Hey ER, what takes so long???

Maverick80 · Feb 24, 2007

i'm a tech in a level 1 trauma center ER. I'm in nursing school and will be done in 2 1/2 semesters with my BSN. I ofen get caught in the middle of these little fights between floor nurses and the ED nurses. The floor nurses get very upset about patients right before or after shift change and i'm the one who gets to hear about it. The ED nurses don't do it on purpose and we have a policy that once the room is assigned the floor has 45 minutes to get the room cleaned and ready. That's the way it is. so when 45 minutes is up your getting the patient. We don't have room for them and once they are out of the computer we can not take them back and put them back in.

I'm not a nurse yet but i've seen ED nurses deal with some pretty crazy things, and being a tech i have been pulled in several directions to do my part when things get crazy. One day at 7am we had a GSW walk through our door and we called the trauma team and then came another GSW through our door a few minutes later ( a couple up at that hour shooting each other :eek: !) and within about a half hour later (trauma teams still going on) a full arrest came in by ambulance followed by a stemi!! Now that's a crazy shift change right there. As you can imagine that's nothing anyone wants to walk into but you do what you have to do!!

colorado ER RN · Feb 25, 2007

It depends on each ER, but in ours we have standing orders that allow nursing to draw labs when the pt arrives so even though the labs were drawn 5 hours ago that doesn;t mean that they saw the doc then, then the doc sees the pt orders any additional test he/she may want and then we wait for results. Then the admitting dr has to be called, but in the middle of all this there could have been cardiac arrest or trauma that have tied our doctor up so we wait in the ER. Then the pt is finally admitted and we finally get a bed for that pt, then right when we go to give report we get an ambulance--which could be another train wreck pt that needs labs,IV,cath etc and we get tied up again. We do usually get pt upstairs asap but until you work er you can;t appreciate it!

ERJunkieBSNRN · Feb 25, 2007

Hey There,

This is my first time posting and I would like to start off by first saying it would be beneficial for us all to spend time in different units to see the adversities within our jobs. I am an ER nurse, have only been an ER nurse but have worked at different facilities and thus have seen the complexities that ED's and nurses face. I work in a facility that has little to no support staff...that means the nurses are taking patients to every service (CT, XRAY, US) and they also run lab work to the laboratory, perform EKG's, etc. Due to the number of patients we see a large majority of our physicians will try to do a basic workup on folks in order to expedite care and turn patients over in a timely matter. So often a BMP and CBC are ordered, something unusual shows up and then additional orders are added. This tends to happen a lot. A few orders here and then add more an hour later when you get your first set of results back. You had indicated that a person was waiting downstairs for 5 hours...there could be a variety of reasons....the adding on of orders as I had stated....CT with oral contrast workups. Waiting for your admitting service. Admitting service taking the chart and showing up an hour later with orders. However, they feel a large number of orders could/should be done by us before they get the patient upstairs. This is a point of contention right now w/in our hospital. Recently I had a patient w/ a GI bleed and it was taking time to get the 4 units of PRBC's and 4 of FFP. The MOD was wanting the patient to stay in the ED so we could transfuse the patient. He was stabile enough to be able to have this done upstairs. I can tell you that w/ 90% of the patients I admit, the majority of what the admitting physicians want done are done in our dept initially. Repeat labs, meds, vitals seem to be the only thing that remains. We start the antibiotics they need, etc. Someone had mentioned that it appears as though an influx of patients come at shift change. The providers gather their charts at their convenience and do their charts/admissions, etc often at once, especially if they know they will be going home soon. While it is a challenge for your floor, it is a challenge for us as well to get orders done on the other patients, to copy charts, gather personal belongings, arranging for security to pick up belongings, getting acutely ill patients to surgery, etc. and then transporting the patient(s). When I get the patient upstairs someone takes the chart from me and I am left alone to get the patient situated in a bed. I can tell you that our department is so busy nurses are sent from other floors/departments to assist. 95% percent of them (and I don't believe this is an exaggeration) are overwhelmed and appear as though they've been thrown into a battlefield. On top of all of those toss in a trauma or an acute MI workup into the mix and see how much more that delays admissions. My two cents worth.:smilecoffeecup:

sunciray · Feb 26, 2007

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.

majadu · Feb 27, 2007

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!

fromtheheartRN · Feb 28, 2007

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.

fromtheheartRN · Feb 28, 2007

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.

PANurseRN1 · Feb 28, 2007

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.

Jen2 · Mar 2, 2007

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.

level1_traumaRN · Mar 5, 2007

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.

mmutk, BSN, RN, EMT-I · Mar 5, 2007

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.

dcs1 · Mar 24, 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!!![/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!