ER nurses not calling report anymore...

Nurses Safety

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Hey all, our hospital started a new policy where the ER nurses don't have to call report on the patients coming to our floor- they can choose if they want to call report. Most don't call report. It is up to us to find this patient and research all about them before they get to the floor, hopefully. Most of the time, they show up before we know they are coming. It is very frustrating and unsafe, we don't know anything about what we are walking into. I work on a medical telemetry unit, with usually 5-6 pts per nurse, it's hectic and busy no time to be clicking through a computer on a new admit. From what I understand this is a trial to test out this new policy, I am hoping it doesn't last. It seems the only one that benefits from this new policy are the ER nurses, it's definitely not ideal or safe for the patients... Anyone experienced this sort of thing? Thoughts? Thanks.

Specializes in Emergency & Trauma/Adult ICU.
The ED core measures sets a goal of 4 hours between admit orders and transfer, I don't think a 5 minute report is delaying people more than 4 hours.

I do agree that floor Nurses are often at fault for delaying report and transfer. There are no situations where a Nurse shouldn't be getting report within 15 minutes of transfer orders.

Do have a reference for the "goal" of 4 hours? I have slogged through the actual JC Specifications Manual and the CMS throughput measures and found no reference to "4 hours". All explanation/discussion of these measurements is in minutes. On the Hospital Compare site there are references to state and national averages ... but no suggestion of specific timed goals.

And assuming we both work in hospitals ... an intelligent discussion would include the role of bed control in these measurements. An ED patient seen and having appropriate diagnostics completed promptly may have a decision to admit quickly ... but wait a long period of time for an available bed. That is beyond the ED's control, and may be beyond the control of the floor ... but the clock remains ticking on the ED's *performance* in getting the patient out of the ED. And that is a major reason why hospital policies are formulated to ensure that the patient leaves the ED as soon as possible when there is an available inpatient bed.

ED nurses not giving report on patients seems inexcusable to me. I'm so tired of ED nurses who think that they're too busy saving lives to do small tasks, like phoning report, when the truth is that unless you work in a big city trauma center, you're dealing with sprained ankles and rashes a majority of the time. So pick up the phone & give report!

Specializes in Critical Care.
As I've said earlier in this thread, Esme ... the process can pass muster with surveyors from JC and the state DOH, so apparently they are not interpreting the NPSG in the same way that you expected.

It's not being interpreted differently, it's that it is still a goal and not a standard. It's an expectation, but not an absolute requirement to pass. Sort of like how a student is expected to do well in Nursing school, but can technically pass with a C-.

Specializes in Critical Care.
Do have a reference for the "goal" of 4 hours? I have slogged through the actual JC Specifications Manual and the CMS throughput measures and found no reference to "4 hours". All explanation/discussion of these measurements is in minutes. On the Hospital Compare site there are references to state and national averages ... but no suggestion of specific timed goals.

There is no hard limit, the measure just requires that Hospitals have policies in place that try to avoid boarding in the ED. "4 hours" is the only example they have given of what an acceptable timeframe might be.

"EP 6 does not go into effect until January 1, 2014. The hospital must measure and set goals for mitigating and managing the boarding of emergency department patients. Boarding can be an indicator that the hospital has more systematic problems. Boarding is a significant risk management and patient safety issue. The four-hour window is new and has led to a lot of discussion in the emergency care community. Some fear this could result in a four-hour delay for admitted patients. It is important to note that this time frame is not a requirement and patient acuity and best practices must be followed.

The Joint Commission now defines boarding as:

“The practice of holding patients in the ED or a temporary location after a decision to admit or transfer is made. The hospital should set its goals with attention to patient acuity and best practice: it is recommended that boarding timeframes not exceed 4 hours in the interest of patient safety and quality of care.”

The Joint Commission’s New Patient Flow Standards

Some Hospitals hold all ED admits in the ED until the next shift, those are the main ones that will have to make changes to comply. One key part is that the timeframe does allow for some flexibility so that "best practices must be followed".

And assuming we both work in hospitals ... an intelligent discussion would include the role of bed control in these measurements. An ED patient seen and having appropriate diagnostics completed promptly may have a decision to admit quickly ... but wait a long period of time for an available bed. That is beyond the ED's control, and may be beyond the control of the floor ... but the clock remains ticking on the ED's *performance* in getting the patient out of the ED. And that is a major reason why hospital policies are formulated to ensure that the patient leaves the ED as soon as possible when there is an available inpatient bed.

I agree, I think it's all about bed availability as well as staffing availability. As the CMS commentary on all the ED throughput measures refer to, their concerns are with Hospitals that aren't properly staffed to handle their admission needs, Hospitals that fail to open additional units when necessary to save costs, and Hospitals that try and maximize or even exceed their capacity to safely care for patients. I work in the ED as well and I do find it frustrating when I get jerked around trying to give report, but I don't think that's a contributor to failing these measures.

Specializes in ER, progressive care.
The second thing- most ER nurses have worked the floor. We know you are busy too. We are not trying to screw over the floor nurses in any way, nor are we lazy. Our assessments are different. We do not do head to toe assessments. Coming from Med-Surg to the ER, this was a hard habit to break. Our assessments are focused to only the chief complaint. For example, an abdominal pain patient won't get a neuro assessment as well, unless something obvious is going on.

Yes, ER assessments are different. And I agree, that was also a hard habit for me to break when I made the switch to ER. We do assessments based on the patient's chief complaint - called focused assessments. I'm not going to look at every crack and crevice on a patient's body. So yes, I have had floor nurses get upset with me because they discover a patient has a decub on their coccyx. Or that I knew about it but didn't do a full assessment of the wound bed unless something prompts me to doing so. The purpose of the ER is to get them in, gather the data, get them stabilized and get them to the floor or wherever they need to go.

IV's.... When I was on the floor, I used to complain about IV's in the AC. Now that I work in the ER I understand why so many are there. An example- A patient with an elevated D dimer needs a chest CT. Radiology needs at least a 20ga in the AC or higher. The floor nurse is upset because this AC IV will make the pump go off all the time. We get it.

Yup, I was this way, too. I'm going to go for whatever vein I see and would be the easiest to get, and hopefully in just one stick so that it minimizes discomfort for the patient. And that is usually in the AC.

I went a little off topic there. It is frustrating for ER nurses because it is the rest of the hospital against us, and every floor has its assumptions about what we do/don't do. Coming from the floor to ER was EYE-OPENING to say the least. It is a different world.

I couldn't agree more with this.

Specializes in Emergency & Trauma/Adult ICU.
There is no hard limit, the measure just requires that Hospitals have policies in place that try to avoid boarding in the ED. "4 hours" is the only example they have given of what an acceptable timeframe might be.

"EP 6 does not go into effect until January 1, 2014. The hospital must measure and set goals for mitigating and managing the boarding of emergency department patients. Boarding can be an indicator that the hospital has more systematic problems. Boarding is a significant risk management and patient safety issue. The four-hour window is new and has led to a lot of discussion in the emergency care community. Some fear this could result in a four-hour delay for admitted patients. It is important to note that this time frame is not a requirement and patient acuity and best practices must be followed.

The Joint Commission now defines boarding as:

“The practice of holding patients in the ED or a temporary location after a decision to admit or transfer is made. The hospital should set its goals with attention to patient acuity and best practice: it is recommended that boarding timeframes not exceed 4 hours in the interest of patient safety and quality of care.”

Given that the national average of reported LOS from decision to admit to the patient leaving the ED is 96 minutes (FY 2012 data published on hospitalcompare.gov) -- I cannot agree with your interpretation that as long as 4 hours has not elapsed, it's all good. We'll have to disagree on that point. Realize, too, that as full implementation of Value Based Purchasing and Meaningful Use are rolled out, not only maintenance of benchmarks but year-to-year improvements on measurements will likely be required so as not to lose ground on reimbursement rates.

Specializes in Critical Care.
Given that the national average of reported LOS from decision to admit to the patient leaving the ED is 96 minutes (FY 2012 data published on hospitalcompare.gov) -- I cannot agree with your interpretation that as long as 4 hours has not elapsed, it's all good. We'll have to disagree on that point. Realize, too, that as full implementation of Value Based Purchasing and Meaningful Use are rolled out, not only maintenance of benchmarks but year-to-year improvements on measurements will likely be required so as not to lose ground on reimbursement rates.

That's not my interpretation, that's CMS's interpretation of their own rule.

Compliance is typically viewed in termed of how much of an outlier a facility is, so at some point throughput in under 4 hours may no longer be, in general, compliant. The average is 96 minutes but there's a lot of variability in that, some take minutes, some take many hours, it's where it takes hours that they are aiming at. I'm looking at Hospitals in my area, one averages 24 minutes from decision to admit to transfer, another about 30 minutes away averages 289.

But they do seem pretty clear they however a facility decides to shorten their throughput, it should still follow best practices which would include an interactive report given that they refer to JC recommendations as best practices.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

compliance with 4 hour rule has nothing to do with calling report......the hand off rule still applies.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
As I've said earlier in this thread, Esme ... the process can pass muster with surveyors from JC and the state DOH, so apparently they are not interpreting the NPSG in the same way that you expected.

Then you have a generous surveyor.

There can be a "faxed report" with the receiving nurse having a specific amount of time, like 1 hour, to fulfill the requirement of an interactive report and the opportunity to ask questions if the receiving nurse decides she doesn't need to call then compliance has been maintained. There are slight variances state to state with compliance variations.

I personally know surveyors...and just sending a patient without report would not fly. The burden is on the sending nurse not the recieving nurse.

But if it works for you facility....and they haven't been sited or had to develop a plan of correction......good for them.

Don't you know how to place an IV? Every med-Surg patient doesn't necessarily need an IV. Didn't you go to nursing school too? Believe it or not, the ER's mission isn't to give you a perfectly package patient, it is so care for the patient until a disposition has been made. Then it's either up to the floor or out the door so the next waiting person can take their spot. Nothing stops the inflow of patients.

ED nurses not giving report on patients seems inexcusable to me. I'm so tired of ED nurses who think that they're too busy saving lives to do small tasks, like phoning report, when the truth is that unless you work in a big city trauma center, you're dealing with sprained ankles and rashes a majority of the time. So pick up the phone & give report!

Don't think so sweetie. Sprained ankles and rashes go through express/urgent care and don't get admitted. My guess the problem with the report is that the receiver isn't available, the patient is held and that stops that patient throughput. Meanwhile triage is bursting at the seems and the ambulances keep rolling in. Sounds like you have some insecurity issues with your job.

I am an ER nurse in a Level I trauma center which is also a teaching hospital. On any given day, there are no LESS than 30 people in the waiting room, and it takes an act of God to get us closed or put on diversion. Therefore, we are open to EVERYTHING and the ambulances just keep on coming. I used to work on the floor prior to becoming an ER nurse so I get it from both sides.

In our hospital, we fax report, confirmed it was received by the floor nurse, we wait 15 minutes (if we can) and then we take the patient up. We also give a quick bedside update once the pt is on the floor if needed. When I was a floor nurse, I knew the minute after report if I had an open bed, so I prepared myself for an admission from the ER that can come anytime during my shift.

Also, the floor nurse can see the ED triage note, as well as the ED nursing notes and the doctor's H&P. I used to look this information up once I knew I was getting an admit so by the time the ED did call me for report, all I needed to know was the last set of vitals, as well as the IV placement and if any meds were passed or if I needed to pass certain meds.

Now, the floor nurses complain that the fax report does not provide certain information, like skin issues. There have been several meetings between the floor directors and the ED director, explaining that the ED does focus assessments only based on chief complaint and once the patient gets orders from the admitting doctor, the ED is responsible for STAT orders only. I don't know how many times the floor nurses are upset that we did not draw their scheduled AM labs although the patient was sent up 3-4 hours before they were due.

We used to call report to the floor, but half the time, it was refused because the nurse was not available. Then the nurse would call back 30 minutes later for report, then spent 20 minutes drilling the ED nurse for every single detail about the patient, while we have an ambulance patient waiting in the hallway for said bed.

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