Admit orders

Ninaer · Jan 6, 2009

Well, I only do the now or stat orders...unless it is detrimental that the patient have the other orders done, will leave it for the floor. However, if it's going to be more than an hour for them to go upstairs I'll give them what i feel is beneficial for the patient.

If it is my only patient and its slow, I will start the admit orders as well as do the admission data base.

But truly, those admit orders are for the floors. We have done our ER orders. However, we are responsible for state or now orders.

This is just my opinion

Have a nice day.

Blee O'Myacin, BSN, RN · Jan 6, 2009

It really depends. If there is a delay (usually is) - I'll see what I can start. We also have admission nurses who stick primarily to the ER to do the admission databases. That has been a huge help in improving relations between the ER and the floor. I just make sure that all STAT and "now" orders are done. But if our ED doc orders a NSS bolus and the maintenace fluids are something that the pharmacy has to mix then I at least fax the order so it will be ready for the floor nurse. We have more of an issue of beds becoming available at 1730 - and are clean and ready at 1815 - and we have to transfer the patient, admin wants them up within a half hour of the bed being assigned (wish they'd let the poor nurses on the floor know that - and housekeeping, as it stands, we are the "bad guys") - causing a great deal of tension. We really can't sit on them until 1945.

pererau · Jan 6, 2009

I do whatever will not delay the transfer. Transition orders are actually (at least in my experience) not meant for the ER but rather for the floor while waiting for the admitting doc to see the patient and start orders. Anything I do in the ER from the orders is a gift.

That said, I always look the orders over and see what I can do given the situation, because in the end we are a team trying to help the patient, and not two teams playing a championship game against each other.

kmoonshine, RN · Jan 6, 2009

I will complete all the ED orders to the best of my ability (if there's 2 antibiotics ordered and the first one is still infusing, I obviously can't start the second in the ED; but I'll send up the second abx with a seperate order sheet signed by our ED doc). I will usually send pts to the floor with a running line, even if its just 25ml/hr UNLESS the IV happens to be in the AC (if its in the AC, I usually just cap the line unless fluids are ordered because when the IV pump beeps it drives me NUTS).

If an admitting doc calls by phone and wants to give orders, I'll take them. But, I'm not going to start anything because they are meant for the floor (VS q 8 hrs, tylenol 500mg q 6 hrs for fever >100.4, etc). When our ED docs call the admitting doc for admission, they will ask the admitting doc if there's anything else to order for the pt while they're in the ED (such as lovenox). So, anything the pt needs right away is taken care of before they go to the floor or before the admitting doc writes/gives formal orders. I've also had admitting docs come to see the pt in the ED to write orders and on a few occasions I've asked the admitting doc to write an order for IV pain meds before the pt goes to the floor - this has only happened a few times and its usually because the ED doc is just being a jerk and witholding pain meds.

Pt care is continuous and I will try to anticipate anything that the pt will need prior to transfer. But, I'm not going to hold them in the ED to complete everything unless it is something lifesaving (such as starting a blood transfusion when the blood bank is ready with the first unit of PRBC's). ED nurses run on "now now now" mode and so many admitting orders do not need to be given "now" - and waiting until the pt goes to the floor isn't all that big of a deal. But, it is a big deal if a pts truly needs something ASAP and I do my best to start those types of orders (such as IV abx to meet the timeframe for pneumonia admission).

We do have a "float" admission nurse who comes to the ED to start the admission paperwork for the floor. Usually it takes at least 45 minutes to get a floor bed assigned (and this is on days when the hospital has open beds), so when the pt is in the ED for more than an hour the float nurse sure gets a lot of paperwork done. They will take care of getting admission orders, give admission meds, restart IVF as ordered by the admitting doc, etc.

I personally feel that when a pt is admitted, it is my job to make sure their VS are up-to-date (including blood sugar if applicable), give meds ordered in the ED, make sure the pt has a patent IV, complete the med rec to the best of my ability, treat the pts pain prior to transfer (esp. for pts with hip fractures), act on my nursing judgement ("hey ED doc, how about running a lactate on this pt"), and to give accurate report as well as make sure all the necessary copies are sent to the floor with the pt. I don't want to "surprise" the floor nurses by sending them a pt who is hypotensive and febrile with a low blood sugar and an IV that has infiltrated, but at the same time I don't feel that it is my responsibility to start admission orders when there is a bed ready for a stable pt.

Perhaps you should see if some of the floor staff can "shadow" in the ED for part of a shift to get a better idea of why we do what we do (and have the ED staff "shadow" on the floor). I meet so many nurses who try out the ED after many years of floor nursing, and they are amazed at how busy we are. I currently work with one nurse who had been on the floor for 10+yrs, and she always says "I don't know how you guys do it ... I mean, we're busy on the floor but its nothing like this ... ".

Floor nursing and ED nursing are truly very different; neither is superior over the other, but please understand that its hard on ED nurses when we are blamed for every little thing that we didn't do. Yeah, I maybe didn't complete the med rec on your pt, but it was because I was cardioverting another pt; but, at least I put in stat orders for a PCXR for your pt, which showed pneumonia even before our doc assessed them - which therefore allowed us to deliver IV abx within 1 hr of presentation to the ED...

JD228 · Jan 7, 2009

appreciate it,,,,,

nursej22, MSN, RN · Jan 7, 2009

Our ED does start a very few of the admit orders, but I am not sure why some are done and some are not, mostly because the RN who gives report and the transporter usually do not know anything about the patient except what is on the chart. But for the most part they do their orders, we do ours.

A frequent scenario: pt with afib and rapid ventricular response. ER doc writes for diltiazem 5 mg IV prn HR >110. Pt gets a couple of doses, HR down to 70 and sent to floor with order for dilt. gtt. On arrival, HR 150, bp 80/50 and chest pain. It can take an hour to get the dilt gtt from pharmacy. So at the same time we are doing assessment, addressing bladder issues, answering family's questions, orienting to room, answering phone call from pharm about weight and allergies (sorry, haven't had time to document yet), we have to call admitting doc for something to stabilize pt until dilt. gtt gets there.

I have asked that ED fax admit orders to pharmacy to try to cut down on wait for meds, but I don't see that happening anytime soon. It took 2 hours once to get an insulin gtt for an ED admit with blood sugar in the 600's. Nothing else for BS ordered in ED. Pt was there for approx. 4 hours.

And I am not flaming the ED nurses. I know they are busting their hinies (sp?) down there. From my few visits there (floated once and there with family) the docs have their own way of doing things and can be very nasty to a RN who is too proactive or pushy.

Ninaer · Jan 7, 2009

Our ED does start a very few of the admit orders, but I am not sure why some are done and some are not, mostly because the RN who gives report and the transporter usually do not know anything about the patient except what is on the chart. But for the most part they do their orders, we do ours.
A frequent scenario: pt with afib and rapid ventricular response. ER doc writes for diltiazem 5 mg IV prn HR >110. Pt gets a couple of doses, HR down to 70 and sent to floor with order for dilt. gtt. On arrival, HR 150, bp 80/50 and chest pain. It can take an hour to get the dilt gtt from pharmacy. So at the same time we are doing assessment, addressing bladder issues, answering family's questions, orienting to room, answering phone call from pharm about weight and allergies (sorry, haven't had time to document yet), we have to call admitting doc for something to stabilize pt until dilt. gtt gets there.
I have asked that ED fax admit orders to pharmacy to try to cut down on wait for meds, but I don't see that happening anytime soon. It took 2 hours once to get an insulin gtt for an ED admit with blood sugar in the 600's. Nothing else for BS ordered in ED. Pt was there for approx. 4 hours.
And I am not flaming the ED nurses. I know they are busting their hinies (sp?) down there. From my few visits there (floated once and there with family) the docs have their own way of doing things and can be very nasty to a RN who is too proactive or pushy.

Now this is unfortunate. First of all after one gives cardizem, one must follow with the cardizem drip thereafter, regardless if this is an admission order. In our ER, we document all the allergies,weights, and med reconciliation sheets. :yawn:

nursej22, MSN, RN · Jan 7, 2009

Now this is unfortunate. First of all after one gives cardizem, one must follow with the cardizem drip thereafter, regardless if this is an admission order. In our ER, we document all the allergies,weights, and med reconciliation sheets.

For the patient I received like this (this has happened more than once) the ED nurse seemed unaware of the short half-life of dilt, and stated she only had orders for the 5 mg doses. :confused:

There are nurses that do the med rec sheets and enter the nursing history in the electronic record while the pt is still in ED, but they are not part of the ED staff, who documents only on paper. Pharm depends on the computer for weights and allergies. This doesn't get entered until pt reaches the floor.

Any attempts on the part of the floor nurses to change this with the view to improving to improving pt care is met with immediate

push back. :banghead: "Your have to give ED some slack because pick your reason: so busy, pts backed up in the waiting room, traumas coming in, lots of new hires, travelers, we under going a remodel, shift change, short-staffed, full moon, blah, blah, blah," every shift, every day.

But I think these are mostly excuses for poor pt care delivery on the part of the docs, pharmacy, and administration, not the nursing staff. And another example of trying to pit the nurses units against each other instead of giving us enough staff!!! :twocents:

TraumaNurseRN · Jan 7, 2009

We have had some conflict at work about what exactly the ER staff will do on admit orders versus what the floor can do once the patient arrives. What admits orders do you routinely perform when there is a bed available for the patent to be transferred too?
(Obviously, stat and now orders) but what other things do you need to get completed before transferring?
Ex. some staff starts Maintenance fluids, some don't- the floor nurse(where I work, not speaking for everyone) tends to complain if the patient hasn't had everything done for them. We are trying to streamline the process and avoid delays in transfers.
Thanks for any suggestions.....

We complete the stat and now orders and that's it. (Normally they have been ompleted anyway in the course of the ER visit. Cultures, ekg,IV etc.There is plenty of work to be done preparing the patient for admission and our management tends to favor us taking care of what we are responsible for rather than the non-emergent admission orders. It's my understanding that it does take awhile to admit a patient, but for us to perform their admission orders takes us away from the emergency orders that are right in front of us...all the time.

kmoonshine, RN · Jan 8, 2009

ER doc writes for diltiazem 5 mg IV prn HR >110. Pt gets a couple of doses, HR down to 70 and sent to floor with order for dilt. gtt. On arrival, HR 150, bp 80/50 and chest pain. It can take an hour to get the dilt gtt from pharmacy. So at the same time we are doing assessment, addressing bladder issues, answering family's questions, orienting to room, answering phone call from pharm about weight and allergies (sorry, haven't had time to document yet), we have to call admitting doc for something to stabilize pt until dilt. gtt gets there. quote]
That is so wrong! If a pt responded well to cardizem bolus, then they should be on a drip to maintain their HR between certain parameters. I know the pt received some meds prior to transfer, but I wonder how long the pt's HR was 150.
We have docs next to us in the ED, so its easy to say "hey frank, i need you to write for xyz". Its unfair to send an unstable pt to the floor just because no one caught on to starting the drip prior to transfer. What if the pt needed to be cardioverted, or what if their BP took a turn for the worse? It just reiterates my responsibilities:
make sure the pt's VS are up-to-date (including blood sugar if applicable),
give meds ordered in the ED
make sure the pt has a patent IV
complete the med rec to the best of my ability
treat the pts pain prior to transfer (esp. for pts with hip fractures)
act on my nursing judgement ("hey ED doc, how about running a lactate on this pt")
give accurate report as well as make sure all the necessary copies are sent to the floor with the pt.

Trauma Columnist · Jan 8, 2009

Has usually depended on what type (how busy) the ER is and that seems to determine what is done. At the level one where I worked, only stat orders were done. At the community hospital where I now work, stat orders are done and there is an admissions nurse that comes and does the med rec, the admit data base and sometimes even transports.