Full to Overflowing

allnurses Guide · Dec 31, 2008

This is a daily occurrence in the UK and to deal with it there are strict government targets (max 4 hour wait in the emergency unit) we also have daily bed meetings, that discuss hospital capacity, all areas have to declare what beds where, and any staffing issues and patients are moved from corridors to the most appropriate available beds.

It's hard work and often we end up with surgical patients in areas where we would rather them not be but at least they have a bed.

We look to neighbouring hospitals for support and assistance with the emergency patient flow, and offer support when they need it as well.

Improving patient flow is something that is constantly developing in the UK, and what we have found is that problems within the hospital backlog into the emergency unit. To counteract this we look at early discharge, effective discharge planning to free capacity on the wards. Staffing issues are brought to the capacity meetings and dealt with before they become a problem to make sure that the emergency unit patients continue to move.

Obviously it's not ideal, it's hard work and we often don't get things right. It puts huge pressure on staff to move patients quickly and it can feel a bit like a production line, but it does help to keep the emergency units a little more free.

CathyLew · Dec 31, 2008

Well, I know in our hospital, they have to abide by the acuity. Or at least the maximum numbers for the floor. Even if there is an empty bed (the max is 23, but there are more beds, since you have to take into account pediatric patients that can't bunk with adults, or numerouse isolations) If the policy says X # of pts per floor, or per nurse.... and the supervisor willingly goes over that, knowing it is in hospital policy, they may be held accountable. In our ED, they have numbers for minimum staff. On Dr, one RN and one LPN. regardless if there is 0 patients, or if the doors are busting open.

I have worked nights where I came in on the floor and was the only RN to show up. They can mandate the day person for 4 extra hourse, but then Im on my own. I have been the only RN with one LPN and one Aid on a MSP floor of 21 patients. at that point, we are over our max for the staff, buy you can't just ship people off the floor. At that point, even though there are beds on the floor, I have protested, and refused to take admits from the ED.

Is is a safety issue, but also a matter of not setting precedence. If you start accepting patients over your policy and safety limits, before long, they will change the policy and up the limits per staff memebers, since they have seen in the past that you can handle it!

bjaeram · Dec 31, 2008

we are over our max for the staff, buy you can't just ship people off the floor. At that point, even though there are beds on the floor, I have protested, and refused to take admits from the ED.
Is is a safety issue, but also a matter of not setting precedence. If you start accepting patients over your policy and safety limits, before long, they will change the policy and up the limits per staff memebers, since they have seen in the past that you can handle it!

I get this but my question is why is the ER expected to work this way. It ALWAYS lands on the ER to take the extra patients when everyone else is full. We can't lock the doors and refuse to take patients. We hold the admit patients and take the new ones and there is no limit to the number we can have in the ER at any one time. If there is a bed on the floor doesn't it make more sense for the patient to be there instead of in our hallway for the whole world to stare at them. That might put you at a couple over max but we are at 10 over max so you still win.

CathyLew · Dec 31, 2008

That might put you at a couple over max but we are at 10 over max so you still win.

Actually the last time I worked as the only RN on Med Surge, with 20 patients and 2 staff members..... I told the ED when they had 20 patients in their holding area, then I would take the 21st one, as long as they sent up their third staff member to the floor. Figured that would make it even.

nurse_mo1986 · Dec 31, 2008

I'm not saying this to start a "Er vs Floor" war, but I personally work in an ICU, and I don't care if we have empty beds or no, If there's not adequate nursing staff to care for that pt, then they're not hitting my unit til there's a nurse available. My manager is responsible for my unit, and the ER manager is responsible for hers. It's up to me to protect my nursing license, and I won't put pt's in danger by taking unsafe pt assignments.

Maybe it would help to speak to your unit manager about your concerns.

racing-mom4, BSN, RN · Jan 1, 2009

I work both ER and ICU (Primarily ICU) so I can see it from both sides...the patients in your hall?? Are they true ICU or maybe truley even a MS patient or are the majority pts that will they eventually be sent home after labs/x-ray/ etc etc??

I know on occassion we have had to house true MS pts in the ER and it sucks for everyone, pt- staff alike..but if there is not a nurse avail to take care of them they are better off down there. Who knows what is going on up on the floor? Maybe a pt is going down fast and is requiring multiple ICU nurses attention.

Over Labor day weekend we were already a light staff--no house supervisor--and we had 2 ICU deaths with in 1 hour and we got an admit during that hour...the admit was basically put in a room and had to wait--would they have been better off staying in ER at least hooked up to tele with the door open for that hour vs sitting in a dark ICU room while we were busy with the critical/dying and rooms and halls full of grieving family?

PS we have been known to divert to another hosp when we were in fact just too full and could NOT care for any more.

nursej22, MSN, RN · Jan 1, 2009

Unfortunately, we would like to take more of those sickies from ED, if only we could get some of our patients to just leave, already!!!! For instance:

Patients who demand the surgery that is scheduled next week, before they leave.

Patients who don't,won't or can't find a ride home.

Families who want a second, or third opinion about their 89 yo granny. For God's sake people, take them home and let them die in peace!

Morbidly obese patients that can't be placed.

Soft rule out MIs who could get a myoview and go home, but the tech is gone for the day.

Patients who need a dose of Vanco before they go, but Pharmacy is backed up and can't get the dose to you.

PCPs who don't round until midnight and write dc orders.

DC orders written hours ago but are totally screwed up and require hours to untangle.

I would love to get that afib with RVR up to the floor so they can get their heparin and dilt gtt started, instead of hitting my head against the wall with stuff they didn't cover in nursing school.

jimbr1 · Jan 1, 2009

It's kind of a double-edged sword-Emergency Departments staff usually according to the number of acute care spaces they have....if there are no patients..they don't downsize because in a few minutes they could be full....on the floors (at least where I work..they staff by census and downsize when the numbers are low)....so we're are always running....What is not a good practice is when the Emergency Dept sends up multiple patients at the same time...this can become a safety issue when a nurse has multiple admissions simultaneously. The mindset is totally different (have worked in both areas)...intake in an Emergency Dept. is usually streamlined, at least compared to the floors...but working in a physician-run hospital...there really is no recourse other than to seek employment elsewhere..we seem to be moving patients quite a lot (hospitalists take patients off of telemetry so we can send them to other floors....often late at night) so that they can admit more patients to the floor...(sometimes I feel like I work for a freight company)...the list goes on.....

diane227, LPN, RN · Jan 1, 2009

I have spent most of a 30 year career in the ED. However, I now work med-surg as the 3-11 charge nurse on a 34 bed floor. Lots of post op's, ortho, and elderly patients. I feel that people need to understand what is required on an inpatient unit. Upon admission, we have about 10 admission forms that we have to complete. It takes about an hour to admit one patient. Our ongoing documentation is 6 pages for each shift. There is no computerized charting. On our floor we cannot over ride many meds in our pyxis so we have to wait a long time for the meds to get to the unit. The ED could help us, but they won't scan the orders before they bring the patient up. Post ops have to have q 15 minute vitals, as do transfusions. People need bedpans, are incont., have lots of care and med needs. The nurses have a 5 to 1 ratio that sometimes goes up to 6 to 1. They are just so busy. Then you have to make time to talk to the families and let them know what is going on. You know we are sitting on our floor sitting on our butts. Perhaps 5 patients does not sound like much but most of us never get lunch and the supervisor is always trying to give us more and more pts when we can't even get caught up with the admits, transfers and post op's that we already have. Or they are pulling a nurse from us. I have worked in ED's where we held patients up to three days. I know how hard it is but we have to understand that everyone is working, not just one area. I cannot put a patient on my floor when I don't have a nurse. I try as much as I can to help everyone get the patients to our beds when they need to come. I don't hide beds or alter my census to keep patients out. We need to remember that everyone is working and we should always be working together.

TraumaNurseRN · Jan 1, 2009

While our 65 bed ER fills daily to compacity, and there are waits out in triage we have never housed patients in hallways. Granted there have been waits for admission rooms but our BED SUPERVISOR has the sole job of juggling beds. Example: a patient who is transfered to a stepdown bed from the ICU to make room for an ICU admit from ER. It's sad that the hospitals get over crowded and there is short staffing. But I gotta say....I'm lucky cause my hospital doesn't seem to have the same problems of short staffing or housing in the ER for hours post admission, let alone days...that's awful for you guys. I guess when I go into work today, I should be grateful. But then again....I can only do so much....and that is an ongoing thought when things seem to get out of hand.

sweetsounds · Jan 1, 2009

It is interesting to read theses posts because of the varying procedures in different hospitals. Some of this must be due to different regions, some due to the almighty dollar(US). My hospital WILL NOT divert except in the case of an actual mass casualty. To avoid holding admitted pts in the ED they are sent to hall beds on the floors. Several hospitals that I personally have worked for have a policy of absolutely NEVER acknowledging the fact that they are out of beds(or lack sufficient #'s of nurses). Therefore the problem just doesn't exist see?

I absolutely understand both sides of this conundrum having worked on each. When this devolves into an us vs. them situation we nurses are spiting each other.

I have to add my little contentious statement though. No matter how many pts I may already have in the ED I cannot refuse the next one, we pile them up in the halls also, then chairs if possible!

This is a huge issue of crisis proportions IMO. I could go on and on...

Here in the US even "not for profit" hospitals must compete with other hospitals in their market area for patients. This leads to an environment that abuses the nursing staff.

Hopefully enough consumers are becoming aware that the landscape needs changing.

Sorry, that kind of veered away from the original ? didn't it?

Well, good luck to us all since we're really all in the same boat.