Tasks that are left for the floor

CodeteamB · Aug 16, 2013

I very rarely send a patient to the floor with outstanding tasks. I will not board a patient waiting for urine/stool/sputum samples or a CT/ultrasound, but I ensure bloodwork, stat meds and X-rays are all completed prior to transfer. That being said, when the poop is hitting the fan it is sometimes necessary.

Getting snarky because you had not hung the third of 3 antibiotics is a giant load of BS. The patient was being covered, and it will take an absolute max of 2 minutes to hang that bag. It is policy at my facility that Vanco is infused last when ordered with other abx and deferring this task is no big deal. You made the right call starting the heparin prior to sending to the floor. That is something where the delay in sending to the floor and them getting their act together to hang it could be unacceptably long, and really shouldn't take up that much of your time.

I know how it is when it feels like one more task is going to be the straw that breaks the Camel's back. A good rule of thumb for deferring tasks (and indeed prioritizing in general) is asking "does this need to happen RIGHT NOW?" And "which of these tasks needs to happen first."

In the case that the answer is "this Vanco does not need to happen right now, first I need to titrate my levophed, then draw blood cultures in curtain 2, then get curtain 5 off the bedpan" I would absolutely send the patient upstairs as the Vanco would probably get hung faster that way.

Also in my facility we have the 15 minute rule. Once the bed is assigned we have 15 mins to get that patient upstairs barring divine intervention, therefore if it is not a stat order it's not getting done. We rarely get beds fast enough for this to matter, but when we do all the general admission orders fall to the floor nurses.

Anyhow, that is my extremely long winded way of saying that it sounds like you made the right call in both instances, don't second guess yourself because someone was ticked off!

Gypsy__RN · Aug 16, 2013

I'd agree with CodeTeamB, you made the right decision. Most nurses I work with will take care of all STAT orders and lab draws/blood cultures prior to sending a patient to the floor. I almost never hang Vanc since it takes longer to infuse than other antibiotics.

Why was the heparin being hung on the patient? To me, that is the most important questions to ask here. If a pt's situation could worsen if there were a delay medication administration, then it should be started in the ER. I'd rather explain to administration that it took 20 min to get the pt to the floor since I was ensuring she was given the proper medications for her PE/DVT.

Altra, BSN, RN · Aug 16, 2013

The answer to your question is "it depends" on what the task is. A heparin gtt is an important part (and possibly the focal point) of treatment -- for PE, cardiac issue, etc. In other words, someone who needs a heparin drip -- really needs a heparin drip. The same would be true of an insulin drip, blood products (if ready and available), steroids, anticonvulsants, respiratory meds if dyspneic, diuretics, and initiation of antibiotics. I think it goes without saying that if pressors are ordered they are needed NOW.

It is important to initiate antibiotic coverage in a timely manner, but if multiple abx are ordered and the patient is assigned an inpatient bed before getting all that were ordered, the inpatient unit can certainly continue abx administration.

Hope this helps.

Anna Flaxis, BSN, RN · Aug 16, 2013

I would not punt a heparin gtt to the floor. No way.

The Vanco, though, I agree with the others that it was not critical since you had already hung the other two abx. There is no reason the floor can't hang the Vanco, especially if the patient has a bed assignment, is ready to go, and waiting for the Vanco to come from pharmacy will delay their transport to the floor.

Bringonthenight · Aug 16, 2013

The vanco example- definitely could have waited for the floor especially since they had already been given 2 IVABx.

I think I would have started the heparin infusion- especially if it were the main treatment plan, ie: a PE/DVT.

turnforthenurse, MSN, NP · Aug 16, 2013

I would have definitely started the heparin gtt before the patient goes to the floor. If the patient is on a heparin gtt chances are they really NEED it. As for the vanc, that could have definitely waited. Usually my vanc never gets hung because the MD orders 2 other antibiotics along with it...and vanc takes at least an hour depending on the dose. I always start with the antibiotics that take the least amount of time to infuse (Zosyn, ertapenem) then if I have time to hang the vanc before the patient goes to the floor, I will do it.

friendlylark · Aug 16, 2013

thank you very much for the thoughtful replies!!! I had all 4 of my patients admitted and no transport (and I had to go get all of their tele's) ... so I was in a bind. But I made it through! And I appreciate the discussion and advice.

The patient had a femoral stent that was occluded, which was why the heparin was ordered!

BrooklynRN11201 · Aug 16, 2013

sounds like the floor nurses have you where they want you if you're delaying care to other pts just to baby an admitted pt. I think it might make sense to set some boundaries so that they don't expect these things from you. I know you're a new nurse (so am I) but it shows that you're professional, not a ******. next time it happens, say something like, "look, you're right about the hep drip, but the vanco was not a stat order and it is UNSAFE to delay care in other patients in order to attend to the admitted pt on orders that can wait a couple of hours. I'm sorry if you don't agree, but I can assure you that I will send patients up with all outstanding orders complete, even the non-urgent ones when I have the time to do so. It's not my goal to make your life harder." If that doesn't work, try the vertical chain of command and perhaps request that the units define what should and shouldn't be done in the ER so that everyone is on the same page.

BrooklynRN11201 · Aug 16, 2013

speaking of, I remember we had an ETOH withdrawal with DTs and seizures admitted to the ICU. he was being sedated with boluses of propofol but our ED doesn't have the bottles for drip on the unit. we SBARed the patient and followed up a few times to see if the ICU was ready to receive him, but they kept telling us they were not. the critical care area was literally FILLED with patients - two strokes, one cardiac and an esophageal varicies. We literally didn't have any room so 45min after the SBAR was given, we went ahead and just took the pt up to the ICU. the nurses were LIVID! "how DARE you?!" "this isn't safe!" meanwhile, they had 3 empty beds... I'm not saying they weren't busy but they weren't ready after 45mins? we (my preceptor and I) told them it wasn't safe to keep him in ED critical care either, and that the physician demanded we bring him up - it shouldn't have taken more than 15mins to prepare for him, etc. Anyway, that was a HUGE to do, but my preceptor ended up not taking it personally and he just told the charge nurse about the incident. I feel like there really should be more policies on admitting patients in terms of what the ED is responsible for and what the floor is responsible for.

MunoRN, RN · Aug 16, 2013

When I'm in the ER I narrow it down to just what the patient really needs right now, which in your examples would have included the Vanco and the heparin. In sepsis for instance, the goal, based on evidence that it does make a difference, is to give the first "appropriate" antibiotic within an hour. If vanco is ordered, then by definition it is the "appropriate" antibiotic and the other's actually don't count towards this when we do outcomes reporting since the Vanco was given based on a suspicion that other antibiotics won't be effective.

There are certainly some Nurses who won't be happy no matter how much you do, but there are also times where there was really just one thing that needed to happen in the ER, and it didn't.

amarilla, RN · Aug 17, 2013

I (try to) do all the stats and anything that seems like a biggie to move treatment forward, i.e., giving units of blood, starting that heparin drip, making sure the blood cultures / ekg / trops / whatever got done, etc. You'd be surprised what seemingly unimportant stuff gets left out that ends up being a RRT or code later on in the shift for the floors.

The stuff I don't do: start the floor orders - we usually don't receive them. I do my orders and set them up - make sure those labs got in, all samples taken if possible, good access established, diagnostics done if ordered on my time - but once they have an admitting doc, that's where the floor should take over, IMO. If the department gets slammed and I have to move that patient asap, I will let the floor nurse know that and send along any meds not given if available on hand.

When I was on the floor, it was a big deal to get a patient with leftover ED stat orders and biggies not given. We usually had to fill out an incident report and remedy the situation with the house sup within two hours - only to then do this ridiculous 'huddle' with the NM after shift on 'how we can improve so this doesn't happen again.' Blarg. So - the floor would get dinged for not being able to hang that heparin drip for the new patient, say, who needs to be admitted, have the admission paperwork put in, activated by bed management, have EMR created by pharmacy, all orders received and transcribed by MD, orders approved by pharmacy and then the looonnng wait for the actual drug to be sent up. If it's an admitting order, that's one thing, but when the order was from six hours ago in the ED and now it takes an additional 2 hours to sort out after admission, it becomes a risk management thing and no fun for anyone.