Hey ER, what takes so long???

wooh, BSN, RN · Feb 8, 2007

Our admissions coordinator always passes out a handful of beds a half hour before shift change...

I wouldn't be surprised if they waited to decide which floor got patients until staffing for the next shift was figured out. (Not a house supervisor, but used to be buddies with a few.)

**canoehead, BSN, RN** · Feb 8, 2007

I our ER it's simple. the admitting docs finish office hours, then come to the ER to write orders on all the patients that have been piling up there since 7am. By the time orders are written and admissions processed it's shift change, and all the pateints are ready at once because all the docs do it the same way.

LeahJet, ASN, RN · Feb 8, 2007

In our ER, the docs change shifts right before we do. So if there is a pt. that has been in the ER and to be admitted, the doc usually takes care of other immediate problems and sees other pts. (In other words, puts the admission on the backburner)

When it's time for the docs shift to end, he/she starts working on the admit so he/she won't have to pass it to the oncoming doc. This usually happens around 6AM or 6PM. Which means......viola..... a "shift change" admission.

To be honest, we (the ER) are always taking patients....shift change or not. We never have the luxury of having ambulances wait outside the door until after we get report and make rounds on our patients.

"How dare you roll in the door with asystole at 6:55am???"

As far as "holding" patients until shift change..... WHY in the world would we want to keep a patient longer than we have to??

If you know anything about ER nurses, you know that we love to treat and send somewhere else.

Anything over 3 hours is too much like floor nursing! :lol2:

Lightning Bug RN · Feb 8, 2007

I work 7p to 7a and I have tell you that almost every night without fail we get a phone call at 10:50 from bed control and then two seconds later the nurse from the ER is on the phone demanding to give report that very second. You ask her to hold on for 2 minutes to print out any orders or labs that may have been done. and you hear "I can't wait for two minutes, don't you understand that it is time for me to go home?" The excuse that the ER has to wait for orders before they can send the pt is rediculous, many, at least 70 percent of the pts we receive from the ER do not have ANY orders for our floor before they are sent. I cannot tell you how frustrating it is to be short staffed on our shift on a constant basis, and to be constantly slammed with ERs at the beginning of a shift, and not being able to see the other multitude of pts on the floor that you just picked up. If someone is going to go bad, it is going to happen on night shift, if they are going to fall out of bed even though they they have been well behaved all day with no sign of attempting to ambulate by themselves, it will happen on night shift. The problem with the Er admits is the fact that often the report you receive from the Er is not complete, that is why I print out all the information I can about the pt before I take report (Potassium way high or way low as an example). There are often enough surprises once they arrive to the floor , like tachycardia uncontrolled, hypertension uncontrolled, of SOB and no pulse ox done or sky high blood sugar and no one even bothered to check it downstairs. So you spend the first hour trying to track down a dr who will take responsibility for this pt, which is often very difficult. I have had pts waiting for pain medications for almost two hours because of someone going bad as it is, the last thing my shift can handle is a ER dump at the beginning of the shift. Ifr you guys are gonna keep them down there, at the very least, please make sure the major issues are addressed, my favorite by far though is the pt who has been in the ER for almost 6 hours with a hip fx, and when I ask about a foley placement, the nurse practically laughs and says I don't have any orders for that. So I am supposed to a have time to address this by the time the pt gets to me and hour later? Please have some mercy for us poor med surg nurses!

Radnurse54 · Feb 8, 2007

As an ER nurse for 28 years I would like to respond to this question. Sometimes there is a misunderstanding about what happens in the ER and h ow patients are taken care of. First of all please remember that your unit has only x number of beds and that is all the patients that can be accommodated.....but the ER has an infinate number of patients who can present to be treated, walkins, ambulance, private cars etc. So patients who may not be see as emergent or even urgent or semi urgent must wait for care, sometimes the MD can start the patients care and then get pulled away to more urgent matters before the decision about what to do with the patient is completed. This is particularly true for admitted patients who may have to wait for attendings to return the ER docs call and if the ER doc has to write orders he has to find time for that too.

Finally when we get to the point of actually needing a bed, you can understand our desire to move that person as quickly as possible, after all there may be 5 other people waiting to get into that bed.

As for the admissions at the 6-7 o'clock time, if the ER docs are on a 12 hour shift just like the nurses then they need to get their patients moved on before they go home and there is usually a rush at that hour of the day.

Also, it has been my experience that the busiest hours for the ER are 8-10 in the morning 6-10 at night. So you can see that while the docs and nurses are changing shifts that there is also a rush of patients at that time.

Trust me, nurses and doctors in the ER dont like keeping patients forever with them before admitting, especially if there isnt a bed issue.

If you really want to know how the ER works, ask to go down and shadow a nurse to see how the ER works. It is very different than working on the floor. Hope this helps.

nuangel1, BSN, RN · Feb 9, 2007

As an ER nurse for 28 years I would like to respond to this question. Sometimes there is a misunderstanding about what happens in the ER and h ow patients are taken care of. First of all please remember that your unit has only x number of beds and that is all the patients that can be accommodated.....but the ER has an infinate number of patients who can present to be treated, walkins, ambulance, private cars etc. So patients who may not be see as emergent or even urgent or semi urgent must wait for care, sometimes the MD can start the patients care and then get pulled away to more urgent matters before the decision about what to do with the patient is completed. This is particularly true for admitted patients who may have to wait for attendings to return the ER docs call and if the ER doc has to write orders he has to find time for that too.
Finally when we get to the point of actually needing a bed, you can understand our desire to move that person as quickly as possible, after all there may be 5 other people waiting to get into that bed.
As for the admissions at the 6-7 o'clock time, if the ER docs are on a 12 hour shift just like the nurses then they need to get their patients moved on before they go home and there is usually a rush at that hour of the day.
Also, it has been my experience that the busiest hours for the ER are 8-10 in the morning 6-10 at night. So you can see that while the docs and nurses are changing shifts that there is also a rush of patients at that time.
Trust me, nurses and doctors in the ER dont like keeping patients forever with them before admitting, especially if there isnt a bed issue.
If you really want to know how the ER works, ask to go down and shadow a nurse to see how the ER works. It is very different than working on the floor. Hope this helps.

very well said.also while floor can have x number of pts and say we can't take anymore we in the ed cannot .eventhough we too have limited space at 18 beds even if we are hold 9-10 floor admits(because we have been told there are no beds) we have to stay open and have pt in halls.even if we are allowed to divert we still get pts by walkin or cars and they can be real sick too.also even if one is on divert if the ambulance has a unstable pt that the emt feels can't make it to farther away hosputal they too will still come to the diverting er .so see the ers can't win either .

**canoehead, BSN, RN** · Feb 9, 2007

I once took a patient up to the floor just about at shift change and the receiving nurse told me they had gotten 5 patients in the last 30 minutes. I sincerely felt sick, that is a huge load to absorb. I also knew how many of the patients and families had been screaming at us about the wait to be moved upstairs- the docs fault- not the nurses'. Perhaps the problem is not with the nursing staff at all- it seems like a multidisciplinary team should get involved.

Why couldn't we send patients to the floor with the ER orders, and obligate the admitting doc to show up on the floor within two hours? OK, not the best idea, but what other ideas are out there?

ParrotHeadRN · Feb 9, 2007

I've been a floor nurse and now I am in the ED, so I feel I can look at this with both perspectives. I work 7p-7a. Our docs will sit on an admission until about 5 am before they call the attending if it's not an emergency. I don't necessarily agree with it, I think if you're on call, you're on call, but it's a professional courtesy they offer each other. Someone else mentioned docs coming in after office hours and that applies to my hospital as well. So there is the change of shift issue. Docs, NOT nurses.

As a former med/surg nurse, I know what a sucker punch it is to get a pt either right off the bat or when you think you are finally able to wrap it up. I really do. However, being in the ED has opened my eyes to a whole new world. I think ED and floor nurses should walk in each other's shoes for a while just to get an idea of how the other half lives.

I work in a fairly small hospital where courtesy is the norm between nurses. I have no problem waiting to give report if the receiving nurse is busy. If it's change of shift, I give report to the house supervisor who then passes it on. That way, report is given and the floor can simply call when they are ready, providing they don't abuse that courtesy. I've been told there are some floor nurses who abuse that, but I've not run into it yet. That being said, there are times when our beds are all full and I have 10 people waiting in the lobby and 3 squad calls out. When that happens, I really have no choice but to be firm about getting my patient over. Usually I am not met with resistance because I am not unreasonable and do not expect it all the time. It's true, the floor has a limited number of beds which means limited number of patients. While I have a physical limitation on beds, that has nothing to do with how many patients end up in those beds.

As for the wait, unless the OP thinks that the pt was the only pt in the ED, I don't think that was an unreasonable length of time. Was any consideration given to what else was going on in the ED at that time?

This has been discussed ad nauseum and maybe now we can lay the topic to rest. Each side has their own agenda, understandably, but until you see both sides of the coin, it's really unfair to judge either way.

ZippyGBR, BSN, RN · Feb 9, 2007

There are several threads where this issue has been brought up. I cannot speak for your particular hospital, but I will tell you what goes on in our hospital.
Scenerio 1. Patient comes in with post op-complications. They need to be seen by the ER physician since the surgeons do not magically live in our department. Before we are able to consult the surgical service, there is a workup we must do since calling the service and simply saying that the wound is red will not warrant a visit. So we work the patient up call the hopefully admitting service with the results and wait and wait and wait. We wait until they are out of surgery, done doing rounds etc. etc.. Once we consult on a patient it sometimes takes that particular service up to 2-3 hours to come and see the patient. The service finally comes and sees the patient and decides to admit them. The ER physician cannot admit a patient. There must be an accepting service.

from my point of view ( as a rightpondian Emergency Dept and Admissions/ assessment unit type bod) System failures all round

1. while not a 'failed discharge' it's pretty obvious this patient will need to be seen by the surgeons

2. why isn't the 'workup' being conducted by Nursing staff from a Uk point of view the 'basic' aspects of work up will be done anyway, the notes have been requested and if indicated bloods taken and sent ....

Wound care and wound assessment should be a basic tool of the RN

3. We would probably move this kind of patient to an assessment baed if the surgeons were unable to come and see the patient - this frees up the ED for ED patients - sometimes without involving ED Medical staff ( if the patient is stable and doesn't need Parenteral analgesia or fluids)

Scenerio 2. Patient comes in as a stroke page and neurology is at bedside evaluating the patient. We start workup and everything comes back to be "stable" from a neurology standpoint. Therefore neurology will not admit the patient to their service. The patient still needs to be admitted so the ER must then consult medicine to see if they will admit the patient. Well before the medicine team will come and see the patient, they want urine results. We get the urine results and wait and wait. Medicine then finally comes and sees the patient. Medicine does there eval and decides to admit the patient. Admission cards get put in and we wait for the H.O. to call us and give us a bed.

so much for stroke patients get admitted under the stroke service ... again fro mthe right pondian perspective stroke patients get admitted to one of three bed bases - the designated 'stroke' beds , medical assessment beds pending a stroke unit bed , or critical care if it's indicated ...

the y are also admitted under the stroke service which saves neurology and general medicien/ elderly medicine having an arguement over who the patient does or doesn't belong to ( the stroke service has 'parts' of several of the neurollgy and medical consultants and is covered by the general medical middle grade )- one of the advantages of the UK system where the middle grades approach the level of seniority of and experience of the new attendings

Scenerio 3. Trauma comes in and is scalped because their head went through the windsheild and a tib-fib fx that needs to be reduced. Admission cards get put in right away by the trauma service and we get a bed right away. However, before we can take them upstairs trauma needs to staple the head lac, we have to wait for plastics to come and suture the face, and have to wait for ortho to reduce the fracture. Can't just send the patient upstairs with a bleeding head wound and an unstable fracture with possible vascular compromise. All of these things takes time.

legitimate use ofthe time in the ED - though that said where i have been working ED we did nearly all of our own suturing except tendon repairsand complex opthalmic / max fax stuff ( e.g. we would suture lips etc - the key thingwith lips is to get the vermillion border right - it's plastics voodoo to boost their consult figures to say otherwise)

Scenerio 4. Have a very stable patient call report and start packing the patient up to bring them upstairs. Charge nurse comes in the room and tells you to hold on, EMS is at the door with a cardiac arrest. Work the cardiac arrest and then take the stable patient upstairs.

workload is workload - that said our clinical site managers (all RNs - they do the balancing act of bed allocation and also screen the primary care admits for those that can waitvs those that must vcome striaght in even if there isn't a ed immediately available - and threfore go to the ED) would likely move that patient if there wasn't a more urgent call on their time

Try and notice what time rounds are done in your hospital. It seems as if in our hospital rounds are done by the services before noon. However, discharges are not made until later in the day. If a patient is not discharged until 5:00 in the afternoon, then this will put a patient being put in that bed at the floors shift change.

valid point -

need to look at discharge arrangements and what can be put in place before the final decision - e.g. if meds are stable the discharge meds can be ordered in advance

there is also the concept ofthe discharge lounge to consider where those who are discharged are moved from their ward beds whilr waiting for things like discharge meds to a (still nurse staffed) area where they can wait for discharge meds and transprt etc rather than sittign dressedand ready to go by their bed for several hours

Sometimes we get into a war with different services where no one wants to admit the patient to their service or the patient has multiple complaints and several differnet services needs to see the patient.

you need to empower the ED s medical shift leaders (i.e. the more senior attendings / consultants/ staff specialists) to be able to referee and make with the Clinicla site manager a binding for at least the first 24 hours decision whose bed base they go under - or admit them to an assessment unit and the arguement can continue there ( we admt the majority of our none critical care 'medical' patients to the assesmsent unit - some cardiology goes straight to cardiology if there are beds same with stroke) and sort them out to the medical subspecialities within 24 hours

TazziRN, RN · Feb 10, 2007

There's nothing I can add to this.......I understand that it's hard on the floors to get admits at change of shift, but floor nurses should come and watch a busy shift in the ER....maybe there would be some understanding in that direction too.

paradisemakai · Feb 10, 2007

Got a call from the House Sup to place a NH pt with HTN, gave him a bed and no sooner than I hung up ER calls to give report. They say the pt got some Clonidine in the field but only Ativan in ER. BP has been OK sonce the pt arrived, pt had refused her daily meds at the NH.
OK......then I look up the lady's labs and find out they were drawn 5 hours ago and she's been sitting down there the whole time. The whole house census has been down, so waiting on a bed wasn't the issue.
So I'm wondering, as this has happened often....are the patients waiting for the doc to figure out what to do with them? Do they drag their feet? What seems to take so long to figure out if they admit or d/c?
Also, what's up with the admits every night from 6-7pm right before change of shift? House calls for a bed at 1630 and they want to bring the pt up at 1830....every night this happens.
I'm sure there's a good explanation for this, so let's hear it!!!

Very interesting - when I worked in ER it was usually the opposite response from the floor nurses - there were never any beds ready so our patients would hang out in the ER for up to 72 hours :scrying:

Delays in the ER are quite commonly due to:

1. MD needs to write admitting orders. How available is MD?

2. Codes/emergent situations that need to be dealt with first

3. Lack of staff to help get patient up to floor. At our unit we got an admissions nurse whose job was to facilitate getting patients from ER to other units - she did all the paperwork and was a tremendous help to both ER and units, as well as decreasing LOS in ER.

Hope that helps.

paradisemakai · Feb 10, 2007

There's nothing I can add to this.......I understand that it's hard on the floors to get admits at change of shift, but floor nurses should come and watch a busy shift in the ER....maybe there would be some understanding in that direction too.

Having worked both floor and ER and thus seeing what it's like from both sides, I can honestly say that both jobs are difficult. It's easy for one unit to badmouth the other, but I wish nurses didn't do that. For the most part we're all working our butts off, and a little understanding of the other person's side goes a long way.