least five hospitals in St. Paul and Minneapolis shut their doors to all admissions -- with the exception of patients who came in through the emergency department -- on two separate occasions this summer.

Hospital administrators attributed the need to place their facilities on "total divert," first on Aug. 10 and again on Sept. 12, to a lack of staff, according to the Minnesota Nurses Association.

*******************

Article from the American Nurses Association November/December 2000 edition of The American Nurse.