Change of shift admissions

[kittymom]

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!!!!!

[patwil73]

As a nursing supervisor this is a big pet peeve of mine - when the floors delay admits at change of shift. It really creates so many problems to delay those admits.

At my hospital you have up to 24 hrs to complete the "admission portion" of the admit (that is history, teaching, care plans, etc). You have 2 hours to complete the assessment portion. As the ER has done a basic history, and the doctor is doing his own history that part can certainly be delayed until things are a bit calmer.

However, what happens is the floor thinks they have to assess, take history all in the span of 1/2 hr. If the patient has been sitting in ED for 8hrs they can handle a bit of delay in starting all that work.

Now what I get irritated at the ED for is when they are trying to move patients quickly (to make room for all the ones in triage) that they start sending questionable admits to the floors that really needed a higher level of care - this creates a lot of problems and leads to trust issues and the desire to immediately see the admit that causes the floors not to want to take them on change of shift.

There are no easy answers to solve these problems (trust me I've been on a flow team for the last few months researching and attempting to solve these problems). The hardest part of my job is balancing the needs of the ER with the capability of the floors - overwhelm one and the whole thing comes crashing down.

Hope this helps

Pat

[mianders, RN]

From your post, I do not think patient safety is your concern. Making patients wait in the ER lobby so you can have 2 hours at each change of shift to get ready to take care of them is unreasonable an UNSAFE.

[kittymom]

From your post, I do not think patient safety is your concern. Making patients wait in the ER lobby so you can have 2 hours at each change of shift to get ready to take care of them is unreasonable an UNSAFE.

Obviously I hit some severely frazzled nerves with this post -- definitely not my intention. Mianders, if you'll review my original post, you'll see that I did NOT suggest a 2-hour time frame at each shift change to keep patients away from the floors. I've worked ER and Critical Care, and I am completely aware that patients come first. Having them wait in the ER for 2 hours is ridiculous, and no true nurse would ever condone that kind of patient care.

To all of you that offered some positive suggestions based on what you have experienced, THANK YOU! I'm going to to a lot more research and maybe make a change for the positive. Have a great new year!

[bkleriRN]

Yes true,but I also feel the patients that are already on the floor suffer when nurses get new admissions at the beginning of the shift it is very time consuming. any suggestions for what you do when getting admission at the very beginning of your shift when you havent even been to see your other patients yet??

[Batman24]

We don't take admits during shift change. There is an hour every day where we don't accept them and ER knows and understands this. The change happened before I started and we don't have much prob with ER at all. The change has worked very well from what I hear and what I can see. It seems to have helped the ER nurses as well because they let the docs know when close off time will be and it keeps the patients moving up at a steadier pace versus a total slam.

[PostOpPrincess, BSN, RN]

This won't help you at all, but I have to give you some of the perspective of WHY there's no such thing as what you are asking. I know what you are talking about--the inconveniences, the annoyances, the ridiculous paperwork, but life is imperfect--therefore nursing is imperfect.

Nursing is 24 hours. Bottom line.

I have worked several areas including ICU, ER, NICU, M/S, and now PACU.

There is no such thing as shift report. I only say that (and I understand about patient safety), but when the OR is coming out, it is coming OUT. There is no holding. There is no waiting (if there is, anesthesia has to stay and they don't stay very long). We just DEAL.

When I worked ICU, or the ER Trauma, it could be 6:45 p.m., but when trauma team tells you there is an MVA or a GSW coming--that's it, it is on it's way and there are NO LINES, NO WAITNG. It's a-comin' and you deal.

There is no perfect looking patient either. Sometimes they'd roll in performing CPR and the line gets pulled out by accident. Or how about being on the Code Team and you just walk in on a code and barely get any information except for what is immediately happening.

Such is life. One has to adjust.

I am probably going to get a lot of flack about this, because, honestly, this is the way I was trained and this is the way I look at things. I don't let "paperwork" get in my way. I do what I need to do, and pass it along. Again, nursing is 24 hours. The next shift HAS to pick up the slack. If they don't like it or have attitude, I am very honest with them and tell them like it is, "take over."

It is the way of the nursing world and it is the best way NOT to "lose" it over things that cannot be controlled.

[PostOpPrincess, BSN, RN]

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.

The ER doesn't close it's doors at those times and the OR doesn't stop operating either.

NURSING IS 24 hours.

LEARN to deal.

[Batman24]

Not taking admits for 4 hours a day will never happen. That's excessive. We do not accept them for 1/2 hour on both shifts and it works very well. We get along just fine with the ER nurses and the fact that this is policy helps them keep the docs on time as well. If the ER docs hold them all until the end of their shift it makes it harder on the nurses on both units and often there is no need for it.

[MikeyBSN]

I think the delay comes from different areas in different hospitals. I know very, very few ED docs who wait until the end of the shift to dispo the patients. There might be a small increase in admissions near the end of a shift, but never one that I've noticed. However, I do agree with your ER nurses who say it's impossible to wait 90 minutes to send a patient upstairs. I don't know about your ED, but ours is non-stop busy. The problem with allowing for nice "breaks" when the floor nurses can do paperwork is that the ED patients don't honor break time. Grandma isn't going to wait until 0800 to have her heart attack. If we have 6 admitted patients on various floors and need to wait 90 minutes to send the patient up then that means the patients streaming in the door now have to wait 90 minutes to get a bed. It's not about the ER nurse not wanting to "hold" the patient for another 90 minutes, it's about that guy in the waiting room who just might be having an MI but has to wait 90 minutes to be placed in a monitored bed because the floor nurses want time to fill out paperwork. The most dangerous patient in the entire hospital is the one sitting in the waiting room. The longer the floor nurse holds that bed, the longer that person sits in the waiting area, and greater the chance that your hospital is going to make CNN. That's to say nothing about the patients who need to be examined in a hallway because there is no other bed for them. I would agree with your ED nurses that having patient hold an extra 3-4 hours in the ED is impossible, as in unreasonable and dangerous. I realize the patient doesn't get the best care if they come up near shift change, but most ICU floors are 1:1, 1:2, or at most 1:3. What type of care do you think that ICU patient is getting in the ER?

[wooh, BSN, RN]

I agree 2 hours at each shift is a bit much. I think 30 minutes at each shift so we can at least manage to get report isn't asking too much.

If the patients are safe waiting in the waiting room on the MDs to get their butts in gear at the end of shift, then they're safe letting us have a few minutes on the floor to get report and make sure all of our other patients are breathing. You can't one minute say that the doctors are to blame for them all coming at shift change, then blame the floor nurses because we won't take them quick enough. I've had ER nurses tell me, "They've been waiting all day." Well then 10 more minutes won't kill them. And if the patients in the waiting room are sooooo needy, then the docs down in the ER should have sped up.

I'm generally more than happy to take them IMMEDIATELY. I generally do pretty well at staying caught up enough to take a patient as soon as needed. But if for some reason I need a few minutes, it's not because I'm waiting for my nail polish to dry.

If I could trust that the ER was only sending stable patients, ok. But sending me up a kid without oxygen, not telling me he's there, and when I walk in the room to set it up I find him and his sat is 78%, well then I don't want them showing up when I'm in the middle of report. Sending me up a kid that I'm immediately calling the MD for orders for continuous xopenex treatments because he's hardly moving any air but he's wayyyyy too tachypneic for albuterol, well I don't want them showing up in the middle of report. Yes, nursing is a 24 hour deal, and the paperwork can wait. But actual CARE cannot.

[PostOpPrincess, BSN, RN]

i agree 2 hours at each shift is a bit much. i think 30 minutes at each shift so we can at least manage to get report isn't asking too much.

if the patients are safe waiting in the waiting room on the mds to get their butts in gear at the end of shift, then they're safe letting us have a few minutes on the floor to get report and make sure all of our other patients are breathing. you can't one minute say that the doctors are to blame for them all coming at shift change, then blame the floor nurses because we won't take them quick enough. i've had er nurses tell me, "they've been waiting all day." well then 10 more minutes won't kill them. and if the patients in the waiting room are sooooo needy, then the docs down in the er should have sped up.

*sigh*.

unless you've worked in the er or procedural areas, things can change for the worse before you can even take your next breath. it's not as predictable as that. granted; when a patient is stable and has been waiting all day--a stable patient can wait another 10 minutes--but if there is an unstable patient that needs that bed in the er, that stable patient is coming up.

i'm generally more than happy to take them immediately. i generally do pretty well at staying caught up enough to take a patient as soon as needed. but if for some reason i need a few minutes, it's not because i'm waiting for my nail polish to dry.

if i could trust that the er was only sending stable patients, ok. but sending me up a kid without oxygen, not telling me he's there, and when i walk in the room to set it up i find him and his sat is 78%, well then i don't want them showing up when i'm in the middle of report. sending me up a kid that i'm immediately calling the md for orders for continuous xopenex treatments because he's hardly moving any air but he's wayyyyy too tachypneic for albuterol, well i don't want them showing up in the middle of report.

that is not a stabilized patient and not acceptable to be left alone. i'd be chopping off some heads if someone sent me a kid (respiratory is their biggest issue) like that.

yes, nursing is a 24 hour deal, and the paperwork can wait. but actual care cannot.

it is not copacetic to send an unstable patient to a regular floor. now to an icu...that's a different story. i agree with mikeybsn. that icu patient is not going to get the best of care in the er because the er nurse is going to be overextended as the doors don't close. things need to be done to an icu patient in the continuum of care; it simply is not feasible in an er setting.

the only way i could avoid getting upset about transfers/admits at change of shift was to make sure that i did a quick look at all of my patients before change of shift, and rounds with the previous rn. i prioritized a lot; and that pitcher of water didn't come close to getting there until halfway through my shift (i did primary care when i was on a m/s floor and did everything--tech? what's a tech?)

i just know that the only way to survive those "annoyances" is to accept them and work with them. flexibility is the key to surviving this profession. it is a great coping mechanism, especially when you have a patient who was stable become unstable on you at a drop of a hat. you have to learn to bend when that hard wind blows. if you don't, you will get angry. your b/p goes up, your h/r goes up...your face wrinkles.....who wants that???????

[Virgo_RN, BSN, RN]

Yes true,but I also feel the patients that are already on the floor suffer when nurses get new admissions at the beginning of the shift it is very time consuming. any suggestions for what you do when getting admission at the very beginning of your shift when you havent even been to see your other patients yet??

You tuck them in, do a set of VS, make sure they're breathing and beating, then go check on your other patients. Do your head to toes, VS, any quick meds that are due within the accepted time frame, then go back and finish up your admission.