Your Gettin a Patient - The Doors Open and In Rolls Your Pt. - page 5

How does this happen??? Pt. arrives is seen in ED @ 2100 as a trauma alert. Primary/secondary survey, orders entered in CAPOE, plain films, CT scans done, etc. I get a call from my AP (unit... Read More

  1. by   Patient_Care_Asst
    Do gun shot traumas give ER nurses "reasonable" advanced notice when they arrive into the ER, so the ER nurse receiving the patient can "better" prepare for their arrival?

    Pffft.

    Floor nurses have it easy in comparison. Give the ER staff a break. All they are trying to do in the ER is move stabilized patients to the floors. This makes more room available in the war zone. It's not like the ER can choose thier patients.
    Last edit by Patient_Care_Asst on Oct 16, '07
  2. by   caroladybelle
    Quote from Patient_Care_Asst
    Do gun shot traumas give ER nurses "reasonable" advanced notice when they arrive into the ER, so ER nurse receiving the patient can "better" prepare for their arrival?
    Actually, generally the EMS do let them know, barring the pt being dumped off on the doorstep, or walking in, both of which happen but not that often.

    There are differences in the ER and the floors. That does not excuse the ER for treating other floors appropriately, barring a major emergency. And most of these cases were not occurring when there is a lifethreatening issue going on.

    Interestingly, when a patient goes bad on the floor, I have frequently had to hold and start major life support treatments on the floor for extended periods of time....treatments for which we do not have an MD standing by, appropriate monitoring equipment, nor trained personnel. Unlike the ER, that at least has an MD to give orders and monitoring equipment. I have also had the ER turf unstable patients to the floor - a brain bleed - that came in after loss of vision. The ER nurse suddenly noticed the patient had a change of mental status and a blown pupil, but sent the patient to the unmonitored onco floor anyway. Despite the fact that the ER had nothing going on or coming in at the time, but did have two MDs and plenty of monitoring equipment.

    Part of the ERs job is to stabilize and treat appropriately. Part of that includes giving the staff adequate information to place and properly care for the pt. That means giving adequate notice when reasonable, and making sure you are not creating an unsafe situation for patients. When one sends a patient without proper notice, one has not done that important part of a job. A job that is now mandated by JCAHO, for that matter.

    If one does not like the responsibilities of ER...like any other type of nursing, feel free to try working the floor. All those lovely repeaters that the ER rapidly dumps on the floors, where they stay for weeks and reek havoc...you'll get to enjoy caring for them for monthes at times, instead a few hour or a day or so.

    But being rude and dumping on another nurse, because you feel "your" time/job is more important than theirs, and that your stress is sooo much harder....that doesn't fly.
  3. by   Patient_Care_Asst
    I am not condoning nurses that fail to provide adequate information as a matter of providing report with the floor nurse.

    Also, it's noteworthy to indicate the downfalls of pre hospital communication between EMS and the ER. There are many unknowns before actual ABG's, X-Rays or other similar diagnostic testing are ordered and conducted in the ER. Pre hospital communication only serves to "outline" and/or "describe" the overall patient's condition prior to their arrival in the ER. In many instances the information provided may be "unclear" without any specifics pertaining to what is actually going on with the patient.

    For example, EMS doesn't always have the opportunity to complete a head to toe assessment and report things like blood exhibited in the patients urine from a recent trauma etc. Sometimes, these things are "added surprises" once they arrive in the ER. EMS can't effectively report the "unknown."

    Getting back on topic, my basic beef is how certain floor nurses "delay" to accept report from ER nurses because it's either:

    A) Not a particularly good time for the floor nurse right now to receive the patient and they intentionally delay the admission process.

    B) They are not their primary care nurse, the primary care nurse is on break right now etc..etc..etc... (I have heard it all..)

    Hence the so called "communication" issue ER seems to have with the floor nurses and vice versa.

    You would think some floors somehow thought they had the added option of refusing medically cleared patients if they don't happen to like certain facts about their overall condition.

    Keep in mind this is really not the ER nurse's decision, (although they may have input to this decision) The decision to discharge the patient to the floor is actually the decision of the public medical officer representing the facility. (AKA The ER doc)

    Also, "stabilized patient" might have a completely different interpretation to the average recent grad floor nurse and an ER doc.

    It's not that ER nurses feel more "important" than floor nurses do etc.., it's just that some floor nurses (not all) don't effectively understand the meaning behind the medically cleared patient concept.

    Receiving the patient on the floor is not somehow an optional issue unless an acute and drastic change in the patient's condition are suddenly noted. That is what I would consider as a reasonable expectation. However the ER may view anything else as excuses and/or unnecessary delays in the admission process.

    This is probably why we have this ongoing admission war. It's a matter of understanding and no matter how I try to understand the floor nurses concerns, I am always perplexed in understanding how any such expressed concerns can possibly meet the criteria of outright refusing an admission they are receiving 89.9% of the time.

    My Best.
  4. by   canoehead
    Patient Care Assistant

    I'm an ER nurse and after reading your posts I suggest you ease off a bit. Floor nurses work just as hard as we do, in different conditions.
  5. by   elthia
    Quote from TrudyRN
    I am troubled by the lighthearted, essentially willing-to-accept being treated in an unacceptable manner that I am sensing from these posts by those who are victims of this practice of incomplete or no report from ER's.

    Just a reminder - this will change only if you guys make it change. Also, you do NOT have a responsibility legally to a patient that you have not agreed to accept. And how can you agree to accept until you get a report?

    I know you don't want the patient, who is hearing all of this intra-personnel stuff, to be scared or feel he/she is a burden to you. But you have a license to protect.

    Make your bosses make this stuff stop. Couch it in terms of patient safety and lawsuit prevention for the employer, not in terms of your own license protection and well-being/fairness to you, as they don't care a hoot about you, only about their own $$$$$$.
    Sorry to be entering the discussion haphazardly, but was out of computer access yesterday. Per protocol at my hospital if the rapid response team is called on any new ED admit or any pt who was transferred from the ICU w/in 24 is a mandatory risk management report. I love being able to make policies and procedures work FOR me instead of AGAINST me at times, too bad it's not always that way.
  6. by   EmmaG
    Quote from MLOS
    I know you're speaking from your experience and your friend's ... but to me you may as well as be describing life on Mars ... I have absolutely no frame of reference to imagine what you're describing. I guess somewhere in the universe there are hospitals that don't look at ER wait/throughput times and where charge nurses are not "charged" with moving the mass of humanity that flows through the ER everyday as quickly as possible just to keep everyone's head above water and prevent occurrences such as waiting room deaths.

    Today I took a patient to the unit while a tech took another of my patients admitted to telemetry to the floor. By the time I came back to the ER we didn't even have to put the stretchers back in the rooms -- I had 2 new patients in their place. This is the rule, not the exception.
    Understood. I think you make a good point regarding the charge nurses. They're the ones who set the tone for (any) unit.
  7. by   EmmaG
    Quote from canoehead
    Patient Care Assistant

    I'm an ER nurse and after reading your posts I suggest you ease off a bit. Floor nurses work just as hard as we do, in different conditions.
    PCA makes valid points. My problem with the whole issue is a lack of communication on both sides. Which is why I want the chance to receive a phone report and to ask questions of the ER nurse who has been caring for the patient. While in my experience it's been rare that an admission is flat-out refused, there have been many cases where this has caught inappropriate placement.
  8. by   elthia
    Quote from Patient_Care_Asst
    I am not condoning nurses that fail to provide adequate information as a matter of providing report with the floor nurse.

    Also, it's noteworthy to indicate the downfalls of pre hospital communication between EMS and the ER. There are many unknowns before actual ABG's, X-Rays or other similar diagnostic testing are ordered and conducted in the ER. Pre hospital communication only serves to "outline" and/or "describe" the overall patient's condition prior to their arrival in the ER. In many instances the information provided may be "unclear" without any specifics pertaining to what is actually going on with the patient.

    For example, EMS doesn't always have the opportunity to complete a head to toe assessment and report things like blood exhibited in the patients urine from a recent trauma etc. Sometimes, these things are "added surprises" once they arrive in the ER. EMS can't effectively report the "unknown."

    Getting back on topic, my basic beef is how certain floor nurses "delay" to accept report from ER nurses because it's either:

    A) Not a particularly good time for the floor nurse right now to receive the patient and they intentionally delay the admission process.

    B) They are not their primary care nurse, the primary care nurse is on break right now etc..etc..etc... (I have heard it all..)

    Hence the so called "communication" issue ER seems to have with the floor nurses and vice versa.
    Sometimes floor nurses have emergencies too. I once posted on this board about how I begged the ED for some time before sending me a new admit, and the admit came up anyways while I was in the middle of a code, and my floor was short staffed on night shift to begin with. A few months ago I was threatened with a write up for hanging up on a ED nurse in report for saying, "i have a lethal alarm, I'll call you back". The nursing super was a witness to me sprinting down the hall and calling for the RRT, or the write up would have stuck.
    Quote from Patient_Care_Asst
    You would think some floors somehow thought they had the added option of refusing medically cleared patients if they don't happen to like certain facts about their overall condition.

    Keep in mind this is really not the ER nurse's decision, (although they may have input to this decision) The decision to discharge the patient to the floor is actually the decision of the public medical officer representing the facility. (AKA The ER doc)
    No we don't refuse medically cleared pt on likes and dislikes, but we may refuse on certain things such as pt requires a monitored bed and all our telemetry monitors are currently being used. Pt requires peritoneal dialysis and we feel it might be prudent to place the pt on the the dialysis floor as pt looks like a lengthy admission and there are 6 open beds on that floor. Pt has TB and we don't have have any airborne isolation rooms on this floor. It's called advocating for the safety of the patient and your coworkers.
    Quote from Patient_Care_Asst
    Also, "stabilized patient" might have a completely different interpretation to the average recent grad floor nurse and an ER doc.

    It's not that ER nurses feel more "important" than floor nurses do etc.., it's just that some floor nurses (not all) don't effectively understand the meaning behind the medically cleared patient concept.
    You imply that the majority of floor nurses are recent grads, then state that ER nurses "don't feel more important'. First off, I am proud to be a floor nurse, and I nor the majority of my coworker are not recent grads.
    A medically cleared pt for my floor would
    1. have a stable BP
    2. have a stable HR, failing that be asymptomatic with the brady or tachy HR
    3. have a decent pulse ox with or without O2
    4. have chest pain less than 2/10 at time of transfer
    5. If s/p cardiac cath, sheath removed and hemostasis at sheath site, PPP, can have femostop in place.
    6. If on restricted cardiac drips, meds are within limits allowed by protocol for my floor, NO TITRATING.

    So when I recieved a pt who is having midsternal chest pain 8/10, his bp is 85/40, he's diaphoretic and his sPO2 is 85 on 2 liters O2 and I haven't recieved report so I have no idea if he has CHF and I'm frantically looking for orders. I do feel justified in saying THIS PT IS NOT STABLE!!!
    Quote from Patient_Care_Asst
    Receiving the patient on the floor is not somehow an optional issue unless an acute and drastic change in the patient's condition are suddenly noted. That is what I would consider as a reasonable expectation. However the ER may view anything else as excuses and/or unnecessary delays in the admission process.

    This is probably why we have this ongoing admission war. It's a matter of understanding and no matter how I try to understand the floor nurses concerns, I am always perplexed in understanding how any such expressed concerns can possibly meet the criteria of outright refusing an admission they are receiving 89.9% of the time.

    My Best.
    You are right, the floor does recieve the pt anyways the majority of the time. But what you don't see is what happens later. After massive interventions, massive meds, lots of work, an exhausted nurse who falls behind and neglects her other pt's, that admit from the ED goes to the ICU anyways. Or the infection control nurse writes up the charge nurse and the TB pt goes to a floor with a respiratory isolation room. The dialysis pt's nephrologist throws a fit and puts in an administrative transfer, because he only wants trained dialysis nurses touching his pts. It would be easier if someone would just take the time to listen to the... what did you call it "average recent grad floor nurse".
    Last edit by elthia on Oct 17, '07
  9. by   CarVsTree
    Quote from Patient_Care_Asst
    I am not condoning nurses that fail to provide adequate information as a matter of providing report with the floor nurse.

    Also, it's noteworthy to indicate the downfalls of pre hospital communication between EMS and the ER. There are many unknowns before actual ABG's, X-Rays or other similar diagnostic testing are ordered and conducted in the ER. Pre hospital communication only serves to "outline" and/or "describe" the overall patient's condition prior to their arrival in the ER. In many instances the information provided may be "unclear" without any specifics pertaining to what is actually going on with the patient.

    For example, EMS doesn't always have the opportunity to complete a head to toe assessment and report things like blood exhibited in the patients urine from a recent trauma etc. Sometimes, these things are "added surprises" once they arrive in the ER. EMS can't effectively report the "unknown."

    Getting back on topic, my basic beef is how certain floor nurses "delay" to accept report from ER nurses because it's either:

    A) Not a particularly good time for the floor nurse right now to receive the patient and they intentionally delay the admission process.

    B) They are not their primary care nurse, the primary care nurse is on break right now etc..etc..etc... (I have heard it all..)

    Hence the so called "communication" issue ER seems to have with the floor nurses and vice versa.

    You would think some floors somehow thought they had the added option of refusing medically cleared patients if they don't happen to like certain facts about their overall condition.

    Keep in mind this is really not the ER nurse's decision, (although they may have input to this decision) The decision to discharge the patient to the floor is actually the decision of the public medical officer representing the facility. (AKA The ER doc)

    Also, "stabilized patient" might have a completely different interpretation to the average recent grad floor nurse and an ER doc.

    It's not that ER nurses feel more "important" than floor nurses do etc.., it's just that some floor nurses (not all) don't effectively understand the meaning behind the medically cleared patient concept.

    Receiving the patient on the floor is not somehow an optional issue unless an acute and drastic change in the patient's condition are suddenly noted. That is what I would consider as a reasonable expectation. However the ER may view anything else as excuses and/or unnecessary delays in the admission process.

    This is probably why we have this ongoing admission war. It's a matter of understanding and no matter how I try to understand the floor nurses concerns, I am always perplexed in understanding how any such expressed concerns can possibly meet the criteria of outright refusing an admission they are receiving 89.9% of the time.

    My Best.
    Good post. I agree that delays from the floor can be a big problem. My hospital has solved that problem by requiring no delay report. Meaning if I'm up to my elbows in poop and can't take report (for trauma alerts where its phone report) patient comes up anyway. That being said as policy does not mean I can't say... "I'm in the middle of changing pt. can I call you back in 2 minutes?" This has almost always been met with "sure." I call back immediately after finished with la poop and take report. Occasionally, I've been told "can't we really need the bed." Then we all do what we gotta do.

    I think we could go on and on with what could be done better by the other department! We all know we're ALL pushed to the limit in ALL departments. BTW, report isn't what I care about most when receiving a pt. What I like is 2 minutes to look ancillary results, labs, and orders. This is where I get my picture. Not to say report is of no value - that would be ludicrous. But when I've already looked at results in the computer, I can just hear the RN's assessment and go from there.

    Cheers all!
  10. by   CarVsTree
    Also, it's noteworthy to indicate the downfalls of pre hospital communication between EMS and the ER. There are many unknowns before actual ABG's, X-Rays or other similar diagnostic testing are ordered and conducted in the ER. Pre hospital communication only serves to "outline" and/or "describe" the overall patient's condition prior to their arrival in the ER. In many instances the information provided may be "unclear" without any specifics pertaining to what is actually going on with the patient.

    For example, EMS doesn't always have the opportunity to complete a head to toe assessment and report things like blood exhibited in the patients urine from a recent trauma etc. Sometimes, these things are "added surprises" once they arrive in the ER. EMS can't effectively report the "unknown."
    This happens to EVERYONE who receives report from someone, whether you work in the ER, floor, or ICU.
  11. by   nursemike
    Quote from Patient_Care_Asst

    Floor nurses have it easy in comparison. Give the ER staff a break. All they are trying to do in the ER is move stabilized patients to the floors. This makes more room available in the war zone. It's not like the ER can choose thier patients.
    I'm a floor nurse, but before I was a nurse, I was a transporter. One of my jobs was bringing pts up from the ED. I routinely made several trips from the ED each shift, so I got a pretty good look at what it was like, even though I haven't worked there as a nurse.

    All I can say about your comment is "Pffft."

    In point of fact, as I told my doc, I don't really have any problems with my ED. Report is often given by any nurse with the time to give it, whether he or she actually knows the pt or not, and it's usually pretty sketchy. Well, the first thing I do with any admission is a full head to toe, so mostly what I need is what meds have been given--and I generally do get that. I'm also starting to learn their lingo--if I'm told the pts GCS is 4-5-6, I know longer wonder, "So is it a 4 or a 5 or a 6?" and I'm not surprised when they arrive upstairs and it's a 15.

    I do sometimes ask whether they can sit on this one for 4-5 more hours, because I'll be off at 0730--but I sure they know I'm kidding. I have--but only twice--asked them to give me ten minutes because I was in the middle of something urgent, and they have. From my transporting days, I know how urgent it is to clear an ER bed, but most of our ER nurses started on the floors, and they're well aware of how "easy" we have it.

    I know we're not supposed to get personal, but I'm thankful every day that attitudes such as that you expressed are pretty rare at my facility.

    I don't know. It makes me wonder whether our administrators might not be quite as demented as they seem.
  12. by   teeituptom
    Quote from Angie O'Plasty, RN
    That is why you have different staffing levels, a doc on the unit, stat preference for all tests, proximity to Radiology, transporters, an entirely difffernt Pyxis system in which you do not have to wait for a Tylenol to be profiled before pulling it.

    The ER has EMTALA to guide your triage function. Your patient, triage nurse or EMS gives you "report." On the floors, we have something called "continuity of care" and we have no less need to know what has already been done for the patient.

    We are certainly not "less than ER" nurses because we are not ER nurses, we too have protocols to follow and a different skill set.

    One of them is that we are to get Report before each patient gets to the floor. Our complaint is that we are not getting Report or that we get insufficient Report or that the patients are coming before we even have the room cleaned.

    In some cases, the patients may have been stablized and became UNstable on the way to the floor.

    You need to stop making this about nurse vs nurse and understand that just like a person doesn't walk in off the street into a Trauma room, we should not be getting patients who have been treated by the ER without getting some form of Report.
    Ive seen some just walk in straight to a trauma room
  13. by   Miss Mab
    ELTHIA SAID:

    You imply that the majority of floor nurses are recent grads, then state that ER nurses "don't feel more important'. First off, I am proud to be a floor nurse, and I nor the majority of my coworker are not recent grads.
    A medically cleared pt for my floor would
    1. have a stable BP
    2. have a stable HR, failing that be asymptomatic with the brady or tachy HR
    3. have a decent pulse ox with or without O2
    4. have chest pain less than 2/10 at time of transfer
    5. If s/p cardiac cath, sheath removed and hemostasis at sheath site, PPP, can have femostop in place.
    6. If on restricted cardiac drips, meds are within limits allowed by protocol for my floor, NO TITRATING.


    Um, isn't that pretty much a home care pt.?

    nowadays anyway...

    also, what are these things called transporters you all speak of??
    Last edit by Miss Mab on Oct 17, '07

close