ER handoff report to floor

VICEDRN, BSN, RN · Oct 3, 2010

I have also been on both sides of this issue. I spent 3 years in ICU, 8 yrs on Cardiac floor, the last 3 years in ER. Let me start by saying I'm not going to criticize either group of nurses here. I honestly believe that most ER nurses have no idea what goes on on the floor and most floor nurses have no idea what goes on in the ER.
When I first transfered to a cardiac telemetry floor it drove me crazy to find that yes my pts are on telemetry, but you could only see it at the nurses desk and you only got a rhythm strip and a heart rate, no BP, no SPO2, nothing else and your pt may be 10 doors away from the nurses desk! I quickly learned that I wasn't receiving pts that were that critical.
On the tele floor if a pt began having chest pain, we got placed them on O2, got an EKG, gave and asa and three nitro and called the doc. Was I capable of starting a nitro gtt,..sure,.but I had sometimes 8 or 9 other pts to care for and couldn't possibly monitor a pt on a nitro gtt! My floor had way different protocols than ICU,..and for good reason.
When I moved to ER it was a whole new ball game. I suddenly had almost no limits on meds I had on hand and was allowed to give,..and I had a doc right there to order what was needed. I never got report on pts,.they just show up! It was a very different atmosphere to work in.
I was recently placed on a committee to address hand off issues with the floor. We were having many of the same concerns you mentioned in your OP. We now call report, then call as we are leaving the ER. We must wait at bedside for the RN to come into the room and wait for the first set of VS. We take a print out of the pts ER chart and record time we arrived at the room, time accepting RN arrived, and the VS. The floor keeps a copy and we keep a copy. Honestly this makes me feel like a 3rd grader,..but it has stopped a lot of the "she didn't tell me that in report" complaints.
I get so very frustrated when I hear my co workers make statements like "the nurse on 3 west is refusing this pt,.she says he isn't appropriate for her floor,..isn't she a real nurse? We took care of him for the last three hours now it's her turn. Doesn't she realize we are crazy busy down here!" Well,..yes but don't you realize that Nitro gtts aren't allowed on her floor,..or that GI bleed with a BP of 90/60 will probably go south on her and she doesn't have the time or the staff to get VS Q 15 min to even notice when it happens! Then of course, when it does happen the pt will be transfered to a unit bed, and turn over of beds on the floor is way more time consuming and complicated than moving from ER to the floor!
I am often ashamed of the behavior of my co workers both in ER and through out the hospital for making the assumption that someone is trying to get out of work, or that somehow they are the only nurse in the hospital that is running their butt off! Get over yourselves folks. We have rules and protocols for a reason, to give the pt the best care we can.
I'll step off my soap box.

I think I understand better than most med/surg nurses which floors take which kind of patients because I have to send my patients all over the place. If it happens that I have a patient with an obviously inappropriate admit, I just tell the floor nurse, "Oh, ok. Let me check with someone. Thanks. Bye." If they tank after they get there, I am sorry but I don't have a crystal ball. A patient probably going south is not a patient who went south and I still don't make bed assignments.

I note that your facility's protocol for hand-off report leaves a lot of the burden remaining on the ER nurse. As you said, no one tells me when the patient is going to be placed in my room in the ER but now, I have to give ample warning to the floor for a bed assignment they already knew was coming and I have to wait in a room with a patient knowing that the ER charge nurse just cleaned my room, put a clean stretcher in it and a new patient in my room. How is that fair to me? I have another patient WAITING FOR ME in the ER!!

No wonder all of the more experienced ER nurse in my unit tell me that I will just have to get used to the idea that the ER gets treated badly! I am kind of hoping to raise awareness here because it seems to me that too much burden for the patient ends up on the ER because as you state, "Its harder to move from one unit to another than to move from ER to a floor." Well, they came in in their street clothes with no IV access, no labs, no history, nothing! The burdens are just different.

APRN., DNP, RN, APRN, NP · Oct 3, 2010

In the ER, the doc is within shouting distance of orders for pain control, hypotensive episodes, agitation, desaturation and "gee...this don't look quite right".

I've worked Med/Surg. The floor nurses are farther removed from the doc, and have quite an impressive ratio of patients to wade through in order to page the doc, wait for the doc to call, not get a call back, call the doc again, wait for the doc to call, get the order, make the order "official", have the intervention available, and give the intervention when something goes south quickly upon arrival to the floor. It is critical to know as much about the patient as possible because you have to give the doc a reason to order what needs to be ordered, and "gee...this don't look quite right" just don't cut it over the phone.

Every single shift on the floor is like a day of getting slammed in the ER. There is no downtime. Ever.

The nurses who learn how to survive and thrive in Med/Surg have time management down to a fine science, and even that can be quickly upset by an untimely arrival with poor information from another unit - be it ICU or ER or tele or wherever. If they don't know this patient from Adam, it's a scenario that is setting someone up for failure, so, it's normally the patient who gets the short end of the stick, and the nurse who wears the guilt.

I thrive in ICU. It's what I do, and I know what I am doing. We have 100% computerized charting. As long as I know what that patient showed up to the ER for, I can take a look at the labs and what's been done so far and go from there. The IV ran dry on the way up from ER, no problem, I have come to expect that and I have an IV start kit waiting in the room to drop in a new 18 gauge. No stat meds have been given? No problem, I've already anticipated that and have called the pharmacy to have the IV meds sent to the unit to give. If they've already been given, what a bonus.

I've worked ER, and a lot of the focus is what is going on in the here and now. The doc wants to admit the patient? Okay, get a transport and let's get the patient to their room. Let the nurse know we're coming. Report? What do they need to know? They're here for xyz and there's a patient waiting for me when I get back. Get em in and get em out, either through the door or up the elevator. It's nothing personal. What? The quicker I get them to the floor, the quicker they can get those stat meds.

PatricksRNMommy · Oct 4, 2010

In my facility, we use a fax report. Er nurses call to confirm that the unit received the report. We then give a few minutes to the floor to prepare themselves and then bring the patient up.
I work in the ER so I have a few things to say to the OP:
I don't make bed assignments. The admitting physician does. Please take your complaints up with them if you have to RR a new admit. I don't always agree with the assignments either. Well I didn't say that you made bed assignments, but ER nurses CAN advocate for patients if the pt is assigned to med/surg when they clearly nedd tele, or tele when they need ICU...
I am sure that you are not surprised that the transfer process can cause a change in vitals or incontinence. Yes I am very aware of that, but i am also aware of the multitude of patients that come to me caked in dried feces or in a diaper FULL of urine

I hate the report game. I have called to confirm receipt of my fax only to be asked if I could just "hold off" a bit longer or could I please just call back in ten minutes as the room is not clean. (only to find out that the nurse has purposely asked the housekeeper to clean other rooms first) A half an hour later and the charge nurse is asking me how come I haven't moved my patient yet (and thinking I am lazy).We give verbal report to ICU and I am so tired of being refused. I hope I never work at a place that insists on verbal report. The ICU refuses almost every single time and it turns into a game. "Oh! nurse is in a patient's room" or "let her call you back in two minutes" and 30 minutes later... Our other 5 of 6 patients on the floor don't magically stop having needs because you need to move your patient up NOW... We aren't sitting at the desk chatting or eating bon-bons when you call... We are likely medicating someone, doing a dressing change, or doing patient teaching... I'm not saying I don't understand your pressures as well, but you need to be a bit more understanding of ours as well. And sometimes we have 10 discharges within an hour and all the beds are immediately assigned... The housekeeper can only do so much.

For the record, if the standard of care requires that the hand off is nurse to nurse, you can meet me in your patient's room in ten minutes. By the time I am done settling them in, I should be on your floor for a total of 20 minutes or so. I also don't like leaving them alone but I don't own whether you are there or not when the patient gets there.

You probably received ample warning from the secretary, charge and house supervisor. You probably already knew that you would get an admit to that bed so why is it such a surprise when I call to tell you I am coming up?
Also, please note: I don't order consults. The doctor does. Let me clarify, with this statement I was speaking of patients that are in the ER for a period of time after admit orders are received. Here for CP, cardio consult ordered.... It IS the standard of care to have the consulting doctors called and STAT meds started, and if you don't think so, I feel sorry for your patients

As for the report sheet, I can't address things that the physician hasn't prescribed for and I won't initiate any orders if I am told there is a bed for this patient. In fact, I can't. I have a timer that tells me I must transfer the patient within a certain number of minutes.

I just feel like patient care should be the priority, and bringing a patient up to a dirty room to a nurse who can't give them the care that they deserve just isn't fair to anyone. :)

Fribblet · Oct 4, 2010

I just feel like patient care should be the priority, and bringing a patient up to a dirty room to a nurse who can't give them the care that they deserve just isn't fair to anyone. :)

And leaving them on an ER stretcher for 12 hours isn't what they deserve either.

PatricksRNMommy · Oct 4, 2010

And leaving them on an ER stretcher for 12 hours isn't what they deserve either.

I didn't say that it was, all I was trying to say was that what is happening now is not working.... for the patients, for the nurses, and for relationships between the ER and the floor... I just want things to get better for our patients, they don't deserve to sit on an uncomfortable stretcher for 12 hours (I've been there, personally ans with family members) but it doesn't benefit them to come up to the floor and wait in the hallway because their room isn't clean because the ER sent the patient without a phone call.... I'm just sayin..... :)

VICEDRN, BSN, RN · Oct 4, 2010

I just feel like patient care should be the priority, and bringing a patient up to a dirty room to a nurse who can't give them the care that they deserve just isn't fair to anyone. :)

Who's patient care? Yours or mine? Why do you think they can get the care they need from me if you are just presently not available to take care of the patient? It makes me sick thinking that somebody with a fever of 103.8 is sitting in the waiting room because someone is playing the bed game. Also, the following items are not stocked in my department: beds, regular blankets (we have bath only), shower supplies, the cream you put on incontinent patients, diapers in bulk (we keep a few), pillows, peace and quiet and I can go on...

I am certainly understanding of your pressures and I think that many med/surg nurses understand mine. I also think there are abuses on both sides of the house. I have seen ER nurses ignore diapers and hold patients in the department until nearly shift change. I have seen a med/surg nurse purposely concealing empty beds and d/ced patients from the house supervisor. (eventually the supervisor literally checked on the darned beds. lol)

I can advocate all day long. It won't change the bed assignment. In the mean time, the ICU will complain that the patient belongs on med/surg and med/surg will refuse the patient. I once held a bipap patient my entire shift because both sides of the house refused her. Was that fair to the patient?

Your comment about the housekeeper ignored the statement I made that I have seen nurses purposely tell the housekeeper not to clean rooms or clean other rooms first because no patients have been assigned there.

I know a physician who puts orders in STAT in case her patient gets held in ER even if there is no way in heck its a stat order. I am not fooled. Sorry. (and yes, she told me that she does this)

I am sorry that you trot out the vindictive "I feel sorry for your patients." Please don't feel sorry for them. They receive pretty darn good care that I work my butt off to give them but I am also not a mind reader. If they are admitted to tele with CHF, how am I supposed to know that they are supposed to get an echo this admit? by guessing? If I can see the test in their orders, then yeah, I make sure they get it by calling the appropriate dept and arranging if necessary but this is an area that med/surg nurses know better than me. THIS is why they belong to you. Med/surg folks have their routine and area of care down pat. Remaining in the ER is uncomfortable, unfair, and ultimately unsafe for the patient.

The truth is: there are abuses in both areas but placing the burden on ER to wait for you is not fair to either nurse or the patient.

BrnEyedGirl, BSN, MSN, RN, APRN · Oct 4, 2010

I didn't say that it was, all I was trying to say was that what is happening now is not working.... for the patients, for the nurses, and for relationships between the ER and the floor... I just want things to get better for our patients, they don't deserve to sit on an uncomfortable stretcher for 12 hours (I've been there, personally ans with family members) but it doesn't benefit them to come up to the floor and wait in the hallway because their room isn't clean because the ER sent the patient without a phone call.... I'm just sayin..... :)

The problem is that we ALL have more pts than we can care for, in the manner we were taught to care for them, in the manner that they deserve to be taken care of. If a pt sits in the hallway, on the floor, that has freed up a bed for someone in the waiting room who hasn't been seen at all. I still believe a lot of our flow-thru issues would be fixed if the hospital would hire more housekeeping staff!

If my stable belly pain, who needs to have her appy out in the am can get upstairs, even to the hall way, I can now see one of the 34 pts in the waiting room who haven't been seen at all. At least we know what's wrong with the admit pt. She has seen a doc, been worked up, we know what's going on. The pt in the waiting room could have an ectopic pregnancy, AAA, MI, CVA, etc because we don't know yet. They need to be seen by a doc and worked up!

I recently triaged a 20 something, healthy young man with a "sore throat". He didn't want to be there, but his Mom insisted. He had been seen 2 days earlier at urgent care and dx with Strep pharyngitis and was started on PO abx. He looked like he didn't feel good, but was afebrile, normal VS, speaking in full sentences and arguing with his Mom about wasting time in the waiting room when he could be home in bed. I kinda agreed with the poor kid, but not my call. He was placed in the waiting room. Three hours later his Mom comes to the triage desk to state she didn't think he was breathing right and was drooling all over himself. He was rushed back, another pt placed in a hallbed to make room, and was intubated 10 min after getting back, nasty tonsilar abscess. At that point I had 32 pts in the waiting room. 7 who hadn't even seen a triage nurse, 16 pts in the ER who had been waiting over 2 hours to get upstairs. All 16 pts had room assignments and orders but for various reasons couldn't go up yet. There has to be a better way to do this!

nursej22, MSN, RN · Oct 4, 2010

I find this discussion, which had occurred many times before on this site, always seems to devolve into nurses blaming nurses. I think we all have horror stories about the tanking patient who arrives on the floor, or a frail elder lying for hours on a stretcher in their own waste.

By and large however, I see most delays are out of the staff nurses' power to fix:

1) Housekeeping getting rooms turned over in a timely manner

2) Getting appropriate admit orders written, before the end of shift

3) Having adequate supplies and equipment in the areas where they are needed

4) Enough staff to deliver care, including physicians, nurses and techs.

I personally try to take every phone report as soon as it comes and I urge the ED to transport the patient ASAP. Unfortunately, I will always have an iso room or two, confused patients climbing out of bed, an occasional rapid response or code, or another patient arriving or departing.

PatricksRNMommy · Oct 5, 2010

After reading some of these posts, I really want to make it clear that I was not bashing ER nurses. I know you are very busy in the ER and I do everything as I can as a charge nurse to get patients up to the floor ASAP. I feel like floor nurses need to be more considerate of the ER nurse's situation and vice versa. We are all professionals and need to treat eachother as such. When I posted the original post I had just had a particularly bad week dealing with my ERs (my hospital has 3 ER's that admit to us - 1 onsite and 2 outlying) and I am in charge of the entire tele floor, so when we are busy we are BUSY. I was venting and I didn't mean to come off as totally negative and hateful, cuz that's definitely not me. I just think there should be a better way of doing things. Sorry if I made anyone mad... it wasn't my intention. :rolleyes:

**canoehead, BSN, RN** · Oct 5, 2010

This is not a nurse to nurse issue. This is a staffing issue, a resources issue, and the result of trying to maximize profits in an unpredictable environment. Both sides are right, and we need to talk together finding ways to ease the actual problems...that we don't necessarily have an official power over.

cmarn · Oct 8, 2010

I see where you are coming from. Let me give a bit of the flip side. I think it's tough for both the floor and ER nurse..

In our facility we call the floor to let them know we are on the way and let them know what's needed in the room ahead of time. We accompany the patient to the floor. In fact, if it is a remote tele or tele patient, the nurse and CNA take the patient to the floor. We also put the patient's complete med list in the computer prior to taking the patient.

Here's our battle...

I have 3 to 5 emergency patients. I put in the med list (which can take a lot of time...) I call the floor. I get to the floor and no one is available right away. The room isn't ready. I empty the room by myself, wait for transfer help. Get equipment for the room. Repeatedly page someone to take report. Sometimes I am on the floor for thirty minutes. During this 30 minutes I have other patients downstairs that might need to be admitted, may be critical, and probably have a new patient in the room I just emptied.

I am not sure what the answer is to this issue? I agree that face to face report is a plus. I agree that it is best for a nurse to accompany a patient to the floor. We all know that patients can go from non-critical to critical in a heartbeat although we transfer them all over the hospital via transporters for all sorts of things. I agree that you should not be responsible for any patient you have not assessed yourself. We have that same issue. For example, my name is put in the computer as the nurse for the patient in the empty room downstairs while I am transporting a patient to the floor.

I would love to know the best practice as well. Tough issue.

cmarn · Oct 8, 2010

Every single shift on the floor is like a day getting slammed in the ER? Really? For many reasons I have to disagree. Both are tough for very different reasons. Kudos to all nurses :)