Change of shift admissions

Guest219794 · May 14, 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.

Ding ding ding.....

Same in one facility in which I work.

I also have seen very little foot dragging by ER nurses. From my point, I hate having responsibility for admitted PTs, as do most of my peers. And even if I figured it as a way to ease my workload, my peers and charge would be on me like stink on C-diff.

As far as the OP question, even without any research, it is clearly a bad practice. But, given a choice of shift change admits vs clogging up an ER, it may be the safer option.

And, there is some research:

Pen State

AHRQ

Last but not least, I would like to thank whoever used the term "disimpact" to describe the process of getting a PT out of the ER. It is visual and poetic.

NurseSpeedy, ADN, LPN, RN · May 14, 2016

Shift change seems to be the witching hour, what causes it is a multitude of factors. I worked the floor for many years and I spent a few 12 hour clinical shifts for my RN program not too long ago in a very busy ER. I will say those poor nurses couldn't hang onto those patients if they wanted to...patients in the hallway inside the ER, being worked up from their chairs in the ER waiting room because there wasn't an ER stretcher bed available, and heck, I would transfer one patient to the floor and come back 10 minutes later and wonder where half of the patients were because there were new people in the beds that were not the same as before I left!

I worked flex pool for a hospital years ago. This meant I went wherever they needed me the most. When things got hairy I would sometimes be pulled off of my assignment to go to the floor that was getting hit the hardest with admissions and work as the "helper". I would take care of the admits (RN had to cosign since I was an LPN but at least wasn't stuck with a new patient PLUS a crap load of paperwork and stat orders to carry out), give an IV push, start a new IV site, etc. Basically, I was the admit/PLEASE HELP! nurse sent to the floor that was having the shift from hell. I don't know how many hospitals do this, but the little community hospital that I worked for utilized flex pool staff this way when necessary.

edmst · May 14, 2016

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.

I've worked the floors for quite a bit, along with CCU and neuro ICU. If you think the floors are not "structured and routine" then you'd be in for a surprise in the ED.

SC_RNDude · May 14, 2016

I've worked the floors for quite a bit, along with CCU and neuro ICU. If you think the floors are not "structured and routine" then you'd be in for a surprise in the ED.

I work in the ED, where there is plenty of structure and routine, like chest pain orders, neutropenia w/fever orders (as in your example), etc.

And, a lot more resources available then what I had on the floor.

ScrappytheCoco · May 14, 2016

I've worked tons of ERs of all sizes, in 2 different states, and it literally never fails that there are no beds all day, or a bed appears at 1600-1700. The hospitalist goes in (finally) and places orders at 1800. By the time I do any stats that he's ordered and find someone to babysit my other 4 patients (some of whom could be ICU admits or have stat orders as well) and find a tech to help me transfer the patient once we're on the floor, it's 1830. There are ESI level 2's coming in droves by ambulance and flooding the waiting room. The admitted patient has somewhere to go, and we need to flow patients. It's a safety concern.

Additionally, I feel like as ED nurses we're not quite as sympathetic as other floors when it comes to admissions. We don't get to tell EMS "Sorry, no STEMIs right now, it's 1900, you'll have to wait till 1945." I understand that we're all busy but I promise at least on my end it's not vindictive, it's just what happens.

anchorRN, BSN, MSN, RN, APRN · May 16, 2016

I'll chime in here. At my last duty station I was a house supervisor at a roughly 300 bed military medical center during my last 1.5 years of my tour there. I can assure you that there are ED nurses who hold onto patients til shift change and then try to rush them up to the floor (dont have to give report to the oncoming ED nurse on a patient you just rolled upstairs), and there are just as guilty floor nurses who dont get their empty rooms turned over (cleaned, stocked, etc after a patient discharge) to accept an admission in a timely manner either. My job as house supervisor was crazy as HELL at the 1900 shift change. I think i have PTSD from it. Charge nurse on the floor calling to complain about the ED sending a pt at shift change and the ED charge calling to complain about the floor not taking report. That was possibly the worst job i've ever held as a nurse and thank god I'm stationed on a ship now and not in a hospital.

I'm not trying to say this is all-inclusive of all ED/Floor nurses, obviously thats not the case. But there are definitely some bad apples out there. This is from first-hand experience managing all the beds in a hospital.