ER handoff report to floor

[PatricksRNMommy]

In the past when receiving patients from the ER, they printed a report to the floor and then called to give a verbal report. Now the process has changed to improve pt flow. Now, the report is printed to the floor, the ER nurse calls the floor nurse to answer any questions. If the floor nurse happens to be busy taking care of one of her other patients and can't answer the call right away, the patient is sent to the floor, accompanied by a tech. Now don't flame me here, I am NOT in ANY way putting down ER nurses... I just feel like it's not safe to send a patient up to the floor without a real report... If the nurse has not received report, they have not really technically accepted the patient assignment, right? How can we safely accept a patient we know nothing about? How do we know a patient is safe to be on our floor if we don't kow anything about them. We can't stand by the printer waiting for a report to print when we have 4 or 5 other patients.

We have recently had several problems with this process, receiving patients with BP of 60/30 (report sheet said 110/70), sats of 78 (99 by report), laying in soiled sheets (continent per report sheet), barely breathing, markedly abnormal labs (also not on report sheet and never addressed), important consults not called (cardio for CP, neuro for CVA), STAT orders not initiated... Almost every day this week we have received a patient from ER and had to call the doctor or call a rapid response right away and send then to the unit. Which takes sometimes an hour or more away from our other patients... then the room gets cleaned and the process starts all over. I don't want to start anything here, I just feel like a verbal report SHOULD happen, even if just a brief reveiw of systems/abnormal labs with oppurtunity to ask questions...

What is the ER handoff process at your facility like? Does it work? And how is the relationship between the ER and the floors?

[cmarn]

Agreed. Again, such a tough issue and both sides struggle. Often in the ER we are caring for one acute MI or stroke while 2 of our other patients have unknowingly been admitted. Once we figure out they are admitted and call to verify the room is ready (but when we get there...it isn't) we have 30 minutes to have the patient to the floor. Guess what? My thirty minutes was up before I knew the patient was going upstairs! Those who get faxed or verbal report...would you be available, the room clean, people available to transfer the patient if the nurse accompanied the patient? That is what our facility does and it ties up the ER staff for 30 to 40 minutes while critical patients are left unattended. The rooms and staff are rarely ever ready and we announced our arrival.

I respect the work on the floor. I just think we both have to see their are two sides. I make a point to complete every order from the ER doc prior to coming to the floor. Once the hospitalist writes or calls in orders for the admission, he/she indicates "now" orders and I do those as well. Everything else is non acute and can be done in time on the floor. Where does the ER nurses responsibilty end? We are flying folks out, doing CPR (on that "unexpected patient in the room that wasn't ready), taking care of babies, adults, geriatrics, hanging drips, bathing the homeless guy before he gets to the floor, calling security for the delusional druggie, etc. It isn't that we don't want to help....we stablilize patients and transfer them for floor care. That's what we do. Our patients don't wait for bed assignments. They fill the rooms, hallways and waiting rooms.

[PatricksRNMommy]

There are some fabulous ER nurses out there that I know do their best to make sure the patient is taken care of and that important information is passed on to the floor nurse, and I appreciate those nurses tremendously. I understand the push from administration to move the patients up to the floor within a certain timeframe (usually 15 or 30 minutes) which is why if the receiving nurse isn't available because she's tied up with another patient, the ER nurses know they can call my extension (I'm the charge nurse) to give a quick verbal report before the patient comes up. My problem arises when they don't do this and the patient just comes up, the room isn't ready because we didn't get report and therefore don't know what the patients needs are (suction, O2, etc.). There just needs to be more understanding both ways.... The nurse isn't always going to be ready to talk when you call, because if she is in the middle of something with a patient or doctor she can't just walk away from it. If you absolutely must get the patient up there, maybe you could ask to give report to another nurse on the floor or the charge nurse. Housekeeping can also be a big issue... As soon as a patient leaves, we put the room number in the system to be cleaned. The room is usually assigned to a new patient right away as well. Sometimes it is an hour or more before that room actually gets cleaned even if we put it in as a "STAT" clean because there is one housekeeper per floor and we often have multiple discharges at the same time... Maybe more housekeepers would help, too. Actually since I posted the original post, things have gotten alot better between my floor and the ER. Their charge nurse and I had a talk and agreed to call eachother to discuss any issues between the floors when they happen so we can come up with better ways to manage these issues. As soon as a bed is assigned, I try to look at all their labs and vitals and notes and if I feel that the admission is not appropriate for our floor, I let their charge know and if he agrees, he gets the appropriate order from the doc for a higher level of care.... As I said before, I had just had a hellacious week and was venting in the original post, not meaning to insult ER nurses in any way...:heartbeat:nurse:

[PatricksRNMommy]

Every single shift on the floor is like a day getting slammed in the ER? Really? For many reasons I have to disagree. Both are tough for very different reasons. Kudos to all nurses :)

Agreed, both are very different... Busy in their own ways, though. We have had ER nurses float to the floor and could not stand it d/t all the charting, the constant phone calls from family, doctors, cat scan, pt, ot, speech, pharmacy, lab, etc. And floor nurses that have floated to the ER that hated it because they felt like it was so fast-paced that they constantly thought they might be "missing something" with a patient. Maybe all floor nurses should have to spend a day floating to the ER and vice versa so we can better understand eachother....

[My pain is a 10]

I've been a nurse for 33 years, struggled with 33 years of handing off, reporting, JCAHO mandates, resource inadequacies, management ignorance...all of it. I see it's still worldwide. Is anyone involved in a report-off system that is working? We spend lots of energy listing our issues, and hoping we can resolve them for the sake of our sanity and survival, but we haven't developed a good solution, that I can see. What, that you've tried...seemed to work best? I need information from both sides. And thanks.

[shygoofyone]

*bumping*

"I've been a nurse for 33 years, struggled with 33 years of handing off, reporting, JCAHO mandates, resource inadequacies, management ignorance...all of it. I see it's still worldwide. Is anyone involved in a report-off system that is working? We spend lots of energy listing our issues, and hoping we can resolve them for the sake of our sanity and survival, but we haven't developed a good solution, that I can see. What, that you've tried...seemed to work best? I need information from both sides. And thanks. "

I would love to know if there is a system working well for both sides, as well. Our floor is getting much busier than we are used to and it's creating several issues with staff from ER and PACU (not to mention the direct admits we receive with no notice). I think most of it is simply all staff being too overwhelmed, but there has to be a way to make it work....right?

[thelema13]

I am an ER nurse, and I understand the floor is busy sometimes, but when I have to phone up 4 different times to get my nurse to give report, I am pis***. Now, I will phone once and give the benefit of the doubt that the nurse is busy. The second time I phone and the nurse is not available, I will ask to speak to the charge nurse. Sorry, but we get slammed all the time with unexpected patients. I have up to 8 at one time, the nurses on the floor have a max of 4. Come on, do your job. Sorry if this is a rant, but a hard day and a few beers and I don't care.

[Lunah, MSN, RN]

Haha.... since I first posted in this thread last year, I've switched ERs (and states, for that matter!), and now it's like being back to square one ... waiting for someone to be available for verbal report. I miss my VoiceCare! But I have to say the floor nurses are pretty good at my hospital. The only snag I've run into was taking a chest pain patient up to the ICU, and the ICU nurse not being able to get the ICU bed out of Trendelenburg. She got flustered, the patient whispered to me, "Can I come back downstairs with you?" Tee hee!

thelema13, sorry you had a hard day. At the end of my hard days, there is sometimes a Guinness or three and a feeling of gratitude that I am an ER nurse ... because I'd hate to be anywhere else! Seriously.

[shygoofyone]

I am an ER nurse, and I understand the floor is busy sometimes, but when I have to phone up 4 different times to get my nurse to give report, I am pis***. Now, I will phone once and give the benefit of the doubt that the nurse is busy. The second time I phone and the nurse is not available, I will ask to speak to the charge nurse. Sorry, but we get slammed all the time with unexpected patients. I have up to 8 at one time, the nurses on the floor have a max of 4. Come on, do your job. Sorry if this is a rant, but a hard day and a few beers and I don't care.

A max of 4? I wanna work there! That being said, I've had 4 that felt like 8...numbers alone don't indicate acquity.

[Roy Fokker, BSN, RN]

My personal thoughts:

* At my facility, the protocol is to call for report. If nurse is unavailable to take report, wait 10-20 minutes and call again. If nurse is still unavailable to take report, fax the chart to the floor and take the pt. up. The only floor where this is unacceptable is the ICU where there MUST be a verbal/face-to-face report before pt. transport.

* Beds are not given to ED unless they are clean and a nurse has been assigned to that bed upstairs.

That being said:

+ Unless I'm balls-to-the-walls slammed with pts. and my waiting room is overflowing; I give the floors the benefit of the doubt. If a nurse tells me 'to call back in ten minutes', I'll give 'em fifteen and I'll call back. I know what it's like to work on a post-op floor with 6 patients (5 of 'em who are fresh post-ops) and then being told you'd be getting two ER admits...

+ But if I AM getting absolutely slammed with pts., I make a polite but firm request - someone needs to take report NOW or I'm faxing the chart and sending the patient up. I don't really have a choice in the matter - I'm not doing it because I'm bored, I'm doing it because I need the bed! (one of my charge nurses actually calls report on pts. if she feels I'm "slacking off".)

What bothers me sometimes with all this is - how come floor charge nurses don't take report if the assigned nurse is truly busy with patient care?

+ I've also observed floor staff take off clean sheets on a clean bed and then make the claim "bed is not clean" or "housekeeping has been paged to clean the bed". Or I'll be told "the bed is not cleaned" or "there is no nurse assigned to that bed yet".

+ I've also observed many of my colleagues with the "that's not my problem" attitude. While it's valid in many cases (because there are more pressing problems to address), sometimes I think it's taken a bit too far.

+ I can't (and I don't) send pts. up without completing now/STAT orders.

+ If I think a pt. bed assignment is in-appropriate (i.e. this pt. needs to go to tele and not med surg ... or this pt. doesn't need tele they can go to med-surg), I call the doc. But I'm not the final arbiter of where the doc sends the pt.

+ One BIG stumbling block I've come across in terms of getting beds is housekeeping. Apparently there aren't enough housekeepers on the 3p-11p or 7p-11p part of the shift. Which means beds are open and not clean, delaying pt. flow.

cheers,

[MursingMedic, DNP, RN, EMT-P]

Just started in a new ER (one of the largest in the state) and our CEO is all about ER flow. In my part of the ER it is 2:1 and we have a 3 hour window from bed to out. Our hospital has set the policy that unless the patient is going to a unit, no report is to be given. Once admit orders are received, our secretary sends it out to placement and once a bed is received from placement, we call for transport. Once transport arrives, we call the floor's charge and let them know that their ER patient for bed XYZ is on the way and to have a nice day. A copy of the ER chart goes with the patient and that is that. Once a bed is received from placement, we have 15 minutes to have them out of the ER.

It was weird getting used to this but it makes sense. Its a busy and very large hospital (800+ beds). Getting a hold of the nurse isn't always feasible and even after getting a report from the ER, they get a full story from the patient anyway. If the patient isn't able to give the nurse upstairs any info, they're typically going to be going to a unit which will get a report from us. And if any questions do arise, the floor nurse is more than welcome to call us with any questions they have. I don't know how well this is going for the floor nurses since I'm still quite new here, but for the ER it is very smooth.

[Penelope_Pitstop, BSN, RN]

One BIG stumbling block I've come across in terms of getting beds is housekeeping. Apparently there aren't enough housekeepers on the 3p-11p or 7p-11p part of the shift. Which means beds are open and not clean, delaying pt. flow.

Story of my life there. I have witnessed a SIX HOUR WAIT in the time of a bed being called into the environmental services system and the bed being clean and available. If the bed is posted, we can change it to a "STAT clean" but that sometimes amounts to a hill of beans.

I feel bad about it when I know a patient is sitting on a stretcher in the ED and should be in a bed upstairs, and there's a patient in the waiting room or hall who should be in the ER stretcher.

[al7139, ASN, RN]

Thank you VICEDRN! I give report the same way, by fax but still the units expect a verbal. I do not have the time to give verbals unless its ICU in which case I will. Why can't the floor nurses read a report? I got through nursing school reading my textbooks, that does not stop because you are a nurse now, read the report and get prepared, I did at the last place I worked, I had mabye 5 minutes before the admit hit the floor, and I dealt with it!!!

It's a hospital, with an emergency department, so you will get admissions! Need I say more?