Admissions during change of shift

[brokenroads27]

who should take it, the day shift or night shift nurse? im curious about all your opinions. i think it could go either way. where i work, nurses work 6:45 am to 6:45 pm, and then 6:45 pm to 6:45 am. if a pt comes at 6:30, who do you think should do the entire admission? because if day shift takes it, they end up staying WAY past their time. and if night shift takes it, they get piled with work before they even stepped in the door. what do you think is the right thing?

[FlyingScot, RN]

At my hospital the floor won't take report "close" to shift change, so problem "solved".

No... problem dumped on someone else.

[locolorenzo22, BSN, RN]

I'm more than happy if I have a admit at the start of shift, if the offgoing nurse has at least put them on a tele monitor, made sure they're comfortable, done basic orders, and explained that the night nurse will be in as soon as possible. When I see a admit like that, they're first, and I do a head to toe, ask if there are any immediate issues, and explain I'll be asking them a bunch of admission questions a little later.

[hiddencatRN, BSN, RN]

No... problem dumped on someone else.

Hence the quotation marks. It's particularly bad in our busiest season, because that admit staying in the ER for an hour or so after their room is ready means a sick patient who needs a room has care delayed further. We don't always get patients or assignments when they are convenient to us in the ER, and that sick patient who needs a room is just as much of a safety issue imo as a floor nurse starting his/her shift already in the hole from a shift change admit. I realize that the floor intake process is exhaustive and time consuming, but as some folks here have pointed out, some things don't need to get done immediately.

I don't work with anyone who sits on ready roomed patients to spare themselves a new patient. First of all, our charge nurses wouldn't let that fly and secondly, the longer they stay the more the floor team pushes to have floor orders started in the ER, which means the stuff we have to do for the patient isn't done and they're not an easy ride.

[FlyingScot, RN]

Sorry, I misunderstood you! Mea Culpa. I was thinking about this on my way to my trainers and I have more to say but I want my breakfast first!!!!

[beckster_01, BSN, RN]

I understand that the ED is an unpredictable, chaotic, and intense place to work. But I just don't understand how I can call to receive report on a patient at 1530/1600, yet they don't show up on the floor until 1830? Perhaps an ED nurse can enlighten me... On our floor, once the floor room is ready, the ED nurse simply has to go to the computer and put in a request for a transporter to bring the patient to my floor, so it can't be that the nurse doesn't have time to bring the patient, right? My hospital also does an overhead page throughout the hospital for incoming stroke, MI, and trauma patients, so our nurses can't tell me that they were busy getting ready for an incoming trauma if I haven't heard that page. I'm not trying to turn this into an ED vs. Floor nurse argument, just trying to understand how it can take so long to get my patients to the floor in a timely manner.

[FlyingScot, RN]

Okay, breakfast in my belly. So I was thinking about this issue and asked myself who was most impacted by the decision to refuse patients at "inconvenient" times and let's face it...that is what we are talking about here. But let's focus on shift change. The original question was who should do the work of admitting the patient. We are not talking about one of your patients is going down the crapper and can you "hold off for 20 minutes while I do CPR". We are talking about assessment and paperwork and the million other things you must do to get a patient properly admitted. It's a pain, it takes time but what it boils down to is work. So here's who I thought was impacted most. It isn't the nurse who is tired and already busy with wrapping things up or the nurse who wants to transition into her shift without being "dumped" on first thing...it's the patients. It's the independent 95 year old who fell at home and laid on the floor for 12 hours before somebody found her who now has a hip fracture and is lying on a hard ER cart who is being told that her admission is going to be delayed for an hour. As if lying on a hard floor for 12 hours wasn't enough torture. It's the exhausted family members of a patient who has been waiting for hours for a bed to open so they can go home and finally get some rest only to be told they must wait yet some more even though the bed is ready. It's the patient with the severe migraine sitting in a plastic chair in a corridor throwing up in a basin because there aren't any beds for him to lie down in. It's the severe vag bleed which is likely her 4th miscarriage waiting in the lobby for a room to open and having 60 strangers stare at her in her grief as she loses yet another child. It's the C-diff patient who has to use a public bathroom two halls over because that's all we have in the ER and they are too humiliated to use the offered bedside commode. It's the febrile, neutropenic cancer patient who is miserable and lying on an exam table not even a stretcher in a clinic.It's the community where the ambulance is out of service because they are standing in the hallway with their patient on their cot while the staff scrambles to find someplace...anyplace to put the confused little old lady from the nursing home.

Nobody is asking you to stop doing the necessary things to keep your current patients comfortable and safe so you can admit a new one. If that's what you're doing I can try to hold my patient for a few more minutes if at all possible. But a blanket policy of no admits from 6:30-7:30 or whatever has a profound affect on the very patients you went to school to learn to care for. ER nurses on this forum have repeatedly told you that we don't hold patients until shift change in order to avoid getting a new one. We LOVE new patients because we like to start IV's and do EKGs and hook up monitors and push meds. That's the fun stuff for us. Give me a new one 15 minutes before my shift ends. I consider it a personal challenge to get them situated in time for the next shift or shortly after. It's a blast! We've also told you that we have no control whatsoever over when we get a bed. We get a bed...we call report. Half of us aren't even aware of the time and most of us don't even work the same hours you do so we're likely not looking at going home for a few more hours so we don't even have a dog in that fight. If the docs are holding up the patients or bed placement is doing the same then say something about it. Why immediately blame the ER nurses who have no say in it at all? We know your job is hard. We know you are busy. We sympathize with you. But knowing and sympathizing does not stop the patients from coming through our doors and we must make room for them.

[hiddencatRN, BSN, RN]

Perhaps there aren't enough transporters to go around? We are always short on medics and techs so I sometimes have to wait or transport the patient up myself.

[Anna Flaxis, BSN, RN]

I would ask the transporter about that. Maybe there aren't enough of them, or maybe they also transport for imaging studies, or maybe they have other duties as well...

[VICEDRN, BSN, RN]

I'm not trying to turn this into an ED vs. Floor nurse argument, just trying to understand how it can take so long to get my patients to the floor in a timely manner.

Please ask transport that very question. If we wait long enough for transport, we push them to the hall and use the bed for another patient. Naturally, this infuriates the patient and their family. Also, the longer they are there, the more stuff they ask for and I hate that.

I agree with the other ER nurses on here. Every single day I give report to another ER nurse and tell the oncoming nurse that a new patient was bedded to me in the last 45 minutes or so and I haven't seen them as I was finishing the admission or discharge or whatever. Since this happens on nights and days, we are sympathetic to one another and don't judge. (This happens because our MDs also change shifts with us and often hurry and finish work up at 0530 forcing us to admit at 0645). Sometimes we work together if the patient is overly critical.

We also have the same issue with bed management in our facility. When there are not enough nurses on your floor, they simply assign beds right before shift change.

On top of both of these things, you can bet your bottom dollar that a charge nurse is riding our tail feathers about our admitted patients. I have 30 minutes to call report. If you won't take report, I call transport. Facilities that allow a black out for report are endangering the safety of patients in the waiting room of the ER. Up to 1/3 of those patients are potentially admits and a lot of them have been waiting a very long time for symptom relief.

Finally, the tendency is for floor nurses to ask for stuff to be done when their patient has been held in ER for a long time. As mentioned, the patient becomes like a fifth wheel to me when they hold long enough and I don't have time to do floor orders and I won't be doing them though I can understand why you want them done as it is before shift change and thus is another reason I will NOT hold people if I can help it.

[FlyingScot, RN]

But I just don't understand how I can call to receive report on a patient at 1530/1600, yet they don't show up on the floor until 1830? Perhaps an ED nurse can enlighten me... On our floor, once the floor room is ready, the ED nurse simply has to go to the computer and put in a request for a transporter to bring the patient to my floor, so it can't be that the nurse doesn't have time to bring the patient, right? My hospital also does an overhead page throughout the hospital for incoming stroke, MI, and trauma patients, so our nurses can't tell me that they were busy getting ready for an incoming trauma if I haven't heard that page. I'm not trying to turn this into an ED vs. Floor nurse argument, just trying to understand how it can take so long to get my patients to the floor in a timely manner.

Well, perhaps just as the nurse was siting down at the computer to place a transporter request the mother of her 6 month old febrile patient who is next to be discharged comes running out of the room because the infant is purple, shaking and unresponsive. Or the little old man with a cough comes back from x-ray in severe respiratory distress from flash pulmonary edema or the septic patient's BP just took a dump or the psych patient went ape@#$% and is now running naked thru the corridors screaming about aliens, or the chest pain has just gone into v-fib and now is being coded. These are things that aren't overhead paged but are not uncommon occurrences on any given shift. Perhaps the nurse is clarifying admit orders so you don't have to or thinking a second PIV might be of benefit to you. Maybe the patient decided they have to go to the bathroom or were incontinent. There's a gazillion reasons why a delay might occurr but it is unlikely they are willful acts on the part of the ER nurse.

[Do-over, ASN, RN]

I just want to step back in a clarify - I also have no control over when admits come to the floor. I prefer to get my admits between 0100-0400, please and thank you.

I can only refuse if I want to get in trouble"", and I've done that exactly once, because to accept another patient when I already could not adequately care for the ones i had would be stoopid. I told my charge NO, and that if she needed to report that to our manager then there would be no hard feelings.

Believe me, I am not blaming ER nurses. I blame the way floors are staffed. I also blame inappropriate admissions (ICU that should be tele, tele that should be gen med, etc). Heaven forbid we get a little extra help at peak admission times to get the patient settled, history done, orders initiated. Same thing with discharges. I bet satisfaction scores would go through the roof if these two processes were streamlined... for both staff and patients.

[terri2622]

hello, I am currently doing research about "no fly zones/black periods" for facility. is it possible for you to send me a copy of your facilities policy on this topic? thanks in advance.