At what point of care does the patient become your responsibility????

[loricatus]

I came off a shift from hell and would like to get feedback and opinions from anyone who is kind enough to listen to this saga:

We were short staffed and I was asked to come in 4 hours earlier than my regular shift for that day. Stupid me came in and was assigned 10 patient spots, 7 of them filled on report from the outgoing nurse [normal is 7]. During this shift change, the 3 additional spots were filled by the charge nurse, without my knowledge [in the spots out of direct site, no report, no chart, patient not locked and labbed, some not even registered yet...] and curtains were drawn to hide the patients from my view when I did my initial walk through.

All during the shift, patients were being moved without my knowledge-always when I was in a room attending to another patient. Some of these patients were moved to the floors without advising me when beds became available; therefore, the receiving nurses had literally been given dumps from patients that had my name as the last nurse to chart on them. Other patients were just at tests where I had not been advised were being scheduled. Still others were swapped around from rooms to hall spots. This mix of patients even had a name alert (2 female patients with the same last name and year of birth). Of course I was complaining up a storm at the charge nurse, the assistant manager, the docs, the residents... Oh, and to top it all off, there were no aides due to short staffing and numerous 1:1 needed for a flood of psych patients [thank goodness I didn't get any of them, I just got all the critical patients-seems that the charge nurse was assigning according to themes].

Later on in the shift, I received a code in progress. Wound up being in septic shock and respiratory arrest, followed 15 minutes later (while I was in the room with the resp arrest) an active MI; and, shortly thereafter, by a very active GI bleed. I now had 11 patients, 3 existing patients were moved to who knows where. I yelled out at the charge nurse something like "Are you trying to kill these patients" after she stuck her head in the room with the resp arrest patient and told me that I was now reeiving the GI bleed and had to 'step it up a notch'. Her response was that I was the one who was asking to be informed of patient changes, and 'this is what I get for complying with your request'

There were many patients that afternoon/evening that I had never even seen, even though I ran nonstop the entire shift (and today every inch of my body is stiff and in pain). I told the charge nurse that the septic shock pt was highly unstable and I was staying in that room until she either died [referring to the patient, not the charge nurse] or became somewhat stable (that patient's family was in the room and heard all of this). Later, I was able to assist with the MI and a little with the GI bleed, as no other nurse had been assigned to them. By the time I left, all were alive despite the inadequate care they had been provided.

Now, my question.

Am I responsible for patients that I was never given report on that were put into my assigned area; or, for the ones that I told the charge nurse I could not accept?

Do you have to take whatever is put your way because the rooms (along with whomever may be put into them) are your responsibility (legally speaking) when it comes to emergency nursing? I am so confused at this point and would appreciate it if someone would share their thoughts or knowledge regarding this.

so.....for all those that have taken the time to read this THANK YOU

[Altra, BSN, RN]

{{{{{Hugs Loricactus}}}}}}

I'm not entirely sure of the legalities, but I don't see how you can be responsible for patients for which you've never gotten report, assessed or charted on.

[MAISY, RN-ER, BSN, RN]

YIKES!!! OMG, I would die if I had that kind of assignment. I would check my state laws, speak to your manager, and if unsuccessful contact my BON. What happened to you and the patients was very scary!!!

Off the top of my head, I would say if patient wasn't endorsed to you it wasn't your responsibility. I would also consider writing down everything that happened that day just in case...Good luck and let us know. Also, just a comment-is this charge nurse new, or just stupid?

Maisy;)

[CritterLover, BSN, RN]

why do yo still work there????? from all that you have written, that place just sounds like a dissaster.

i'm not sure where the dividing line is for when your responsibility starts. i know that my er is required to keep room assignment data for several years. if your name is on their charts, then i'm sure you would be held at least partially responsible for anything that happens.

however, the charge nurse is also held responsible.

it is the responsibilty of the charge nurse to assign a patient to a nurse capable of caring for him. it is possible that you were the nurse most capable of caring for those patients at that time. that is something that she would have to justify should legal and/or disciplinary action take place.

[nuangel1, BSN, RN]

first off i am sorry this happened .second you need to protect yourself .you were put in a very unsafe situation and the pts safety was at stake as well.no one in any er should have 10-11 pts .i have worked in 4 ers the most i ever had was 6 .and not 3 critical ps at same time with no help .you need to follow this up the chain of command your nurse manager the supervisor director of nurses ed director etc .if this is a routine thing i say get thee out of there quick protect yourself and your nursing license.

[AngBthatsme]

Call me crazy slap me silly holy crap.........can't believe that you had that kind of day!! First of all if that is at all close to how things are on a regular basis, give your notice and leave that facility. Personally if it was me, I probably would have started vomitting and told the charge nurse I was ill and needed to go home. I would not have done that assignment. Sometimes I read these posts about these awful assignments and patient loads and I cannot believe it. Sometimes I have crazy days, but I have never been in that type of situation. Good luck.

[bigsyis]

I came off a shift from hell and would like to get feedback and opinions from anyone who is kind enough to listen to this saga:

We were short staffed and I was asked to come in 4 hours earlier than my regular shift for that day. Stupid me came in and was assigned 10 patient spots, 7 of them filled on report from the outgoing nurse [normal is 7]. During this shift change, the 3 additional spots were filled by the charge nurse, without my knowledge [in the spots out of direct site, no report, no chart, patient not locked and labbed, some not even registered yet...] and curtains were drawn to hide the patients from my view when I did my initial walk through.

All during the shift, patients were being moved without my knowledge-always when I was in a room attending to another patient. Some of these patients were moved to the floors without advising me when beds became available; therefore, the receiving nurses had literally been given dumps from patients that had my name as the last nurse to chart on them. Other patients were just at tests where I had not been advised were being scheduled. Still others were swapped around from rooms to hall spots. This mix of patients even had a name alert (2 female patients with the same last name and year of birth). Of course I was complaining up a storm at the charge nurse, the assistant manager, the docs, the residents... Oh, and to top it all off, there were no aides due to short staffing and numerous 1:1 needed for a flood of psych patients [thank goodness I didn't get any of them, I just got all the critical patients-seems that the charge nurse was assigning according to themes].

Later on in the shift, I received a code in progress. Wound up being in septic shock and respiratory arrest, followed 15 minutes later (while I was in the room with the resp arrest) an active MI; and, shortly thereafter, by a very active GI bleed. I now had 11 patients, 3 existing patients were moved to who knows where. I yelled out at the charge nurse something like "Are you trying to kill these patients" after she stuck her head in the room with the resp arrest patient and told me that I was now reeiving the GI bleed and had to 'step it up a notch'. Her response was that I was the one who was asking to be informed of patient changes, and 'this is what I get for complying with your request'

As one who has been on both sides of the coin in ER (Charge and Staff) TRIAGE is the thing that is constant. The Staff Nurse must constantly be triaging who or what is next, even if it is subconsciously, and of course respond to the most critical pt first/longest. The Charge Nurse must know her department well enough to know whose pts require more assistance than the Staff Nurse alone can provide, especially if there is more than one very critical pt., and Triage assistance to the needed areas appropriately.

The CN's "thematic" approach makes me want to question her competency to be Charge. What the he77 was she thinking, anyway? Was she wanting to be sure that all of you were subject to legal liability by attempting to load you out with the most dangerously ill pts? Any Charge Nurse in her right mind wouldn't have done that! It is physically impossible to be at the bedside of the septic pt, the actively GI bleeding pt, and the infarcting MI pt. The very LEAST she should have done was to help you with these pts herself, or request temporary assistance from ICU/CCU to loan a nurse until the crunch let up.

As to your question about your liability for pts that you hadn't actually seen-I am not an attorney, but just because they were assigned to you (or even if your name was on the chart as having made the initial assessment and/or intervention) does not make you liable for all subsequent care before they left the ER. If you were protesting and requesting assistance, then multiple staff members knew that you needed to relinquish responsibility for the care of those pts while attending the most critical of yours. If the Charge Nurse didn't make temporary reassignments of the pts then it would ultimately become her responsibility, I would think.

You certainly weren't rewarded in any way for agreeing to come in 4 hours early. I'll bet that you'll think twice before you agree to do that again, huh?

[loricatus]

I so appreciate all the input you have given me. And, a special thanks to you MLOS-a really needed the {{{{}}}}}.

This is the 2nd day off after that unbelievable shift and I really think I am in some sort of PTSD. I keep reliving certain things, like flashbacks, and get anxious thinking about going back to work. I do think it is time to leave this place; and, made a big mistake taking the job in the first place. I recently left another job because of its toxic environment-that's why I hestitated about leaving here. No, this isn't the first time I have had an impossible load; but, the day I described was, by far, the worst. Management is aware of this and chooses to do nothing. Most charge nurses rotate from staff and view the position as one that must clear the waiting room and fill up the ED (they actually line the hall with stretchers and will sit 3 patients on a stretcher)-acuity does not come into the equation. All they do is complain about the nurses who are complaining about them and blame the medical director-it's certainly a passive-agressive thing going on where I work. The BON in the state where I work does not get involved with things like this and it is a non-union facility. It is, very simply, every man for himself most of the time. Although, I do have to say, some of my coworkers are wonderful; and, actually try to help when their workloads calm down. I truly have come to believe that management is hoping that an incident takes place in order to have something to bring to administration to initiate change.

I am trying very hard to avoid the particulars. I will need this job for a reference. I have just decided, after speaking to my husband, to start traveling. Once I find a place that is decent, we will consider relocating there. I already have a few leads and will have to get myself motivated to start the dreaded job searching again.

I really wish I could find out about when the patient officially becomes the particular nurses' responsibility. I know, on the floors, it is once report is accepted. But, in an ED, at times, you may have many nurses attending to a single patient-----who is considered the primary nurse? Many of you have made excellent points regarding this situation. I think that I will advise the charge nurses that they are to take responsibility for a patient until I am ready (or able) to attend to them; and, that I consider notification of my inability to handle more patients a statement of not accepting the responsibility. I will probable be fired, so I better find a travel job quickly.

Funny thing, I just became eligible for my medical coverage from this newish job-my first doctor visit is going to be for anti-anxiety medication from work-related incidents!

[teeituptom, BSN, RN]

I came off a shift from hell and would like to get feedback and opinions from anyone who is kind enough to listen to this saga:

We were short staffed and I was asked to come in 4 hours earlier than my regular shift for that day. Stupid me came in and was assigned 10 patient spots, 7 of them filled on report from the outgoing nurse [normal is 7]. During this shift change, the 3 additional spots were filled by the charge nurse, without my knowledge [in the spots out of direct site, no report, no chart, patient not locked and labbed, some not even registered yet...] and curtains were drawn to hide the patients from my view when I did my initial walk through.

All during the shift, patients were being moved without my knowledge-always when I was in a room attending to another patient. Some of these patients were moved to the floors without advising me when beds became available; therefore, the receiving nurses had literally been given dumps from patients that had my name as the last nurse to chart on them. Other patients were just at tests where I had not been advised were being scheduled. Still others were swapped around from rooms to hall spots. This mix of patients even had a name alert (2 female patients with the same last name and year of birth). Of course I was complaining up a storm at the charge nurse, the assistant manager, the docs, the residents... Oh, and to top it all off, there were no aides due to short staffing and numerous 1:1 needed for a flood of psych patients [thank goodness I didn't get any of them, I just got all the critical patients-seems that the charge nurse was assigning according to themes].

Later on in the shift, I received a code in progress. Wound up being in septic shock and respiratory arrest, followed 15 minutes later (while I was in the room with the resp arrest) an active MI; and, shortly thereafter, by a very active GI bleed. I now had 11 patients, 3 existing patients were moved to who knows where. I yelled out at the charge nurse something like "Are you trying to kill these patients" after she stuck her head in the room with the resp arrest patient and told me that I was now reeiving the GI bleed and had to 'step it up a notch'. Her response was that I was the one who was asking to be informed of patient changes, and 'this is what I get for complying with your request'

There were many patients that afternoon/evening that I had never even seen, even though I ran nonstop the entire shift (and today every inch of my body is stiff and in pain). I told the charge nurse that the septic shock pt was highly unstable and I was staying in that room until she either died [referring to the patient, not the charge nurse] or became somewhat stable (that patient's family was in the room and heard all of this). Later, I was able to assist with the MI and a little with the GI bleed, as no other nurse had been assigned to them. By the time I left, all were alive despite the inadequate care they had been provided.

Now, my question.

Am I responsible for patients that I was never given report on that were put into my assigned area; or, for the ones that I told the charge nurse I could not accept?

Do you have to take whatever is put your way because the rooms (along with whomever may be put into them) are your responsibility (legally speaking) when it comes to emergency nursing? I am so confused at this point and would appreciate it if someone would share their thoughts or knowledge regarding this.

so.....for all those that have taken the time to read this THANK YOU

I feel your frustration

Welcome to the Wonderfull World of ER Nursing

If in your zone yes they are yours.

Rememeber the most difficult step on an arduous journey is the first one.

One step at a time

I have a unit manager who one day asked me if I could speed things up

I told him flat out, Come talk to me on the day you can begin to keep up with me.

He hasnt come talk with me yet.

[crazyrn00]

Oh my gosh, that is a horrible position to be in. I've been in some rough situations in the ER, but none compares to that kind of patient load or that many unstable patients at one time.

I have been in a similar position several times throughout the past 7 years in the same ER, not to that extent. It doesn't happen too frequently (thank God), but it was becoming more frequent. I asked our shared leadership committee to explore the answer to the same question of when care becomes your responsibility. After exploring this issue further, they found no written policy or professional council that could give a cut and dry answer. After I had posed the question, I found that many other coworkers were wondering the same. Our unit decided through discussions with management, charge nurses, staff nurses, shared leadership, and educator that your assigned rooms, patients, etc. becomes your responsibility upon placing the patient in your assigned zone, unless you specifically state that you cannot accept report or the patient and you inform the charge nurse of your situation. The person that places the patient within your assigned rooms is responsible for that patient until finding someone, such as the charge nurse, or another staff nurse to accept care for that patient. If they leave the patient after you refused to accept care without someone to care for that patient, then it is considered abandonment. This was agreed upon and understood by all the nurses in the ER, but still happens occasionally. Fortunately, the abandonment issue has never had to be addressed thus far. Hope this helps.

[beachbum3]

I am a ADN student (3rd semester of 4) and just did my ER rotation and loved it... I always thought that was what I would want to do when I graduate and now I am sure... but I digress.

I'll preface my statement with this: I am only a student, so I don't know much about anything, and know that the real world can be quite different than school. However, in my legalities class we just discussed the issue of when the patient becomes your responsibility. It was when a nurse-patient relationship is established, which is at the point when you deliver any nursing care to a patient. Again, I'm not sure if this is even relevant, but it might be.

Either way, even to me, your load sounds completely inappropriate. I'd definitley suggest filing a complaint and following the chain of command until it gets resolved, and if it doesn't, I'd quit. It seems impossible to be able to give safe care with a load like that and from what they say in school.. its the RN's behind (and license) on the line. I'd document everything and CYA...

I'm sorry you had such a terrible day, and hope that it gets better.

Hope I didn't overstep the boundary by offering my 2 cents, considering I'm just a student, but even to an inexperienced (nearly 30 yr old) baby like me it sounds crazy!

[RNinED]

Whoa, after reading your post all I can think is...I LOVE MY JOB, I LOVE WORKING IN CA. WITH 4:1 ratios and I love working in a rural hospital where the nurses are, overall, treated with utmost respect by the admin. I think it must make a difference that the law requires certain standards of care.

I used to have my beds filled without my knowledge, but now if the charge/triage nurse puts someone on a bed they give me report and/or make the first notes and assure the ball is rolling and the pt is hooked up to monitors, orders, ekg etc. and tell me if the pt can wait for further attention. If immediate attention is required we all jump in or they call the house supervisor. That was one of my big changes at this ED with a certain Triage nurse. She would not listen when I said I was getting too many critical pts or that 1:1 was needed for intubation so I started telling her she had to call the house supervisor because I was tied up in the room with whatever and that pts at risk of injury. If she didn't I would. My license says I am capable and responsible to assess my abilities and reporting unsafe conditions to protect pts. If the BON won't get involved I bet the state would. I would rather be fired for protecting pts than be negligent and hurt someone. bottom line the triage nurse didn't want her behavior to come to light so she adjusted without much noise. good luck with traveling and think about states with reasonable ratios by law.