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

[CarVsTree]

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 clerk) @ 0230, "you're getting a pt., report's in the computer." I knew there was no bed in the room, as I walk out into hall to get the bed to bring it to 17A, the doors open up and in rolls the pt. Fortunately, the pt. was A&O and could tell me his injuries. I stood there and read report in front of patient.

We won't even begin to talk about the crazy orders the first year put in... But in his defense, he was just hired a few days before to replace a first year that quit.

I don't mind short notice but how about 5 minutes... Hmmmm.... How 'bout 2 minutes.... 10 seconds just don't cut it.

[scattycarrot, BSN, RN]

I agree. Which is why I wonder why I have to wait hours after being told I'm getting an ER admit... only to have them show up at shift change. (I certainly can't speak for anyone else, but one of my co-workers transferred to our ER and confirmed that many of the nurses there wait til the end of their shift to send patients out to the floor...)

Unfortantly, there are bad apples in every department. That doesn't mean that every ER nurse is the same or that every floor nurse is the same. I have worked with good and bad(e.g, lazy, unmotivated, unsafe) floor nurses who swing through ER sometimes but I wouldn't want to label them on someone elses experience of one hospital ( I appreciate that you were talking from your own experience, which is valid, its just unfortunate that this is turning into an ER nurse vs floor nurse discussion).

[Altra, BSN, RN]

Like I said, I can only vouch for what my friend told me of her experience in one ER, however after working in a number of hospitals since I started traveling, I suspect it isn't as rare an occurrence as some would think.

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.

[caroladybelle, BSN, RN]

Ok, I am a bit confused here. In the uk we transport our own patients from ED to wherever it is they are going and then give report to the nurse on the new unit. Do you not do that in the US? Or am I reading this wrong!

In the USA, things are a bit different......

On the floors, the nursing supervisor has low censused several nurses or floated nurses to the point that each floor has the minimum number of possible nurses to handle the maximum number of patients apiece. That do this by assessing the census sheets, and the patients' admitting diagnosis.

(the admitting diagnosis often has little to do with actual extent of work that the patient actual requires nor the actual treatment the patient needs. For example, an 80 year old violent dementia patient, in renal failure requiring peritoneal dialysis every 6 hours, and positive for weeping shingles and TB....the MD admits the patient as "Prostate Cancer" to a two person room, despite the fact that he is not being treated for it, it is not the cause of the current issues, nor is the Oncology unit this place to actual treat this pt, as no one there can do peritoneal dialysis, infectious patients do not belong there unless absolutely essential, and you shouldn't place a pt a semiprivate room with TB.)

The admission clerk will see that they need to admit the "prostate ca" patient and place them in an oncology semi-private.....despite the fact that there is only one empty bed, and 4 scheduled admissions for chemo in the AM. And no possible DCs. This means that the main person placing patients is often ignorant of the "whole picture", and even if they did, have little medical knowledge with which to make proper placements.

The Admit clerk notifies the nursing supervisor who alerts the charge who alerts the nurse.

Meantime the ER nurse faxes the report/calls report, often before the floor nurse is not even notified. And then gets annoyed, when they ask the patient's name, etc. or if the nurse is not IMMEDIATELY available.

Often the the staff nurse does get report and notes that this as problem. If s/he is lucky they catch any problems before the pt arrives. Sometimes, s/he is not lucky. Examples: The "lung cancer" pt that was sent up, had severe dementia, 8 stage 3/4 decubes, and a shortened, externally rotated rt leg and no pulse in it. Of course, the hip/leg had been xrayed and consulted on, none of which was on the written report. And as the report the patient as up "ad lib" to the BR, well, so much for assessment. I can also cite a cancer patient (and hospital employee) sent up to floor on 3 separate occasions, soiled and soaked, the final insult - the ER "accessed" the pass port by sticking a regular needle in it to draw blood.....leaving a lovely 18 gauge open hole in the port, that patient was bleeding out of.....they dressed the site with a pressure dressing and kept reinforcing it. I received the patient at shift change, completely soiled and with 4 bloody ABDs wrapped on her arm. She promptly to get FFP because of bleeding out of the passport.

There are numerous cases of ER error.....just as there are numerous floor errors and numerous ICU errors.

On another wellknown thread here, where ER nurses were vented, I defended their right to vent, against those that felt that should not be allowed to, that they were "not very nice/good nurses".

Floor nurses deserve the right to vent, also.

Anyway, since ER nurses rarely deliver patients to the floor, and often don't even have to talk to us.....this issues foster animosity on both sides at each other, instead of the real enemies...the supervisors/budget crunchers that deliberately leave us short, management that has a nonmedical person making placement decisions instead of someone qualified, MDs that do not put the real admission data down, because they want to turf a pt and wait to the end of their shifts to do so (much of the problem with shift change admits is the ER MDs "clearing the Board".

[CarVsTree]

Obviously, we can all site instances in both the ER and the floors of nurses that just don't care or are incompetent.

ER nurses I empathize with you the best I can (never having worked ER) to the pressures that you have to move patients. My original post has to do with patients arriving on the floor with little or no notice.

In my hospital phone report is not required with the exception of trauma alerts. All the ER RN has to do is chart on their patient and a report is automatically generated that I can access. It is however the responsibility of the ER RN to give a courtesy call that the patient is on the way. My problem was that I was never told I was getting a patient and the courtesy call came as the patient was rolling in. In this case, what was the point of the courtesy call? Why was I not called at the same time transport was called? Or as the transporter that was standing around waiting for my patient (not likely!) in the ER walked off with the litter.

Not the ER's fault that I was never told I was getting a patient. Perhaps the ER nurse told someone at the desk to call the floor re: my patient being transported. My point isn't the ER is tyring to ruin my night and the point isn't well we get patient's in a moment's notice and we do just fine. Different areas, different staffing, different roles.

Point is, our patients deserve to have a floor nurse that is aware and prepared for their arrival. Point of post was that it's not great for the patient, not great for the RN receiving, but it is dealt with. I'm sure there are ways to make it better.

[Crash_Cart]

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.

[caroladybelle, BSN, RN]

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.

[Crash_Cart]

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.

[canoehead, BSN, RN]

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.

[elthia]

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.

[EmmaG, RN]

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.

[EmmaG, RN]

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.

[elthia]

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.

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.

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!!!

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".