Recieving a patient from ER

[jkr2020788]

I know this topic will differ greatly from hospital to hospital.

I am a nurse that has been working in ER/ICU for almost 3 years and have never worked on a general nursing floor. The way my ER sends patients up is fairly straightforward. ER doc calls admitting doc, ER doc and admitting doc write orders together, room is requested, report is given, and patient is brought up.

I often have problems with floor nurses complaining that nothing on the admission orders were done.

First off let me say that our ER uses computer MD ordering and to have any orders that are written out completed by ER requires me to ask to busy ER doc to put in for a lisinopril because the BP is high even though it is on the admission orders and not meant for ER.

I don't mind doing this kind of stuff to help out if I'm not extremely busy, but it kills me when a nurse says "can u give the lisinopril for that 160/90 BP" when I have 5 brand new sick patients every hour.

I don't know if it's floor nurses thinking we are trying to dump patients on them, but I think a lot of them don't realize that I am getting new patients constantly, having to collect urines/ekgs/blood, start ivs, titrate and monitor drips, and appease pain med seekers, all while trying to separate sick ppl from ppl that need to go home.

My question is if there is anything in particular that I can do as an ER nurse to make the receiving nurses more accepting without me having to get a med that I have to stop the MD for for something of relatively low importance.

[Altra, BSN, RN]

Well done.....have they had a survey under this "electronic" handoff? For I see some documentation and QI holes that they (The JC) may not like. As a long time ER nurse and manager.....I would be uncomfortable with this system but it's their policy.

we have a standardized written hand off sheet that we complete for the admit.we then fax this to the assigned unit .per policy we call the floor in 15 min to verify fax was received and to give the accepting nurse opportunity to ask questions.sometimes we need to fax again or wait for the rn to call us back in 15 min.if we don't here from the floor nurse in that 30 min period.we assume no questions and bring pt up.

Our system is like nuangel1's ... and yes, we have had at least 2 JC surveys while utilizing this system without any issues.

[Esme12, ASN, BSN, RN]

our system is like nu angel 1's ... and yes, we have had at least 2 jc surveys while utilizing this system without any issues.

the standardized written sheets are fine......they follow a pattern that allows questions to be asked. that is fine.....there is a documented traceable way for report to be given a chance or dialog and exchange of information........

what is the requirement for handoff of care ?

every hospital must implement a standardized approach to “handoff” communications. this includes an institutional

definition of when handoff must occur, what elements must be communicated, that handoff must be “verbal” and include

an opportunity to ask and respond to questions, and that “like” handoffs are performed in a consistent way.

from nuangel 1

we have a

standardized written hand off sheet that we complete for the admit.we then fax this to the assigned unit .per policy we call the floor in 15 min to verify fax was received and to give the accepting nurse opportunity to ask questions.sometimes we need to fax again or wait for the

rn

to call us back in 15 min.if we don't here from the floor nurse in that 30 min period.

we assume no questions and bring pt up.

perfectly fine.......

the one i'm curious about is this........no exchange of information and opportunity to ask question/dialog and admitting a patient without holding orders? wow. who is caring for the patient in the meantime? if there are no orders for the care of the patient and no doc covering that is a cobra violation.

floors sometime get upset, for a few reasons and really they have nothing to do with me personally. i

n the er, we dont call report until the pt is going to a critical floor, so tele and m/s admits just roll upstairs after the floor has been "paged" through the computer system. the er timeline is accessible through the system and just requires a little bit of research.

it kinda sucks, yes, but that's how it is. we used to give them a courtesy call to tell them we were going to be on our way, but that

turned into excuse time as to why they couldn't take the pt and so the courtesy calls were put to a stop by the nurse supervisor,

as they at least see that the er is teeming with people with nowhere to put them. now the floors get upset,

we don't have to call,

some er staff will call from the elevator as a 2 minute heads up. its sucks for both sides.

the floor feels like they are dumped on and the er is attacked when we arrive with a pt.

( i can see why they feel dumped on)

also, we

don't always have admitting orders for pts before they go upstairs.

i think this is stupid and a bit of a liability, but we are not allowed to hold pts in the er for orders unless the admitting doctor is actively there and seeing the pt and writing them out. i cant tell you how many ****** off calls ive fielded about a lack of orders, this is the way its always been. but the process is very simple. page the doc and they'll either say their on their way in or they'll give you verbal admit orders. i did it for years on the floor.

the er docs stop prescribing after the admitting doctor is assigned

, so calls to the er for this or that are not happening where i work.

the computerized "handoff" requirement mean a consistent screen to give report and the opportunity to ask questions remains even if by phone so that there is a consistent exchange of information.....not a "look it up yourself....it's all there in the computer" is not fulfilling the requirement.......in my opinion.

then to send a patient to the floor without orders to cover the patient and the ed docs "stop ordering" is an emtala/cobra violation as the patient has not technically been transferred to another md's care and is not under the care of orders from a physician.

but if this facility has passed then that's cool.....but this is not standard of care nor good practice...these floor nurses should feel abused, patients showing up from the ed without a phone call, orders and report....yuppp, if i was that nurse......i'd be slightly p.o.'d

[Altra, BSN, RN]

Then to send a patient to the floor without orders to cover the patient and the ED docs "stop ordering" is an EMTALA/COBRA violation as the patient has not technically been transferred to another MD's care and is not under the care of orders from a physician.

But if this facility has passed then that's cool.....but this is not standard of care nor good practice...these floor nurses should feel abused, patients showing up from the ED without a phone call, orders and report....yuppp, If I was that nurse......I'd be slightly P.O.'d

This is splitting hairs, IMO. If a patient has been admitted, then by definition they have been admitted to a specific physician who has assumed care. If the physician/team/hospitalist process for actually seeing the patient and/or writing some orders is not prompt, that may certainly be an issue ... but I do not think this rises anywhere near the level of an EMTALA violation. (COBRA is not applicable here, IMO)

[Delete_Me_Please]

If the call for report and movement of the patient would not come right at shift change, I would be the most freaking flexible floor nurse ever. True story.

Amen to that. It sucks hard when the end of a doctors shift coincides with nursing shift change or scheduled med times.

In regards to the OP, As an ER nurse, I found it helpful to ask myself what things, if any, I could do that would make the admission transition easier or more efficient from the perspective of the patient and not from that of the inpatient nurse... After all, that nurse has the same priority as you; what's best for the patient. Little things go a long way, like giving them pain mess before you send them up, as it often takes 30-60 min for the pt to get added to Pyxis/acudose and get pharmacy to add all orders etc etc.

...but in general, if you want to know why an inpatient nurse isn't very accepting and warm about getting an admit, ask yourself how accepting and warm you are when that EMS radio goes off and you take report on another thousand year old nursing home patient presenting with chronic vagueness and maybe a fever sometime last year.

[Esme12, ASN, BSN, RN]

Everytime I type EMTALA alone someone in the crowd mentions COBRA. And visa versa.

It is EMTALA and it is splitting hairs but that patient while "technically under the care of the designated MD" there are no orders for their care. As one who has intimate knowledge with regulatory practices......I have to say it's a violation and a liability. The patient in the ambulance is covered by the EMS MD and their standing protocol (orders), that admitted patient is covered by the admitting MD but it is the absence of orders that is the issue, it is a liability as well, once the ED patient is no longer under the care of the EDMD there are no orders then for IVF running, meds to be given (or due) or even to be able to feed the patient. No consistency, no continuity.....I don't feel this is standard of care and places the nurses in a precarious position of liability and that's not fair. All this to shorten ED stay times, I'm sorry it's not cool. But, again, I don't work there.

Being that you don't have to self report EMTALA/COBRA violations........ they do as they wish. Again, I don't work there. As someone with plenty of experience with regulating entities and the bad practices out there.....It is frightening and overwhelming to keep up with......EMTALA/COBRA/HIPAA/Safety/adherence...all over the country. The stuff out there really is scary. EMTALA like HIPAA has many interpretations by many experts and usually what constitutes a violation is whan a patient is injured or hurt as a result of bad practices.

Again it's not my department, nor do I work there and yes I do nit pick regulations, but I have also never been sued. (knock on wood)

[Crux1024]

The computerized "Handoff" requirement mean a consistent screen to give report and the opportunity to ask questions remains even if by phone so that there is a consistent exchange of information.....not a "Look it up yourself....it's all there in the computer" is not fulfilling the requirement.......In my opinion.

They are the same thing. You look it up on the computer, if you chave any Q's you can call., its pretty simple. IVe never been called by a floor nurse prior to the pt coming up, but the ER number is pretty well known and all nurses carry their portable phones, anyone would be reachable if there was a question. Ive been called after their up if theyre trying to figure out if an abx was given or something like that.

Another part of this issue, in my hospital anyways, is that the ER MDs type their orders in the comp, so we have no written orders. So sometimes if theres something we havent carried out that was ordered by the ER MD (and that rarely happens, believe me), the floor calls to wonder where the order is for the med or whatever thats showing in the MAR or on the system. I agree the system could be better.

But if this facility has passed then that's cool.....but this is not standard of care nor good practice...these floor nurses should feel abused, patients showing up from the ED without a phone call, orders and report....yuppp, If I was that nurse......I'd be slightly P.O.'d

They are paged through the computer system to alert to a new pt, all the info is there for them. As soon as they are paged, the expectation is the pt can be up there as soon as 10 mins. Its their responsibility to be prepared. Obtaining orders are also their responsibility if theyre not up with the pt from the ER. The phone calls were stopped d/t floor resistance. Basically we would call be told they they werent ready etc. Im not sure about any other hospitals, but the ER beds where I work are GOLD, if there is a bed assignment the pt is transferred ASAP.

This is splitting hairs, IMO. If a patient has been admitted, then by definition they have been admitted to a specific physician who has assumed care. If the physician/team/hospitalist process for actually seeing the patient and/or writing some orders is not prompt, that may certainly be an issue ... but I do not think this rises anywhere near the level of an EMTALA violation. (COBRA is not applicable here, IMO)

I agree. Everyone is sent up under an admitting physicians service, they are responsible for the pt after they leave the ER. The admit md is aware of the pt and has verbally spoken to the ER md and agreed to accept the pt. The pt gets to the floor and the floor nurse puts a page in to be called back. Alot of times the doc is already in the hospital and systematically going down his list. Other times its all verbal orders over the phone (if its late) with the intention of seeing the pt early in the AM. But we cant hold the pts in the ER to wait for this to happen.

Im curious, as Ive only worked in the one facility. Is this (sending pts up without orders) not usual is other places? If not, does it seem to work for you? Is this a larger ER or what kind of census are you usually dealing with? I honestly have no idea, all I have is my ER to compare to. When the waiting room has 20+ people and theres bed assignments, the bottom line is truly $$ and seeing as many people as possible. Not to mention the hospital hates when people LWBS and will find a way to blame the ER staff/management. Our census' is historically BAD on Mondays and Tuesdays, resulting in 3hr + wait times, the ER MD group has actually added an additional doctor on these days to see if that would shift the census a bit. Of course they didnt increase our room numbers.

We'll see how that works, they just started about 1 month ago.

[hiddencatRN, BSN, RN]

I work at two hospitals that both have busy ERs. In one we call report on all patients, at the other we call for ICU and trauma patients and other patients get a faxed report.In the hospital we call on everyone, all Med surg patients are held in the ER until orders are written, ICU and step down units have doctors there on hand to write orders when the patient is at bedside. At the call/FAX hospital, computerized hold over orders are automatically placed with an admission order so no one goes up without orders.Beds are "gold" in the ERs I work in to, but you can only speed throughput so much before you're cutting corners in patient care.I actually am not a huge fan of faxed report. There's always info about the patient that isn't contained in the chart.

[Esme12, ASN, BSN, RN]

They are the same thing. You look it up on the computer, if you chave any Q's you can call., its pretty simple. IVe never been called by a floor nurse prior to the pt coming up, but the ER number is pretty well known and all nurses carry their portable phones, anyone would be reachable if there was a question. Ive been called after their up if theyre trying to figure out if an abx was given or something like that.

Another part of this issue, in my hospital anyways, is that the ER MDs type their orders in the comp, so we have no written orders. So sometimes if theres something we havent carried out that was ordered by the ER MD (and that rarely happens, believe me), the floor calls to wonder where the order is for the med or whatever thats showing in the MAR or on the system. I agree the system could be better.

They are paged through the computer system to alert to a new pt, all the info is there for them. As soon as they are paged, the expectation is the pt can be up there as soon as 10 mins. Its their responsibility to be prepared. Obtaining orders are also their responsibility if theyre not up with the pt from the ER. The phone calls were stopped d/t floor resistance. Basically we would call be told they they werent ready etc. Im not sure about any other hospitals, but the ER beds where I work are GOLD, if there is a bed assignment the pt is transferred ASAP.

I agree. Everyone is sent up under an admitting physicians service, they are responsible for the pt after they leave the ER. The admit md is aware of the pt and has verbally spoken to the ER md and agreed to accept the pt. The pt gets to the floor and the floor nurse puts a page in to be called back. Alot of times the doc is already in the hospital and systematically going down his list. Other times its all verbal orders over the phone (if its late) with the intention of seeing the pt early in the AM. But we cant hold the pts in the ER to wait for this to happen.

Im curious, as Ive only worked in the one facility. Is this (sending pts up without orders) not usual is other places? If not, does it seem to work for you? Is this a larger ER or what kind of census are you usually dealing with? I honestly have no idea, all I have is my ER to compare to. When the waiting room has 20+ people and theres bed assignments, the bottom line is truly $$ and seeing as many people as possible. Not to mention the hospital hates when people LWBS and will find a way to blame the ER staff/management. Our census' is historically BAD on Mondays and Tuesdays, resulting in 3hr + wait times, the ER MD group has actually added an additional doctor on these days to see if that would shift the census a bit. Of course they didnt increase our room numbers.

We'll see how that works, they just started about 1 month ago.

If it works for them....It's all good.

[ecerrn]

I see both sides of the question, I really do...I just wonder why it's such a big issue and why isn't administration, who ultimately sets the rules, doesn't seem to be doing much about resolving the conflict or feeling the animosity.

I also found out why there is such a flux at shift change, it's because the person 'holding' beds for surgery patients now knows whether or not they will need the beds from or...they divi them up to the er giving all beds at once. So now I have to pack and ship four pts at once and it's seldom easy to get through, but the or staff has to clock out on time you know.

I wish floor rns did rotate through the er as a requirement, so they can see how much was done for the pt while they were there.

[amarilla, RN]

As a floor nurse (trying desperately to leave float pool and the floors for good), I love if I can have called report and always try to pick up or call back within 10 minutes so we can have a conversation. If not, I ask charge RN to take report for me before it is faxed. Being able to ask a few things - like if disoriented patient with litany of issues has kin on hand or that we can call for consents/meds/history/etc - is golden. I've worked in a facility or two that just faxed report - SBAR that many times wasn't even accurate to the patient - and it just isn't the same. Too much missed.

I don't expect admitting orders to be done, those are mine...though I always appreciate the nurses who peek and tell me what I can expect. Our admitting orders are still mostly paper so I won't see them until the patient arrives. If you see there are tons of labs or a wonky fluid ordered, it's so cool if I can be ready with it when the patient arrives in the room. Knocks out a few trips up and down the hallways and patient is happier too. If the patient is coming without orders, I'm secretly like 'oh sh*t.' This, everywhere I have worked, means a cluster of nonsense is about to transpire. The only docs I've worked with - only medical, surprise! - who admit without orders don't respond to numerous pages and usually have to be escalated after several hours have passed with no response. Poor patient sits with no pain, nausea meds and confused why nothing is being done. This happens over and over and yet doesn't seem to ever be addressed. *sigh. Not your problem, ED folks, but just so you know where our frustration comes from sometimes.

The only thing I would *love* if done are diagnostics when possible. Our diagnostic suite is located in our ED. Nothing worse on nocs than to work short and have your behind handed to you, get the new patient and look in the chart...only to find that you need to take that patient (yourself, no tech permitted to transport to diagnostics on our shift) back down to the ED for a CT stat. UGG!!! The other thing: please be honest. If patient needed something and it didn't get done, just tell me and I'll do it. Please don't let me get my butt chewed when the patient arrives, doc behind them, and we see it together.

Last thought: much has been mentioned in this thread about turfing admissions. We have high ratios - too high, another reason I'm trying to get out - and getting that 12TH patient IS scary for us, particularly if the patient isn't appropriate for our floor - i.e., needs drips I can't hang, telemetry I don't have, or has a diagnosis that is appropriate for the unit, (Q1 blood sugar checks, BS still over 500 and potential insulin drip? No thanks!). We don't always know that the 'weakness' patient is really a new syncope with a closed head injury and uncleared spine- inappropriate for surg and must have tele neuro bed in my facility, for instance - and after we find this out in report, the patient needs to be rerouted. If they get to my floor anyhow, now they need to be admitted (completely) and then transferred (again, by me.) This is a big safety issue as well as a time suck; particularly on nights, we don't have help and our other 8, 9, 10 or 11 patients still need their meds, dressing changes, suctioning, toileting etc in the interim while you're messing around with the unstable patient.

Our common enemy should really be the boobs in bed management, people!

[nuangel1, BSN, RN]

I agree. Everyone is sent up under an admitting physicians service, they are responsible for the pt after they leave the ER. The admit md is aware of the pt and has verbally spoken to the ER md and agreed to accept the pt. The pt gets to the floor and the floor nurse puts a page in to be called back. Alot of times the doc is already in the hospital and systematically going down his list. Other times its all verbal orders over the phone (if its late) with the intention of seeing the pt early in the AM. But we cant hold the pts in the ER to wait for this to happen.

this is how it works in my ed as well.once our w/u is done and ed doc decides to admit pt he calls the dr who agrees to the admit and accepts the pt.sometimes the dr will come to ed and write orders before pt has a bed and has gone up.but once the pt has a bed we need to get pt up that bed ie we have faxed report spoken to floor nurse pt then goes up.it is not our responsibility to obtain admit orders.i have had instances where the admit md is in hospital but will call down to ed and give us a page of telephone orders as admit orders.i am sorry but we should not have to do that .the md should go to the floor and write orders.if pt gets to floor and needs something immediately the floor

rn

can page him/her for orders.

[stephynic21]

We are not required to fill any orders other than STAT orders. I usually get the antibiotic going if there is one since we have a pharmacy in the ER and will give any meds that are needed IF i have time. If i have a low H&H i usually get blood going and get the first sets of vitals. If the admitting doc has ordered additional radiology, i will TRY to get the patient over to MRI/CT/US etc before they come up. If they can't take them....oh well. As soon as we get a room#, we are given 30 minutes to get the patient to the floor. Within 3 minutes of the room number showing in the computer, our coordinator is asking how long and what else needs to be done to get them to the floor now cause we have 10+ patients in the lobby, 10 just waiting to be triaged, and ambulance after ambulance calling report. I usually am patient while holding to give report (sometimes 5-10 minutes or more) but if my coordinator gets wind of the fact I've been on hold that long then he is on the phone with the nursing supervisor. Its him, not me. I understand why tho....we can't make people stop coming into the ER or tell them to "hold on" cause we are busy with other patients....we just tell them to come on in and find them a stretcher and start treating them in the hall if needed. And as soon as that stretcher rolls to the floor, another one is rolling in with mawmaw clutching her chest and we start the whole process over again (ekg, iv, lab, meds, radiology, etc) and pray that we don't end up having to run up to the cath lab with a STEMI. And honestly, unless blood sugar is an issue, feeding the patient is not priority to me (our cafeteria does not deliver trays to the ER, we have to send staff to pick them up and everyone in our department is usually pretty busy).

Its chaos on most days. I've also worked on the floor and been the nurse that really was just too busy to take report from the ER. Thankfully i have come to know the majority of the nurses that i have to call report to. They know that I will do my very best to get things done but if not....it has to be sorted out on the floor. They are grateful for what we do so that when we miss some things its easier to let it go.