[ZippyGBR]

Originally Posted by Jen2

There are several threads where this issue has been brought up. I cannot speak for your particular hospital, but I will tell you what goes on in our hospital.

Scenerio 1. Patient comes in with post op-complications. They need to be seen by the ER physician since the surgeons do not magically live in our department. Before we are able to consult the surgical service, there is a workup we must do since calling the service and simply saying that the wound is red will not warrant a visit. So we work the patient up call the hopefully admitting service with the results and wait and wait and wait. We wait until they are out of surgery, done doing rounds etc. etc.. Once we consult on a patient it sometimes takes that particular service up to 2-3 hours to come and see the patient. The service finally comes and sees the patient and decides to admit them. The ER physician cannot admit a patient. There must be an accepting service.

from my point of view ( as a rightpondian Emergency Dept and Admissions/ assessment unit type bod) System failures all round

1. while not a 'failed discharge' it's pretty obvious this patient will need to be seen by the surgeons

2. why isn't the 'workup' being conducted by Nursing staff from a Uk point of view the 'basic' aspects of work up will be done anyway, the notes have been requested and if indicated bloods taken and sent ....

Wound care and wound assessment should be a basic tool of the RN

3. We would probably move this kind of patient to an assessment baed if the surgeons were unable to come and see the patient - this frees up the ED for ED patients - sometimes without involving ED Medical staff ( if the patient is stable and doesn't need Parenteral analgesia or fluids)

Scenerio 2. Patient comes in as a stroke page and neurology is at bedside evaluating the patient. We start workup and everything comes back to be "stable" from a neurology standpoint. Therefore neurology will not admit the patient to their service. The patient still needs to be admitted so the ER must then consult medicine to see if they will admit the patient. Well before the medicine team will come and see the patient, they want urine results. We get the urine results and wait and wait. Medicine then finally comes and sees the patient. Medicine does there eval and decides to admit the patient. Admission cards get put in and we wait for the H.O. to call us and give us a bed.

so much for stroke patients get admitted under the stroke service ... again fro mthe right pondian perspective stroke patients get admitted to one of three bed bases - the designated 'stroke' beds , medical assessment beds pending a stroke unit bed , or critical care if it's indicated ...

the y are also admitted under the stroke service which saves neurology and general medicien/ elderly medicine having an arguement over who the patient does or doesn't belong to ( the stroke service has 'parts' of several of the neurollgy and medical consultants and is covered by the general medical middle grade )- one of the advantages of the UK system where the middle grades approach the level of seniority of and experience of the new attendings

Scenerio 3. Trauma comes in and is scalped because their head went through the windsheild and a tib-fib fx that needs to be reduced. Admission cards get put in right away by the trauma service and we get a bed right away. However, before we can take them upstairs trauma needs to staple the head lac, we have to wait for plastics to come and suture the face, and have to wait for ortho to reduce the fracture. Can't just send the patient upstairs with a bleeding head wound and an unstable fracture with possible vascular compromise. All of these things takes time.

legitimate use ofthe time in the ED - though that said where i have been working ED we did nearly all of our own suturing except tendon repairsand complex opthalmic / max fax stuff ( e.g. we would suture lips etc - the key thingwith lips is to get the vermillion border right - it's plastics voodoo to boost their consult figures to say otherwise)

Scenerio 4. Have a very stable patient call report and start packing the patient up to bring them upstairs. Charge nurse comes in the room and tells you to hold on, EMS is at the door with a cardiac arrest. Work the cardiac arrest and then take the stable patient upstairs.

workload is workload - that said our clinical site managers (all RNs - they do the balancing act of bed allocation and also screen the primary care admits for those that can waitvs those that must vcome striaght in even if there isn't a ed immediately available - and threfore go to the ED) would likely move that patient if there wasn't a more urgent call on their time

Try and notice what time rounds are done in your hospital. It seems as if in our hospital rounds are done by the services before noon. However, discharges are not made until later in the day. If a patient is not discharged until 5:00 in the afternoon, then this will put a patient being put in that bed at the floors shift change.

valid point -

need to look at discharge arrangements and what can be put in place before the final decision - e.g. if meds are stable the discharge meds can be ordered in advance

there is also the concept ofthe discharge lounge to consider where those who are discharged are moved from their ward beds whilr waiting for things like discharge meds to a (still nurse staffed) area where they can wait for discharge meds and transprt etc rather than sittign dressedand ready to go by their bed for several hours

Sometimes we get into a war with different services where no one wants to admit the patient to their service or the patient has multiple complaints and several differnet services needs to see the patient.

you need to empower the ED s medical shift leaders (i.e. the more senior attendings / consultants/ staff specialists) to be able to referee and make with the Clinicla site manager a binding for at least the first 24 hours decision whose bed base they go under - or admit them to an assessment unit and the arguement can continue there ( we admt the majority of our none critical care 'medical' patients to the assesmsent unit - some cardiology goes straight to cardiology if there are beds same with stroke) and sort them out to the medical subspecialities within 24 hours

[TazziRN]

There's nothing I can add to this.......I understand that it's hard on the floors to get admits at change of shift, but floor nurses should come and watch a busy shift in the ER....maybe there would be some understanding in that direction too.

[paradisemakai]

Originally Posted by RunningWithScissors

Got a call from the House Sup to place a NH pt with HTN, gave him a bed and no sooner than I hung up ER calls to give report. They say the pt got some Clonidine in the field but only Ativan in ER. BP has been OK sonce the pt arrived, pt had refused her daily meds at the NH.

OK......then I look up the lady's labs and find out they were drawn 5 hours ago and she's been sitting down there the whole time. The whole house census has been down, so waiting on a bed wasn't the issue.

So I'm wondering, as this has happened often....are the patients waiting for the doc to figure out what to do with them? Do they drag their feet? What seems to take so long to figure out if they admit or d/c?

Also, what's up with the admits every night from 6-7pm right before change of shift? House calls for a bed at 1630 and they want to bring the pt up at 1830....every night this happens.

I'm sure there's a good explanation for this, so let's hear it!!!

Very interesting - when I worked in ER it was usually the opposite response from the floor nurses - there were never any beds ready so our patients would hang out in the ER for up to 72 hours

Delays in the ER are quite commonly due to:
1. MD needs to write admitting orders. How available is MD?
2. Codes/emergent situations that need to be dealt with first
3. Lack of staff to help get patient up to floor. At our unit we got an admissions nurse whose job was to facilitate getting patients from ER to other units - she did all the paperwork and was a tremendous help to both ER and units, as well as decreasing LOS in ER.

Hope that helps.

[paradisemakai]

Originally Posted by TazziRN

There's nothing I can add to this.......I understand that it's hard on the floors to get admits at change of shift, but floor nurses should come and watch a busy shift in the ER....maybe there would be some understanding in that direction too.

Having worked both floor and ER and thus seeing what it's like from both sides, I can honestly say that both jobs are difficult. It's easy for one unit to badmouth the other, but I wish nurses didn't do that. For the most part we're all working our butts off, and a little understanding of the other person's side goes a long way.

[evilnightwitch]

Well in our ER since we are never busy placing IV's or busy doing all lab work and since we have time to twidle our thumbs we never get sidetracked doing all of the admission orders like initial antibx ans we never bother to get patients started on anticoag therapy we like to wait till change of shift because we like to stay extra so that we can spend less time with our families, because we just love to be in the er. LOL just try seeing 10 patients on your shift with full assessments medication administration and all lab draws. That is a slow night in our ER.

[postmortem_cowboy]

I have been on the end of both sides of this coin, and it's not a good feeling in either direction, the ER nurse is trying to get his/her patients up to the floor as quickly as possible (as if we don't hear it from the patients how uncomfortable an ER gurney is) and then when you finally get there the floor nurse is yapping about why couldn't this patient have waited till after shift change. When on med/surg, I try and go with the flow, I try and understand how busy the ER is, and it's not like my buddies down there are tactically planning a pre-emptive strike against me since i got shoved into M/S for the night. I think from the ER side of the coin no one seems to understand that they're running around like a chicken with their heads cut off down there and that they're doing their best to get everyone up in a timely manner. M/S seems to think we get to choose when we call report, in between codes, traumas etc etc. on the M/S side of the coin, ER seems to think that just because they're ready, M/S is ready, and although ER found out an hour ago that this particular patient was going into this particular bed, M/S just got notified of the patient altogether.

I actually have worked with a couple of ER nurses that would sit on their patients and not move them when they had more than an opportunity. I've worked with other nurses that have said they don't like those people to work down in ER as well, and to send them to the floor if they want to sit on patients all night long. I think there just needs to be better communication between nursing staff on both floors, ER doesn't do this intentionally, and neither does M/S.

Wayne.

[TrudyRN]

I think there needs to be a Nursing Supervisor who oversees the calls to accepting MD's and coordinates with Admitting and with the floors.

When an ER nurse has a patient who's ready to be admitted, that nurse will turn the pt over to the Supervisor, who will finish out the case from that point. That nurse will get the orders, call report, and coordinate with the receiving nurse on the best time to actually send the patient to the floor.

I think ER nurses are forgetting that floor nurses can be just as busy as they are and that the floors are not immune to Codes, falls, SOB, chest pain, and other emergencies. And, yes, I have worked both ER and floors, ICU, too. All of the above. So I do know how it is in all these areas.

The doctors' shenanigans need to be addressed with and by the Chief of Staff. Docs who are unreachable and/or unreasonable or who hold patients in the ER until the last minute or do other selfish things need to be sanctioned by their boss.

We have no smoking in our facility. If a nurse or UAP violates it, it's curtains. If a doc does it, there are no repercussions. As a manager, I would not write up or discipline my staff if the docs aren't also disciplined. Same thing with ER doc/other doc violations of the topic we're discussing.

We need to think globally on this one. It is a pain for ER, floors, docs, nurses, and patients. There is a solution. Let's put our heads together and see what we can do in our personal situations.

[Altra]

Originally Posted by TrudyRN

I think there needs to be a Nursing Supervisor who oversees the calls to accepting MD's and coordinates with Admitting and with the floors.

When an ER nurse has a patient who's ready to be admitted, that nurse will turn the pt over to the Supervisor, who will finish out the case from that point. That nurse will get the orders, call report, and coordinate with the receiving nurse on the best time to actually send the patient to the floor.

Trudy, are you saying the nursing supervisor should assume care of ER patients after the decision is made to admit them?? I don't see how this would work.

I work in a 26-bed ER. At any given time, assuming our beds are full, there are probably at least a dozen patients somewhere in the process of admission. Using the dozen figure, 9-10 of them are on cardiac monitors which need, well, monitoring. One or two are probably intubated & sedated. Another 1-2 are probably in c-spine precautions. Even the more stable ones are receiving care (fluids, meds, pain assessment, help w/ADLs, etc.) up until the minute they go upstairs.

I just don't see how this could work, to dump them onto some other nurse. And as far as the "best time to send them to the floor" that should be, IMO, as soon as humanly possible.

[postmortem_cowboy]

Let's face it gang, it's a no win situation on both ends. Both the floor and the ER need to understand that the other is doing everything they possibly can to accomodate the other.

I don't know how many times i've gotten bed assignments and gone to call report and m/s says call back in an hour... ok, no problem, then you call back and it's call back in 30 minutes, ok... call back again and now the nurse isn't available she's on her break... call back in another 30 minutes... ok... call back again and it's we can't take report right now. By this time it's been several hours, and the patient downstairs is getting antsy. I've tried my best to accomodate the floor, but there just comes a point that no more excuses will do and a bedside report ensues.

I've also been on the flip side of it, and have taken report from ER as quickly as I can, and still get all my stuff done, you have to prioritize, will this stable M/S patient that hasn't gotten any meds but is just chillin' out in their bed watching tv be a priority, or my other 5 patients getting their meds ontime. And after 9's are done and we start into a lul for the evening, then start the admit because you now have time.


Wayne.

[luckylucyrn]

At our hospital, unless the patient is going to ICU stepdown or ICU we don't have to call report. We call and talk to anyone on the floor and notify that person that we are faxing report on the patient. If I get any requests to hold that patient longer, I comply. I always get anything done off the admission orders that I can, and I don't send up a patient that I don't think can wait a reasonable amount of time before the floor nurse can see them. If the patient is that unstable, they don't need to leave my ER. I do my best to send up patients who will not need anything immediately upon arrival.
But yes, for some reason, all our beds get called at shift change. If its time for me to leave, I get all my patients ready to go and then page transportation. We aren't allowed to have patients transported from 6:30-7:30 am or pm, so hopefully that helps out the floor.