Er Nurses

RNcDreams · Jul 15, 2008

Ahhh the ER nurses vs. Floor nurses.
Ya know the thing that gets me about the ER. Antecubital IV starts. You start them there, they come to the floor and if they need IV fluids, people sleep with their arms bent and the darn things beep all night and I usually have to resite them.

If I may, I'd like to explain why that sometimes happens.

Often, if a pt arrives to the ER and is SOB, possibly needing a Chest CT, we go for the AC because the CT techs will not give the IV contrast through anything smaller than a 20, anywhere lower than the AC.

I don't know what the policy is at other places, but I know we will do it on a case by case basis to make sure that the patient doesn't wait for their test because we have to place another IV.

That being said, some patients just have no veins... and some nurses are too lazy to look at hands and forearms!

Here's to hoping we can all appreciate each other's workplace struggles :)

time4meRN · Jul 15, 2008

Been on both sides of the fence, but I have to say that the same is also true for ER nurses, many times the nurse on the floor is not taking care of the critical pt, we are taking care of a critical pt as well as pt's that keep flowing in one after another by medic, we have pt's in the hall, 65 waiting, our numbers are under attack by admin if we don't get them up to the floor in certain amt of time etc.... I can't recall the last time a floor nurse told me , I know you hava a critical pt, so bring the pt right up. We start the darn IV, put in caths, start all lab work, have xrays', ct's and meds started , ng's down, before they come up to you. I've been in your shoes, I know where your coming from, maybe you should try walking in ours for a while. I'm not saying that there are some ER nurses that could be of a team player. But the same is also true for floor nurses. Nursing is stressful, busy but it is a wounderful job. People are loosing jobs, companies closing every day. At least the medics are still bringing pt's to the er and the ER is bringing pt's to you. We are in buisness to be busy. Sucks sometimes but that's life as a nurse. Been a nurse 30 years and hasn't changed, never will. Take the heat (meaning a constant flow of pt's) or get out of the kitchen.

BrnEyedGirl, BSN, MSN, RN, APRN · Jul 15, 2008

As a former floor nurse now in the ER, the floor vs ER battle is a huge pet peeve of mine! I've been there,.done that,.and to be honest with you,.the floor doesn't understand the ER and the ER doesn't understand the floor.

A huge gripe from the floor is ER calling report durring shift change. Guess what,.we are at shift change too,...the floor doesn't want to get report but then are upset when 45 min later they get report from a nurse who hasn't even seen the pt,...that's because the nurse that had the pt the last 6 hrs tried to call report before she left,.the floor "couldn't take report durring shift change" so she had to give report to the oncoming ER nurse and so it goes,....

And yes, the AC IV is a pain on the floor with a pump,...but you seem to forget that by the time the floor gets the pt we have some sort of idea what's going on with the pt. When they walk into triage saying they have CP and SOB I don't know jack about this pt and I'm getting a large IV ASAP. One time of starting that 20g in the hand and then have a pt code because of a GI bleed (try pumping 4units of PRC's in 30 min through a 20g),....then trying to get a larger IV on a pt who now has no BP,...only happens once and now unless you're here for a med refill, you get at least an 18g in the AC.

I think the mind set of the floor and the ER are so different that it is often hard to understand "what that ER nurse was thinking" or "why that floor nurse wanted to know that". I had a real hard time the first few months in the ER. I didn't have an old chart to look at,.no old H&P,..often no hx and it was very hard for me to get to the mind set of "we are here to treat the emergency",..we are supposed to keep the pt from dying and then send them to the floor/unit/OR or wherever to get them better. I transferd from a cardiac unit and when I got to the ER I couldn't believe that we didn't weigh our CHF pts!!! Well after awhile I now see that from an ER point of view,.it really isn't important to me,..yes it is to the floor,.but not so much for the ER.

I hate to hear all the complaining that goes on both from the ER staff and the floor staff. We are all working to take care of pts. It's a 24/7 job and we do what we can in the time we have and pass it on. We just have different roles and priorities, one is not more important or harder than the other just different. It saddens me to hear nurses bash each other when we're all just trying to do our jobs (which now includes feeding family members, always smiling, making sure the coffee is hot and handing out cab vouchers :banghead: ).

okay,..off my soap box,..can't we all just play nice?

PeachyERNurse, BSN, RN · Jul 15, 2008

Two words: faxed report
Other than that, I'm not going to get involved with the ER vs. Floor Nurse battle. LOL

We fax report to all floors except Psych. We then call to make sure they received it, and if there are any questions, we answer them. Then we send the patient on up. Seems to work out perfectly.

Nightcrawler, BSN, RN · Jul 15, 2008

but what I mean is to keep the flow going, help your fellow nurse out - I take report from EMS on a patient who won't be mine, but I do the triage and VS to get one portion out of the way. You always go in there to assess them anyway as the primary. Getting report from another floor is just an overview anyway - it shouldn't hold things up to get a one to one report. Besides, when the ER calls, that nurse likely just assumed care and doesn't know jack about that person (like at shift change) - so what, then. That's not helping you out, because they're reading from the previous shift report and we don't have time to review everything. It IS just best to have someone take report (if they'd be so helpful) when your hands are full and you'll get a better idea when they get to the floor..... it's one of my pet peeves, too, to hear "she's on a break, or eating" meanwhile I'm digesting my spine from my own hunger - we don't get breaks (EVER) and to use that as an excuse is unacceptable - there is always a nurse covering so that one is able to take a break who can take report. At least that's how it should be, legally....

It is great for you to call report before you leave because you know the patient- but only if they are ready to come up. If they are going to be down in the ED for 2-3 hours receiving more tests and waiting for orders to be written, then the oncoming ED nurse has plenty of time to get to know them.

One of the things that I wonder sometimes is if the ED nurses see report as a inconvenience that they need to get out of the way. ED nurses never know what is coming in the door, so I think that they forget how much more prepared we can be to treat the patient with a timely and thorough report. I have always seen report as a necessary component to continuity of care, and I like to know what is going on, to myself and the other nurses on the floor, we see report as much more than a mark in a required box.

MassED, BSN, RN · Jul 15, 2008

It is great for you to call report before you leave because you know the patient- but only if they are ready to come up. If they are going to be down in the ED for 2-3 hours receiving more tests and waiting for orders to be written, then the oncoming ED nurse has plenty of time to get to know them.
One of the things that I wonder sometimes is if the ED nurses see report as a inconvenience that they need to get out of the way. ED nurses never know what is coming in the door, so I think that they forget how much more prepared we can be to treat the patient with a timely and thorough report. I have always seen report as a necessary component to continuity of care, and I like to know what is going on, to myself and the other nurses on the floor, we see report as much more than a mark in a required box.

there may never be time to provide a "thorough" report from an ER nurse to a floor nurse - just won't happen. You can get the quick and skinny of what was done, what is their history - and what I try to do is pull up the last H&P dictated from their last admission and mention that in report... if I have time. What is done emergently and stabilized and the rest is just minor details to US. I can recall having a floor nurse ask me when this person's last BM was when they were being admitted for cp..... come ON now.... I could care less - unless they're there for a bowel obstruction... It's fair for the ER nurse to understand the floor nurse might be tied up and can't take report right then (and I understand since I started out on the floor).

Just to all nurses who haven't been in the ER need to understand - most ER nurses will provide you with a PMH that is complete to the BEST of their knowledge (and what was provided to them by patients, EMS personnel, family) - we sometimes have limited information. On the floor, you have the time to do a more detailed admission assessment - where we, most often, do not have that luxury. I have made a nice little sheet for when I provided report - I include PMH, PSH, meds, allergies, C/C, history of present illness, labs, tests done, IV, fluids... family coming up (that might cause a stir) - as much as I can provide. That is quite comprehensive and the best that can be expected from an ER nurse. Remember it's not the floor where all halts for 30 minutes for a face to face report. That is not realistic to have that amount of detail. I always tell them, over the phone, if there are more questions when the patient gets up there that I might not have covered, give me a buzz.

It's hard to understand unless you have walked a mile in the ER nurse shoes... I've worked on the floor, so I understand from your viewpoint. Which is why a nurse should take a report for you and hand off the info - you can get more detail later, when you're no longer wrapped up from the ER nurse or just deal with it and get the info from the patient. It's not a perfect world and sometimes you can't get every bit of info you may like from the ER nurse - just as you sometimes assume care for your shift and patients haven't had VS done, Blood sugars covered... you just roll with it and adjust.

MassED, BSN, RN · Jul 15, 2008

As a former floor nurse now in the ER, the floor vs ER battle is a huge pet peeve of mine! I've been there,.done that,.and to be honest with you,.the floor doesn't understand the ER and the ER doesn't understand the floor.
A huge gripe from the floor is ER calling report durring shift change. Guess what,.we are at shift change too,...the floor doesn't want to get report but then are upset when 45 min later they get report from a nurse who hasn't even seen the pt,...that's because the nurse that had the pt the last 6 hrs tried to call report before she left,.the floor "couldn't take report durring shift change" so she had to give report to the oncoming ER nurse and so it goes,....
And yes, the AC IV is a pain on the floor with a pump,...but you seem to forget that by the time the floor gets the pt we have some sort of idea what's going on with the pt. When they walk into triage saying they have CP and SOB I don't know jack about this pt and I'm getting a large IV ASAP. One time of starting that 20g in the hand and then have a pt code because of a GI bleed (try pumping 4units of PRC's in 30 min through a 20g),....then trying to get a larger IV on a pt who now has no BP,...only happens once and now unless you're here for a med refill, you get at least an 18g in the AC.
I think the mind set of the floor and the ER are so different that it is often hard to understand "what that ER nurse was thinking" or "why that floor nurse wanted to know that". I had a real hard time the first few months in the ER. I didn't have an old chart to look at,.no old H&P,..often no hx and it was very hard for me to get to the mind set of "we are here to treat the emergency",..we are supposed to keep the pt from dying and then send them to the floor/unit/OR or wherever to get them better. I transferd from a cardiac unit and when I got to the ER I couldn't believe that we didn't weigh our CHF pts!!! Well after awhile I now see that from an ER point of view,.it really isn't important to me,..yes it is to the floor,.but not so much for the ER.
I hate to hear all the complaining that goes on both from the ER staff and the floor staff. We are all working to take care of pts. It's a 24/7 job and we do what we can in the time we have and pass it on. We just have different roles and priorities, one is not more important or harder than the other just different. It saddens me to hear nurses bash each other when we're all just trying to do our jobs (which now includes feeding family members, always smiling, making sure the coffee is hot and handing out cab vouchers ).
okay,..off my soap box,..can't we all just play nice?

WELL SAID (ah, WRITTEN). :yeah: :yeah:

smk1, LPN · Jul 15, 2008

I'm a clinical decision unit nurse so I kind of fall in the middle of the ER and the floors. Can kind of see both sides. From the perspective of someone who admits patients from the ER in large volumes nightly, I can say that it is a huge benefit if you can get the actual nurse who took care of the patient to give you report. It isn't always possible, but a LOT of potential problems can be nipped in the bud before they blossom into a full scale issue simply by having this communication. At the same time if I am in the middle of admitting 2-3 patients in the last hour I may not be able to take the next report when the nurse calls, and I get that she is busy and if that means that now someone else will have to give report when I call her back, then I have to deal with it and ask more questions to get the info I need for safe patient care. 99% of the patients come up with an AC iv start. I can deal with that because I understand why, what I do not get is the nurse who doesn't put and adapter on the EMS IV start so that it is compatible with our needleless luerlock devices. Yeah I can do it upstairs, and I am one who always flushes IV sites during assessment to make sure they work, but it frustrates me to no end that others do not. Not good nursing practice. Also don't question me if I say that the unit is full. I am not lying to you, feel free to come up and look if you like. (this last rant is mainly for doctors who think they are the only ones admitting patients to the unit, and can't understand why we have no available beds if they have only admitted 2 patients so far.)

Tweety, BSN, RN · Jul 15, 2008

I understand that many hospitals do a faxed report, but with more and more requirements for adequate hand-offs when changing levels of care, I see this being phased out more and more.

I don't think so because the requirements are for some written documentation of the condition of the patient at the time of transfer. What better way than to have a written report?

allnurses Guide · Jul 16, 2008

We have shifted to a "CHAT" form, covers each system briefly, has a spot for meds given and times, brief chief complaint and history. One page. The floor has 15 minutes after it arrives to call back with questions, otherwise we are supposed to be able to simply send the patient; without regard to change of shift. It is making things go a bit faster, because I can call and just ask if there were questions, and the secretary can call the floor nurse and relay the message. If none, she doesn't have to stop what she is doing to answer the phone.

It was developed because we were having really significant flow problems in getting people to the floor. Several times last winter we ended up housing over 30 people in the ER overnight, and we only have 36 beds.

In reality, if the supervisor asks me to hold someone a bit longer, I will. If transport can't come soon enough, we wait longer. If I get tied up with the next incoming patient, I can't arrange for transport in 15 minutes on the dot. If there are no telemetry boxes available, obviously I can't send the patient in that 15 minutes! Last night the floor complained we were sending too close to shift change when we'd had the room assignment for the last 5 hours, well, yeah, there were no tele boxes until then, and we did inform people of that. It all comes down to communication, (same old song).

allnurses Guide · Jul 16, 2008

Another point about antecub IVs. We don't admit the majority of our patients, I get a large number of people who get a liter or two bolus, we want it in fairly quickly and then let them go home. We are also drawing labs, and too often get told it hemolyzed (usually becuase of a too small bore catheter). So, we go the sure, fast and yes, easier route.

Ditto on the CT contrast need as well. I hate getting called over to CT to restart someone because we didn't anticipate the need for an AC.

Nightcrawler, BSN, RN · Jul 16, 2008

there may never be time to provide a "thorough" report from an ER nurse to a floor nurse - just won't happen. You can get the quick and skinny of what was done, what is their history - and what I try to do is pull up the last H&P dictated from their last admission and mention that in report... if I have time. What is done emergently and stabilized and the rest is just minor details to US. I can recall having a floor nurse ask me when this person's last BM was when they were being admitted for cp..... come ON now.... I could care less - unless they're there for a bowel obstruction... It's fair for the ER nurse to understand the floor nurse might be tied up and can't take report right then (and I understand since I started out on the floor).
Just to all nurses who haven't been in the ER need to understand - most ER nurses will provide you with a PMH that is complete to the BEST of their knowledge (and what was provided to them by patients, EMS personnel, family) - we sometimes have limited information. On the floor, you have the time to do a more detailed admission assessment - where we, most often, do not have that luxury. I have made a nice little sheet for when I provided report - I include PMH, PSH, meds, allergies, C/C, history of present illness, labs, tests done, IV, fluids... family coming up (that might cause a stir) - as much as I can provide. That is quite comprehensive and the best that can be expected from an ER nurse. Remember it's not the floor where all halts for 30 minutes for a face to face report. That is not realistic to have that amount of detail. I always tell them, over the phone, if there are more questions when the patient gets up there that I might not have covered, give me a buzz.
It's hard to understand unless you have walked a mile in the ER nurse shoes... I've worked on the floor, so I understand from your viewpoint. Which is why a nurse should take a report for you and hand off the info - you can get more detail later, when you're no longer wrapped up from the ER nurse or just deal with it and get the info from the patient. It's not a perfect world and sometimes you can't get every bit of info you may like from the ER nurse - just as you sometimes assume care for your shift and patients haven't had VS done, Blood sugars covered... you just roll with it and adjust.

Let's not get carried away here, no where in any of my posts did I say that I wanted to know when the last bm was. However, if the patient came in with chest pain I WOULD like to know what their rhythm is, where the IV is, a set of vitals within the last hour, and maybe whether their pain responded to nitro. I have taken report from nurses that could tell me none of those things. To be truthful, I will usually have looked up the labs and the last H and P myself prior to receiving report so that the ED nurse can just tell me what is going on today. I am capable of asking all of those questions myself- but another nurse is often able to give me cogent answers and I won't look like such an idiot when I ask the patient what brought them to the hospital tonight.