Length of stay in ED before admission

LoisJean · Sep 20, 2001

Hey, Girl--is it possible you are posting from my neck of the woods?! What you describe is the NORM where I come from. I am not an ED worker-I'm in the home care field but I hear this from area nurses ALL THE TIME. So many times people who are sent to the ED, by field nurses who have assessed serious symptoms, are held in the ED for hours and hours and then sent home--only to have that patient return to the ED later the same day (or night) in rapid deterioration...or worse, to die.

I am at a loss, myself. One day I arrived at a patient's home to find her on the floor, (L) pupil fixed; unable to speak; flaccid (L) sided extremities; BP 280/120; pulse thready. 911 called; to hospital ED; I accompanied. After 2 hours of 'monitering the blood pressure', the ED doc said he was going to send her home because, "She does not meet the requirements for admission". That's exactly what he told me. His reasoning: her blood pressure had decreased after two hours. One look at her and I knew she met the requirements and then some because none of her other symptoms had abated. I told him that I was documenting the entire situation from the time I found her to the time she was discharged and that I was going to call the family who lived many miles away and tell them exactly what I observed and what was NOT being done. My patient was 72 years old at the time and had been, up to the point of her unfortunate situation, vibrant and very active. Age discrimination is not out of the realm of possiblility here.

That doctor reassessed and decided that perhaps a CAT scan would be appropriate and of course it revealed the evidence of brain attack. She was admitted after 12!!!! hours. OH MY GOD THE HELL SHE WENT THROUGH! This is only one of many, many incidents akin to this that we hear about in our area. And yes, I did document the entire situtuation from the time I found her until the time she was finally admitted.

Thanks for posting on this. Maybe we can get some answers.

kaycee · Sep 20, 2001

On a good day when there are beds for them to go to, our admissions generally are in the ER about 3hrs. That is about how long it takes to triage, have MD access, xray, CT, or anything else we may be doing. It also depends on how busy the dept is,how fast the doc is and if there is efficient staff. Some reasons for delays are , slow doc, slow lab, unorganized staff but mostly pt's are held for looong periods because the unit they are going to won't take report, or the bed is not clean or most often lately there are no beds to put them in.

If the admits are going to be held longer then usual we do feed them. Some however expect to be fed as soon as they unload from the ambulance stretcher.

Any chest pain admit going to a monitored unit always have an IV and are monitored by an RN on transport. All IV's ordered on any admits are always started in the ER because if we don't start them we'll be called later to the floor to do it, because the med surg nurses can rarely start their own IV's. We also give all first dose antibiotics in the ER so the pt doesn't have to wait hours before it is hung on the med surg floor where the nurses are frequently overwhelmed and much more understaffed then we are. We rarely use an anticube for an IV start unless there is nothing else. The medics do frequently however and if the pt doesn't mind being stuck again we will change it,but it's up to them. I don't know the other side of the story of the ER in your particular hospital but if there are beds available for your pts and the eval is complete, there is no reason in my mind from a nursing standpoint that they should be there 8-12hrs. It may be an MD problem. Most ER nurses are very happy when they can move pts in and out of the ER quickly.

As far as no IV or monitors for chest pain admits, your asking for trouble and there is no excuse for that. That is negligent care as far as I'm concerned. I work in a community hospital in an ER with no turnover, where we all get along and work as a team. We are the highest rated unit in the hospital. The other units, MSU, PCU, ICU, Rehab are all understaffed and the nurses there are stressed and frustrated. We understand that and try to do as much for the pt in the ED as we can prior to admission depending on how busy we are. You didn't really say where you work now.

Have you actually asked any of the ER nurses there the questions you are asking here? I would like to hear what they have to say.

Oh well good luck to you.

el · Sep 20, 2001

At the hospital where I work we track the time it takes for patients to be moved from the ed to the floors. I am on a med-surg floor and our time last month was

suzannasue · Sep 20, 2001

Whew...not really a relief to know that this happens elsewhere,but at least I know I am not alone in the frustration.

I have,indeed, asked my Buds in the Ed what takes so long for an admission and it seems to be a combination of slow docs,slow docs and slow docs...one nurse even told me that if they hold the "real" patients in the ED, the stuffy noses and constipation (victims) will eventually leave after several hours of waiting. :rolleyes: On our med/sug/ tele floor we have 34 beds.

Occasionally we are at maximum capacity and if possible we transfer afebrile pts to other deps like OB,PEDS to make room for admissions. If we have a late discharge,we do have environmental services to clean the rooms if they leave before 2300,but occasionally an outpatient surgery we are reacting, or an out patient blood transfusion leaves after midnight and WE clean the rooms. Another bone of contention I have with this ED is that they rush to have all of the pts admitted between 0430 and 0630...ok...if they have been there since 2000 last evening,couldn't thay have arrived before 0430??????? And God forbid thay should do anything like hang the first dose of antibiotic and starting IV's is not a problem on our unit so if a pt arrives without IV access,I fill out an incident report.

We have an automated medication dispenser however we cannot get many of the meds that are ordered and we must call the house supervisor for initial doses of meds. Pharmacy has told us that we cannot have access to everything due to JCAOH standards and I have told them that is ODD to me that we can over-ride the system and get Metoprolol and Lasix IV but cannot access the p.o. meds of the same... we can also over-ride and get all classes of controlled substances...which is ok if the pt is having pain,at least we don't have to wait on the supervisor to fetch those for us. If the doc orders a STAT dose of "whatever",we have to wait and wait and wait and wait until the supervisor can break free from whatever situation is the priority of the moment. :eek:

I also had brief employment with HH and also had a very similar situation. Called to home,pt having classic MI symptoms...

c.p.,diaphoresis...blood pressure was 100/40,heart rate was 98...I fussed at her hubby for calling me before he called 911 but she was transported to the closest ED and was given a complete GI workup...never put on the monitor,no EKG,no labs...NOTHING was done. The attending physician said within earshot of me "who was the Home Health idiot who sent this stupid S&*^

here"...and of course I identified myself as the NURSE who sent her. He proceeded to call me everything but a child of God.

It was not PRETTY!!!!!!! I returned to my pts bedside and the nurse discharged her!!!!! When I asked her to advocate for this woman,she said,"I have a whole waiting room full of people to see before I get home,yall need to leave". I took the hubby aside and told him to refuse to take her home but he said "the doc said she is ok". I tried to explain to him that she was horribly neglected but he took her home anyway. Later that night the nurse taking call,notified me that my pt had just died at home.

I was heartbroken and ANGRY.

I HAVE STRAYED FROM THE SUBJECT!!!!!!!!

Anyhoo.....I cannot fathom any justification for pts being "held

hostage" in the ED unless a critical case arrives. Just seems inhumane to keep them on a stretcher for hours,then admit them in the wee hours of the morning and then they cannot be allowed to rest because we are busy doing the admission "novel" JCAOH requires and initiating the orders.

A couple of months ago, we began recieving a faxed report from the ED in an effort to expedite the admission process...the only information we get is a general demographic picture. And do they get to the floor any sooner???????? NOPE. They have still been in the ED for most of the day...not unusual for them to arrive by the

truckload at 0500...looks like the Darlington Speedway!!!!!!!!!!!

I wonder...perhaps if there were some sort of financial reward for decreasing the ED time if the docs would get offa their thrones and step down from the pedestals. But I also wonder if the patients are being charged x # of $ for the first hour, x # of $ for each half hour of the second hour, X # of # for each quarter hour after that....hmmmmmm....that's a thought.

I have had marriages that didn't last as long as some of these ED visits!!!!!!!!!!!!! HAHAHAHAHAHA...JUST KIDDING FOLKS!!!!!

Again,thank you for your time and consideration regarding this matter!!!!!!!!

suzannasue · Sep 20, 2001

El,

Have compiled volumes of info for management and have had pts and family members describe in great detail their experiences.

NADA...ZIP...nothing has been done to address any of the complaints,concerns.

It's like the ED is immune from all reproach. I dunno.

But thanks for your input...I will continue in my efforts to resolve this situation.

Thank God for Lady Clairol...I would be be white haired for sure without her!!!!!!!!!

CIAO

janine3&5 · Sep 21, 2001

I work in a very busy ER: 100,000 visits/year. Once a pt is seen by the doc, it takes another 1-3 hrs for labs and so forth to come back. They're usually admitted after 2-3 hrs. And that's when the real wait starts. Pts are usually with us AT LEAST 3-4 hrs for a non monitored med/surg bed. I've seen pts stay over 24 hours waiting for a critical care bed. And that's just what it is....waiting for a bed to open up.

Our charge nurse is very big on getting pts transferred out of the ER as soon as possible. I know that if I don't have report called and transport notified within 15 minutes of getting a bed, she's going to be on my phone, asking why the pt's still here. Which is fine with me, I hate sitting on pts who have been admitted for hours and hours. It's very frustrating....about half of the time, the admitting doc doesn't even see the pt in the ER, there are no floor orders to help with even if we have the time to do so. The pts don't understand why they're waiting so long, they're uncomfortable and hungry. When we do have floor orders, we're responsible for doing any stat orders. Beyond that, policy is that we need to start looking at orders when the pt has had them for 2 hrs. I do always try to hang the antibiotics asap.

Just to touch on a few other topics here that I can relate to. IV access, I can't imagine any admitted pt being sent up from the ER without IV access. They ALL get IVs. And yes, most times we put them in the AC when the pt has something acute going on. Yes, it may be inconvenient, but it's the easiest site to access and get blood from in one shot without the lab calling to say our specs are hemolyzed (which I think they LOVE to do!). In the ER, there is so much to do at once, and there is a need to get it done fast, searching for other veins is not a big concern of mine. But if the pt is not too bad off, or has veins jumping out at me, I use the FA.

I quite often have nurses who can't take report, say they'll call me back for report and never do, etc. I understand that these nurses are busy too, but feel like they don't understand that I already have a pt literally waiting outside my room on a stretcher with EMS, along with my charge nurse wanting to know why I'm taking so long to move my pt out.

Pts going to the unit or cardiac floor are ALWAYS transported by an RN with a life pack to the floor. I have yet to see that rule be broken.

There are just NOT ENOUGH beds or TOO MANY pts, bottom line. Yes, it's frustrating, BOTH to floor nurses and ER nurses; I don't think either type of nurse has a clue of what the other one is trying to do and balance. There are different priorities.

samrn32 · Sep 21, 2001

we have a small hospital and a small emergency room. people

generally stay in er about 3 hours before being admitted. the

nurses in er are pretty good about getting iv's in before admit

and the first doses of a/b . it would be nice to get more

advanced warning of admits to out unit (ccu) when we are

full. it does take time to empty bed, clean room , transport patient

complete their charting when possible otherwise we have to go

to the floor later and complete charting. there are of course many

times they aren't aware of our census and they don't know if

they will be a ccu admit until the last minute. i think the biggest

problem we had was a 56 yr. old female with a pot. level of 8.2

who had been vomiting and having copious loose stools thru

her ileostomy for 2 days with poor oral intake . we were told

by er that they had gotten everything going except the tx for

the hyperkalemia. she arrived with a 22 gauge saline lock in her

foot. but mind you when we reviewed the orders and subsequently called the on call md urgently there were no orders

for tx of hyperkalemia or dehydration. all of our cp admits and

ccu admits are always accompained by monitor and nurse or

paramedic. our er has a chest pain protocol and stroke protocol

in place and in use and all suspected cva's go to ct as soon as

iv access established.

aussie oi oi oi · Feb 24, 2002

:confused:

Dear suzannasue,

I am almost glad to hear that Australia is not the only place that has this problem. The hospital that I came from used to float me to ED on a regular basis. The problems were much the same. They split the ED up to emergency, acute sub acute and recently a short stay unit. They have had some success with the short stay. This unit is for non trauma pts that are likely going to need hospilisation for eg: those that present with typical chest pain but have no ecg changes and are waiting for blood results, or pts who have had snake bites, given appropiate trt but just need observation for 6-12 hrs. Like every ED the system does get abused and we were always in the media for keeping a child waiting 12 hrs etc etc, as I worked on a cardaic unit, we would get the pts finally after about 12 hrs, the relatives would be angry, the pt usually hungry and we woudl be lucky if they had obs done once and hour, FBC were usually not kept up to date, the handover was generally well this is not my pt but such as such was busy, so the it is a case of don't shoot the messsenger......

I don't know if there is any answer to the crisis, the problem then goes back to the wards, Ed needs a bed, we are waiting on docs to dc pts so we will have a bed, we then wait dc meds, no waiting area available, you get the Ed tfr, put the dc pt in a chair, the dc pt then gets chest pain but wella no bed, if you keep the pt in the bed Ed crack up, if you don't then the docs, pt or family crack up and the nurses are the ones in the front line. It is a circle that just gets worst. While there is much discussion to 24 hr medical centres may ease some of the burden, pts still have to pay the med centre, many pts don't have the money so they go to the hosp, the other problem is the dr/nurse shortage, if a pt goes to ED you can't turn them away. It seems it is the same wherever you go. I have found generally waiting times are on average 8 hrs but can be as long as 18 hrs. I don't know how the problem can be tackled but as long as pts need care then we need to open the doors even when it is a full house.

Lets hope something can be done about the situation soon, but I fear there is no easy answer. I would be interested to see how other hospitals cope.

frann · Feb 25, 2002

our waits are as long , or longer than 24 hours. No beds. Talked to a lady the other day. Her husband was waiting on a icu bed going on 24 hrs. Construction is going on all the time now. Hard to keep up with the fast growing community.

stevie b · Feb 25, 2002

I work on busy telemetry floor in a resort town. Full of snowbirds and their recurrent USA. We are always full,if we discharge 16 in a shift, we will admit that many. The wait for the bed is what holds our pts. in ED.We are also under constatnt construction to expand space.