Hey ER, what takes so long??? - page 3

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.... Read More

  1. by   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.
    Last edit by TrudyRN on Feb 13, '07
  2. by   Altra
    Quote from 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.
    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.
  3. by   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.
  4. by   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.
  5. by   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!
  6. by   Marie_LPN, RN
    Quote from TazziRN
    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.)
    Last edit by Marie_LPN, RN on Feb 19, '07
  7. by   TinyNurse
    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............
  8. by   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
  9. by   neneRN
    Quote from 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
    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!
  10. by   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!!!
  11. by   Maverick80
    i'm a tech in a level 1 trauma center ER. I'm in nursing school and will be done in 2 1/2 semesters with my BSN. I ofen get caught in the middle of these little fights between floor nurses and the ED nurses. The floor nurses get very upset about patients right before or after shift change and i'm the one who gets to hear about it. The ED nurses don't do it on purpose and we have a policy that once the room is assigned the floor has 45 minutes to get the room cleaned and ready. That's the way it is. so when 45 minutes is up your getting the patient. We don't have room for them and once they are out of the computer we can not take them back and put them back in.

    I'm not a nurse yet but i've seen ED nurses deal with some pretty crazy things, and being a tech i have been pulled in several directions to do my part when things get crazy. One day at 7am we had a GSW walk through our door and we called the trauma team and then came another GSW through our door a few minutes later ( a couple up at that hour shooting each other !) and within about a half hour later (trauma teams still going on) a full arrest came in by ambulance followed by a stemi!! Now that's a crazy shift change right there. As you can imagine that's nothing anyone wants to walk into but you do what you have to do!!
  12. by   colorado ER RN
    It depends on each ER, but in ours we have standing orders that allow nursing to draw labs when the pt arrives so even though the labs were drawn 5 hours ago that doesn;t mean that they saw the doc then, then the doc sees the pt orders any additional test he/she may want and then we wait for results. Then the admitting dr has to be called, but in the middle of all this there could have been cardiac arrest or trauma that have tied our doctor up so we wait in the ER. Then the pt is finally admitted and we finally get a bed for that pt, then right when we go to give report we get an ambulance--which could be another train wreck pt that needs labs,IV,cath etc and we get tied up again. We do usually get pt upstairs asap but until you work er you can;t appreciate it!
  13. by   ERJunkieBSNRN
    Hey There,

    This is my first time posting and I would like to start off by first saying it would be beneficial for us all to spend time in different units to see the adversities within our jobs. I am an ER nurse, have only been an ER nurse but have worked at different facilities and thus have seen the complexities that ED's and nurses face. I work in a facility that has little to no support staff...that means the nurses are taking patients to every service (CT, XRAY, US) and they also run lab work to the laboratory, perform EKG's, etc. Due to the number of patients we see a large majority of our physicians will try to do a basic workup on folks in order to expedite care and turn patients over in a timely matter. So often a BMP and CBC are ordered, something unusual shows up and then additional orders are added. This tends to happen a lot. A few orders here and then add more an hour later when you get your first set of results back. You had indicated that a person was waiting downstairs for 5 hours...there could be a variety of reasons....the adding on of orders as I had stated....CT with oral contrast workups. Waiting for your admitting service. Admitting service taking the chart and showing up an hour later with orders. However, they feel a large number of orders could/should be done by us before they get the patient upstairs. This is a point of contention right now w/in our hospital. Recently I had a patient w/ a GI bleed and it was taking time to get the 4 units of PRBC's and 4 of FFP. The MOD was wanting the patient to stay in the ED so we could transfuse the patient. He was stabile enough to be able to have this done upstairs. I can tell you that w/ 90% of the patients I admit, the majority of what the admitting physicians want done are done in our dept initially. Repeat labs, meds, vitals seem to be the only thing that remains. We start the antibiotics they need, etc. Someone had mentioned that it appears as though an influx of patients come at shift change. The providers gather their charts at their convenience and do their charts/admissions, etc often at once, especially if they know they will be going home soon. While it is a challenge for your floor, it is a challenge for us as well to get orders done on the other patients, to copy charts, gather personal belongings, arranging for security to pick up belongings, getting acutely ill patients to surgery, etc. and then transporting the patient(s). When I get the patient upstairs someone takes the chart from me and I am left alone to get the patient situated in a bed. I can tell you that our department is so busy nurses are sent from other floors/departments to assist. 95% percent of them (and I don't believe this is an exaggeration) are overwhelmed and appear as though they've been thrown into a battlefield. On top of all of those toss in a trauma or an acute MI workup into the mix and see how much more that delays admissions. My two cents worth.:smilecoffeecup:
    Last edit by ERJunkieBSNRN on Feb 25, '07

close