Change of shift admissions

Simonesays, BSN, RN · May 9, 2016

This is not an ideal situation, for sure, but as others have said it is most likely not an intentional decision made by the ED nurses. There tend to be extenuating circumstances (bed availability, the need to stabilize pts in the ED prior to sending them to a non-critical-care environment, etc.).

However, two things you said jumped out at me:

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.

Eep! As hard as the ED nurses work to stabilize pts and complete orders, emergency-admissions are particularly vulnerable to rapid changes in condition and instability. They need to be assessed and orders need to be reviewed as soon as they arrive to the floor.

Since you said this happens everyday, it is a problem that needs to be addressed. I would bring this up to the manager as a safety issue and propose a swing-shift nurse who could tend to these pts (good suggestion by a previous poster!). We did this at my old hospital and it worked out well.

Other things that I've seen tried are: hallway pts (sending "stable" pts up from the ED to wait in the hall on the floor until one of the planned discharges left), imposing a 'no admissions to the floor during 6:45-7:15' rule, and staggered departmental start times. None of these three things really seemed to work well, though.

Boomer MS, RN · May 9, 2016

I cannot see how having patients board in the hall of an inpatient unit until the bed is ready is feasible, although I've heard it is done. The ironic part is since there is so much emphasis on patient satisfaction, hanging out in the hall would not seem to go over well. Geez....Hanging out in the ED hall is bad enough. The last place I worked our ED shifts were one hour different (i.e., day: 8am-4pm instead of 7am-3pm) from the rest of the hospital. It did not help. Another RN on the floor to facilitate admissions is my solution. Another RN means more $, and that suggestion may not go over well.

The CDU models are where I thought many hospitals were heading, at least at large academic institutions. One thing I never agreed to do was to send a patient up without an oral report. I found that disrespectful of the floor nurse. And I never left a patient without touching base with the accepting RN I spoke with, even if just a smile. Haven't we all heard about or had a patient who crumped after being put in the room?

jena5111, ASN, RN · May 10, 2016

I had never heard of an "admissions nurse" until I started talking with one of our travelers. She was amazed at having to do her own admission(s) on our unit on night shift with five other patients and maybe one tech. She told me her previous assignment had an admissions nurse q shift to do the history and medication reconciliation for new patients.

As a new nurse of nearly five months, I've only ever known doing my own admissions so...it's just what I do. But I've noticed that we pick up most of our new patients toward the beginning of night shift or toward the end.

On my last shift, I picked up a new admission at 0530. Not a big deal in and of itself. But considering that I had to grab vitals and weights, field critical lab value calls, and tend to the "waking up" needs of five other patients in that same moment, it was a challenge. Especially since a new admit MUST be seen immediately and carefully assessed to avoid the crumping referred to by another poster on this thread.

Is there a perfect solution to shift-change admits? I don't really think so. My hospital's ED is the busiest in my city, so I don't think those nurses have a ton of control over when they send patients to my tele floor.

Honestly, better staffing on MY unit would help the most--another tech to do VS/weights/provide turning assistance and maybe an admissions/tasking nurse on nights. Heck, even knowing we'd have a dedicated unit secretary every night (rather than the charge with her own patient load answering call lights/phones and assembling charts) would make a big difference.

Rionurse92 · May 10, 2016

concur, I work in one of the busiest ER's in LA, beds magically appear for inpatient between 6-7 pm, and of course when I come onto shift I have 2-3 pts that I have to call to give report and transfer immediately, way out of my control!

gonzo1, ASN, RN · May 10, 2016

I work ED and ICU. In the ED you are expected to get your pt out and to the next bed ASAP, usually within 30 minutes. There is always a charge nurse asking why you haven't gotten the pt to the floor yet. So while there might be a tiny bit of sandbagging done by some doctors/nurses it isn't as much as you think. Patients come and go throughout the shift and of course some of that happens at shift change. It sucks and we all hate it, but it is, what it is. Admission and discharge nurses are a great idea, but most places won't pay to have them.

**canoehead, BSN, RN** · May 10, 2016

Where I work now there is rarely an available bed, getting someone out within the hour calls for balloons and glitter. I worked an ER in the past that tended to send all their admits up between 1700-1900. The problem was that the ER doc would determine patients needed to be admitted, but the family doc would need to write the admission orders. Family docs would finish their office hours around 4pm, and come over to round and write orders. We'd get the final orders between 5 and 6pm, so the floors would get hammered just before shift change. It was ridiculous, but no one had enough drag to make the docs change.

MedicFireRN · May 11, 2016

Where I work now there is rarely an available bed, getting someone out within the hour calls for balloons and glitter. I worked an ER in the past that tended to send all their admits up between 1700-1900. The problem was that the ER doc would determine patients needed to be admitted, but the family doc would need to write the admission orders. Family docs would finish their office hours around 4pm, and come over to round and write orders. We'd get the final orders between 5 and 6pm, so the floors would get hammered just before shift change. It was ridiculous, but no one had enough drag to make the docs change.

This is also an issue- the ER doc may make the decision to admit, but sometimes it takes hours for the inpatient doc to come see the patient and then even longer for them to actually put their orders in on the patient. We can't send up a patient that has absolutely no inpatient orders yet.

I also forgot to mention that at our hospital, the stat and now orders input by the hospitalist are the responsibility of the ED nurse prior to sending up the patient; as are time sensitive orders if they are going to be more than an hour late by the time the patient gets settled on the floor. For the most part, we get these done unless it's a med we don't stock in the ED (because we aren't holding the pt in the ED to wait on the med from pharm unless its an antibiotic or something similar that affects a NPSG).

XNavyCorpsman · May 13, 2016

I had the same complaint. When I am about to end my shift and we get an admission, I at least do an ABCDE on them and then leave the rest for the next shift. Even at the very beginning of the shift at least do the ABCDE and then go back and do the full admission.

_Andvari · May 14, 2016

When I started charging on my former unit (medsurg/PCU), I was in constant contact with the individuals that decide bed placement. Through casual/ under the table conversations, I found out many things about the hospitals inner workings... One of which is: the flood of change of shift pts is *sometimes* related to the admitting physicians and their schedule. If the daytime hospitalist is nearing the end of their work day, they may delay certain things so that they don't have to assess and write admit orders for that patient. Aka- they want to leave it for the oncoming doc!

edmst · May 14, 2016

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!

Really? Have you worked in an ED where in a 12 hour shift the ED will see almost 200 pt's? I doubt you have by your response. Floor nurses can get stat orders but for the most part, everything is structured and routine. Big deal if a floor nurse has to start an additional IV...Not sure what hospital you work at but a pt does not get admitted to the floor without a diagnosis (your statement seems odd because in all my years and hospitals I've worked in, a pt cannot be ADMITTED without an ADMITTING diagnosis. Really odd statement you made). And like I said, yes, there can be an occasional stat order however EVERY single order in the ER is stat and everything is timed. A chemo pt with a fever: the whole triage has to be done at bedside, whole rainbow has to be drawn (6 tubes), blood cultures x 2, lactic acid, urinalysis/urine culture has to be collected and antibiotics have to be started and all has to be done within an hour or its considered a "fallout" from CMS. Mind you, this is with 3 other pt's with severe chest pain, abdominal pain/blood transfusion/stroke/seizures. I never said we did all the work for the pt but we do work up and stabilize the pt. Again, I'm not sure what hospital you work at but at my ER, we cannot send up an unstable pt.

XNavyCorpsman · May 14, 2016

I have had pt come to my floor without results from flu swab, later determined to be Pos. I have had pt come to my floor with a pulse of 150 and resp in the 50's. The other day I had to call the Nurse Supervisor the stop the ER from sending a pt to us until the flu swab results came back because the only bed left was with another pt. And get this, this pt was the only one in the ER at the time. You have to weigh each circumstance.

SC_RNDude · May 14, 2016

Really? Have you worked in an ED where in a 12 hour shift the ED will see almost 200 pt's? I doubt you have by your response. Floor nurses can get stat orders but for the most part, everything is structured and routine. Big deal if a floor nurse has to start an additional IV...Not sure what hospital you work at but a pt does not get admitted to the floor without a diagnosis (your statement seems odd because in all my years and hospitals I've worked in, a pt cannot be ADMITTED without an ADMITTING diagnosis. Really odd statement you made). And like I said, yes, there can be an occasional stat order however EVERY single order in the ER is stat and everything is timed. A chemo pt with a fever: the whole triage has to be done at bedside, whole rainbow has to be drawn (6 tubes), blood cultures x 2, lactic acid, urinalysis/urine culture has to be collected and antibiotics have to be started and all has to be done within an hour or its considered a "fallout" from CMS. Mind you, this is with 3 other pt's with severe chest pain, abdominal pain/blood transfusion/stroke/seizures. I never said we did all the work for the pt but we do work up and stabilize the pt. Again, I'm not sure what hospital you work at but at my ER, we cannot send up an unstable pt.

Whoa, easy there.

I think the point was that not everything "structured and routine" on the floor like you think.

Yes, we do get 200 or more patients down in the ED sometimes. And, 75% of them aren't really that sick. And, the floor has a lot of their own stuff to deal with that the ED doesn't, often with fewer resources, in my experience. And, most of the patients are actually sick.

Yes, we like to think we are bad asses down in the ED. But, let's not pretend the floor is a picnic.