Holding patients in ER

[Nursinist]

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?

[mattsmom81]

Provision of SAFE care is the goal. ER is a different focus than the floors, and we have differing liabilities and priorities, different expectations from everybody too.

Creation of holding areas and bringing in extra staff nurses to care for these patients are a good solution to our problem of overflowing patients/overflowing ER's.

Overloading the floor nurses with unsafe nurse patient ratios are NOT a good solution.

Blindly accepting duty when one is not staffed to give safe care is a recipe for disaster...for the nurse, the facility, and most of all for the patient.

I follow my AACN staffing guidelines for delivery of safe care and an angry ER nurse will not change my mind if I'm unable to safely accept another patient in my ICU. To do so would be foolish, IMO.

Yes I understand ER's problems well, I no longer work ER for that reason. Floors don't exist to solve the problems of an overflowing ER however...and those who think so are missing a bigger picture, IMO.

[MQ Edna]

Pt safety should always come first, and unfortunately that's not always the way it works. We do shift change at 6:50a to 7:20a, at 7:00 I recieved two ER admits. What I was told was "the first one is here all the time, you'll know him. and the second one, the charge nurse took report". Okay, so now I have two telemetry patients not being monitored because the ER staff dumped 'em and ran. First guy is demanding breakfast (no orders) and the second is confused, wobbly and climbing out of bed. I'm still in report trying to get the facts on the other four patients I'm responsible for. I just have a real problem believing that at 6:50a on a Friday morning the ER has suddenly become overrun with folks with chest pain. This does create a lot of animosity between the floor and ER. There are nurses who slack off, and jack the ER around, but does the ER need to retaliate? I find it immensely irresponsible to "dump and run". And while we're at it, why can't the ER weigh patients? or if they're an active MI, why can't they hang Heparin, and if their blood sugar is 350, why can't they give insulin? Okay, I feel much better now:) thanks for letting me vent. I honestly do understand that the problem goes higher than just the ER, but to the "powers that be". I just felt a bit defensive there for a moment, but I'll get over it!

[RN34TX]

Pt safety should always come first, and unfortunately that's not always the way it works. We do shift change at 6:50a to 7:20a, at 7:00 I recieved two ER admits. What I was told was "the first one is here all the time, you'll know him. and the second one, the charge nurse took report". Okay, so now I have two telemetry patients not being monitored because the ER staff dumped 'em and ran. First guy is demanding breakfast (no orders) and the second is confused, wobbly and climbing out of bed. I'm still in report trying to get the facts on the other four patients I'm responsible for. I just have a real problem believing that at 6:50a on a Friday morning the ER has suddenly become overrun with folks with chest pain. This does create a lot of animosity between the floor and ER. There are nurses who slack off, and jack the ER around, but does the ER need to retaliate? I find it immensely irresponsible to "dump and run". And while we're at it, why can't the ER weigh patients? or if they're an active MI, why can't they hang Heparin, and if their blood sugar is 350, why can't they give insulin? Okay, I feel much better now:) thanks for letting me vent. I honestly do understand that the problem goes higher than just the ER, but to the "powers that be". I just felt a bit defensive there for a moment, but I'll get over it!

Now hold up!! I used to be a Med/Surg nurse so I've been on both sides.

You bring up very valid points. When I worked Med/Surg I can't tell you how many times the charge nurse told me "You're going to get an ER admit"...2...3...4...5... hours later I got report and no, I never refused to take report and on my floor it was not acceptable to say that you were at lunch.

Then it was getting close to shift change and the famous ER saying was"I just got here so I don't know that much about the patient."

I always asked "Why didn't your previous nurse call me with report before he/she left?" The answer: "Oh, we're so busy you know."

Amazing how I get word that I'm going to receive a patient 2-5 hours before it actually occurs, then at shift change, it's a freaking emergency that the patient be sent up stat!!

Everyone holds and sends patients at their unit's convenience. We all need to be considerate of the whole hospital.

Now in ICU, I still deal with it. Except now, I get the floor nurses putting off receiving a patient from me as long as they can and the ER knowing that a patient is coming up to me and waiting and waiting until it is convenient for them to send them. Funny how a patient is so "critical" that they need an ICU bed yesterday and at the same time gets sent up to me when ER is well good and ready.

[RNin92]

Oh my the anger is leaping off my monitor.

First...no one should "dump and run" as one poster put it.

That goes without saying. But if your charge nurse took report why isn't he/she settling in your patient while you are in report? And where is your off-going shift? Nursing is still a "team sport" isn't it?

Second...as to the time factor is sending up patients. I can only speak for my hospital...but we have an admitting nurse who places all the admitted patients. She knows when people are discharged, transferred, etc. She also is notified when beds are cleaned. So what happens is...

she will be notified that a patient is being discharged...

she tells the FLOOR of an admit (from wherever)...

houskeeping cleans the room and notifies her...

THEN she tells the ER.

HOURS may have gone by between those times and we (in the ER) have had no idea about a room assignment.

So now we call the floor...who is not so very happy about this and, well, the rest is history.

And third...as far as ER not hanging Heparing in an AMI or giving glucose for a DM or whatever else the poster said...

We, like you on the floor, try to do the best we can.

If it is life and/or limb threatening...you better believe it is handled.

If it is beyond that...I'll do my best between the rest of the life and/or limb things.

But healthcare is a CONTINUUM...what I start you continue and so on...

If we all strive to keep the patient in view and do our best not to destroy each other...the patient may survive...and nursing, too.

And by the way...since I have heard this from many nurses in my own hospital...having a doctor "5 feet away" is really not true. Once the patient is admitted...they are NO LONGER AN ER PATIENT. PERIOD. We have to page the attending just like you do. Our docs will NOT step in unless it is a code...just like they would respond on the floor. That is the way the ATTENDINGS want it by the way. Their patient-their money.

[RNin92]

Sorry my last post was so long winded!!

I did forget one thing...

Remember it is NOT an ER problem, overcrowding and holding patients..it is a HOSPITAL problem. We have become the solution. It's just that it isn't a workable solution.

The problem isn't overcrowding of ER patients...it is the backup of admitted patients. The lack of beds, the inappropriate admissions, the use of inpatient beds as "respite care", the list is endless.

Those are the true issues.

Until the administration of all our hospitals stop pitting us against each other, and us letting them, this issue will never be resolved.

[Nursinist]

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?

[RNin92]

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 guess we did get away from your original question...so sorry! But you are right...it is a hotbed issue and not easily resolved.

I still think you need to document what is happening. Just as the floor needs to document if things are unsafe there. We ALL need to protect ourselves, each other and most of all the patients.

[NYCRN16]

An indisputable fact- Once the floors are full, the nurses up there can only have X amount of patients period.

We dont have a limit of patients in the ER. We routinely carry 9-14 patients, some of which are ICU or CICU admits. Even in our critical care/trauma room we can carry up to 4 patients. I think the shortest time I ever got a patient upstairs after they were assigned a bed is like 3 hours..The average time is about 6 hours from the time the bed is assigned until the time the patient actually goes up. We fax report, and then the clerk will call and see if the bed is ready. They will tell the clerks to keep calling back every half hour, and they will still say the bed isnt washed, or whatever excuse they have.If the fax on the floor is "broken" (even though it says it went through), and I try to call the nurse, I get excuse after excuse..I have heard it all..

The nurse cant take report because she is:

"washing the bed" (really?? I didnt know that we washed beds! :angryfire )

"getting ice cream" (I would like some ice cream too! Do I get skipped next in triage because I am going to get ice cream? :angryfire )

"the nurse is pregnant, she cant take report, she is too tired" (WTF!! :angryfire :angryfire I am tired too!)

"this patient is confused and there is no companion to sit with him" (well, there is no companion here either, just "mr. posey" and he has been working for me all shift)

"we are not taking any more patients, we are short nurses" (every night you are short nurses, and you know what, so are we)

"they need another set of blood drawn, they cant come up before that is done" (they dont know how to draw blood on the floor?)

There is ALWAYS a problem EVERY night trying to get patients up to the floor. I can give report at 2300 and the patient is still here at 0600..Guess what..if the nurse stalled taking the patient up all night, then I feel you lose the right to not get the patient at 0600. Sorry, I didnt have the luxury of an empty bed all night. If however, the bed opens up at 0600, I will fax report but will hold the patient until after the change of shift. I would never send an unstable patient that is going to crash during transport, unless in the case where they are going to do some procedure in the ICU and the doctors are the ones actually transporting. I dont send my patient upstairs full of doody, you get them clean and ready.

[MrsWampthang, BSN, RN]

Putting in my two cents. I know it stinks on both ends, I work in the ER, and I hate it when the doc doesn't give me orders to admit the patient until almost time to go home. I try to get everything together and call report to the floor before I leave, so the only thing my relief has to do is send the patient upstairs. I try to get as much done for the patient before he/she goes up as I can. I have never heard of not hanging Heparin, or Insulin and have done it frequently. That may be a certain facility problem, but I doubt that it is universal. The other thing I hate is when I have everything ready to go and am getting ready to call report and the admitting doc shows up to see the patient! See them upstairs for pete's sake!!!!!! If I have had this patient down in the ER already for several hours, it irritates me to no end when I have to delay admitting them cause their admitting doc comes to the ER and then adds more orders on to what I already have to do for that patient, plus my other 3 patients! Believe me in stinks in ER too. We don't have the luxury of not taking patients as they roll inthe back door or walk in the front. I do document when I try to call report, I've never been told not too. As for shift change admissions, like I said, I simply try to call report before I leave, because I hate getting an admission as soon as I walk in; trying to call report on someone you haven't taken care of stinks too. I wish our facility had an admitting nurse, that would be so great!!!! Anyway, this is just another perspective from the ER side. :)

Pam

[RN34TX]

Oh my the anger is leaping off my monitor.

And third...as far as ER not hanging Heparin in an AMI or giving glucose for a DM or whatever else the poster said...

We, like you on the floor, try to do the best we can.

If it is life and/or limb threatening...you better believe it is handled.

If it is beyond that...I'll do my best between the rest of the life and/or limb things.

But healthcare is a CONTINUUM...what I start you continue and so on...

If we all strive to keep the patient in view and do our best not to destroy each other...the patient may survive...and nursing, too.

That may be true for your ER and if it is I would like to know where you work because I will come to work there.

But in 4 different states and many hospitals that I've worked, ER is notorious for sending up crashing patients that should have been handled long before they left ER.

I work ICU now so I'm ok with the unstable patients because that's what we're here for. But I'm telling you what happened to me as a Med/Surg nurse getting a patient from ER around the country:

1. We couldn't get them a telemetry bed so they are going to you with god knows what rhythm. --- Guess what? If they are that unstable, they should never go to a Med/Surg floor with no telemetry, but they do.

2. I got patients with BP's through the roof only to be told by ER nurses "the MD ordered clonidine, Norvasc, or whatever for that but I haven't given it yet." ----they send them up with no meds given.

3. Hypo/hyperglycemia-- Their blood sugar was 58 or 429 last time I checked 4 hours ago--- again, not stable and in ICU this patient would need to be checked every 1-2 hours.

In a nutshell, I'm tired of ER thinking that once the patient is going to go upstairs somewhere that they no longer have any responsibility.

Yes, you still need to check the patient's blood sugar even though you called report upstairs, it's still your patient right now. It could be hours before they get upstairs and yes you still need to provide care for them.

Another ER gripe of mine--- PLEASE stop telling patients that they can eat as soon as they get to the floor!!

At 3am, it's a little difficult to find food and I know you tell them that to get them off your back.

Either feed them yourself or at least make sure that the MD wrote a diet order before they come up!!

ER forgets that Med/Surg floors are for STABLE patients, not patients that you want to get rid of to lighten your load.

[MrsWampthang, BSN, RN]

That may be true for your ER and if it is I would like to know where you work because I will come to work there.

WOW! I can feel the heat! Sorry you have had a bad experience with ER, but remember when you say ER, that the nurses don't make the decision where the patient goes, the admitting doc does, I don't know how many times I have been asked by the admitting nurse, "why are WE getting the patient?" I don't know! I just call the floor that they tell me to send the patient to. As far as sending unstable patients to the floors, med/surg or otherwise, the only "unstable" patients that I have ever seen sent to the floors were DNRs and death was imminent. I have also seen these type of patients sent to the ICU to take up an ICU bed until death. And don't think I don't get questioned by ICU nurses for that, cause I do. I have also seen ICU nurses delay getting an unstable patient and the admitting doc is in the ICU waiting for the patient! Don't think poop didn't hit the fan for that! Especially when the admitting doc called down to ER and asked where the h#$% his patient was! Our doc simply told him that it wasn't us delaying, it was the ICU staff. This isn't meant to knock ICU nurses....PLEASE don't think that. I'm just pointing out that there are problems at some time or other with all floors (ER included). All we can all do is try to be the best nurse we can be and treat our coworkers like we would want to be treated. When calling report or receiving report, try to remember the nurse on the other side of the phone, kindness can go a long way! Just a thought.

Pam :)

[RN34TX]

WOW! I can feel the heat! Sorry you have had a bad experience with ER, but remember when you say ER, that the nurses don't make the decision where the patient goes, the admitting doc does, I don't know how many times I have been asked by the admitting nurse, "why are WE getting the patient?" I don't know! I just call the floor that they tell me to send the patient to.

Pam :)

I did not mean to put all the blame onto ER. I looked at my post and it came out a lot harsher than I intended. I was merely trying to explain actual experiences of mine as a former Med/Surg nurse in different parts of the country so I know these situations are not unique to any particular hospital or area.

I know that the ER nurse is only sending the patient where the MD has ordered them to be sent. That doesn't make it ok to send patients to inappropraite units such as ICU for DNR patients who won't be getting any cardiac drips or other ICU interventions. Or to send patients to Med/Surg who clearly have cardiac indications but there are simply no telemetry beds at the time. Definitely not a valid reason to send a patient to Med/Surg.

I've also worked telemetry when there were no Med/Surg beds available so the patient in ER suddenly gets slapped with diagnostic labels of vague symptoms of "chest pain" which really turns out to be epigastric pain and they were lap chole patients to begin with or "syncope" is another popular reason to get them to telemetry. They come up to me with normal rhythms, no real chest pain, no syncope, normal cardiac enzymes and yet ER will tell me that these things occurred down there.

This works for the docs in ER just fine until specialized units that they sent these patients to like telemetry or ICU get full.

Then when they actually get a patient that really needs these kinds of services they call up to me and are upset that we are full.

Then I say well doc, I have an ICU full of 88 year old DNR's who don't want "anything done" and you and your colleagues put them all here, so we're full now.