Admissions process, is this how it is everywhere?

[RNdaze]

Greetings to all you wonderful nurses! Apologies in advance for the long post.

I'd like to know what you all do in the way of admitting a new psych pt onto your unit as it compares to my hospital.

I'm working 2nd shift (3-11pm). Frequently we have pt's that are admitted after 5, often we have multiple admits coming in shortly before or after shift change. Pt's come to us in a variety of ways from all over the area, as we are the only facility that take acute/crisis pt's except for the state hospital (and due to insurance and acuity, most people don't go to the state hospital). This includes counties an hour or more away.

Usually, a pt is seen in an ER (that can't WAIT to get rid of them), then they are transported to us. Sometimes they come via the police who call our mobile crisis unit, then are sent to us. Sometimes they are sent by a therapist, or just walk in the front door.

This impacts the amount and quality of info we have about any given pt; sometimes we get a good idea of what's going on with them, sometimes not. Sometimes they are frequent flyers so to speak, sometimes not.

The RN's are responsible for checking the initial committment certification to make sure it's filled out properly, and then for calling for a 2nd cert, and in some cases, a 3rd cert.

We "usually" get a "face sheet" from our admissions office, and if we're lucky, some labs from an ER, or an assessment from mobile crisis. Then we have a nrsng assessment to complete on the pt.

First is the physical search, where we, with a tech, go through clothes and do a body search, document any wounds and scars, etc. This can be an ordeal at times. We take vitals, ht and wt.

We get medication hx (last night a woman brought in a bag with over 30 pill bottles, all of which must be written by hand on a med reconciliation sheet which then serves as an order form). To get MD orders, we have to get as accurate a picture of the meds they are on as possible, but if the patient comes in actively psychotic, seeing people covered in blood and hearing voices commanding them to cut their wrists, it's pretty safe to assume that they aren't going to be the most reliable historian.

Then we have an assessment, about 10 pages long. We take a full medical hx (which is sometimes laughable, sometimes heartbreaking) and a psych hx, a suicide risk assessment, a psych assessment, and a physical assessment with additional in-depth assessments for wounds or pain.

Then we are supposed to verify meds (which is often impossible because pharmacies in outlying counties close at 5pm) and then call a (usually) cranky doctor to get orders to admit the pt. One of our on call docs is infamous for hanging up on you if you take too long to give report. Others are just plain disdainful if you have a difficult pt with multiple problems. I am truely perplexed as to why doc's treat nurses this way, like they are doing us a favor by doing their job. (That's a whole other issue I suppose.)

By this point, we've filled out by hand: med rec sheets including drug, route, dose, frequency, duration, last time taken (hahaha) with effectiveness and/or reactions, and maybe/hopefully verified the meds; the written assessment, a treatment team plan where we list each major problem in nsg dx form, a seperate nsg dx sheet for each problem (3 -5 usually), a med teaching form, a form for pneumococcal vacination, a nsg flow sheet, the KARDEX, and finally the MD order form used to call the doc.

Then, we have to find a secretary (often we have one secretary for 3 units, who is overwhelmed with work) to put all this in the system and then they hand write a MAR for standing orders and another MAR for PRN's. We then have to check the handwritten MARs against the orders. Until the pt is put in by the secretary, they are in pre-admission status.

For some reason, certain meds are only available on certain units, so we have to run to X unit for one group of meds and then Y unit for another group of meds.

You can guess that the pt is pretty much the same or worse than they were when they arrived by this point. And all they will get are meds (hopefully) and a bed until the following day when they are (hopefully) seen by everyone else (2 doc's, a therapist, and a case manager.)

According to management, all this should be accomplished in 45 minutes. Ummmm...... on an easy admit if everything goes smoothly, I can maybe get it done in a little over an hour. If I'm handwriting 30 meds, talking to a pharmacist, writing 4-7 care plans, with a pt who is psych acute with extensive medical problems, it can take hours.

With the push to HURRY, I tend to make more mistakes. Then there are 8-12 other pt's to worry about as well. One can only pray that none of the other pt's escalate or have a seizure, etc.

This is my first job, so I have nothing except my school clinical experience to compare it with. Is this normal???

Does anyone have any tips to help me speed up the process? Tips on how to talk to these docs? Reasons I shouldn't run screaming out the door? Thanks so much!!

-- daze

[fgoff]

OMG! If you had not said you are not working at a state facility, I would have swear you & I work the same place. But mine is a state facility, and this is "normal" for us as well.

[FutureNewYorker]

Yep that pretty much describes it except we have no secretary and we are allowed to use preprinted care plans for each dx. Other thankthat, you're on point. I'm from SoFL, you?

[medsurgrnco, BSN, RN]

Psych admits take staff approx 2 hours at my facility. But we usually have an admit nurse for part of the shift.

[kiwipsychnurse]

You will be pleased to know that its very much the same in New Zealand. NZ law requires that in order to be sectioned (placed under the mental health act) they require assessment from a doc, hence they are with them when they come in. So the medication issue is sorted there and then. More paperwork if they end up in seclusion. Which upon admission is not uncommon.

[RNdaze]

Welllll .... it's comforting to hear this isn't out of the ordinary. Thanks for your responses. It's nuts (haha) IMO to expect this to be accomplished in 45 minutes.

I've noticed (when I have time to dig in charts a little) that things are commonly missed due to the rushed process. For instance, last night I noticed a psychotic pt on levothyroxine who is not yet stable post 5 days inpt who has never had a thyroid panel run, even though the admitting nurse stated on the admitting orders than it was done in the ER. And I'm supposed to chart that her hypothyroidism is controlled? OOOhkay.

I know the admitting nurse is a good nurse. Just a mistake caused by too much to do in too little time to do it properly.

Maybe I just haven't found the hidden phone booth where I'm supposed to go change into my Supernurse costume yet!

[FutureNewYorker]

Welllll .... it's comforting to hear this isn't out of the ordinary. Thanks for your responses. It's nuts (haha) IMO to expect this to be accomplished in 45 minutes.

I've noticed (when I have time to dig in charts a little) that things are commonly missed due to the rushed process. For instance, last night I noticed a psychotic pt on levothyroxine who is not yet stable post 5 days inpt who has never had a thyroid panel run, even though the admitting nurse stated on the admitting orders than it was done in the ER. And I'm supposed to chart that her hypothyroidism is controlled? OOOhkay.

I know the admitting nurse is a good nurse. Just a mistake caused by too much to do in too little time to do it properly.

Maybe I just haven't found the hidden phone booth where I'm supposed to go change into my Supernurse costume yet!

I used to be really good at catching this stuff, and understand it's from the rush of things. That's why I used to try so hard to catch it all. However, the nurses from the other shift started to get offended like I was trying to point out mistakes, when I was just trying really hard to cover us all... with the best of intentions. And the nursing supers started relying on me to do their chart checks, never following up my team.... on top of my already heavy work load, you know. Now I just watch out for the safety of my team and take care of what i can and let the rest go... I guess my supernurse costume got to many holes in it.

Oh the joys of transitioning from a graduate nurse to and experienced nurse. hehe

[medsurgrnco, BSN, RN]

My last admit took 3 hours!