Hey ER, what takes so long???

[RunningWithScissors]

Got a call from the House Sup to place a NH pt with HTN, gave him a bed and no sooner than I hung up ER calls to give report. They say the pt got some Clonidine in the field but only Ativan in ER. BP has been OK sonce the pt arrived, pt had refused her daily meds at the NH.

OK......then I look up the lady's labs and find out they were drawn 5 hours ago and she's been sitting down there the whole time. The whole house census has been down, so waiting on a bed wasn't the issue.

So I'm wondering, as this has happened often....are the patients waiting for the doc to figure out what to do with them? Do they drag their feet? What seems to take so long to figure out if they admit or d/c?

Also, what's up with the admits every night from 6-7pm right before change of shift? House calls for a bed at 1630 and they want to bring the pt up at 1830....every night this happens.

I'm sure there's a good explanation for this, so let's hear it!!!

[TRAMA1RN]

Well in our ER since we are never busy placing IV's or busy doing all lab work and since we have time to twidle our thumbs we never get sidetracked doing all of the admission orders like initial antibx ans we never bother to get patients started on anticoag therapy we like to wait till change of shift because we like to stay extra so that we can spend less time with our families, because we just love to be in the er. LOL just try seeing 10 patients on your shift with full assessments medication administration and all lab draws. That is a slow night in our ER.

[postmortem_cowboy]

I have been on the end of both sides of this coin, and it's not a good feeling in either direction, the ER nurse is trying to get his/her patients up to the floor as quickly as possible (as if we don't hear it from the patients how uncomfortable an ER gurney is) and then when you finally get there the floor nurse is yapping about why couldn't this patient have waited till after shift change. When on med/surg, I try and go with the flow, I try and understand how busy the ER is, and it's not like my buddies down there are tactically planning a pre-emptive strike against me since i got shoved into M/S for the night. I think from the ER side of the coin no one seems to understand that they're running around like a chicken with their heads cut off down there and that they're doing their best to get everyone up in a timely manner. M/S seems to think we get to choose when we call report, in between codes, traumas etc etc. on the M/S side of the coin, ER seems to think that just because they're ready, M/S is ready, and although ER found out an hour ago that this particular patient was going into this particular bed, M/S just got notified of the patient altogether.

I actually have worked with a couple of ER nurses that would sit on their patients and not move them when they had more than an opportunity. I've worked with other nurses that have said they don't like those people to work down in ER as well, and to send them to the floor if they want to sit on patients all night long. I think there just needs to be better communication between nursing staff on both floors, ER doesn't do this intentionally, and neither does M/S.

Wayne.

[TrudyRN]

I think there needs to be a Nursing Supervisor who oversees the calls to accepting MD's and coordinates with Admitting and with the floors.

When an ER nurse has a patient who's ready to be admitted, that nurse will turn the pt over to the Supervisor, who will finish out the case from that point. That nurse will get the orders, call report, and coordinate with the receiving nurse on the best time to actually send the patient to the floor.

I think ER nurses are forgetting that floor nurses can be just as busy as they are and that the floors are not immune to Codes, falls, SOB, chest pain, and other emergencies. And, yes, I have worked both ER and floors, ICU, too. All of the above. So I do know how it is in all these areas.

The doctors' shenanigans need to be addressed with and by the Chief of Staff. Docs who are unreachable and/or unreasonable or who hold patients in the ER until the last minute or do other selfish things need to be sanctioned by their boss.

We have no smoking in our facility. If a nurse or UAP violates it, it's curtains. If a doc does it, there are no repercussions. As a manager, I would not write up or discipline my staff if the docs aren't also disciplined. Same thing with ER doc/other doc violations of the topic we're discussing.

We need to think globally on this one. It is a pain for ER, floors, docs, nurses, and patients. There is a solution. Let's put our heads together and see what we can do in our personal situations.

[Altra, BSN, RN]

I think there needs to be a Nursing Supervisor who oversees the calls to accepting MD's and coordinates with Admitting and with the floors.

When an ER nurse has a patient who's ready to be admitted, that nurse will turn the pt over to the Supervisor, who will finish out the case from that point. That nurse will get the orders, call report, and coordinate with the receiving nurse on the best time to actually send the patient to the floor.

Trudy, are you saying the nursing supervisor should assume care of ER patients after the decision is made to admit them?? I don't see how this would work.

I work in a 26-bed ER. At any given time, assuming our beds are full, there are probably at least a dozen patients somewhere in the process of admission. Using the dozen figure, 9-10 of them are on cardiac monitors which need, well, monitoring. One or two are probably intubated & sedated. Another 1-2 are probably in c-spine precautions. Even the more stable ones are receiving care (fluids, meds, pain assessment, help w/ADLs, etc.) up until the minute they go upstairs.

I just don't see how this could work, to dump them onto some other nurse. And as far as the "best time to send them to the floor" that should be, IMO, as soon as humanly possible.

[postmortem_cowboy]

Let's face it gang, it's a no win situation on both ends. Both the floor and the ER need to understand that the other is doing everything they possibly can to accomodate the other.

I don't know how many times i've gotten bed assignments and gone to call report and m/s says call back in an hour... ok, no problem, then you call back and it's call back in 30 minutes, ok... call back again and now the nurse isn't available she's on her break... call back in another 30 minutes... ok... call back again and it's we can't take report right now. By this time it's been several hours, and the patient downstairs is getting antsy. I've tried my best to accomodate the floor, but there just comes a point that no more excuses will do and a bedside report ensues.

I've also been on the flip side of it, and have taken report from ER as quickly as I can, and still get all my stuff done, you have to prioritize, will this stable M/S patient that hasn't gotten any meds but is just chillin' out in their bed watching tv be a priority, or my other 5 patients getting their meds ontime. And after 9's are done and we start into a lul for the evening, then start the admit because you now have time.

Wayne.

[luckylucyrn]

At our hospital, unless the patient is going to ICU stepdown or ICU we don't have to call report. We call and talk to anyone on the floor and notify that person that we are faxing report on the patient. If I get any requests to hold that patient longer, I comply. I always get anything done off the admission orders that I can, and I don't send up a patient that I don't think can wait a reasonable amount of time before the floor nurse can see them. If the patient is that unstable, they don't need to leave my ER. I do my best to send up patients who will not need anything immediately upon arrival.

But yes, for some reason, all our beds get called at shift change. If its time for me to leave, I get all my patients ready to go and then page transportation. We aren't allowed to have patients transported from 6:30-7:30 am or pm, so hopefully that helps out the floor.

[RunningWithScissors]

I think it should be mandatory for all floor nurses to spend half a shift down in the ER, and vice-versa; it would make interdepartmental relations SOO much better!

[Marie_LPN, RN, LPN, RN]

There's nothing I can add to this.......I understand that it's hard on the floors to get admits at change of shift, but floor nurses should come and watch a busy shift in the ER....maybe there would be some understanding in that direction too.

I worked with a few nurses in my brief stint as a fill-in weekend nurse for the ER, who had only worked in the ER in their nursing careers, and these nurses said things like "got it easy" "lazy" "whiners" "princesses" and "cakewalk" in reference to floor nursing and floor nurses.

Which it why i feel it would be beneficial if part of a nursing job orientation included an observation of various depts. that nurses would encounter and/or communicate with, other than the one they're working on, to give a glimpse of the other side of the fence, so to speak. It might eliminate some of the departmental stereotyping (ex. OB nurses play with babies all day, OR nursing is easy because they have one pt. at a time, and other such inaccuracies.)

[TinyNurse, RN]

wow, it's exactly the opposite in the facility I work in..........patients are waiting 50 hours for a bed, and oftentimes get discharged directly from the ER after their admission............

[RNinED]

I have seen our ER docs clean house about the same time daily because they don't want to pass those cases on to the next DR. And yes they are usually the soft calls and those we tried to treat in ED with wahtever that didn't work. OUr next big thing will be I-STAT bedside lab testing so dispositions can be decided sooner----Hopefully

[neneRN, BSN, RN]

I have seen our ER docs clean house about the same time daily because they don't want to pass those cases on to the next DR. And yes they are usually the soft calls and those we tried to treat in ED with wahtever that didn't work. OUr next big thing will be I-STAT bedside lab testing so dispositions can be decided sooner----Hopefully

I wouldn't hold your breath about I-Stats helping with quicker dispos, we've had them for years (Chem 8, H & H, and troponin), but its very rare that the doc stops there- they always want more labs that we can't do on an I-Stat and we end up waiting the same amount of time for all the other labs to come back. Does speed up some things though!

[wyowyome]

I can't speak for all ER's, of course, but there really is an increase in patient flow into the ER around mealtimes (4-6p) and this might account for the admits around the bewitching shift change. We actually have something in our hospital called the "no fly zone" to make the floor nurses happy. This means we cannot take patients to the floor from 645-720 to allow for shift change/report. This is usually acceptable, but when the ER is overflowing with a 2+ hour wait in the lobby, we call the house super and she overrides the "no fly zone". We get evil looks from the floor nurses as we deliver our patients, but it really isn't ED's fault. Believe me, we're running our ASSES off down here!!!