ER nurses not calling report anymore...

Here.I.Stand, BSN, RN · Oct 21, 2014

Patients arriving at 7:15? Are you kidding me? Are we trying to make this any more unsafe? Plus the floor nurse gets stuck with the new admission before she/he can go home.

Part of the problem sounds like an issue with this floor, regardless of why they're rolling up at 7:15. (Which, FTR, I don't believe for a minute that the ED nurse is trying to stall the next pt. He/she *can't* stall the next pt, so wouldn't it behoove the ED RN to get that pt to the floor?)

But anyway, if an admit rolled up at 7:15, the offgoing RN shouldn't be "stuck w/ the new admit before s/he can go home." The offgoing RN where I work (and any other place I've worked) would help get the pt to his new bed, get him on the monitor, check VS. The oncoming RN would be responsible for the rest. Nursing is a 24/7/365 duty, so there's no reason that one should be expected to stay OT to finish a change-of-shift admit when there's a new RN on the clock and assigned to that pt.

Karou · Oct 21, 2014

Floor nurses also really need to get over the fact that in the ER, we do FOCUSED assessments. SOMETIMES we turn patients and check for "any skin issues" if it's relevant to the chief complaint, but more often than not we don't specifically check for skin breakdown. That's the way the ER operates and the sooner that floor nurses accept that the ER functions differently than the floors, the better off we all will be.
I try to give as much information about my patients in report as I can, but it's also irritating for me to have to try to provide every detail that the floor nurses want (at my hospital) just so that they can pre-chart on the patient before they get to the floor! ALL of our patients, for instance, are admitted with an IV, so it's annoying as all get-out for our floor nurses to ask me if my patient has an IV! I mean, we drew blood, he got IV dilaudid and Zofran, and we gave IV antibiotics, so is this question really necessary??? And the floor nurse is required to do an assessment when the patient gets to the floor anyway, so why oh why is it necessary for me to inform the floor nurse in report WHERE the IV is located? So she can get her admission charting done before patient gets to the floor, that's why!

I just wanted to say that I 100% agree with your comment about skin! Admitted patients will get a head to toe skin assessment in my floor, so why do I need to ask the ED how their skin is? Unless it is pertinent to their admitting dx. then I don't ask. This also gets on my nerves when I am giving report to the next shift and they ask how the patients skin is. Really? If their was an issue, I would have told you. We have to do a skin assessment each shift anyway.

The IV question can be important though. Especially if the patient is to receive blood, IV antibiotics, ect... I have had the ED send someone without an IV with a BSG under 50. It is our policy to have all patients sent with a patient IV, and they don't always chart it. Since they have the ability to do sono guided IV's (takes hours on the unit to wait) I expect them to come with an IV. Agree with you that the location of the IV isn't important, just as long as it is there. Bugs me in report when someone will ask me exactly where the IV is then get attitude when instead of in the hand, like I said, it is the wrist or forearm.

Karou · Oct 21, 2014

A thought on admissions at shift change...

Okay so most of our admissions occur either right at or shortly after shift change. This isn't always safe, and certainly can be frustrating. I understand there is a lot of blame placed on the ED nurses "holding" patients, but I can imagine other situations as well.

PACU, for instance sends many patients at this time. I suppose since surgeons try to get out oft he hospital at a decent hour, they do the last of their surgeries late in the day (say 17:00 at the absolute latest) and we happen to get those patients to the floor around shift change (19:00-20:00)

I work night shift. I Know of at least one day shift nurse who delays her discharges so she doesn't get an admission, or intentionally does it late so of the admit does come night shift does the paperwork. Example- orders to discharge placed at 12:00, patient actually discharged at 17:30, room gets cleaned around 18:00, now an admit is assigned and arrives by 19:00.

Most discharges happen during the day. Many physicians don't round and put in discharge orders until the afternoon. Sometimes extra things have to be set up for the patient (home health, IV antibiotics, walkers, ect...) or the patient may even be waiting for a ride (think: most people work 8am-5pm so rode arrives at 18:00). It makes sense that as soon as the patient leaves, the room gets cleaned, then very quickly admit gets assigned... By now it's darn close to shift change. We get admits assigned almost as soon as the discharged patient lifts up off of the bed. Our ED is always busy and my unit stays at full capacity.

The ED nurse may "hold" a patient to avoid another. The day shift floor nurse may take their sweet time with a discharge to avoid an admit. The doctor may do his usual afternoon 16:00 rounds and discharge a patient late. Patient may be waiting on family member who has a normal day job for a ride. Social worker and case manager may be frantically trying to set up transport, home equipment, ect before they leave for the day. It all leads to admits at or around shift change.

It's not ideal to get patients close to shift change, but it happens, and I can understand that there are many different factors as to why,

**RosesrReder, BSN, MSN, RN** · Oct 21, 2014

We can all sit here and argue until pigs flew, but the bottom line is that we are overloaded with way too many tasks, not enough help/support and anencephalic management/administrators for the most part. They love to see the nurses beat each other down. They love to have systems in place for the poor nurses to report, attack and rip each other apart.

I am so glad I didn't walk but ran out of the hospital setting. Although I am now in pre-hospital setting with it's unique sets of quirks, never ever like I have experienced and continue to witness in the hospital setting. Main reason is because I am the only nurse on shift where I work and mingle with medics, EMTs who don't do this crap to themselves or their professions.

It saddens me to see all the bickering and I've been on all the sides and at the end, it's the crummy system in place that leaves everyone attacking themselves for no reason other than a pee-poor working environment in nursing.

vent over!

Beverage · Oct 21, 2014

Our ED has a digital camera and will photograph wounds, skin issues and PU's before pt is admitted to show these were not hospital acquired injuries.

If the nurse doesn't know she's getting an admit, it's not a given that she will know pt received dilaudid, zofran and IV antibiotics. Perhaps she was tied up in isolation cleaning up a c-diff code brown or something similar and unable to answer her phone. I just want to know if the IV is a field stick or if it was placed in ED 

In our hospital when given an admit slip, nurse has 10 minutes to look up Pt info then we call the ED for report. This seems to be working well and our charge makes sure no lolly gagging or admission avoidance is happening.

It know ED is pressured to move their Pt's to the floor ASAP but keep in mind while you have 4 pts (vomiting, pain, laceration, fever...) and 1 needs admit, floor nurse has 3 who are sick enough to be hospitalized, may have more than 1 of the 3 on a cardiac gtt and getting a 4th.

I urge every nurse to show some compassion towards each other.

GM2RN · Oct 22, 2014

I just wanted to say that I 100% agree with your comment about skin! Admitted patients will get a head to toe skin assessment in my floor, so why do I need to ask the ED how their skin is? Unless it is pertinent to their admitting dx. then I don't ask. This also gets on my nerves when I am giving report to the next shift and they ask how the patients skin is. Really? If their was an issue, I would have told you. We have to do a skin assessment each shift anyway.
The IV question can be important though. Especially if the patient is to receive blood, IV antibiotics, ect... I have had the ED send someone without an IV with a BSG under 50. It is our policy to have all patients sent with a patient IV, and they don't always chart it. Since they have the ability to do sono guided IV's (takes hours on the unit to wait) I expect them to come with an IV. Agree with you that the location of the IV isn't important, just as long as it is there. Bugs me in report when someone will ask me exactly where the IV is then get attitude when instead of in the hand, like I said, it is the wrist or forearm.

I agree that having an IV is important, but our patients are required to have an IV if being admitted, so it should be a given that they have one. Also, if I've just told the receiving nurse that I gave IV meds, common sense should tell her that the patient has an IV! That's the point I was trying to make but apparently I didn't make that clear.

GM2RN · Oct 22, 2014

Our ED has a digital camera and will photograph wounds, skin issues and PU's before pt is admitted to show these were not hospital acquired injuries.
If the nurse doesn't know she's getting an admit, it's not a given that she will know pt received dilaudid, zofran and IV antibiotics. Perhaps she was tied up in isolation cleaning up a c-diff code brown or something similar and unable to answer her phone. I just want to know if the IV is a field stick or if it was placed in ED 
In our hospital when given an admit slip, nurse has 10 minutes to look up Pt info then we call the ED for report. This seems to be working well and our charge makes sure no lolly gagging or admission avoidance is happening.
It know ED is pressured to move their Pt's to the floor ASAP but keep in mind while you have 4 pts (vomiting, pain, laceration, fever...) and 1 needs admit, floor nurse has 3 who are sick enough to be hospitalized, may have more than 1 of the 3 on a cardiac gtt and getting a 4th.
I urge every nurse to show some compassion towards each other.

The receiving nurse knows that the patient got IV meds because I would have just told her in report. That's the only way I would expect her to know. Ergo, the patient has an IV, right? I can't tell you how many times I have reported that IV meds were given in the ER when the very next question was, "Does the patient have an IV?"

I don't see your point in the next to last paragraph. We aren't talking about ratios; we are talking about the need to move patients to the floor (or out the door if d/c) as quickly as possible in order to free up rooms in the ER for the patients in the waiting room. The ER nurse doesn't decide which floor nurse gets a new admit, so we have to assume that whoever is making that decision knows what they are doing in assigning that patient.

Just to be clear, the patients on cardiac drips come from the ER originally, so it's entirely possible, even common, that a single ER nurse will have more than one patient on such a drip. ER nurses can also have one or more ICU patients along with 2-4 others at the same time, whereas the ICU nurse would have only one or two critical patients in many hospitals, but that isn't the point either. The point is that admitted patients have to move and we are paid to get the job done so that we can continue treating new patients that flow through the doors, and most nurses have little to no control over when admitted patients hit the floor.

**RosesrReder, BSN, MSN, RN** · Oct 22, 2014

GM2RN, perhaps picking your battles wisely is a good idea. If you know you get the silly question if whether the pt has an IV quite often, then perhaps changing your report style to say "18g to R AC in place and ABC meds administered". Guess it is easier to change ourselves than the rest of the world.

When I worked the floor, I couldn't tell you how many times I got pt's who had received ABC med via IV down in ER only to get an IV-less pt on the floor. Sometimes it would be discontinued because discharge was almost guaranteed to happen from ED only for some last labs to come back warranting an admission instead. Other times it was just not patent anymore or quite honestly taped all to heck where one would have to play hide and seek looking to see what color it was under all the tape, in order to chart the IV.

I'm not disagreeing with you but sometimes we pick our battles wisely perhaps.

Karou · Oct 22, 2014

I agree that having an IV is important, but our patients are required to have an IV if being admitted, so it should be a given that they have one. Also, if I've just told the receiving nurse that I gave IV meds, common sense should tell her that the patient has an IV! That's the point I was trying to make but apparently I didn't make that clear.

We said similar things. Our policy is also that a patient has to go to the floor with a patent IV, but in reality that doesn't always happen. I agree that it should be a given that per policy they come with one, I just know from experience that that isn't always true.

I gave an example of an incident where I received a patient with no IV who had a low BSG. I have has other experiences of patients sent without patent IV access.

I understand that if you report giving IV medication that it should be a no brainer that the patient has attention IV. Based off of my personal experiences, I know this does not necessarily mean that the patient is coming to my unit with a patent IV. That is why I ask. IV's infiltrate, get dislodged, cause phlebitis, ect...

As nurses we go off of our experiences to guide our expectations. I personally have received patients without patent IV's (weather or not they have been receiving IV medication in the ED), so in report I ask if the patient has an IV. I have never had an ED nurse complain when I have asked, although I rarely have to ask since they usually tell me first.

NICUmiiki, DNP, NP · Oct 23, 2014

This is what our facility has been doing for shift-change admits, and most seem pretty happy about it.

The oncoming floor nurse arrives at 6:45. She/he will call the ER for report on the newly admitted patient first. She/he will then take report on her/his floor pts. The ER will send the pt after 7:30 to give the floor nurse time to check on her/his pts.

This allows the primary ER nurse to give report to the primary floor nurse.

nowim clean · Nov 2, 2014

Next thing there will be no triage patients will just be put in an ER room for a nurse to find. Maybe we could try that also and see how it works. There is no excuse for the nurse not to call report to the floor nurse if they don't want to do that they could always bring the patient up and do bedside report.

Loo17 · Nov 2, 2014

I am not sure where the misconception came from that ED nurses hold on to admitted patients until shift change so they don't get another patient. Having an admitted patient boarding in one of my rooms does not stop me from getting new patients. If a STEMI comes in, I cant say "sorry my rooms are full they will have to wait".

Also, I make every effort to call report on ICU/intercare patients as soon as the bed blinks available on our bed board (which very often is at 645pm because staffing census is improving at 7pm on the units). But as far as not calling report, we write an SBAR report on all non ICU or intercare patients. I happen to write a very thorough report and include the ED MD's note as well. I think the problem with the SBAR is not everyone does a good job at writing them. Sometimes I will take over a pt and the nurse will tell me the SBAR is done and when I look at it says "Pt presents with SOB, IV, labs, CXR complete". Said pt was in the department for 8 hours I am sure the inpatient nurse expects more info than that. Are they a/o x 3, steady gait, on O2, medications or other interventions, what is their PMH or reason for admission? I don't think SBAR would be such a bad thing if a little more effort was put in to them.