When will everyone understand things are different in the ER

2mint · Aug 21, 2017

....So no, I don't know when his last BM was or if he got a flu shot this year....

I was hired for the ED, boarded in MS for about 9 months, been an ER nurse for a while. Level 1 Trauma center, Teaching Hospital, we have Psych ED, Fasttrack, Main ER, Trauma bay, Peds ER, and Obs.

So I'll give you a sample of my report and some insight:

Name. Age. Gender. Allergy status.

CC and duration. Pertinent medical Hx. What we did for the Pt, what's currently infusing, last pain meds. Abnormal labs/diagnostic. IV site. Reason for admission.

*if on a bipap/cpap, I'll just ask "What settings would you like to know?"

Rationals from a former MS nurse:

1. Flushot/PNA vac: this is part of MS nurse admission process, so that nurse was just being lazy.

Conclusion: illegitimate question.

2. Last BM: also part of MS nurse admission process, but this one is ALSO used to determine if the Pt is incontinent or independent. Yep, taking care of bed-bound Pts eats up extra time.

Conclusion: a legitimate question from the perspective of time management. Also, last meals/BM is part of your SAMPLE Hx.

3. Last VS: since all my Pts are on monitors, spouting out VS takes less than 5 sec.

4. Medicine Team: I always see the admitting Team on my track, but ward nurses may not see this info for another 15-30 minutes.

TIPS:

#1: End report with: Pt is independent/ambulatory

#2: Lift the other units up by being diplomatic and encouraging, e.g. Whoa, this Pt has a nasty left hook, be careful. You can handle it; I believe in YOU. :smokin:

MunoRN, RN · Aug 21, 2017

Good synopsis and I agree it is widely misunderstood. I don't think people really think about it at all. The only reason ED docs were EVER writing "admission" orders to begin with was as a courtesy to private practice physicians, based on a basic phone call between the two and usually the primary's preferences. The days of it being acceptable from a legal standpoint are long gone.

Nothing has changed about the legality of this practice, so long as an ED doc as hospital privileges there's not that says they can't write admit orders. At every I've worked at except for a teaching hospital, it was common for ED docs to write initial admit orders, although technically "in coordination" with a hospitalist or primary MD, which typically consists of: "the patient new AMS and needs to be admitted, CT recommended an MRI so I'll write for that, do want anything else other than the basic admit orders?" It could be the hospitalist at that point that clicks the 3 boxes necessary to initiate these orders instead, although I don't think that really makes any practical difference.

If anything I've seen this practice increase as the push quickly move patients through the ED has become more of a priority.

JKL33 · Aug 22, 2017

I think that's basically the same process I described (?) - that's the way I'm familiar with it having been done in the past also. It doesn't make a huge practical difference who enters the admitting orders, but there is certainly a difference in who is liable for them - - just like any other order. Either X person's name is on it, or Y person's name is on it. Generally-speaking, the orderer is responsible and liable for orders s/he writes.

JKL33 · Aug 22, 2017

Nothing has changed about the legality of this practice, so long as an ED doc as hospital privileges there's not that says they can't write admit orders.

I stand by what I said, which was in the context of a reply to a previous poster who said that his/her ED doc's orders were good for 24 hours, and that it's good for patients to come up with orders so that the admitting physician doesn't have to be awakened for patient needs. I know nurses have no need to concern ourselves with these things, but from the medical side if the ED providers talk to their malpractice people I bet money that they will be advised against writing admission orders, especially outside of fairly strict and narrow parameters/guidelines. And yes, the days of EDs providing admission orders for the sole purpose that admitting services don't have to be bothered at 0300, are gone. From whatever standpoint one wants to consider. Yes, places still do it. I'm just hearing more conversations about it now than ever before.

Perhaps I tend to agree since if I were a patient I would certainly prefer my admitting service be actively involved in my care.

ErickaQ · Aug 25, 2017

I too tell them I don't have that information or to "check in their chart". It is very frustrating when they keep you holding or trying to stall to receive report from you while you have EMS dropping a cardiac alert patient off to you, etc... The other ER I worked at would just fax a SBAR to the floor and verify if it was received and that they were heading up. Obviously, if there was something the nurse should know we would call up. But this seemed to deter from the stalling and extra BS I get now at my new ER. I understand the floor isn't easy work either but we all need to stop pointing fingers and work together.

nightbrightener · Oct 2, 2017

I charge frequently so get the joy of both passive aggressiveness from the floors, irritation from my staff, and irritation from the floors at the rudeness of my staff. Some of it is just systemic and lack of understanding on all sides. Yes there are lazy/rude floor nurses and lazy/rude ER nurses. But honestly most of the genuine knock down drag out fights I've gotten dragged into have been over personalities, not pertinent clinical issues. When I charge I find that a relaxed but firm approach works well for giving report, don't make it personal, no one wins. If I don't know, say I don't know, then just wait them out. The thing that still sometimes chaps me is that often the delay is at the expense of a patient for convenience of floors. But there are work arounds. For example in our hospital if the floor is unable to take reports (barring critical care floors, or a code on their floor) we will send the patient up with a note with the nurse's number and they can call with questions. But conversely, if the floor asks for five minutes due to chaos and we are not blowing up, I will cheerfully agree and accommodate. I can tell just in the last 5 years how much different/better the vibe is just because I stress civility and demand it for both my staff and the floor nurses I interact with. As an aside, make friends/ be a team player with the nursing sups, you will get a huge amount of benefit in those confrontations with floor nurses.

LM NY · Oct 6, 2017

I feel terrible for not being able to read all the comments so forgive me if this was already mentioned. I understand the intensity of the ED, but there are a few things that bother me. One thing is not doing a proper skin assessment. If the ED nurse is not documenting on a pressure ulcer or wound as present on admission, then it looks like it was acquired in the hospital. I'm sure it seems like a small issue compared to the actual problem they came in with, but when these things are tied to hospital reimbursement then it does matter.

HiddencatBSN, BSN · Oct 7, 2017

I try my best to give a thorough report. But sometimes I get busy and things just get forgotten. Tonight the ICU called to complain about me because I sent a patient up with only one line. They were also upset because it was only a 20 gauge and I was transfusing PRBC through it which was "unacceptable". NUMBER ONE: When I called report, I stated they had one IV, it was a 20, and I was infusing blood through it. The nurse taking report never said a word(don't call my charge to complain after the fact, say it to my face please). NUMBER TWO: I have read a lot of EBP studies that show you can infuse through even a 22 with no increased risk of hemolysis. NUMBER THREE: I forgot to put a second line in (my bad) because at the same time I found out this completely stable pt was going to the unit, we had a pedi trauma, geriatric trauma, and a chest tube insertion going on in my 26 bed ER, 30 minutes after I was supposed to go home. I really try to do my best with report. I will even offer to hang around and help with particularly sick patients. But getting reported for such petty crap when I obviously have a lot going on really frustrates me.

In the Peds world we transfuse through 24s without issue.

Roy Fokker, BSN, RN · Oct 11, 2017

It used to annoy me as a new ED nurse (And I transitioned from Med-Surg to the ED!!!)

Now it doesn't bother me as much. I say "Sorry, I don't know" and leave it at that.

I do get annoyed when a NURSE or Radiology Tech etc. would call me (about an ADMITTED patient on the floor!) and ask "Why wasn't XYZ labs ordered" or "this test was ordered wrong and needs to be ordered as..." - How about you call the ruttin' ATTENDING (or the provider) who wrote that GORRAM order??!!

Speaking of transitioning, when I worked nights and used to take verbal admission orders - I'd try to make sure the floor had: something for pain, something for nausea, something for constipation, something for insomnia and something for a fever - to get them through the night. I'd also try and advocate ("Yeah, 2 mg Morphine q 3 hrs isn't gonna cut it Doc. Wanna do 4 mg q 3 PRN?" Or "You ordered percocet. Can I get an order for some Zofran just in case?" etc.)

When I worked Med-Surg and got admissions, I'd usually want to know:

* Pertinent PMH. If they're being admitted for Sob, DO tell me about cardiovascular disease and diabetes etc. Don't really care if they had hemorrhoids or not (i can get that bit when I have to do my admission stuff anyway).

* Change in status. Meaning? What did they look like when you first got them. What do they look like now. Better? Worse? More confused? What is baseline by history and what was baseline in the ED?

* Any abnormal findings on assessment/radiology/labs. I'm going to review the chart and do a head-to-toe when pt. gets us here anyway. A heads up on what to watch for is always nice.

* Treatments/meds administered. Allergies.

That was pretty much it.

I will admit that I used to think that the ED used to hold their patients until shift change too - until I started working in the ED. What I didn't realise was that on the floor, if you had a 4 patient assignment (for example) and you hit 4 patients, you were done. In the ED, you'd get a 5th or even a 6th patient in the hallway. And in some places I've worked, if you had a room assigned and admission orders in - if you were taking too long to call report and dispo the patient (goal was to have pt. dispo within 60 minutes of bed assignment) your charge nurse or assistant managers would call report and get the patient up!

I feel terrible for not being able to read all the comments

I'm glad you mentioned that. Because to me, your post is the essence of "When will everyone understand things are different in the ER", in my honest opinion.

One thing is not doing a proper skin assessment. If the ED nurse is not documenting on a pressure ulcer or wound as present on admission, then it looks like it was acquired in the hospital.

Well, no. A patient isn't admitted (since you mentioned reimbursement later on in your post) while in the ED.

Emergency Department (ED): These units are within a hospital and provide initial treatment to patients with a broad variety of illnesses and injuries that could be life-threatening and require immediate attention, hospital admission or surgery. The ED is open 24/7 and is a major entry point for hospital inpatients. Patients can either walk into the ED or be transported via ambulance. Patients can be admitted, discharged, or placed in observation from the ED-all depending on the condition of the patient. Note: ED patients who are discharged from the ED are considered outpatients. If the patient is admitted to inpatient status an attending physician is assigned and an order to admit to the hospital is written. Patients can be placed in observation and remain in the ED or be transferred to a nursing unit. Either way the patient's status remains outpatient.[/Quote]
Patient Status Explained
More: Medicare Guidelines about Inpatient/Observation - https://www.medicare.gov/Pubs/pdf/11435.pdf (PDF Warning!)
Also, every facility has a set amount of time (usually 24 hours from admission) to document any skin breakdowns before the facility "owns it."
I'm sure it seems like a small issue compared to the actual problem they came in with, but when these things are tied to hospital reimbursement then it does matter.
It matters so much with hospital reimbursement that nobody from risk management, QI, or administration has come down and talked to us sloppy ED nurses (in any of the EDs I've worked in over the years) about our negligent skin assessment documentation.
Y'know, the same folks who are probably aware that I routinely take care of acute strokes, coding babies, MIs, abusive drunks and drug seekers, traumas and vented pts. on multiple drips etc... but won't let me sign up on the schedule to work if my yearly Glucometer competency and testing is not complete??!!
cheers,

LM NY · Oct 12, 2017

Roy Fokker-

The simple fact that I couldn't go through all the posts is the essence of the topic? Really? You come off like you were offended by my post. The problem with pressure ulcers is a legitimate issue in my hospital, especially when they are not being documented upon arrival. By the way, a patient does get admitted while still in the ED, which is the only reason why they come up to the unit. Unless, it is a direct admit for an upcoming surgery or chemotherapy administration.

I don't know where you've worked, but sometimes it takes more than 24 hours to get a bed assignment in my hospital. I think I made a mistake in my original post. While in the ED, the question is if the pressure injuries are "present on arrival?" and once admitted/transferred, the question is "present on transfer?"

Also, not sure if your reference to "sloppy ED nurses" was your way of being sarcastic, but if you want to conclude that it was my opinion, so be it. I have respect for all nurses. If an ICU nurse ever made a comment about things that bothered them when they get patients from Med/Surg units, I would definitely take is as a learning moment.

Maybe I'm wrong and just misreading the tone of your post. The world will never know.

JKL33 · Oct 13, 2017

I don't know where you've worked, but sometimes it takes more than 24 hours to get a bed assignment in my hospital. I think I made a mistake in my original post. While in the ED, the question is if the pressure injuries are "present on arrival?" and once admitted/transferred, the question is "present on transfer?"

LM, I can appreciate your problem, but just the same, patients who are being boarded in the ED is THE actual problem of that scenario. That is a dangerous, costly, and risky situation (yes, I know it is common, but all efforts should be toward finding a solution, not looking for ways to cobble things together so that the situation can continue with no deleterious effects to the hospital's bottom line). The larger topic of ED boarding is a current CMS ED measure (Admit Decision Time to ED Departure Time for Admitted Patients), so if boarding is causing confusion about whether or not a pressure ulcer was POA or not, all efforts should be put toward reducing and eliminating significant ED boarding.

CMS defines POA as "present at the time the order for inpatient admission occurs" - and yet, interpreting that to mean that all documentation related to any POA condition must be done in the ED has never been the official expectation nor the common practice, regardless of whether the patient was boarded in the ED for any significant length of time or not.

With regard to things like this, I like to think that nurses should consider the issues from a patient-centered POV. Is this how you would want an ED/trauma nurse to spend his/her time? If you're the one having a STEMI or involved in a trauma, or even just a run-of-the-mill (but exceedingly painful) kidney stone, would you feel it is ethical to have the ED resources tied up in efforts to meet the regulatory documentation requirements of inpatients? Our opinions that we form about these things should be based in patient-centered ethics so that we can advocate appropriately.

If your place is boarding in the ED all the time then at the very least those boarded patients should be staffed appropriately, not tacked onto ED assignments.

Editorial Team / Moderator · Oct 13, 2017

Where I have worked where boarding is commonplace, we would release the inpatient orders at the two hour mark and we were then on the hook for doing the inpatient assessment and admission in the EMR.