Holding patients in ER

Specialties Emergency

Published

My Manager has told us we are "not to chart" when we have an unsuccessful attempt at calling report to the floor or ICU. We are a very small facility and have no nursing supervisor or even a charge nurse to intervene when the floor refuses to take report. We are especially vulnerable at change of shift. I have offered to participate on a committee to look into the causes and am still waiting for our first meeting after 2 months have gone by.

In the past, I have always charted 1. The time I called for the bed assignment 2. The time or Times I have attempted to call report & 3. The time I actually transfered the patient.

Anyone else out there had this problem? What do you put in the chardt?:rolleyes:

Which shift change are you refering to?

At my hospital it could be...

0600, 0700, 0800, 1000, 1100, 1500, 1600, 1900, 2200, 2300, 2400, or 0300.

When would you suggest we call?

Wow! You work in a facility that has shift changes every hour on the hour? That's pretty intense. Shift change at my facility is at 7a, 3p, 7p, 11p. Those are the hours that are bad to send a patient to the floor. Don't know how your facility would handle it. Maybe send pt on the half hour? Anyway, I don't think anybody could argue that sometimes no time is a good time to get an admit. However leaving a pt with no nurse is even worse. Just a thought.:)

Wow! You work in a facility that has shift changes every hour on the hour? That's pretty intense. Shift change at my facility is at 7a, 3p, 7p, 11p. Those are the hours that are bad to send a patient to the floor. Don't know how your facility would handle it. Maybe send pt on the half hour? Anyway, I don't think anybody could argue that sometimes no time is a good time to get an admit. However leaving a pt with no nurse is even worse. Just a thought.:)

We have:

06-18 and 18-06

07-19 and 19-07

07-15 and 15-23 and 15-03

08-16 and 16-24

10-22

11-23 and 23-07

Somewhat of scheduling nightmare at times...but it works.

We consider the "taboo" shift change times 07-0730 and 19-1930. Period. No other ones count.

All the rest of the times the offgoing shift takes the report and settles in the patient. Or the oncoming shift takes our report first and the offgoing just settles in the patient. Our patients are never nurse-free anymore than the rest of the patients who are already on the unit. SOMEONE is watching them during your shift change, aren't they!!??

Specializes in ER, PACU, OR.

I always charted everything, that's the way it was going to be. Not don't do this, don't do that....

Bottom line are they the facts? Yes Sir!

Specializes in 6 years of ER fun, med/surg, blah, blah.

What about all the psych patients held over in the ED whilel awaiting placement? There have been times we've had up to 12 psych pts. either waiting to be seen, waiting for placement, esp. those without insurance, & have no place to see other medical pts. In my ED there are 18 acute beds open 24 hrs & 18 subacute beds open from 9a & start closing from 11 pm to 3 am. We have had a semi-permanent pt. for 2 weeks, waiting for placement. Not a danger but just crazy & won't/can't take her own meds. And she had no place to go. So much for closing all those government funded facilities.

Specializes in ER.
My Manager has told us we are "not to chart" when we have an unsuccessful attempt at calling report to the floor or ICU. We are a very small facility and have no nursing supervisor or even a charge nurse to intervene when the floor refuses to take report. We are especially vulnerable at change of shift. I have offered to participate on a committee to look into the causes and am still waiting for our first meeting after 2 months have gone by.

In the past, I have always charted 1. The time I called for the bed assignment 2. The time or Times I have attempted to call report & 3. The time I actually transfered the patient.

Anyone else out there had this problem? What do you put in the chardt?:rolleyes:

We chart each attempt to call report. Usually, we can give report on the first try without a problem - except when sending the patient to our inpatient psych or chemical dependance unit, where they simply ask a million questions about the patient's community outpatient care.

Our problem is when the Residents are to come and admit the patient. It takes a 15-20 minute procedure (when done by the ER doc and the private attending) and stretch it into a 4 hour ordeal. Of course, this is a nursing problem and we get blamed for it!

In theory, the Residents are supposed to arrive within 30 minutes of being called and write orders first. That is supposed to let us get the patient to the floor (and off the stretcher and into a bed). In reality, they usually write the H&P, review two or three other patients, eat, drink, be merry, and then get around to the orders.

Does anyone else have problems with the Residents getting patients upstairs?

Specializes in emergency nursing-ENPC, CATN, CEN.

Mattsmom-

"While I'm sorry ER is not getting the support/staffing they want, I still have my own critical care standards to worry about and can't worry about ER. AACN says 2:1 ratio...that's what I go by. I will not be convinced to take 3-4 ICU patients because ER is holding them...that simply is not a good reason for ME to take the risk IMO. This is each nurses' call.

I won't work for a facility that would tell I cannot refuse an admission, if I determine it is unsafe to do so"

Obviously the ED is not for you--how wonderful that you have hospital administrators who allow you to refuse to care for more patients. And while your "potentially 4 critical unstable ones" were in your dept--how would it feel if the ED brought in 2-3 more-without report or warning and stood in your hall with the pt and their family wondering when are you going to care for them? The ED nurses do not utilize alot of ancillary staff-we are our own phlebotomists, resp therapists and IVteam, ECG dept. Some depts have ED techs -to help w/ transports and splints/dressings-but they don't help much ith the 'HOLD in the ED crowd'

ENA and College of Emergency Physicians recommends a 3:1 ratio I believe. I can just see myself telling the charge nurse--"sorry I'm at my limit, these people will have to wait- I don't care if they have chest pain, trouble breathing, bleeding, were in a car accident, etc, etc, etc.". I'm sure my VP in nursing would support us--NOT. We can't even get the administrators to allow us to go on divert (we're a 16 bed unit and yesterday we were holding 14 admitted patients with a 3-4 hr wait in the WR for walkins--and the direct admits kept coming-the attendings said-"no bed available-send them to the ER 'til one is". I have to combine ED care w/ following all the other departments' standards and policies-I was just glad these HELD pt's got their meds, labs, IVs and tests done. When I took 2 of them upstairs- I was reprimanded because I didn't fill out one of their flow sheets correctly! )

No wonder many ED nurses feels unsupported by other nursing units. The chaotic environment belongs to the ED-we know it-and unless you live it-you can't imagine what the days can be like. It's hard to get that point across to other nursing units. I know they are busy as well- but it's usually controlled and limited to a degree.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
It's hard to get that point across to other nursing units. I know they are busy as well- but it's usually controlled and limited to a degree.

I agree 100%.

It's also hard to get the ER to see the staff nurses point of view that we have a maximum ratio that is safe, because the ER while having perhaps similar ratios doesn't have any power to control those ratios when ambulances arrive.

Your response is mature and understanding.

Specializes in emergency nursing-ENPC, CATN, CEN.
I agree 100%.

It's also hard to get the ER to see the staff nurses point of view that we have a maximum ratio that is safe, because the ER while having perhaps similar ratios doesn't have any power to control those ratios when ambulances arrive.

Your response is mature and understanding.

I worked med surg/telem/PRN before going to the ED for several years (when I graduated nursing school) Another reason why I think specialty nurses should spend time in med/surg/telemetry prior to going to more critical and challenging areas. I find that the ED nurses who have this experience, for the most part ,don't have personality-relationship issues with the other nursing units. A"walk in my shoes" type experience that benefits the ED nurse. (except for yesterday when I got written up, obviously that ICCU nurse wasn't as busy as me that she could spend 30 minutes filling out a complaint form--:angryfire )

Oh well- tomorrow's another day:rolleyes:

Anne

Mattsmom-

"While I'm sorry ER is not getting the support/staffing they want, I still have my own critical care standards to worry about and can't worry about ER. AACN says 2:1 ratio...that's what I go by. I will not be convinced to take 3-4 ICU patients because ER is holding them...that simply is not a good reason for ME to take the risk IMO. This is each nurses' call.

I won't work for a facility that would tell I cannot refuse an admission, if I determine it is unsafe to do so"

Obviously the ED is not for you--how wonderful that you have hospital administrators who allow you to refuse to care for more patients. And while your "potentially 4 critical unstable ones" were in your dept--how would it feel if the ED brought in 2-3 more-without report or warning and stood in your hall with the pt and their family wondering when are you going to care for them? The ED nurses do not utilize alot of ancillary staff-we are our own phlebotomists, resp therapists and IVteam, ECG dept. Some depts have ED techs -to help w/ transports and splints/dressings-but they don't help much ith the 'HOLD in the ED crowd'

ENA and College of Emergency Physicians recommends a 3:1 ratio I believe. I can just see myself telling the charge nurse--"sorry I'm at my limit, these people will have to wait- I don't care if they have chest pain, trouble breathing, bleeding, were in a car accident, etc, etc, etc.". I'm sure my VP in nursing would support us--NOT. We can't even get the administrators to allow us to go on divert (we're a 16 bed unit and yesterday we were holding 14 admitted patients with a 3-4 hr wait in the WR for walkins--and the direct admits kept coming-the attendings said-"no bed available-send them to the ER 'til one is". I have to combine ED care w/ following all the other departments' standards and policies-I was just glad these HELD pt's got their meds, labs, IVs and tests done. When I took 2 of them upstairs- I was reprimanded because I didn't fill out one of their flow sheets correctly! )

No wonder many ED nurses feels unsupported by other nursing units. The chaotic environment belongs to the ED-we know it-and unless you live it-you can't imagine what the days can be like. It's hard to get that point across to other nursing units. I know they are busy as well- but it's usually controlled and limited to a degree.

Hmm...well I won't repeat myself but I don't buy into this line of thinking. I've been a nurse too long (an ER nurse many years ago) I cannot take care of other depts: ICU keeps me hectic enough. Jealousy of ER nurses on this issue is apparent but hey...again not my problem. Overflowing ER's are the HOSPITAL's problem, and it is not my responsibility in ICU to become an extension of ER.

We all have choices. I don't work ER anymore and I won't work for a hospital that tells me I must accept a dangerous nurse pt ratio. I will retire before I take that responsibility on. Again, choices.

"Hmm...well I won't repeat myself but I don't buy into this line of thinking. I've been a nurse too long (an ER nurse many years ago) I cannot take care of other depts: ICU keeps me hectic enough. Jealousy of ER nurses on this issue is apparent but hey...again not my problem. Overflowing ER's are the HOSPITAL's problem, and it is not my responsibility in ICU to become an extension of ER.

We all have choices. I don't work ER anymore and I won't work for a hospital that tells me I must accept a dangerous nurse pt ratio. I will retire before I take that responsibility on. Again, choices."

It is funny how it isn't ok for an ICU nurse to go beyond her nurse-pt. ratio, but it is ok for an ER nurse to do it. I have no problem holding a pt. in the ER if there is not any beds available. However, when the problem is not beds being available, but nurses not being willing to take the pt. then that is a different story. If the ICU is not staffed to where there will be a safe nurse-pt. ratio if the ICU was full then that is a problem with staffing. The problem with the ER is that we can be staffed for a "SAFE" nurse-pt. ratio if all of our beds were full and then we could get thirty more pt's in the hallway. Also for the comment that someone made about every nurse should have med/surg experience, well as much as that is true, every nurse needs ER experience. As an ER nurse I can tell you that I do many "Med-Surg" tasks in the ER. Not very common that Med-Surg nurses do what the ER does (not saying that you guys aren't busy) Basically, if the ER is not busy then I have no problem helping the floor out and holding the pt. if the nurse on the floor is busy. However, when I have a cardiac arrest, respiratory distress and a multi pt. trauma coming in and no beds to put these people in then I would say getting a bed open is a little bit more important than the excuse "It is shift change" I don't have the opportunity to ask EMS to drive around the block a few times before they bring that Cardiac arrest in because "it is shift change" We all went into nursing to give good pt. care and instead of thinking about what time our shift ends maybe we need to think about the pt.

when i call report and i am told that the nurse is busy, i ask if anyone else will take report. if the answer is no i inform them that i am going to chart "rn,s on 6north unable to take report at this time" (unless they then tell me a code/precode is in progress) if i attemp to call report and the nurse says she "won't" take report i inform that rn that i am charting it as a refusal. when i inform they floors of my charting i tell them that it is not bashing them but covering myself when our department does QA on our charting to find out why there were delays in transferring the patient. i find that the nurses on the floor call back within 5-15 min if i tell them what i am about to chart. i also try to be flexable and play "let's make a deal". i tell the RN that i f i can at least Give report now i can wait 30-45min to transfer the patient. that usually works well.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

It is funny how it isn't ok for an ICU nurse to go beyond her nurse-pt. ratio, but it is ok for an ER nurse to do it. I have no problem holding a pt. in the ER if there is not any beds available. However, when the problem is not beds being available, but nurses not being willing to take the pt. then that is a different story. If the ICU is not staffed to where there will be a safe nurse-pt. ratio if the ICU was full then that is a problem with staffing. The problem with the ER is that we can be staffed for a "SAFE" nurse-pt. ratio if all of our beds were full and then we could get thirty more pt's in the hallway. Also for the comment that someone made about every nurse should have med/surg experience, well as much as that is true, every nurse needs ER experience. As an ER nurse I can tell you that I do many "Med-Surg" tasks in the ER. Not very common that Med-Surg nurses do what the ER does (not saying that you guys aren't busy) Basically, if the ER is not busy then I have no problem helping the floor out and holding the pt. if the nurse on the floor is busy. However, when I have a cardiac arrest, respiratory distress and a multi pt. trauma coming in and no beds to put these people in then I would say getting a bed open is a little bit more important than the excuse "It is shift change" I don't have the opportunity to ask EMS to drive around the block a few times before they bring that Cardiac arrest in because "it is shift change" We all went into nursing to give good pt. care and instead of thinking about what time our shift ends maybe we need to think about the pt.

We can go round and round and round and not get anywhere. Because the fact remains that no it's not funny that ICU and Med-Surg nurses refuse to go above safe established ratios and ER nurses don't have that luxery. It's just the way it is.

But don't feel that just because I'm at my maximum safe ratio, and have empty beds on my unit, you're helping me out by holding the patient. You're not helping me out. I'm already doing my job, what is happening in the ER is not helping me out and not my concern.

We're talking apples and oranges. The argument that you don't have the luxury of adhering to ratios doesn't invalidate the established safe ratios on the units. Sorry, but if you're above and beyond a safe ratio doesn't make it necessary for me to be. Not that I'm not sympathetic to the patient's needs, but it isn't going to help the patient to go from one potentially unsafe situation to another.

Again, apples and oranges, no need to go round and round. We've both put in our two cents. :rotfl:

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