Waiting for bed- start floor orders sooner or later?

UM Review RN, ASN, RN · Jul 30, 2007

We face similar problems when getting a direct admit. It's awkward and slow because we have to do everything from scratch - start an IV, draw labs (which are not ordered stat), yet at the same time, we have time constraints due to the patient's Dx.

For instance, when we get a Direct Admit with a CP r/o MI order, we have to do the complete admission paperwork, start the IV, make sure the EKG and ASA and labs are drawn within an hour of getting to the room. This really strains our resources.

Every hospital has a policy on certain Dx's that have a time factor involved, such as having Rocephin and Zithromax ordered for pneumonia, or NIHSS for TIA patients.

It's probably safest to get your hospital policy and treat the patient even if waiting for a bed, so that all the priority things are done on time.

Dixielee, BSN, RN · Jul 30, 2007

A lot of it depends on the projected length of stay in the ER. If it is only going to be a few hours, then we start all now or stat orders (we do that even if there is no wait), first antibiotic, feed if appropriate, etc.

If it going to be an all night stay, we give the routine meds, draw labs as ordered, follow up troponins and AM labs if needed. We don't put patients in hospital beds, and they remain on our horribly uncomfortable stretchers.

If the problem is continuing and often, then someone needs to come up with some guidelines. We do not do the admission forms they use on the floor and do not switch to any of their paperwork, we just carry on as if they were an ER patient.

This is becoming a problem more and more and many are going to have to address this serious problem.

shandsburnRN-CRNA · Jul 30, 2007

When I worked in the ED our policy was once the patient was admitted and orders written, after the patient was in the ED an addtional 2 hours after hospital admission (not ED admission) we began with the inpatient hospital orders.

nuangel1, BSN, RN · Jul 30, 2007

in our ed once pt is adm to a floor dr ,we are responsible for completing transfer form,getting old medical record if we haven't already,and once we have a bed we fax report and send pt to floor .if the supervisor tells us we have beds we don't even get md orders from floor dr ,unless he/she requests to give tel orders.most of our dr wait to do orders till pt on floor or they see them in ed.even if we get admit orders we are not obligated to start them.it is the floor nurses responsibility to get and carry out admit orders.exception to this rule is if supervisor says we will not get a bed and pt holds in ed as eu hold.in this case the pt is adm and stays in ed we do have to get orders carry them out and do admit paperwork ,which is very time consuming when you still have traumas and ambulances coming in.

crysobrn · Jul 30, 2007

It's been a while since I have worked on the floor but when I did it was annoying (or poor nursing whatever you want to call it) when patient had orders for the floor in ER and they were disregarded when the patient was sitting down there waiting for a bed... For example while getting report on several occasions the reporting nurse would say "he's on sliding scale insulin, we fed him supper" I'd say "what was his blood sugar, did he get coverage?" they would say "oh we didn't check a blood sugar" Or if the doc orders a certain IV solution or antibiotics they were often not started while they are "waiting for a bed" on the floor. I guess those are the only specifics I can think of right now. Our OB pts rarely go to ER and if they are in ER and need to be admitted (very rare) we usually just call the docs ourselves because we get more thourough orders that way.

bill4745, RN · Jul 31, 2007

Ww have no specific policy. It's a judgment call based on how important the order is and how long before they go to a room. What is a problem is when the admitting doc writes STAT orders but doesn't tell anyone in the ER-we keep telling them that we don't always have time to read a page of orders on a chart.

neneRN, BSN, RN · Jul 31, 2007

We do any STAT or NOW orders as soon as we get them and will carry out any orders that the pt NEEDS before they go up (pain meds, 1st dose of antibiotics, Nebs, etc...) Our HUC puts in all computerized orders (consults, ECHO, GXTs, etc.) as soon as the pt is admitted. Other than that, we have a 2 hour window (from the time orders were written) before we are required to start working on their floor orders. Only exception are our ICU pts, we carry out the ICU orders immediately. This time of year, pts are rarely in the ER for two hours after being admitted...its during our winter season, when pts are held sometimes >24 hours, that its really an issue.

MAISY, RN-ER, BSN, RN · Aug 2, 2007

A patient may be held for hours prior to an admission order. Generally, the patient that comes during the night and a decision is made to admit will have no orders till the morning. We will call for physician orders and initiate. I will scan to pharmacy and dietary, as well as, order any tests that need to be done. These may or may not be done while patient awaits bed. I do am meds, iv fluids, and any continued labs that need to be done(not everyone does this). I will also do preps that involve stat orders. I'll even call for consults if beds are scarce(ie. wound care, pt etc...) 99% of our patients are worked up to the hilt on entry to er-including ekg, xray, labs. if CE or repeats, BC, or antibiotics need to be given-It's done by the time the admit physician gets there. We have a great ER staff! I also try to provide Am care if needed-in addition, patients are placed on beds for comfort. Have I had horrible days that I was lucky to give emergent meds-you bet! There have also been times I haven't been able to turn a patient over to look for wounds due to high patient volume and needs. I do what I can-I wll say that I almost never have a problem with the floor, someone may not like having to do some admit orders, but they all know I do what I can...and floor staff know it. Are there nurses who don't do anything, yup...and they wonder why people give them a hard time. Technically, we have no policy and I suppose I would not have to do it, however, I feel that the patient's care will suffer and their hospitalization will be longer if the ball doesn't start rolling. I remember having 24 hour urine on a patient on ice, the nurse who had given me report in the am could not believe I still had the patient at 7pm and was disgusted that I had urine on ice in the room. (the patietn was in er for 36+hours-when was she supposed to do it, 48 hours later?) I feel we all need to work together.

Maisy;) Almost forgot FS-that's common sense-have DM do FS prior to meals and get orders from ER doc if no admit orders yet. Who doesn't do that?

Altra, BSN, RN · Aug 3, 2007

No specific policy for patients admitted to the floor where I work. For unit patients who will be held in the ER for some unavoidable length of time, the ICU resident will have to come down, see the patient & write some orders. We are required to carry those out.

For floor patients who are held in the ER ... I will get them a tray if not NPO, and try to keep up with pain meds and insulin. No other admission orders are done in our ER - we don't even look at the admitting orders of floor patients unless there's some kind of unusual situation.

Kinky Slinky RN · Aug 4, 2007

we do not start floor orders until 4 hours after the orders were written. the only time we start orders early is if we are on divert (meaning we literally have no beds in the hospital), then we start floor orders 2 hours after they are written.

when we are extremely short staffed (like one rn to 15-30 patients), we may initiate the orders but only complete the most emergent. like if someone is being admitted for cellulitis, obviously we would start abx and totally forget the multivitamin =) and sometimes we may not even initiate the orders depending upon how many true emergencies we have going on in the department.

thankfully, more often than not, we have phlebotomy that draws most of the labs. so we fill out the order sheet for their inpatient labs and not worry about it.

hi
i am new to the ed and i have a question about the following:
if you have a hold (tele, medsurg, etc) waiting for a bed, and the person has their inpatient/floor orders already written, how long do you wait until you do them? i know that if a med is urgent (like an inhaler for sob, or a pain med that hasn't been given,etc) i should do it...but for consistency purposes, is there a specific amount of hours that elapses before you consider treating the person like an admitted patient? i get nervous letting the person go up with their stuff incomplete, but at the same time, it's not the floor.
i want to protect my license, but also be reasonable. there isn't always time to do all of the inpatient tasks when they aren't really pressing, and i'm still working on prioritizing.
thoughts?