Change of shift admissions

vintagemother, BSN, CNA, LVN, RN · May 8, 2016

I'm just a student. My experience is as follows regarding this problem.

1st, some nurses work very hard to have the ED pts treated and discharged. Be this to home, a floor, or to another ED unit. I precepted with a nurse who worked like this.

In my experience, after all of her assigned pts and rooms were clear, about 1/2 to 3/4 the way through the shift, she became the break nurse.

On breaks, we would clear out and move along almost every single pt assigned to the nurse we were covering for.

By default, not be design, this would result in sending many pts to the floor late in the shift.

Plus, I sometimes observed a "relief" or float nurse state s/he had nothing to do and when she came to my preceptor, my preceptor would inform her of the pts needing to be transported to a floor.

I guess what I'm saying is that it may not be intentional to send you pts at the end of your shift.

Then again, it might be...I can only speculate on reasons why the other nurses tended to not "turn" and move pts as quickly as possible.

I would never, as a student, presume to know the demands that the ED nurses face that may have prevented them from completing the tasks necessary to move pts to a new area or to d/c them.

I've subscribed to this thread and am looking forward to experienced ED nurses sharing their experiences.

edmst · May 8, 2016

I work in a VERY busy ED in S. Florida (3rd busiest) so I can chime in from experience. I used to work the floors many years ago but I think what the floor nurses don't understand is everything is beyond our control. We only have so many beds and if a critical pt comes in, we have to have a bed available, so the time whether its around shift change or not does not matter to us when sending a pt up. The other day in pre-shift actually, we all commented that miraculously beds open up around 1800 (approximately 15-20 at a time) even though all day nothing was available. We have to send pt's up because we can't tell rescue they cant bring pts because its about to be shift change, so why should the floor nurses get that luxury? You complained about having 4 pt's and then an admission. Try having 5 pt's in the ED. Every order in the ED is STAT. It's not easy doing stat orders for 5 different pt's. At least on the floor the orders are routine and structured...not so in the ED. Pt's that are admitted to the floors are already worked up. They've been triaged by ED, IV started by ED or rescue, blood work completed in ED, imaging(s) completed in ED, and diagnosis finalized in ED.

LadyFree28, BSN, LPN, RN · May 8, 2016

I concur that bed assignment is out of the ED's control, and many days we get bed assignments from 17:30-1850; so in essence, we can have pts sit f0r 8-10 hours waiting for a bed, then if a nurse starts report on the floor, they may not take the admit for another hour, hence making the it sit for up to 12 hours while we continuously get other pts.

Each of the roles are busy, however, in terms of comfort, we really should be thinking of the patients sometimes; I find it frustrating that the pt is sitting for hours when they could be in a room with a better bed, and a quieter atmosphere than the chaos of the ED.

Altra, BSN, RN · May 8, 2016

I was discussing with a coworker the other day the prevalence of change of shift admissions. At our hospital it seems like the ED holds onto the admissions until shift change. Think I'm being dramatic? Nearly everyday we get 5 admits between 1500 and 1600 and at leaSt 3 between 1830 and 1930. Besides how frustrating this is I am wondering if there is any research on if it is dangerous? It increases time in the start of patient treatment and care. During this time we start caring for 4 patients as well as taking on a brand new one. I did not find any research directly related this but was curious if anyone else has? Thanks! (Also please don't make this ED vs. Inpatient unit type of thing.)

I don't want to make it an ED vs. inpatient thing either. :banghead:

So the first thing I want to ask you, OP, is ... when do discharged patients leave your unit? The bulk of them? Is it mid- to late-afternoon? So ... does the daily cycle of patients go home - rooms get cleaned - new patients are admitted then seem more logical to you?

I certainly can't speak for ED operations at your hospital. But I have worked in 3 EDs, and even if I as an individual staff nurse were to somehow set out to "hold on" to my patients until close to the end of shift ... it just wouldn't happen. If there is an inpatient bed assigned -- if I don't get the patient out quickly enough, someone else will. Charge nurse ... float nurse ... anyone who has a free minute.

I hear that these unicorns exist - EDs where there is such poor control of patient flow that nurses, or even MDs for that matter, are allowed to drag their feet. But it just doesn't happen where I work.

Nurse131382 · May 8, 2016

The hospital I work at is considered a smaller hospital. Our patients discharge by noon and beds are usually cleaned within the hour. If this happened every once in awhile it wouldn't be a big deal but it happens every single day. It isn't much better when a patient comes to the floor and due to shift change isn't seen for an hour. The er at my hospital is rarely at capacity. If it was a large and busy ED I wouldn't even question when admissions come. I was just curious on if anyone knew if there was research pointing to the potential danger of this. Again this is not A floor nurse versus ED nurse type of thing. If this is believed to be dangerous what so you guys think are some ways we could fix it for both patient safety and satisfaction?

Boomer MS, RN · May 8, 2016

I don't want to make it an ED vs. inpatient thing either.
So the first thing I want to ask you, OP, is ... when do discharged patients leave your unit? The bulk of them? Is it mid- to late-afternoon? So ... does the daily cycle of patients go home - rooms get cleaned - new patients are admitted then seem more logical to you?
I certainly can't speak for ED operations at your hospital. But I have worked in 3 EDs, and even if I as an individual staff nurse were to somehow set out to "hold on" to my patients until close to the end of shift ... it just wouldn't happen. If there is an inpatient bed assigned -- if I don't get the patient out quickly enough, someone else will. Charge nurse ... float nurse ... anyone who has a free minute.
I hear that these unicorns exist - EDs where there is such poor control of patient flow that nurses, or even MDs for that matter, are allowed to drag their feet. But it just doesn't happen where I work.

Unfortunately, this is a continuing problem. I have read several articles published on "thoroughput", specifically in the Journal of Emergency Nursing, about moving patients to inpatient units more quickly and efficiently. The articles described ways to disimpact their departments. I was not convinced. The ED is the only place where patients can't be kept from coming in the door. One ED where I worked diversion was tried which turned into a global disaster. Ours diverted, another became overwhelmed and diverted and so on and so on.That plan was abandoned. I know of a Level I Trauma Center that goes on divert frequently for everything except trauma because of the great number of trauma patients coming in by ambulance. Other places have instigated a CDU, Clinical Decision Unit, where patients can be held outside of the ED, until a more definitive decision can be made. Seems like a possible solution. But that takes more resources, money and staff.

I did some floor nursing during my career and know what those nurses go through. What I also know is the ED is predictably unpredictable. Sometimes I used to wish that someone in administration would witness and experience having to wait for hours in an uncomfortable ED bed because he/she could not be moved for various reasons. Just not right for the patient.

HouTx, BSN, MSN, EdD · May 9, 2016

Hmm - there is quite a bit of evidence on the connection between mis-communication & patient harm. Handoffs are based on communication - so there is a correlation between handoffs and patient harm.

However, trying to control throughput (patients moving around the hospital) is a daunting task - that involves so many operational functions that it's very difficult to accomplish. If it is true that you ALWAYS have a bump in admissions at specific times of the day, I would suggest that a better approach may be to adjust staffing to accommodate it. Talk to your manager. Maybe there could be an overlap shift or a mini-shift for someone to take care of admissions. It would be worth a shot. Much easier to adjust work times than try to control the actions of other departments.

MedicFireRN · May 9, 2016

I can just say from the ER side at my hospital- once we get admit orders and a ready bed, I call report. I don't pay attention to what time this happens. We are hounded for good throughput times- patients don't like sitting in the ED- our beds are uncomfortable, they want to get settled and get a meal tray, etc etc. I know there are days when for whatever reason, a patient is assigned a bed and its dirty for hours before it gets changed to clean. We try to look at the bed assignments and send pts up gradually if we have 3 or more going to the same unit; but really, when bed board gives us a bed, we are expected to call report and get the pt out of the department within the hour (optimally within 1/2 hour). We have gone to voicemail reports if the nurse for the room is unavailable to take report when called to facilitate throughput. It's just how it is. I try to get things done, but usually when we are slammed and waiting on a bed, there's so much I don't have access to in the ER that is part of the patient's order set without waiting for pharmacy to be able to send it (which often takes a really long time when the whole hospital is busy like that). I don't know of any nurses in my department that purposefully hold admits until shift change. Some days it just seems to be when beds come available. Also have to take into account that we (in my hosp) tend to get an influx of ED patients around 12:30-1, so often this leads to 3pm-ish admissions. I'd be willing to guess that your ED experiences similar heightened check ins after lunch and that leads to your 3-4pm admits.

Jedrnurse, BSN, RN · May 9, 2016

Sounds like a lot of it is a function of when med-surg beds open up, which is often towards the end of day shift.

ontheway2crna · May 9, 2016

I work in a VERY busy ED in S. Florida (3rd busiest) so I can chime in from experience. I used to work the floors many years ago but I think what the floor nurses don't understand is everything is beyond our control. We only have so many beds and if a critical pt comes in, we have to have a bed available, so the time whether its around shift change or not does not matter to us when sending a pt up. The other day in pre-shift actually, we all commented that miraculously beds open up around 1800 (approximately 15-20 at a time) even though all day nothing was available. We have to send pt's up because we can't tell rescue they cant bring pts because its about to be shift change, so why should the floor nurses get that luxury? You complained about having 4 pt's and then an admission. Try having 5 pt's in the ED. Every order in the ED is STAT. It's not easy doing stat orders for 5 different pt's. At least on the floor the orders are routine and structured...not so in the ED. Pt's that are admitted to the floors are already worked up. They've been triaged by ED, IV started by ED or rescue, blood work completed in ED, imaging(s) completed in ED, and diagnosis finalized in ED.

I am an ICU nurse who used to work on the floor and none of what you said is true. Floor nurses get stat orders, their patients may still need imaging or additional IVs, and their diagnosis may be pending if they are waiting for bloodwork, imaging, etc. ED is just the beginning so dont make it sound like you have done all the work for the pt!

Pat_Pat RN · May 9, 2016

I've worked both ER and Med/surg and it IS a thing to admit people at shift change, which is ridiculous in my opinion. As the OP said, it is a safety concern.