Hey ER, what takes so long??? - page 4

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.... Read More

  1. by   sunciray
    As an emergency nurse for 18 years, I can say that the problem is a combination of many factors: indecisive emergency physicians that write orders in a piecemeal fashion because they are concerned about lawsuits, failure to either implement or enforce hospital admission policies, power plays, and unfortunately, many nurses that are burned out or lazy and do not want to get another patient...so they hold onto to the ones they have as long as possible. Additionally, there are the uncooperative attending physicians that do take some time in writing orders, or if you are in an academic facility, the numerous residents and interns that have to see the patient before they are admitted. Lastly, the on-call personnel that are found in many ancillary departments such as radiology in the smaller facilities also compound the problem. Patients must wait until the CT tech or sono tech comes in to do the test before the patient disposition can be made. It is a mess, and the solution is just not a simple one.

    One thing that I strongly believe will help to alleviate the problems is the nurse to nurse relationship. I believe that floor and critical care unit nurses need to do a share day in the emergency department, and the ED nurses need to do a share day on the floors and in the units...nothing fosters more understanding of what each other must deal with than getting a first hand account.
    Last edit by sunciray on Feb 25, '07 : Reason: grammar
  2. by   majadu
    RE: Hey ER, what takes so long???

    I would be interested to know what other studies the pt had. Sometimes we wait for the lab results, x-ray, or other ancillary testing, then the ER Doc has to contact the admitting physician, and/or Consutling physicians, who by the way may not call back until they are done with office hours, dinner, golf or whatever). Remember, when the pt hits the door, ER nurses start the line, draw the labs and in some facilities we order per protocols to initiate the tx. I have had results back before the ER doc has even seen the patient. The other consideration is many times the patient gets a "million" dollor work up to help accomodate the admitting Dr. It all depends on the facility. Sorry for the inconvience, I just wish everyone, medics, Dr's., ancillary departments and receiving nurses realized the team does not begin or end at the ER doorway. Thanks!
  3. by   fromtheheartRN
    Quote from neneRN
    I'd like to know too, and I'm in ER! Our admissions coordinator always passes out a handful of beds a half hour before shift change...she's not a nurse, so she doesn't care/doesn't have any reason to hold them....the ER nurses hate it...the floor nurses hate it...ER nurses think somehow the floor nurse has made it happen....Floor nurses think somehow the ER nurse did it....who knows?
    I am a recently new charge nurse on a tele floor. What an eye-opener it has been! I will try to give a few reasons about the "magical shift change influx of admits."
    AMH, we have a bed board where we can see each pt who is waiting for a bed in the ER-and for how long. Our shifts run from 7-7 on our floor, 3-3 on ICU and they are quite variable in ER.
    We are a 40 bed unit (quite large), and our staffing matrix is 10 and 4 for all 40 beds during night shift (in a perfect world). 13 and 4 for days. These numbers INCLUDE the Charge. Typically, and because of RN shortage, we only have 5 RNs scheduled and 2 techs. So, IF we do not get any sick calls, AND we get a minimum of 5 RN's from float or agency, AND two techs from float, we can bed to full capacity. A majority of our DC's happen between noon and 3pm. Night shift can call off (without penalty) up until 430pm. Staffing cannot give us a number of floats or agency RN's until at least 5pm. So by the time we can finally ascertain exactly how many beds we can fill, it is probably 530 or so. But, then again, if the hospital is in danger of diverting because of staffing issues "But what do you mean we can't bed these people? There are half a dozen beds empty!!!" The answer most often is (from the HS) "Bed them anyway. The Charge can take an assignment, and the floor RNs can take 7 each." THIS IS IN TELEMETRY! As a new dayshift charge, I am, of course, reluctant to fill em all up. The first day I was charge, I was being pressured into doing just that. In one ear, I was hearing, "Bed to the staffing matrix!!" In the other ear, "Who cares about the ratio? The hospital is about to go to divert! BED!" I bedded 6 patients at 630 (still being very mindfull about acuity). OMG! I thought every floor RN and the charge was going to strangle me the next morning!
    Also, we wait to see if some of the CP-ers rule out in the ER with a stress test. I know that some of this is off-subject, but in short, the "magical shift change admits" has more to do with staffing issues and other logistics than with ER or floor RN "holding."
    And, I learned my lesson. When the HS comes around near end of shift (630), and brings up her bed board on the puter screen, I take a list from 'her priorities.' I say, "No, I will take care of it," and walk away when she asks if I want her to bed them for me. I continue with my final rounds and I take this list and give it to the oncoming charge at 645. Maybe this is wrong to do, but this way, the HS has done her job of communication, and I haven't caused chaos for either shift at shift change that can last the entire next twelve hours and sometimes into the day. Cop out? No--I am simply supporting our floor nurses--and the night shift charge can regulate and delegate according to their needs. I will never dump on night shift again! Increased stress and workload translates into decreased patient safety. And THAT is the bottom line.
  4. by   fromtheheartRN
    Also, I find it very helpful if I ask the ER RN--or the ER Charge if it would be possible to at least get a patient admitting history prior to floor transfer. Sometimes we are lucky enough to get this if the ER has a "resource RN" hanging out down there-for that reason. I can assure everyone that us floor nurses are eternally thankful if this is possible. Sometimes not, but it is VERY appreciated if it is.
  5. by   PANurseRN1
    Quote from jannieannie79
    Also, I find it very helpful if I ask the ER RN--or the ER Charge if it would be possible to at least get a patient admitting history prior to floor transfer. Sometimes we are lucky enough to get this if the ER has a "resource RN" hanging out down there-for that reason. I can assure everyone that us floor nurses are eternally thankful if this is possible. Sometimes not, but it is VERY appreciated if it is.
    You mean you think the ED should be doing your admission paperwork? No chance...we have enough to do as it is.

    Where I work, you can't call report to the floor from 7-8a, can't call at lunchtime (which can be very loosely defined), can't call from 3-4p, can't call at supper (same thing as lunch, very fuzzy about what supper time truly means), can't call from 7p-8p and can't call from 11p-12a. So that pretty much hamstrings the ED. Then there's the "can't come to the phone because she is off the floor/passing meds/with a pt./doing a dressing change/in the bathroom," etc.

    I realize the floors are busy, but it really gets my nose out of joint when they kvetch about the ED "taking so long" to get the pt. upstairs. When you have so many times tht you can't call report, you have to keep moving and take care of other things. And ED pts/ambulances don't seem to abide by the "don't call hours" the floors have.
  6. by   Jen2
    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)
    I agree with the systems failure part. There is only so much a nurse can do as far as workup. Yes I can order and draw labs/cultures etc., However when the white count comes back to be 18,000, I need an MD to write an order for that antibiotic. Even with the high white count and first round of antibiotics started by the ED, that does not gaurantee that the surgeons will get there any sooner. Basic wound care can be done by a first semester nursing student. The problem is and it is hospital policy that if the surgery has been less than 30 days. The sugery team that performed the surgery must evaluate the patient. Nine times out of ten the patient has already called the surgeons office and was told to go to the ER, becasue they have no appointments available for the day. Once the patient gets to the ER, the surgeon will not come and see the patient until all testing from an ED standpoint is done, and they are done doing their rounds, scheduled surgeries etc. I wish we had the luxury of an assessment bed, but that is not the case. We cannot turn a patient away and say, "It sounds like a problem of the surgeons, sorry but we will not be able to see you today." There is a thing called the EMTALA law.
  7. by   level1_traumaRN
    In my ER we have 42 beds, it's a level 1 trauma center and there are only 2 in the state. Our problem is that the hospital is always full and it has 450-500 beds. However, we work as hard as we can, whenever there is a bed ready we will call up to the floor (we don't care if it's 6:52pm), we have took care of them ALLLLL day or ALLLL night (or they have been in the ED for 1-2days and finally have a bed ready). The floor nurses are always getting angry at us but they don't understand that this patient needs to get upstairs because there is always someone else waiting to be put on their stretcher.
  8. by   mmutk
    My future response to any nurse who asks the question 'hey ER what takes so long', is .... come on down and hang out with us for a shift and I'll show ya.
  9. by   dcs1
    [quote=RunningWithScissors;2056836]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!!![/quote

    Everyone that walks throught the ED doors thinks they have an "emergency". Every one wants all your undivided attention NOW. Some things take more time than others. If you are thinking we are probably waiting till shift change on purpose, remember, ED is a different world. Most the time our shifts are all overlapping and don't usually end with the floors come and go times. Waiting till shift change is for the nurses on the floors who are lazy (and I am definately not saying that any of us is lazy, but, you know the ones who are on your floor or unit!).
    Labs may be drawn 5 hours ago. When did they get to the chart? When did the Doc get to review all results and call the PCP if needed? And what happens if your ED is full and the Priority ambulances just keep rolling in?
    Lots of answers possible for your question!
  10. by   JessicRN
    Typical day in our ED we are a teaching hospital. Pt comes in lets say HTN nurses do line and lab EKG and chest per protocol. The lab takes 45-90 minutes if the blood was not hemolysed which happens often. Then you need to redo it and rewait. The PA/intern is assigned the pt and he gets around to the pt about 30 to 3 hr as he has several other patients he needs to see. He then goes to the attending, presents the case then the attending comes over in 30-1 hr to assess the pt. He may order some other test that the intern forgot. He then calls the patients doctor if he has one then the floor resident is called to admit the pt and the supervisor is called. The floor intern comes down within the hour to assess the pt then review the chart.he then calls the resident whomay or may not come down but in the patients chart it says the pt had a cardiac hx so the pt is now r/o MI status so since 4 hours have passed they order new labs and ekgs as well as medication so there is a repeat draw and a repeat EKG. Hopefully by then the supervisor has given us a bed number if not we wait. Report is faxed we call the floor then have to wait 30 minutes to bring up the pt. That is an easy pt and a typical admit without any complications.
    Welcome to a typical teaching hospital
  11. by   mamalle
    :uhoh21: wow if the floor actually called it would be a act of god where I work. How many times do I have to call and finally get a nurse to take report is more like it! besides the fact that every weekend we are holding in the ER since the floors have so many call ins... we were holding 14 last saturday am when we came in. its nothing new. as far as taking so long- traumas come first that delay the er, finding a hospitalist to come down and give orders is another or waiting for the private doctor or whoever is in call for that patient's insurance is another issue. we have standard nursing protocals to intiate the process but sometimes waiting on a ER doctor or PA to see the patient is another..