admission delays

  1. I work in a busy ER and there are times when we are so busy and overloaded that we have no room to put patients in. Most often times than not, our monitored beds are often occupied by patients that are waiting to go upstairs because the nurses upstairs are too busy to take report, or actually refuse to take the patient period because they don't have staff, or someother reasons.....becuase of this we've had to put patients in the hallways on monitors. Have some of you encountered this? If so, what have you done to help alleviate this problem? by the way,
    supervisors never support the ER (They tell us to hold the patients in the er until the floor are ready to take them), they tend to be more supportive to the floor nurses, floor managers/and floor nurses feel that the ER are chronic complainers and are hostile in general
    toward the er staff. I know this happens everywhere, I'm just curious on what your opinions/solutions are for this.
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  2. 12 Comments

  3. by   debbyed
    Our administration noticed about 5 years ago that >75% of all admissions came from the ER, so for the time being we are the golden children for once.

    If the floors can't be staffed with regular employees the holes are filled with agency nurse (God love them).

    When an ER nurse calls to give report it is understandable that they may be involved in direct patient care, therefore they have 10 minutes to return the call. If they do not return the call the patient is taken to the room after that ten minutes and a bedside report is given.

    Our biggest delay is not having ready beds, we turn over about 35-40% of the inparients each day.

    Our night shift supervisors have been great about getting us beds. We also have two additional nursing positions that help out.

    We have S.W.O.T's (staff with out territory) who are either med/surg trained and float those floors, or ER/Critical Care trained and float in those departments. They help fill in the holes.

    We also have Resourse nurses that are compitent to assist in any area. They go to the floors that are getting slammed with admissions or have a patient going bad and come to us in the ED when we are slammed.

    There will always be problems but over all we have been able to eliminate the most demanding ones. As one would expect these two nursing positions have a higher payrate, which goes along with more dificult assignments.

    Now, after our new ER opens they will have to begin thinking about building a new wing, we seem to run out of Monitored beds pretty frequently, and that causes the back-ups we experience within the ER itself.

    The other thing that has brought all of this to be, is the new emphasis on customer service. When ER patients have to wait 2-3 hour to be seen they are not happy campers, and are very vocal about letting administration know. When you live in an area that has more that 10 hospitals within a reasonable drive radius it is necessary to keep our customers as satisfied as possible. If not, they will go somewhere else. {and they won't be the ones that we pray will go somewhere, it will be the one's we'd rather keep.}
  4. by   CEN35
    we see about 40,000 a year. we are responsible for 47% of all admissions. we run into all the same crap, and excuses also. it does where on us. the thing i tell the floor is this......when your rooms are full.........i can guarentee you will not take another patient, we do not have that luxery......they come whether we are empty.....or the halls are packed......so lets get this one out of here. it is tough.........we started working on this issue in march.......and are in the proccess of working through it with a company called h works. unfortunaetly........we are in the midst of very very short staffed.........about 1/2........not on the hospitals part.....but trying to get positions filled. if we cant get them filled......nothing will fix the problem.
  5. by   iseeu270
    Long waits up to days is not unusual in Canada in
    ER depts. We can't get the patients to the wards
    because there are no avalible beds not that the
    medical or surgical staff will not co-operate.

    What this amounts to is another in patient unit.
    The problem is ER dept were generally only designed for short stay and lack the beds and
    other equipment resources to care for all these
    ER admitted patients.

    In as much as possible we use every avenue to
    improve conditions ie bed utilization, documentation,staff meetings, staff meetings
    with the other depts, OH&S, lobbying managment
    like dogs without bones for non nursing support
    like clerks, aids and social workers. We have
    found having a social worker in ER very helpful.

    The biggest stumbling block is getting the nurses
    to take the time to write things down or document.
    Once the get mad enough then they will usually
    have more motivation to try and work towards solutions.

    I hope this may be useful to you.
  6. by   mikemw
    I work in an ER with 17 treament areas and a co-located fast track area with 8 treatment rooms for nonurgent patients. We see around 140 - 150 patients a day. Often we have "boarders" patients who have been admitted to the hospital but do not have available rooms. I just ended my shift and we had 4 patients in the er who had been admitted to telemetry beds but none were available. This is a daily problem to the extent that we have an oncall nurse from 11pm to 7am for the sole purpose of caring for "boarders".

    It is not that wee don't have the physical beds, we don't have the staff needed to utilize all available beds. Our telemetry and critical care areas ALWAYS have opening for nurses. We have 5 critical care units but one of them is closed every weekend because we do not have staff to keep them open.

    Even when we do not have boarders we often experience as much as 3 hour delays getting bed assignments for telemetry patients. This backs up our ER significantly. Our medical staf is as frustrated as the nursing staff but we still have not got the "pull" needed to change this situation.

    We often have patients in the hallway. So much for privacy and confidentiality; not to mention just plain unsafe. without doing this the CHFers and Chestpains would be sitting in the lobby.

    We have 5 major hospitaals in our city and tonight all five ERs were diverting patients because of this problem.

    I'm envious of you DEBBYED. If only we could get our administration to wake up and realize the lost revenue and dissatisfied patients.

    Mike M
  7. by   kaycee
    We have always had sort of an on going problem of med surg nurses refusing to take report because they were too busy. Our ER is the highest rated unit in the hospital for pt. satisfaction and we also admit >75% thru ER so when we yell they do listen. With a little increase staffing on the floors it has improved. The biggest problem is holds as everyone has said. Nobody has any beds so pts are held in the ER and we don't have the staff to take care of them the way they need to be cared for. We are lucky we can run in and see if they are ok let alone give them scheduled meds, treatments ect. We don't get sent any extra help when there are holds mostly because there isn't any. All the hospitals in my area have been on code red(no beds) or code yellow(divert, no ambulances). So when everyone diverts where do the ambulance's go? We have plenty of beds in all these hospitals just no one to staff them. Too bad the public doesn't know that's the reason. They are just told the hospital is full. I wish I knew how to change things. Oh well thanks for letting me vent, I needed that.
  8. by   NinaC
    Originally posted by kaycee
    We have always had sort of an on going problem of med surg nurses refusing to take report because they were too busy. Our ER is the highest rated unit in the hospital for pt. satisfaction and we also admit >75% thru ER so when we yell they do listen. With a little increase staffing on the floors it has improved. The biggest problem is holds as everyone has said. Nobody has any beds so pts are held in the ER and we don't have the staff to take care of them the way they need to be cared for. We are lucky we can run in and see if they are ok let alone give them scheduled meds, treatments ect. We don't get sent any extra help when there are holds mostly because there isn't any. All the hospitals in my area have been on code red(no beds) or code yellow(divert, no ambulances). So when everyone diverts where do the ambulance's go? We have plenty of beds in all these hospitals just no one to staff them. Too bad the public doesn't know that's the reason. They are just told the hospital is full. I wish I knew how to change things. Oh well thanks for letting me vent, I needed that.
  9. by   NinaC
    I would like to thank you all for the replies I received for "Admission Delays." I just find it so frustrating that I often wonder if any other hospital has this problem. In general, ERs are the money makers of the hospital but yet we have no support by administrators, supervisors. We sometimes have nurses pre-booked to assists with ER holds but as soon as management finds out that its overtime for them they get cancelled. We often go on ambulance divert....but like you all know, all priority 1's, code 500s have to still come in not to mention the patients who are walking in with active MI's, CVA's, etc. and no where to put them because every monitored beds are occupied with critical patients. But we as nurses continue to work in these conditions, and you know what somehow, we get through it (I think only ER nurses can ) Despite all of this, I really do love what I'm doing.
  10. by   LtlBit RN-ER
    Our ER had the same problem. We just initiated faxed reporting. When the pt. gets assigned a bed, we fax a copy of the triage sheet along with a report sheet, the floor secretary gets called letting them know that a report was faxed and we send up the pt. 15 min. after the report is faxed. Might be something you want to try.
  11. by   NinaC
    originally posted by ltlbit rn-er
    our er had the same problem. we just initiated faxed reporting. when the pt. gets assigned a bed, we fax a copy of the triage sheet along with a report sheet, the floor secretary gets called letting them know that a report was faxed and we send up the pt. 15 min. after the report is faxed. might be something you want to try.
    apprarently this has been discussed as one of the options but it seemed that a lot of managers on the units upstairs were resistent to the idea but no explanations were given as to why they did not want it as an option. infact, the unit wanted us to write down a report and then fax it up but still they wanted us to call them and give report. but really, my issue is that, the patient is sitting in the er waiting for a bed, even if the nurse is not yet ready to take report, why can't the patient just go up to the assigned bed and wait instead of the patient waiting/occupying an er bed while we are extremely packed in the hallways, waiting rooms and we're on divert
  12. by   teeituptom
    well NinaC
    we tried faxing reports to the floor and then taking the patient up shortly thereafter and giving rhem to the floor to take care of. One major problem occurs frequently. I f they are not ready for the patient, for whatever reason they choose to employ, you are responsible for that patient untill they assume care and responsibility for that pt. If you just leave the patient up there to some degree at least you are guilty of abandonement. Therefore faxed reports are not acceptable for the sole purpose of getting the patient to the floor. Now they are helpfull to document that yes you went over the history and care of that patient, and you use it as documentation that the nurse recieved report and assumes care of the patient then faxed reports are acceptable and should be considered part of the pt care record.
    I work in a busy er also we see about 60 k a yr. wer have the same bed and staffing issues plaguing most hospitals now. The only way to deal with hold over patients is to establish a PI committee comprised of er staff and doctors and admin, along with various other department heads and brainstorm. first identifie the problems and where the breakdowns in the system are occuring, then you can come up with ways to make changes or adapt to the new responsibilities. But it has to be a shared committee and should be open to all. I dont like closed committees, I feel they are always trying to hide the truth from us.
    Our outpatient surgery department is open all night anyway, and they are absorbing some of the admit overflows and delays to help us out. But then if they get to many of those then they have to cancel and reschedule some of the elective surgeries, this costs them money and they dont like that. So that always gets admins attention big time.. We also have set up an observation unit in the ed to assist with this also, accounts for an extra staff member IF YOU CAN FIND THEM AVAILABLE.
    As far as everything else goes anything you can do is considered fair game and you adjust any way you can to deal with whatever happens,
    PRAYING A LOT HELPS
    it sure dont hurt anyway
    You are not alone out there
    thomas livingston rn anm
  13. by   Jen S
    We either fill out a report sheet or call a voice mail report. We then call the floor and give them a 20 min warning and sent the patient or take them up ourselves. This has really helped in getting patients upstairs. We do call a nurse to nurse report on CCU or ICU patients
  14. by   NurseNancy
    I agree that we all have problems getting our patients out of the ER. However it's not med-surg that gives me the excuses. It's the criitical care unit. When I call up report they are always "to busy". However they only have 1 patient. Heck i don't know what i would do if i only had one critical care patient who was already worked up past the acute phase. Then when i do take the patient up they are still moaning about how busy they are.. I just turn to them ( outside of the patient's room) and say " if you want a paycheck this week you should be grateful we have patients".. I am smiling the whole time....

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admission delays