ED Admissions Right At Shift Change

[chordringer]

Hello everyone -

I am interested in getting some feedback on a problem we incur rather routinely at our hospital: ED admissions right at shift change. I currently work on a Surgical ICU Stepdown unit and our patients aren't always the most stable bunch. Oftentimes, a patient report called to us from the ED will be from a task nurse or someone who has not had a chance to thoroughly assess the patient. They are instructed by their charge nurse to call report. Usually the only information given is what we can view from the EMR ourselves (lab values, time of ED admission, etc.), but nothing that would resemble a full head to toe assessment.

This is complicated by the fact that the patient is usually dumped on us within the 20 minute window surrounding our shift change (when nurses are typically in report at their other patient's bedside). We do not have techs on our floor and usually have a 3:1 Nurse to patient ratio (which is more than enough given how complex they usually are).

The concern that many of us have is not so much the admission itself, but the manner in which we may not have a full idea about what the incoming patient might have in terms of acuity, and how we are not able to effectively tend to our other two patients during the immediate time of admission. There have been too many instances where an admission might require one to two nurses working on that admission due to the emergent necessity of interventions, and the other two patients (who possibly might have just as much acuity) are sort of left hanging.

Does anyone else have problems that are similar? And if so, how has the situation been addressed at your hospital? We have obvious ideas on how to improve this problem and make it easier for everyone involved, but it's not as easy to get addressed as it would seem. So, I'm trying to research and see if there are similar issues out there and to get input.

Any and all comments welcome!

Thanks,

Jason, RN

St. Louis, MO

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

Have you asked the ER staff about the timing? From my experience in ER's, we don't want to keep patients any longer than we have to because it makes a lot of extra work for us caring for these patients while they tie up beds which could be used for patients in the waiting room. Typically, the patients are there for hours waiting for the attending. The attendings finish their office hours, then cometo the ER and write orders for all these patients leading to a bolus of amits for the floors, usually at shift change.

As for report, there's no excuse for a bad report. Continuity of care is lost and the patient endangered. That's a serious issue your manage should help you with.

Hope this helps.

[Esme12, ASN, BSN, RN]

A problem as old as the medical institution itself!

[LegzRN]

Jason,

In my hospital it has become policy for the primary nurse to call report, and then physically bring the patient to the floor to give a mini bedside report when being admitted to the "unit" (SDU, CCU, ICU). Maybe working to institute a policy like this could be beneficial.

As for the "dumping" of patients at shift change. The flow of patients to the ED doesn't stop at shift change. For example, say I come on at 7p and receive report. There is a patient in room 12 who is being admitted and they just received a bed and the waiting room is rolling 20 deep. I know that the nurse I'm taking over for is really scheduled until 7:30, so I see if she'll call report. If she will and the floor will take report, they'll get a detailed description of the patient full of information. If she won't call (rare) or the floor won't accept it (not so rare), then prepare for a less than stellar report.

[mentalhealthRN]

Not that I have worked with this directly but the largest hospital here has what they call an admissions team. They hire nurses and techs for this team specifically. The nurses have to have ED and/or ICU experience and the techs work along side them to assist. This teams job is just admits. I believe they have two admit teams. One for all of the ICUs (they have several) and one team for the med/surg units. I am not sure of their hours but they are responsible to go to the ED or unit the pt is being transferred from and they do the who transfer and admit. The paperwork and the hands on stuff. For example if a pt in the ED is getting admitted to the floor they go and find the nurse assigned in the ED and get a brief report and the admit nurse takes over from there. Does any paperwork needed for the transfer to the unit, assures there are admitting orders. Physically with the help of the admit tech takes the pt to the unit. Gets him/her settled. VS, starting a line, putting in a foley, getting on the tele leads, whatever. She takes off the admitting orders onto the care pathway. Admitting labs. Starts fluids, PCA. Anything. Does an initial assessment and then once settled gives the floor nurse a report. This gives the floor nurse some breathing room that the new pt is stable and not needing anything immediately anyways. The nurses seem to love it. Both the floor nurses and the team that works just doing admits all day and night. They staff if 24/7. I think there are fewer nurses on nights then days/eves but they always have people working admit team. Kinda like a code team. And like I said they have their own techs to help which works well too to run around and get all the stuff the new pt needs......linens, pillows, bedpan, whatever and they can help with other things if trained and allowed. (phlebotomy, cath, EKG, etc.) which is why they get techs from the ED and ICUs for these teams. This whole thing seems to work well for everyone and the patient care during a transfer/admit overall is better. I would maybe talk to your hospital DON about the idea. The other thing they do sometimes if admits are slow is help with discharges.

[Orange Tree]

ED or anyone else (PACU, dialysis, etc.) is not allowed to send patients to our floor between 6:45 and 7:30 (AM & PM). Attempts are made once in a while, though.....and depending on circumstances, they are sometimes successful.

[RNMeg]

mentalhealthRN, do I ever wish we had a system like that! It would solve SO many problems. My hospital is broke as it is, though, so I can't see it happening any time in the near future.

[LegzRN]

Not that I have worked with this directly but the largest hospital here has what they call an admissions team. They hire nurses and techs for this team specifically. The nurses have to have ED and/or ICU experience and the techs work along side them to assist. This teams job is just admits. I believe they have two admit teams. One for all of the ICUs (they have several) and one team for the med/surg units. I am not sure of their hours but they are responsible to go to the ED or unit the pt is being transferred from and they do the who transfer and admit. The paperwork and the hands on stuff. For example if a pt in the ED is getting admitted to the floor they go and find the nurse assigned in the ED and get a brief report and the admit nurse takes over from there. Does any paperwork needed for the transfer to the unit, assures there are admitting orders. Physically with the help of the admit tech takes the pt to the unit. Gets him/her settled. VS, starting a line, putting in a foley, getting on the tele leads, whatever. She takes off the admitting orders onto the care pathway. Admitting labs. Starts fluids, PCA. Anything. Does an initial assessment and then once settled gives the floor nurse a report. This gives the floor nurse some breathing room that the new pt is stable and not needing anything immediately anyways. The nurses seem to love it. Both the floor nurses and the team that works just doing admits all day and night. They staff if 24/7. I think there are fewer nurses on nights then days/eves but they always have people working admit team. Kinda like a code team. And like I said they have their own techs to help which works well too to run around and get all the stuff the new pt needs......linens, pillows, bedpan, whatever and they can help with other things if trained and allowed. (phlebotomy, cath, EKG, etc.) which is why they get techs from the ED and ICUs for these teams. This whole thing seems to work well for everyone and the patient care during a transfer/admit overall is better. I would maybe talk to your hospital DON about the idea. The other thing they do sometimes if admits are slow is help with discharges.

This is such a great idea.. love it! No idea how a lot of us could get management to give the okay... too much $$$ and rooms needed, but a guy can wish...

[classicdame, MSN, EdD]

We did a root cause for this and found that one of the ER docs was stacking up the charts, then charting and discharging to the floor all at once. Created stress for nurses in both units. Once the CEO got involved that has improved. Now the ER nurse faxes a report to the receiving unit (phone reports required both nurses to be free at the same time and bedside meant the ER nurse had to leave other patients in ER for a period). The faxed report suffices in many instances. The receiving nurse may end up calling for clarification. I think bedside would be great, but again, it means both nurses have to be available at the same time and other patients are not receiving attention.

[piratern]

Let me come at this from the ED side of things. What you are describing is not a unique situation. Many of the issues result from a misunderstanding of what each other does and the type of nursing required for each area. Any ED nurse would take offense at being referred to as "functional". Any ED nurse would tell you we can't stop the ambulances from coming during our shift changes. Any ED nurse would tell you we'd love to have a stable 3:1 ratio but can not turn patients away. Therefore we must make room for them and that means getting admitted patients upstairs to admitted rooms. We just got a group together to discuss this very issue and improve our report process. ED nurses should be reporting on those they are assigned to care for. What you describe is unacceptable. However, the "no fly zone" between shift change presents a problem. ED nurses change shifts at the same time as well. If you hold admitted patients in the ED, you are forced to have the off going nurse stay over or the oncoming nurse give report and they don't know the patient. Determining how to handle this requires a concerted effort by all involved. Until we all view this as a system problem and not an ED problem or a floor problem, we won't be successful. When we begin to think outside the box, we'll all come up with some really good ideas and solve this situation. One more thing... always think about this from the aspect of what's best for the patient and let that be your guiding principle. Good luck to us all!

[mentalhealthRN]

Again I vote Admit Nursing teams!! Especially if they worked different hours to have them covering that change of shift. I tell you it works and is worth the money! A win-win for everyone!!!

[mama_d, BSN, RN]

Oh how I would love to have the solution to that problem!

In my ideal world, as soon as the pt was dispo'ed from ED they would be brought up. Aside from during the hours of 6-8 (am & pm). Unfortunately that will never happen, in our ED at least. Much of our problem lies with housekeeping...they just don't have the staff required to keep up with the turnover adequately. That means that it is not unusual to walk into a shift with 5-8 empty rooms per unit that need to be cleaned, and when we're on red capacity with pts lined up in the ED waiting for those rooms they get pulled in all different directions. Seems to me like they should clean the rooms in acuity order (ICU first, medical last) so that the ED is at least able to get the less stable pts moved off more quickly. But what do I know, I'm just a floor nurse...I'm sure the COO & CEO have a much better idea how to effectively deliver safe care than I do.

Our ED used to be REALLY bad about sitting on pts until shift change and then dumping them all...like we'd have report for three hrs and be sitting there with a clean room as well and the pt would roll up @ 6:30. Apparently it was the docs doing it and nurses on both ends finally had enough and were vocal enough that something changed b/c it rarely happens that way anymore. Of course, we've also been too busy the last several months. Seems like we're on red or close to it most of the time.

(On red means that we would be on diversion if it wasn't against the law.)

Sorry, I don't have any great insight into how to solve your problem. I know it's a widespread issue and can cause a lot of contention between ED and floor nurses. Maybe someone on here who has worked both sides and is incredibly brilliant can give all the rest of us some advice. :)