Holding patients in ER

Specialties Emergency

Published

My Manager has told us we are "not to chart" when we have an unsuccessful attempt at calling report to the floor or ICU. We are a very small facility and have no nursing supervisor or even a charge nurse to intervene when the floor refuses to take report. We are especially vulnerable at change of shift. I have offered to participate on a committee to look into the causes and am still waiting for our first meeting after 2 months have gone by.

In the past, I have always charted 1. The time I called for the bed assignment 2. The time or Times I have attempted to call report & 3. The time I actually transfered the patient.

Anyone else out there had this problem? What do you put in the chardt?:rolleyes:

I wish to thank all of you for responding! I know this is an area of heated debate and shared governanace...the solutions must come from a collaborative effort---I in no way intended to "blame" the floor or the Icu. I was mainly interested in how to chart/document the wait?

I should have expanded on my earlier post. More important than simply documenting the wait is involving the supervisor which will encourage him/her to look at holding/boarding area options to relieve everybody's gridlock.

There are units in most hospitals that can, if properly staffed with additional nurses, alleviate the gridlock of available beds and open up ER for the critical ER needs again. Rather than making this a competition between ER and the floors, which does end up an aggravating situation in too many cases, creation of additional holding/boarding areas is the smart effective way of managing it, IMO.

Just about every facility has a unit or two used for short stays, recoveries, etc..and with a little tweaking can be made ready for boarding overflow patients.

I learned a long time ago if I didn't speak up, I was always going to be overloaded and understaffed and be covering for someone elses 'emergency need.'. Facilities are quick to pass the blame to a nurse, unit, etc. who isn't smart enough to know her safe boundaries and demand the facility be a part of the solution vs part of the problem.

Off my soapbox now, to everyones' relief I'm sure. :coollook:

My experience is all about how the hospital is geared twords reimbursement.

If we charge for an ICU bed at midnight and a bed was assigned at 7pm. you darned well had better be able to justify keeping a patient until 1am. regardless of the reason. So I will docucment "spoke with Sam Rn. transfer is delayed due to current resident lack of transpo. (home). So there REALLY is not a bed ready, and so on. But in the end, once transfer orders are written, there SHOULD be a decreased charge so that the level of care of a step down patient reflects the level of care received.

There are federal or maybe state, sorry, guidelines (er people help here), that state a patient can only be held in the ER for 23:59. So this was an additional reason for theER nurses to chart the reason for the delay.

Regardless, management in any facility can tell you not to document anything. You must follow your board guidelines and best judgement to show that all attempts at quality and safe patient care exist. In choosing so, unfortunately in some facilities... you face reprocussions.

Unless a policy is in writing prohibiting the documentation, that can be called upon in a court of law...... It's your word against theirs when a patient files neglect charges or so on. A facility should have a "pre-policy" handed out to staff before any changes are made (this means the policy is in effect per administration, and just must pass through the paperwork committee, yet the policy is valid meanwhile, pre changes).

to be concise, we were instructed to document and the facility had active "focus" groups to resolve the delays. didn't mean they all worked... but there was an active attempt to improve the process... eventually without finger pointing, just conversation, with policies that reflected administrations requests.

My experience is all about how the hospital is geared twords reimbursement.

If we charge for an ICU bed at midnight and a bed was assigned at 7pm. you darned well had better be able to justify keeping a patient until 1am. regardless of the reason. So I will docucment "spoke with Sam Rn. transfer is delayed due to current resident lack of transpo. (home). So there REALLY is not a bed ready, and so on. But in the end, once transfer orders are written, there SHOULD be a decreased charge so that the level of care of a step down patient reflects the level of care received.

There are federal or maybe state, sorry, guidelines (er people help here), that state a patient can only be held in the ER for 23:59. So this was an additional reason for theER nurses to chart the reason for the delay.

Regardless, management in any facility can tell you not to document anything. You must follow your board guidelines and best judgement to show that all attempts at quality and safe patient care exist. In choosing so, unfortunately in some facilities... you face reprocussions.

Unless a policy is in writing prohibiting the documentation, that can be called upon in a court of law...... It's your word against theirs when a patient files neglect charges or so on.

to be concise, we were instructed to document and the facility had active "focus" groups to resolve the delays. didn't mean they all worked... but there was an active attempt to improve the process... eventually without finger pointing, just conversation.

heart queen...

i do not know of a law that states a patient cannot be "held" in the ER longer than 23 hours and 59 minutes. I would LOVE to see that law.

We routinely hold patients in our ER and many times the patient is discharged from the ER...NEVER making it to the floor.

RN34TX...

You have obviously had some really bad ER experiences. We (in the ER) have obviously had some really bad experiences with nurses on the floor. It is really a shame all around.

We do this all of the time in our ER. I always note time and attempts at giving report. It has gotten to be such a hot topic in our hospital that we also have a bed control person. There are so many reasons not to take report but we all should remember the poor patient who is sitting in the ER wondering where they went wrong that day. Think about being sick enough to actually get admitted and then you have to spend extra time in the ER because someone can't take report on the floor.

What about there not being any beds on the med/surg unit? We hold patients over night so often. There are days where we begin our shift with eight holds in the ER. I think its horrible for all concerned. Anyone out there find an answer to that?

quick story......

sunday night, i had 8 ER holds (2 ICU, 4 med/surg, 2 adolescent psych). this was not an issue of the floor nurses not wanting to take a patient. it was not a case of not having beds available. the floors simply did not have the nursing staff to cover those patients.

my gripe? our hospital will not hire agency to cover. will not under any circumstances. yet, my patient load is expected to be that of 2 ICU nurses as one of those holds was a 2 nurse to 1 patient acuity; 1/2 a med/surg nurse; and 1/4 psych nurse. those percentages add up to wayyyyy more than the 100% i'm capable of giving.

not safe, not safe at all for any nurse, much less the ER nurse that has no control over what comes through those doors next.

In our ED, the ONLY time a refused report is acceptable is during a code. If for some reason the accepting nurse cannot or will not take report...report is faxed. The pt can go up 45 minutes after the initial attempt to give report. We try to be courteous and understanding of certain situations. We started faxing because the accepting nurses would do anything not to take the pt. I.E. nurse is at dinner, getting report, taping report, busy blah blah blah. Well guess what? When we are holding 20 and EMS is lined up at the desk and we are putting chest pains in the waiting room because we have no beds, I don't want to hear it.The floors and units have a limit to their census..we on the other hand do not. even if we are filled to capacity and on full bypass, they still keep coming in. Maybe if it were their family member lying on a hard stretcher in the hallway for 7 hours, they would understand and not give us such a hard time. The fax system has been EXTRMELY effective..although the accepting floors ***** about it. Too bad!

we are still playing phone tag in our hospital. we fax report to all m/s floor and can send the patient up 15 min. later. if the bed is ready. sometimes 2-3 hours will go by before the bed becomes clean and usually this occurs right after the supervisor gets involved. we have now learned that we have to involve the super earlier.

anyways, i chart every time i call the floor.

but once we do get the patients upstairs you have to take someone up with you because it is nearly impossible to find someone that can help you move the patient into bed. i feel so bad for some of these patients (and for our backs!)

we are still playing phone tag in our hospital. we fax report to all m/s floor and can send the patient up 15 min. later. if the bed is ready. sometimes 2-3 hours will go by before the bed becomes clean and usually this occurs right after the supervisor gets involved. we have now learned that we have to involve the super earlier.

anyways, i chart every time i call the floor.

but once we do get the patients upstairs you have to take someone up with you because it is nearly impossible to find someone that can help you move the patient into bed. i feel so bad for some of these patients (and for our backs!)

my patient load is expected to be that of 2 ICU nurses as one of those holds was a 2 nurse to 1 patient acuity; 1/2 a med/surg nurse; and 1/4 psych nurse. those percentages add up to wayyyyy more than the 100% i'm capable of giving.

not safe, not safe at all for any nurse, much less the ER nurse that has no control over what comes through those doors next.

I hear what you're saying, Rena. Please don't blame ICU nurses however...as we would quickly be caring for 4 unstable critical patients each (without the ancillary support other units may have) if we didn't set some limits. If I have a bed open but no nurse to safely care for a patient, I will refuse too.

While I'm sorry ER is not getting the support/staffing they want, I still have my own critical care standards to worry about and can't worry about ER. AACN says 2:1 ratio...that's what I go by. I will not be convinced to take 3-4 ICU patients because ER is holding them...that simply is not a good reason for ME to take the risk IMO. This is each nurses' call.

I won't work for a facility that would tell I cannot refuse an admission, if I determine it is unsafe to do so. My NPA charges me with some responsibility should I blindly accept an unsafe assignment. We all have to establish that 'line' we can't cross.

I do know where you're coming from and its why I don't work ER anymore.

I know sometimes floors DO stall and delay...I sure haven't done this though.

At my facility a written report is sent from ER in orange tubes: admit dx, vs, labs, orders, meds given in ER, any specific need to know info. The ER nurse and a transport person brings pt to the floor and notifies nurse station of delivery. Our ER sends people out in droves. We've had four new admits at one time. Then again our ER is very busy. As soon as they empty out, they're full again. As far as nurses refusing take a report, I've never understood why people try to call report or transfer a pt during shift change any way. RN's don't even have their assignments yet so who is going to take report, Jenny the friendly Time Life operator? If a pt does come in, they'll wait until the RN finds out who pt belongs to. Not to safe a practice. I've mentioned this to others, but the others say, "that's just the way it is".

As far as nurses refusing take a report, I've never understood why people try to call report or transfer a pt during shift change any way. RN's don't even have their assignments yet so who is going to take report, Jenny the friendly Time Life operator? If a pt does come in, they'll wait until the RN finds out who pt belongs to. Not to safe a practice. I've mentioned this to others, but the others say, "that's just the way it is".

Which shift change are you refering to?

At my hospital it could be...

0600, 0700, 0800, 1000, 1100, 1500, 1600, 1900, 2200, 2300, 2400, or 0300.

When would you suggest we call?

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