ED Admissions Right At Shift Change

classicdame, MSN, EdD · Feb 17, 2011

I agree with piratern - it is so easy to complain about "them" being at fault, when none of us really understands what another person is dealing with at the time. Sometimes Housekeeping has to clean a room before the unit can take another, or the right bed has to be located and transferred, or another nurse has to be called in or a code in ER prevented the patient from being transferred to the unit more quickly - I have worked where day shift and night shift in the same dept. did not appreciate the work the "other" shift did. I believe it is because we all are working under stress and need to vent. Just for the record, I appreciate my ER nurses.

Esme12, ASN, BSN, RN · Feb 17, 2011

This is a topic that has been highly discussed here. It is a complex problem and a difficult one to slove. There are many reasons this occurs. One is the ED itself. The constant ebb and flow of patient traffic. There are times it's ok to let them marinate for the next shift and times it is not. Odds are if the floor is crazy so is the ED...it's like a vibe that invades the walls. There are times the patient will be safe out of the ED due to the events present or comming to the department. It there abuse.....sadly, yes...but more often the patient is better off in a controlled enviorment out of the ED. I know your floor doesn't feel controlled but compairson it is......

Then there are the ED doc's. Some are Angels others are Lucifer himself. They drag their feet believing as long as someone is on that gurney no one else can come in......a million dollar work up later......now they decide to call the attending. Ok the patient with an extensive cardiac Hx comes to the Ed with pain at 0900.....Even when the triage nurse called for the bed in triage because we all know who's a keeper and who isn't the patient gets their labs,ultrasound ,CT scan, Echo, and CXR while they wait. The attending calls back after lunch at the office now it's 1:30 or 2:00 admitting orders recieved bed assigned...it's 3:00 the patient is starving and angry at being on the gurney for so long....the ED MD is leaving at 3 and doesn't want to dispo the patient to the next MD....another can of worms because they are no longer ED paitents but still in the ED. Or that Ed MD who has 2 speeds, slow and stop being relieved by stop and reverse and the whole cycle begins again. NO one like to come into their shift to unfinished business. AHhh the tangled web we weave.....

There is the code dump and the PITA dump.......so you see it's very complicated. Add in housekeeping trying to keep up because we all know how the churn them in and out these days and it's near impossible to figure it out.

An admitting nurse is a good solution as they complete the paper work and turn them over to you. but this is expensive for smaller facilities. A bed coordinator who is a nurse who has worked both the ED and the floors is ideal as she can assess the needs of all. Holding admissions until shift change is over can be extremely difficult as the PACU will go into overtime if they stay and the patients are charged by the 15 min increments....EXPENSIVE!!!! The ED has no beds anyhow and here comes a trauma. Some states have stopped diversion status because patient travel wait times to an ambulance or hospital care became disproportionate and long enough to cause delay of treatment issues.

The biggest idea is for everyone to play nice in the sandbox and try to walk a mile in the others shoes and those who abuse their dumping power be held accountable. Have one person be it supervisor or bed coordinator in control of the movement of the patients themselves to control and assess each situation individually so that the best decision for all is reached. It's all in the delivery of the message with cooperation and understanding.....a really complex issue with no cut and dry solutions.......take deep breath and smile...

https://allnurses.com/general-nursing-discussion/change-shift-admissions-270086.html

Riseupandnurse · Feb 18, 2011

What a great idea--admitting teams!! And I don't actually think it would cost extra money. An admit at shift change means major overtime for the floor nurse, most of whom are working 14 (supposed to be 12, ha ha) hour shifts in the first place. We ALWAYS got change of shift admits at our facility, rarely any other times. PACU had a habit of that too, so it got crazy. Not to mention dangerous for the patient.

Cessna172 · Feb 19, 2011

I was always having patients dumped at shift change. I finally had enough and called the ER doc and gave him a piece of my mind. Thankfully he got the message. Often they would hold the patients, then clear them just before shift change. I told him that I have a family and other things to do after work. I also pulled shifts in the ER which only has 7 beds, so I know the nurses. And I've had to tell the nurses too. If it was truly a need to get a patient out because they need the bed, then thats cool, bring him up. But my hospital isn't swamped with codes flying in the door. It's almost like it's every man (or woman) for himself at shift change. I've seen the same practice at other hospitals too.

KayDee68 · Feb 19, 2011

I like Legz' idea of calling report then that nurse transfers the patient with an add'l report. That way the responsibility is in their face to do a good job.

If you are not ready to accept a pt to the floor there is one simple solution - don't take report!! Tell them you are in shift change and you want to give them your undivided attention, so you'll call them back in ____ minutes! Once you take report, the responsibility is then yours.

Lots o'luck!

CCL RN, RN · Feb 19, 2011

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

As an ICU/CCL nurse, I can somewhat sympathize.

However, as an ICU nurse, I can take a pt with minimal to no report and still know what to do. ED nurses don't do head-to-toe assessments. The do focused assessments. The head to toe assessment is our job.

And I know it sucks to get late admits, but also sucks holding patients in the ED. It sucks having the EXACT same patient but instead of having only one other patient, they have 5 other critical ones-and they need procedures, CT trips, interventions as well...It sucks to be a patient in the waiting room, waiting hours to be seen. It sucks to be told, "we will take them after shift change" and then when you try to call report, they refuse to accept report, because they are in report....

Strange, huh?

I don't work the ED, but as a cath lab nurse, I get STEMIs that have spent maybe 5 minutes or less in the ED. We cath them, do what we have to do, and we get the same run-around when trying to send them to the ICU.

I also get a lot of static because I don't know their past medical history! Seriously! You have all day or night to figure this out. I had report from a nurse who has spent less than 5 mins with a patient, and then I spend an hour with a draped patient, covered with monitors and radiation equipment, who is sedated (or dying) and no chart! No, I don't know what pharmacy they use!!! I know they were dying before, and aren't now!

You should, should, know how to care for any patient, with minimal report (and when I say you, I don't mean anyone specifically). Think about rapid responses, ED admits, codes, etc. We can care for the patient now, and fill out our report sheets later.

And other ICU nurses need to be understanding if you get a shift change admit, that you won't have everything filled out. Do your best to stabilize the patient, and ensure that they are safe.

Btw, 3:1 ratios are ridiculous. Thats where a lot of your problems stem from. No ICU should have greater than 2:1 IMO...

star77, MSN, RN · Feb 20, 2011

From the ED side:

I can speak for myself and say I am completely mystified as to WHY bed control releases beds to us at 0615 or 1815. We hate it as much as the ICU nurses do.

And, I also want to say (not trying to be snide here, being serious): Last I looked, my RN license didn't magically go away at 0715 or 0730 (or 1915/1930).

From our side, I can tell you that we are watching for that bed to be "assigned" the moment we get a patient - any patient who is being admitted- because we have another 30 (or more) in the waiting room, 2 on the way from an MVC or a gang fight with multiple penetrating injuries. Yes, I might be taking care of the guy who has a fractured femur, multiple decubes, is intubated, and his lytes are all over the place and his pressure's in the toilet, but changing OUR staffing ratios downstairs to ensure that we're 2:1 for the ICU patients in the ED means that the guy in the waiting room who is having chest pain and has a history of stents placed 5 years ago might have to be placed in a hallway on a telemetry monitor.... or that girl with abdominal pain and a positive pregnancy test with a history of 3 ectopics might wait longer... or the COPD'er with a fever and hypotension who is going to be my next septic patient might be delayed until the ICU can take the patient who has an Assigned bed... so that we can open up another few and I can go back to taking 4 patients.

Remember, we're trying to treat people as quickly and safely as possible- and once someone has a bed somewhere else, that means another waiting person can be treated for their injury or illness. And this issue is also why we get so mad at all the BS that walks through our door... (but that's another thread).

Yeah, I'm tired too. In fact, the last thing I want to do at the end of my shift is to take some unstable patient upstairs to an angry ICU nurse who thinks I'm trying to wreck their world by giving them an admit, when really, I would have taken that person up 3 hours prior had bed control said it was cool to do so. I promise, I've done everything I can to make your life easier. I apologize if I forgot something. Sometimes we are trying so hard to stabilize someone that little things go by the wayside.

In any case, it's not a malicious thing. At our hospital, our hands are tied until bed control/admin gives us a bed.

Riseupandnurse · Feb 20, 2011

I am willing to accept that the ER nurses aren't necessarily responsible for the fact that the huge majority of admissions are at one time or another, but SOMEONE is responsible. It can't possibly be coincidence that 90% of the admits come up to the floor from ER during the shift change. I have yet to find out why this is happening, but since both ER and ICU/floor nurses care that the patient gets at least the minimum attention necessary on admit, and it doesn't happen very well when patients come up at shift change, why can't we figure out what is going on?

xtine618 · Feb 21, 2011

However, as an ICU nurse, I can take a pt with minimal to no report and still know what to do. ED nurses don't do head-to-toe assessments. The do focused assessments. The head to toe assessment is our job.
You should, should, know how to care for any patient, with minimal report (and when I say you, I don't mean anyone specifically). Think about rapid responses, ED admits, codes, etc. We can care for the patient now, and fill out our report sheets later.
And other ICU nurses need to be understanding if you get a shift change admit, that you won't have everything filled out. Do your best to stabilize the patient, and ensure that they are safe.
Btw, 3:1 ratios are ridiculous. Thats where a lot of your problems stem from. No ICU should have greater than 2:1 IMO...

Yes! So true! In a perfect world, we would get the perfect report and not receive admits between 6-8. But this probably won't happen. I worked at a hospital where report from the ED was faxed to us and it was only minimal info: diagnosis, resp status, most recent vital signs, IV access and of course anything important like if they were coded. It worked pretty well for us. Most of the time our best source of information was the MD him/herself. We have hospitalists and intensivists that do the admissions and they usually come up to the unit anyway to see the patient, so any questions about their history I ask the MD.

In the facility I work at now, our charge nurses don't take patients. So they are available to help get new admits settled in. This isn't an admission team, but it's an extra set of hands to help you. If this isn't possible, then you have to rely on each other. When someone gets an admission, hopefully another nurse is able to keep an eye/ear out for the other patients. We all get busy, but you can only do so much and keep your patients safe at the same time. Just remember that the other floors and units are going through the same craziness you are, if not more.

gcupid · Feb 21, 2011

How about icu nurses do 6a-6p and ER nurses do 8a-8p & bed control at a different start/end hour shift if it is that much of a problem?

Or half of scheduled icu nurses do 6a-6p & the other half 3p-11p wih some type of bonus incentive to work them hours

In-service Doctors, nurses, housekeeping/bed control on issues...

I dont know much but it seems like if this has been an ongoing problem for decades...Shouldn't there be some type of resolution to the problem outside of admit teams that may or may not be able to handle all of the admits at change of shift time.....

Come on experienced nurses...What really needs to be done in order to satisfy all er,floor, & icu nurses?

LegzRN · Feb 21, 2011

How about icu nurses do 6a-6p and ER nurses do 8a-8p & bed control at a different start/end hour shift if it is that much of a problem?
Or half of scheduled icu nurses do 6a-6p & the other half 3p-11p wih some type of bonus incentive to work them hours
In-service Doctors, nurses, housekeeping/bed control on issues...
I dont know much but it seems like if this has been an ongoing problem for decades...Shouldn't there be some type of resolution to the problem outside of admit teams that may or may not be able to handle all of the admits at change of shift time.....
Come on experienced nurses...What really needs to be done in order to satisfy all er,floor, & icu nurses?

That would be good, except ER staffing runs all kinds of crazy hours. For example: 7a-7p, 10a-10p, 11a-11p, 12:30p-1a, 3p-11p, 3p-3a, 7p-3a, 7p-7a, 11p-7a... and all the other goofy shifts I missed.

gcupid · Feb 23, 2011

That would be good, except ER staffing runs all kinds of crazy hours. For example: 7a-7p, 10a-10p, 11a-11p, 12:30p-1a, 3p-11p, 3p-3a, 7p-3a, 7p-7a, 11p-7a... and all the other goofy shifts I missed.

Okay, So do you know what I interpreted from this response?

The fault or issue mainly lies moreso with the ED rather than the other departments....

However, bc the ED may have issues that may take precedence etc... it's not logical for other departments to expect (a controlled & routine environment) patients sent up at convient times for icu/floor nurses....

The only thing I can think of next is that there must be a way of detecting routine abuse on the ED side especially when things in the ER shouldn't be so otherwise predictable (aka, the dumping of what seems to be almost all admits around shift change)

Any productive ideas?

Correct me if I'm wrong because I have the slightest idea of what goes on both sides (er/icu), I'm acting as a mediator, LOL!

One last thing..Ive heard bed control being used as a legitimate excuse or scapegoat.....What could eliminate that problem? Should management hire more nurses @ 20+ an hr or do they just need more of housekeeping at 10+ an hr?