[LeesieBug]

I guess I never understand the question of "why do patients get sent up at shift change?". ..That is just when they are ready. The ER personell are not twiddling their thumbs waiting 'till shift change. And once the pt is ready, we aren't allowed to sit on them because its shift change...we are supposed to get them up ASAP.

Pt care and the work needed to be completed in order to get them going generally does not fall into a nice clean schedule. Just as I am sure pt care on the floor does not always fit into a nice clean, tidy schedule....stuff happens.

If it makes you feel better, I get new pts at shift change everyday

Seriously,though, thanks for putting up with shift-change admits. I know it must be frustrating

[EmerNurse]

One thing about the shift-change thing... I work nights and long about 5am, our ER docs start hollaring for admitting doc call-outs. The reason? The next ER doc comes on at 7am, and they don't want to hand-off too many patients to the next doc. Same thing happens around 1700 for the 7pm doc coming on.

The on-coming docs don't want to be responsible for the "almost admitted" patients. So the off-going doc wants them out of the ER, or at LEAST admitted (as in, we can't send them up yet because it's 0630 (can't send between 0630 and 0730 technically) but because they're admitted, they're off of the ER doc's list.

That's one reason for the close-to-shift-change admits. It drives ER nurses just as crazy. Here I am winding up my shift, and suddenly I'm taking admitting orders on 3 of my patients at 0645. And most of the time, at least one of them will be a NH patient with 45 meds and they'll all be diabetic. I have to transcribe all those orders before I can go - so much for getting out on time. And then on the floor, that patient is sent up when they've barely gotten report on thier other 7 patients!

It's a horrible bit of gripe for ALL of us!

[wooh]

Originally Posted by neneRN

Our admissions coordinator always passes out a handful of beds a half hour before shift change...

I wouldn't be surprised if they waited to decide which floor got patients until staffing for the next shift was figured out. (Not a house supervisor, but used to be buddies with a few.)

[canoehead]

I our ER it's simple. the admitting docs finish office hours, then come to the ER to write orders on all the patients that have been piling up there since 7am. By the time orders are written and admissions processed it's shift change, and all the pateints are ready at once because all the docs do it the same way.

[LeahJet]

In our ER, the docs change shifts right before we do. So if there is a pt. that has been in the ER and to be admitted, the doc usually takes care of other immediate problems and sees other pts. (In other words, puts the admission on the backburner)
When it's time for the docs shift to end, he/she starts working on the admit so he/she won't have to pass it to the oncoming doc. This usually happens around 6AM or 6PM. Which means......viola..... a "shift change" admission.

To be honest, we (the ER) are always taking patients....shift change or not. We never have the luxury of having ambulances wait outside the door until after we get report and make rounds on our patients.
"How dare you roll in the door with asystole at 6:55am???"

As far as "holding" patients until shift change..... WHY in the world would we want to keep a patient longer than we have to??
If you know anything about ER nurses, you know that we love to treat and send somewhere else.
Anything over 3 hours is too much like floor nursing!

[Lightning Bug RN]

I work 7p to 7a and I have tell you that almost every night without fail we get a phone call at 10:50 from bed control and then two seconds later the nurse from the ER is on the phone demanding to give report that very second. You ask her to hold on for 2 minutes to print out any orders or labs that may have been done. and you hear "I can't wait for two minutes, don't you understand that it is time for me to go home?" The excuse that the ER has to wait for orders before they can send the pt is rediculous, many, at least 70 percent of the pts we receive from the ER do not have ANY orders for our floor before they are sent. I cannot tell you how frustrating it is to be short staffed on our shift on a constant basis, and to be constantly slammed with ERs at the beginning of a shift, and not being able to see the other multitude of pts on the floor that you just picked up. If someone is going to go bad, it is going to happen on night shift, if they are going to fall out of bed even though they they have been well behaved all day with no sign of attempting to ambulate by themselves, it will happen on night shift. The problem with the Er admits is the fact that often the report you receive from the Er is not complete, that is why I print out all the information I can about the pt before I take report (Potassium way high or way low as an example). There are often enough surprises once they arrive to the floor , like tachycardia uncontrolled, hypertension uncontrolled, of SOB and no pulse ox done or sky high blood sugar and no one even bothered to check it downstairs. So you spend the first hour trying to track down a dr who will take responsibility for this pt, which is often very difficult. I have had pts waiting for pain medications for almost two hours because of someone going bad as it is, the last thing my shift can handle is a ER dump at the beginning of the shift. Ifr you guys are gonna keep them down there, at the very least, please make sure the major issues are addressed, my favorite by far though is the pt who has been in the ER for almost 6 hours with a hip fx, and when I ask about a foley placement, the nurse practically laughs and says I don't have any orders for that. So I am supposed to a have time to address this by the time the pt gets to me and hour later? Please have some mercy for us poor med surg nurses!

[Radnurse54]

As an ER nurse for 28 years I would like to respond to this question. Sometimes there is a misunderstanding about what happens in the ER and h ow patients are taken care of. First of all please remember that your unit has only x number of beds and that is all the patients that can be accommodated.....but the ER has an infinate number of patients who can present to be treated, walkins, ambulance, private cars etc. So patients who may not be see as emergent or even urgent or semi urgent must wait for care, sometimes the MD can start the patients care and then get pulled away to more urgent matters before the decision about what to do with the patient is completed. This is particularly true for admitted patients who may have to wait for attendings to return the ER docs call and if the ER doc has to write orders he has to find time for that too.
Finally when we get to the point of actually needing a bed, you can understand our desire to move that person as quickly as possible, after all there may be 5 other people waiting to get into that bed.
As for the admissions at the 6-7 o'clock time, if the ER docs are on a 12 hour shift just like the nurses then they need to get their patients moved on before they go home and there is usually a rush at that hour of the day.
Also, it has been my experience that the busiest hours for the ER are 8-10 in the morning 6-10 at night. So you can see that while the docs and nurses are changing shifts that there is also a rush of patients at that time.
Trust me, nurses and doctors in the ER dont like keeping patients forever with them before admitting, especially if there isnt a bed issue.
If you really want to know how the ER works, ask to go down and shadow a nurse to see how the ER works. It is very different than working on the floor. Hope this helps.

[nuangel1]

Originally Posted by Radnurse54

As an ER nurse for 28 years I would like to respond to this question. Sometimes there is a misunderstanding about what happens in the ER and h ow patients are taken care of. First of all please remember that your unit has only x number of beds and that is all the patients that can be accommodated.....but the ER has an infinate number of patients who can present to be treated, walkins, ambulance, private cars etc. So patients who may not be see as emergent or even urgent or semi urgent must wait for care, sometimes the MD can start the patients care and then get pulled away to more urgent matters before the decision about what to do with the patient is completed. This is particularly true for admitted patients who may have to wait for attendings to return the ER docs call and if the ER doc has to write orders he has to find time for that too.
Finally when we get to the point of actually needing a bed, you can understand our desire to move that person as quickly as possible, after all there may be 5 other people waiting to get into that bed.
As for the admissions at the 6-7 o'clock time, if the ER docs are on a 12 hour shift just like the nurses then they need to get their patients moved on before they go home and there is usually a rush at that hour of the day.
Also, it has been my experience that the busiest hours for the ER are 8-10 in the morning 6-10 at night. So you can see that while the docs and nurses are changing shifts that there is also a rush of patients at that time.
Trust me, nurses and doctors in the ER dont like keeping patients forever with them before admitting, especially if there isnt a bed issue.
If you really want to know how the ER works, ask to go down and shadow a nurse to see how the ER works. It is very different than working on the floor. Hope this helps.

very well said.also while floor can have x number of pts and say we can't take anymore we in the ed cannot .eventhough we too have limited space at 18 beds even if we are hold 9-10 floor admits(because we have been told there are no beds) we have to stay open and have pt in halls.even if we are allowed to divert we still get pts by walkin or cars and they can be real sick too.also even if one is on divert if the ambulance has a unstable pt that the emt feels can't make it to farther away hosputal they too will still come to the diverting er .so see the ers can't win either .

[canoehead]

I once took a patient up to the floor just about at shift change and the receiving nurse told me they had gotten 5 patients in the last 30 minutes. I sincerely felt sick, that is a huge load to absorb. I also knew how many of the patients and families had been screaming at us about the wait to be moved upstairs- the docs fault- not the nurses'. Perhaps the problem is not with the nursing staff at all- it seems like a multidisciplinary team should get involved.

Why couldn't we send patients to the floor with the ER orders, and obligate the admitting doc to show up on the floor within two hours? OK, not the best idea, but what other ideas are out there?

[ParrotHeadRN]

I've been a floor nurse and now I am in the ED, so I feel I can look at this with both perspectives. I work 7p-7a. Our docs will sit on an admission until about 5 am before they call the attending if it's not an emergency. I don't necessarily agree with it, I think if you're on call, you're on call, but it's a professional courtesy they offer each other. Someone else mentioned docs coming in after office hours and that applies to my hospital as well. So there is the change of shift issue. Docs, NOT nurses.

As a former med/surg nurse, I know what a sucker punch it is to get a pt either right off the bat or when you think you are finally able to wrap it up. I really do. However, being in the ED has opened my eyes to a whole new world. I think ED and floor nurses should walk in each other's shoes for a while just to get an idea of how the other half lives.

I work in a fairly small hospital where courtesy is the norm between nurses. I have no problem waiting to give report if the receiving nurse is busy. If it's change of shift, I give report to the house supervisor who then passes it on. That way, report is given and the floor can simply call when they are ready, providing they don't abuse that courtesy. I've been told there are some floor nurses who abuse that, but I've not run into it yet. That being said, there are times when our beds are all full and I have 10 people waiting in the lobby and 3 squad calls out. When that happens, I really have no choice but to be firm about getting my patient over. Usually I am not met with resistance because I am not unreasonable and do not expect it all the time. It's true, the floor has a limited number of beds which means limited number of patients. While I have a physical limitation on beds, that has nothing to do with how many patients end up in those beds.

As for the wait, unless the OP thinks that the pt was the only pt in the ED, I don't think that was an unreasonable length of time. Was any consideration given to what else was going on in the ED at that time?

This has been discussed ad nauseum and maybe now we can lay the topic to rest. Each side has their own agenda, understandably, but until you see both sides of the coin, it's really unfair to judge either way.