Hi to everyone. I need help. After my last three shifts, I have left work so-o-o-o frustrated due to admissions being sent to my floor during the last hour of my shift. I work on a critical care unit, and the paperwork alone needs at least twice that to complete! Last night there were 2 nurses and 1 tech, and 2 admissions came up within 10 minutes of each other between 6:00 pm and 6:15 pm. Report is supposed to start at 6:45. One was vomiting coffee-ground emesis, and the other was pale as a sheet and shaking from hyperglycemia. Neither got the care they deserved, but we did the very best we could, then handed off to the next shift.
There are plenty of reasons NOT to accept a patient during the last hour, but when the Nursing Supervisor and your Charge Nurse say do it, then we have no choice. However, what do other hospital do? Does anyone out there limit admissions at shift changes? I've heard of hospitals that send only emergency admits between 0600 and 0730, then again from 1800 to 2030 . . . but my ER nurses tell me, "That's impossible!" Why is it impossible? Am I missing something? If a patient has been in the ER for 8 hours, why can't they be handled there for another hour or so? Is it just me? Am I barking up the wrong tree?
By the way, I was an ER nurse for 2 years, so I know the Docs are the biggest problem with admission times, not the nurses. Can't they be educated?
Help -- I'm thinking of putting together a research study to help with these times, but I need to know what other places are doing. Thanks for letting me vent!!!!!
This is a very interesting topic to me as a floor nurse, because it is my #1 problem at work. We virtually never get an admit from ER except within an hour of change of shift. I'm not advocating that patients wait unnecessarily in the ER, but I really don't understand why 95% of the admissions from ER have to arrive at these times. Yes, we on the floor could leave some of the admit work for oncoming shift, but there is an unwritten code that whoever receives them gets them admitted, because it is easier for offgoing shift to stay over than for oncoming to try to deal with a new admit when they haven't even seen any of their other patients yet. Not to mention the poor patient, who is usually scared, in pain, etc. I really and truly don't get it, why ER can't sometimes bring patients up at other times as well. And it is very demoralizing to know that no matter how you hustle and how well you seem to be doing, odds are pretty substantial that you will wind up having to stay an hour or two overshift anyway because of late admits. Any solutions?
Maybe ER docs need to go on a different shift schedule from the rest of us. Maybe 5 to 5, so their hustle to not turn over patients will be before the end of our shifts.
It's not the ER nurses!!!!!! Many ER docs are notorious for filling their rooms then holding their admits until the very last possible moment to avoid having to start a new workup. EVERYBODY knows this but we can't do anything about it. In addition the supervisors often hold onto bed assignments and then call them down all at one time. Sometimes this happens because the floor charges don't tell them what beds are open until the very last minute, sometimes the supervisors just wait. Most ERs have a rule that once the bed is assigned there is a certain time limit we have to get the patient upstairs. Believe me when I say that ER nurses don't much relish having to move 4 admit patients up all at once either. Really, it's not a conspiracy against the floor staff by the ER nurses. As soon as we have a bed we try to get the patient upstairs especially when their are 70+ angry people sitting in the waiting room. Some of whom are very, very sick. Also, sometimes we call report and get the patient packaged only to have a code or critically ill patient roll through the door whom we have to attend to immediately. I would try to have someone call the receiving floor to explain the delay but there wasn't always somebody around to do it. Again, it wasn't done on purpose to irritate the floors it just sometimes happens that way. I think the first step in finding a solution is to quit blaming each other for the problem. Take the emotion out of it and try to find a common goal. I would assume that goal would first and foremost be good patient care for ALL of our patients not just the ones in our personal units. We need to get rid of the "unwritten rules" about who is responsible for admission paperwork and write real ones that make sense. How about an admissions nurse who's job is to fill out all of that paperwork? I think there is a solution out there but each of us will have to be able to look past ourselves and our own needs to find it.
Maybe ER docs need to go on a different shift schedule from the rest of us. Maybe 5 to 5, so their hustle to not turn over patients will be before the end of our shifts.
In our place, our ED MD schedules are as follows:
Pediatricians work 12 hours 7a/7p and 7p/7a
"Adult" MD's 7a/4p; 4p/0100; 9p/7a
NP in Fast Track-12/12
So, as stated in a previous post, our problems remain the admission process and the delay of consulting residents assessing patients, then writing their 3 page H/P along with an additional 3 pages of orders. Yikes!
To me, this is a situation where a little flexibility and teamwork can really make the difference. If I get an admit close to the end of my shift, I can at least get them settled in and get their VS and orient them to the unit, and check for any immediate orders. That may be all I have time to do before the end of my shift. If I can do more, I will. But the oncoming nurse needs to understand that I am tired and ready to go home, and that I did what I could and they'll have to pick up where I left off.
floor nurses need to stop complaining about ER admits @ strange times...
i am an ER nurse.. i have worked on every floor you could possibly fathom...
those admits are nothing... NOTHING compared to an admit in a LTC facility...
i work @ one of those too... and trust me... world of difference... every floor nurse out there should bow there heads and thank the nurses that work in nursing homes.. cause those admits are... well.... intense!!!
I never would have thought to complain about the ED nurses regarding this....they get slammed with admits too, and they're doing the best they can down there, I'm certain. We need to work together. Now, the quality of report from some of them is a different story, but I am capable of looking at the patient's H&P and labs for myself, and doing my own assessment, so I don't get as bent out of shape about that as I've seen some nurses.
Specializes in Emergency, Nursing Management, Auditing.
Coming from an ER nurse... I can totally understand why it must be difficult to receive a patient at shift change, but as other posters have said, 9 times out of 10 it's not the ER nurse's fault that the admission happens to be ready at shift change. I can't tell you how many times I've looked at the clock and winced because I know I'm going to get a verbal lashing from the floor nurse for giving report at shift change, but I know as soon as I bring that patient upstairs I'm going to have to start a whole new assessment on a whole new patient that will be replacing the one I just admitted. I work 3p-3a so it's not like I'm trying to dump my patients off at 1900, it doesn't matter to me, but the patients are constantly asking "When can I get into a more comfortable bed?" and the charge nurse is telling me, "You need to get that patient upstairs so we can take in x y and z." So I try to get my patients up as soon as a bed is available and the orders are written. Doesn't matter if it's at 1600 or 1900.
We all need to look at it from all sides; it's usually the admission doc that we're waiting for and we can't help it that it takes him/her a year and a half to write the admission orders only to give them to us at shift change. They're on call so they don't care when the nurses go home. I agree with some of the previous posters; maybe it'd be better for the nurse going off to take report, get basic vitals etc, and leave it to the next shift to do a detailed assessment and deal with all the paperwork so you don't end up staying til 2000. On a related note, I can't tell you how many times I've been about to head out the door and the admission doc decides to give me orders over the phone at 0305 and the charge nurse asks me to pretty please stay til all that stuff is done since I know the patient, and I don't end up leaving til 0345. So I know how you feel, floor nurses... it's a process improvement thing.
I think there should be a 'no transfer, no admit' between 6-8am and 6-8pm. In the end, the most important factor should be patient safety.
I'm all about patient safety, but what aboutall of the patients sitting in the lobby waiting for treatment rooms to be available....and the ambulance patients who are packed, stacked and racked in the hallway waiting for placement....and the incoming helicopter patients? What about their safety? There is no diversion policy for the ED.
Specializes in Spinal Cord injuries, Emergency+EMS.
for many years hospitals worked worldwide on the ED pushing patients into the system ...
in some places this has been changed andthe push is now out the 'back door' via discharge planning , allowing the units to 'pull' patients from the ED to the most appropriate Clinical area...
add in targets to prevent over long waits i nthe ED , such as the original 12 hour trolley wait target (100% of patients do not wait more than 12 hours for admission) then the 4 hours total time in the ED (98.5 % of patients are 'out' of the Ed within 4 hours whether this is admistted or discharged as clinically approrpaite doesn't matter - and those who spend longer in the dept have a full route cause analysis undertaken - although many of the RCAs stop dead when the 'waiting for critical care bed' or 'waiting transfer to off site specialist critical care bed reasons come round).
wards /floors need to look at how they 'empty' and how and when they declare the empty beds to site management - some wards have a habit of not declaring beds until they have several or until the site manager rings round , they then whinge and moan about being hit with several admissions in the space of half an hour ...
Specializes in ICU, CCU,Wound Care,LTC, Hospice, MDS.
Our policy was that the paperwork and admission on any patient who arrived on the floor after 6am, 2pm, 6pm, or 10pm would be passed to the next shift (our reports start at quarter to the hour). The off-going shift would be responsible for getting them settled into bed and taking a set of VS. If there was nothing urgent to be done immediately upon arrival, the on-coming shift took care of things. That seemed to work out very well.
Same here. Get them settled in bed, take vitals and check for stat orders only.
Riseupandnurse
658 Posts
This is a very interesting topic to me as a floor nurse, because it is my #1 problem at work. We virtually never get an admit from ER except within an hour of change of shift. I'm not advocating that patients wait unnecessarily in the ER, but I really don't understand why 95% of the admissions from ER have to arrive at these times. Yes, we on the floor could leave some of the admit work for oncoming shift, but there is an unwritten code that whoever receives them gets them admitted, because it is easier for offgoing shift to stay over than for oncoming to try to deal with a new admit when they haven't even seen any of their other patients yet. Not to mention the poor patient, who is usually scared, in pain, etc. I really and truly don't get it, why ER can't sometimes bring patients up at other times as well. And it is very demoralizing to know that no matter how you hustle and how well you seem to be doing, odds are pretty substantial that you will wind up having to stay an hour or two overshift anyway because of late admits. Any solutions?