ER nurses bringing pts to the floor soiled

[garn12]

at my hospital this is becoming a norm. im wondering is this a common unethical practice seen alot by nurses elsewhere? i find it really disrespectful and inconsiderate to floor nurses.

[cardiacfreak, ADN]

Sometimes, the hospitalist comes in, writes the time on their order sheet, then goes to see the patient and spends an hour in there. Then they come out and spend another hour writing orders, so at least 2 hours have passed between the time on the order sheet and the time the ED RN actually sees the orders. At my hospital, staffing goes down to one RN at midnight, so if that one RN has an admit, and that admit is stable, then they are lower on the priority list, as the RN needs to focus on new/unknown/potentially unstable patients, get their workups going, etc.

At my current place of employment, we try to have the primary RN call report on their own admits, but sometimes it doesn't work out that way. At my old place, it was really common to call report on others' patients (when we did telephone report; once we changed to faxed report, it became a moot issue).

Stargazer, I was just wondering if you used an SBAR report or something else? Do you ever have a problem with the floors not calling you in a timely manner to take the admission?

[Anna Flaxis, BSN, RN]

Stargazer, I was just wondering if you used an SBAR report or something else? Do you ever have a problem with the floors not calling you in a timely manner to take the admission?

We don't have an official policy. I typically will use a narrative, start to finish type of report where I start with name, age, admitting diagnosis, why the person originally came and how they got here (EMS vs. POV), where they came from (SNF, home) any significant findings on presentation, what we've done since they've been there, vital signs, IV access, a quick systems/head to toe, any family members present and whether they are helpful/involved, then ask the floor nurse if they have any questions.

We use a paging system where we page the admitting RN when we're ready to call report, then they call us back when they're ready to accept. Typically they call back within 10-15 minutes. Delays are uncommon unless it's around shift change time, then they'll call back and ask to hold off until after shift change, so then I'm sitting on the patient for another hour since shift change is a thirty minute window, then the oncoming RN likes to have at least thirty minutes to get their feet on the ground before taking the patient.

[SL2014]

Unfortunately I have also encountered this frequently at my hospital. I have attributed it to the fact that ED nurses aren't normally thinking along the lines of "ADLs and Patient Comfort". ED nurses have a totally different set of tasks which rarely include assisting a patient with ADLs, therefore I think that it's just not something that they usually think about. This doesn't make it okay, and more should be done to prevent it. But I really think that this is the "reason". Perhaps just reminding the nurse to be aware of patients basic needs would be helpful.

[cardiacfreak, ADN]

Unfortunately I have also encountered this frequently at my hospital. I have attributed it to the fact that ED nurses aren't normally thinking along the lines of "ADLs and Patient Comfort". ED nurses have a totally different set of tasks which rarely include assisting a patient with ADLs, therefore I think that it's just not something that they usually think about. This doesn't make it okay, and more should be done to prevent it. But I really think that this is the "reason". Perhaps just reminding the nurse to be aware of patients basic needs would be helpful.

I'm not an ED nurse, but I don't agree that they need reminding of basic needs, I think they DO in fact deal with patient comfort because that is the reason the patient comes to the ER in the first place, they are in pain or can't breathe, etc...

I also believe that there are very good ER nurses and some that are not so good, and those are the ones that don't think about the patient. This also can be said about any floor in a hospital or any other area in nursing.

[sistrmoon, BSN, RN]

Sometimes what happens where I work is that the patient comes in and because of their condition we already know they're going to be an admit, so we give the house supervisor a heads up so he or she can get us a bed. But the ED workup still hasn't been done yet, so that needs to happen first, and takes a couple of hours. Then the ED MD contacts the hospitalist, who may take an hour or so to come down and see the patient. Then the hospitalist spends another hour in the patient's room (and it's frustrating because they have the chart, so I can't start on the med rec or do the admission assessment in the computer), and then they come out and spend another hour writing orders. So then we get the chart back and have to update the meds in the computer and put in the admission assessment, do any stat orders, one more set of vitals, print off the vitals, make sure the patient is not soiled, all while caring for our other patients as well, and by that time several hours have passed between when the patient was first identified as a potential admit and the house supervisor notified, and when the patient is actually ready to be moved. And often, it happens right at shift change, not because ED RNs have it out for the floor nurses, but because that's just how it worked out. Or, it's also OUR shift change, and it's not fair to the oncoming RN to leave it to them, especially when they have a full lobby, people waiting to be triaged, and an ambulance on its way. If the patient is ready to go, they need to go, shift change or not. I really liked the process at my old place. We faxed report up to the floor, so there was no telephone interaction, and we took the patient up whenever they were ready, regardless of shift change. If the hospitalist wasn't there and the patient was ready, the ED MD would write quick admit orders so we could get the patient rolling. It made the process so much smoother and more efficient.[/quote'] Our patients come to the floor with holding orders. MAR comes to the floor and does the H&P(there's often a delay with this and we are sometimes asked to renew holding orders another 4 hours), med rec and admission assessment is the floor nurse's responsibility. MAR hogs the chart, sometimes for hours, then finally enters admitting orders. So if all that is done in your ED, I could understand the delay but that's not how it goes here.

[Anna Flaxis, BSN, RN]

Our patients come to the floor with holding orders. MAR comes to the floor and does the H&P(there's often a delay with this and we are sometimes asked to renew holding orders another 4 hours), med rec and admission assessment is the floor nurse's responsibility. MAR hogs the chart, sometimes for hours, then finally enters admitting orders. So if all that is done in your ED, I could understand the delay but that's not how it goes here.

I get that the process is different where you work, and I am fully willing to admit that some nurses are less attentive to basic needs, but I'd just like to encourage floor nurses to keep an open mind and consider that there may be processes or other factors involved besides simply laziness or disrespect.

[Anna Flaxis, BSN, RN]

Okay, so today I had one of those days where my patient could easily have been soiled upon arrival on the floor. We were slammed, triage after triage...they just wouldn't stop coming, and as much as I tried to get back into her room again and again, I kept getting pulled in multiple directions. Literally every single time I started walking in her direction, somebody would flag me down to do something else. Finally I took her to the floor fully prepared to assist in whatever cleanup was needed, but lo and behold, she was not soiled, thank goodness. I thought of this thread.

I did get some flack from the RN for the redness on her behind from lying on wrinkled linens, which irritated me because it's not like I just bunched up a bunch of linens and put them under her bottom so she'd get red! Seriously, I was doing the best I could.

Plus, instead of leaving all the extra dirty linens on the floor, I picked them up and put them in the hamper. When I wasn't looking, the CNA placed the bag of linens on my gurney. Fine, whatever, I'll deal with the linens. I get it. You resent the extra work I've just given you by putting linens in your hamper. Gosh, I thought you'd appreciate the fact that I bothered to pick up the linens instead of leaving them on the floor, but whatever.

Then the RN requested that I take the paperwork to the desk for her (instead of leaving it in the room with her so she could look it over) even though the desk was out of my way back to the ED. Fine, okay, I can take a few extra steps to deliver paperwork to the desk.

As I started heading back to the ED where we were getting killed and I knew I was needed desperately, the CNA asked me to drop the bag of linens in their dirty utility room. I don't know their floor, as I don't work there, so I said "I'll just take it back to the ED with me, that's just easier for me". Huffing and puffing, stating "Really, it's just right there", she grabbed the bag of linens roughly off my gurney and stomped down to the dirty utility room, opening the door dramatically and dropping the bag with a flourish, stating "There, that was easy".

I wish we could just cut each other some slack sometimes. We're really in the same boat. We're understaffed, you're understaffed....we're all doing our best, let's not fight with each other.

Sheesh.

[TriciaJ, RN]

Some do, but sometimes people are lazy and want to pawn work off on others. You can't blame everything on management.

Yes, you can. If there are lazy people who are passing their work to others, it is a function of management to deal with it appropriately. Most problems stem from weak leadership in some form.

[1RN4Christ]

Our hospital has cracked down on this. I used to get patients transferred to our bed from the ER stretcher and find the bottom sheet was soiled, then a new sheet had been placed on top. Or, they come to the floor still on the bedpan and the individual who has brought the patient up had no idea the patient was still on it.

[smile_through_it]

I worked on a tele floor and now am in the ED. I see both sides of it. When most pts come to they ED they have family in the room and they usually don't want to say 'excuse me nurse? I wet the bed.' They want to wait until family leaves and usually that's when they get a room assignment. It also is very hard to roll a patient side to side to get them clean when the litter is not wide. The beds on the floor have a lot more room to change sheets. I'm not saying its acceptable to leave a patient soiled but, sometimes it happens.

[NurseKatie08, MSN]

Happens ALL the time. We expect it as floor nurses now. I've also had transport drop the pt off in the room (while I'm with another pt) and not hook up the O2 to the wall. They literally just leave the pt... and I get tp the room and the o2 is in the 80s...pt has a cannula on their face but it's not hooked to the wall. Really???

Or confused pt's come in with all their street clothing on, the disposable sheets from EMS, the sheets from ER, plastic caps and paper from syringes all in the bed. Dirty diapers... But the ER skin assessment says "no breakdown" Um, just how the hell did you figure that one out???

In defense of transport (not sure how it is at your hospital), at my hospital they are not allowed to hook up O2 as it is outside their scope. However, they should wait until someone comes in who can!

[Kooky Korky, BSN, RN]

Have been on both sides. On the floor, rarely got a soiled (e.g. caked poo, on an incontinent pt, I can give the benefit of the doubt) pt from ED. And I have never intentionally sent a patient up soiled, as I would expect of my peers (except if unstable, but by then all orifices are probably plugged). I'm sorry for your run of luck, but simply calling the nurse in the ED or asking them to stay with you and help clean the pt can stop that problem. In the ED it's incredibly frustrating when you are seeing, discharging, transferring, coding sometimes dozens of pts in a night and someone griping with their 6 stable patients because you forgot to give a pair of socks.

That being said, thanks for advocating for patients. Keeping skin clean and intact is incredibly important, but not as important as a patients dignity.

Those six aren't always stable, there are likely to be more than six, stable doesn't mean nothing's going on with family, etc.