ER nurses not calling report anymore...

[plinytheRN]

Hey all, our hospital started a new policy where the ER nurses don't have to call report on the patients coming to our floor- they can choose if they want to call report. Most don't call report. It is up to us to find this patient and research all about them before they get to the floor, hopefully. Most of the time, they show up before we know they are coming. It is very frustrating and unsafe, we don't know anything about what we are walking into. I work on a medical telemetry unit, with usually 5-6 pts per nurse, it's hectic and busy no time to be clicking through a computer on a new admit. From what I understand this is a trial to test out this new policy, I am hoping it doesn't last. It seems the only one that benefits from this new policy are the ER nurses, it's definitely not ideal or safe for the patients... Anyone experienced this sort of thing? Thoughts? Thanks.

[morte, LPN, LVN]

Ok....here is what I think....I think we need to be considerate of each other as co-workers and professionals. Calling each other lazy isn't going to be conducive to an effective work environment

I think sending patients without calling is bad nursing....I have worked both sides of that fence and I have supervised and assigned the beds. There is no excuse.

There is also no excuse for bad nursing. NO NURSE should be leaving a heparin gtt without a pump.....so it is a poor practice issue of this nurse and not an "ED nurse" thing. Of course there are many times in the ED when the patients come in IV's are in the AC or can only be started in the AC. Patients are anxious and cold...constricted and sometimes no other vein can be found....once they arrive on the floor...warm and comfy the veins appear.

Now we are sounding like the government....blaming each other for our own shortcomings.

We are all being asked to do more with less. We need to help each other and not tear each other apart. I blame administration and the managers for not enforcing good nursing practice and developing policies and procedures that reinforce safe practice.

divide and conquer, need more staff, persons are NOT WIDGETS!

[MunoRN, RN]

I don't think you understand, it's not that if we leave inpatient orders to the floor, then we will have more time for eating Bon Bon's, it is that there is ALWAYS someone to take the place of the patient being sent upstairs. longer the patinet stays in the ER room, the more crowded the waiting room gets.

Yes there will always be someone to take their place, they keep coming in through the door, I get it, I get the same feeling when I'm in the ER, but it doesn't make it OK to just push them through without providing proper care, which ends with a good report.

Report is called into a messaging system, where receiving (floor) RN retrieves report and call call back if they have any questions. My experience is that they very rarely do.

You're incorrectly assuming they don't call back because they don't have questions. They often don't call back because ER Nurses have a way of being, well, unwelcoming to these calls.

[NickiLaughs, ADN, BSN, RN]

I've been on both sides. When I worked ICU, I read the nurse notes mar, history etc so when ER called me, I was good. I usually just said see you when you get here and hung up. My assessment was going to be done anyway. As long as I knew why they were there and the big stuff which was in the chart, I was good.

Now in my ER, we only call report on ICU pts. Everyone else is expected to look it up. If I take my pt up and they are on a heparin drip, I stay until a nurse acknowledges my existence. Then I run back down to the craziness.

My priorities for pts I take to floor:

Pulse and stable BP (obviously if their pressure sucks, OR or ICU is where they are going.

Working IV line

Stat labs and meds, antibiotics

If I have time, I get the admit orders going, but that's only if all stat items are done on my other patients.

We have a little post it note area on the chart for nursing communication. So if there is family issues, etc we post it there.

There is no perfect system, but trying to coordinate two busy nurses for a 5 minute report that can be read via the EMR with likely more details...

That's 5 minutes I could have spent starting that second line or getting the NG per MD request before the pt goes upstairs.

It does break my heart when I take a pt up that we all worked very hard on and almost everything is done but they choose to focus on the one think that wasn't done because it took me, another nurse, a RT and finally a doc to get an ABG, plus the second IV line he truly needed.

Lateral violence is not appropriate in the work place, the vast majority of nurses work very hard, and to protect our profession we need to respect each other.

[Esme12, ASN, BSN, RN]

I've been on both sides. When I worked ICU, I read the nurse notes mar, history etc so when ER called me, I was good. I usually just said see you when you get here and hung up. My assessment was going to be done anyway. As long as I knew why they were there and the big stuff which was in the chart, I was good.

Now in my ER, we only call report on ICU pts. Everyone else is expected to look it up. If I take my pt up and they are on a heparin drip, I stay until a nurse acknowledges my existence. Then I run back down to the craziness.

My priorities for pts I take to floor:

Pulse and stable BP (obviously if their pressure sucks, OR or ICU is where they are going.

Working IV line

Stat labs and meds, antibiotics

If I have time, I get the admit orders going, but that's only if all stat items are done on my other patients.

We have a little post it note area on the chart for nursing communication. So if there is family issues, etc we post it there.

There is no perfect system, but trying to coordinate two busy nurses for a 5 minute report that can be read via the EMR with likely more details...

That's 5 minutes I could have spent starting that second line or getting the NG per MD request before the pt goes upstairs.

It does break my heart when I take a pt up that we all worked very hard on and almost everything is done but they choose to focus on the one think that wasn't done because it took me, another nurse, a RT and finally a doc to get an ABG, plus the second IV line he truly needed.

Lateral violence is not appropriate in the work place, the vast majority of nurses work very hard, and to protect our profession we need to respect each other.

I am curious...honest question...how does your facility make this Ok for the JACHO hand off initiative?

[Altra, BSN, RN]

Now in my ER, we only call report on ICU pts. Everyone else is expected to look it up.

I am curious...honest question...how does your facility make this Ok for the JACHO hand off initiative?

Hospitals where I have worked have done the same since ... 2005-ish. All 7 hospitals in my current system have the same practice.

[SionainnRN]

Just a scary update on this situation, ER sent up a patient with no report. They came in for hyperglycemia in addition to something else (not my patient). They came at a time when the BG didn't have to be checked, but the receiving nurse knew better, and assessment tipped her off, and found them to have a BG of 27. no insulin was charted, there was no way to know what they had been given except to call and ask, which isn't going to happen when you are dealing with a BG of 27... Frequently the ER does not chart meds they have given. Not to mention a sticky situation that happened the other night when a pt was sent up at shift change, no one knew they were there (not sure all the details) and they coded and died. Scary stuff. Such a lack of communication and patient care suffers.

I find it very hard to believe that the ER nurses don't chart their meds. Everyone has to chart meds given, no matter what floor. Maybe you can't see the ER MAR, but to imply we just give meds willy nilly without charting it seems over the top.

[Esme12, ASN, BSN, RN]

Hospitals where I have worked have done the same since ... 2005-ish. All 7 hospitals in my current system have the same practice.

There is no other communication other than the receiving nurse looks it up? No faxed report? No opportunity to ask questions?

The ED practices that I know there is no real face to face but faxed report is filled out with important information and faxed to the unit. The receiving nurse has 1 hour before the patient arrives to look at it and ask questions if necessary giving the opportunity to ask questions. I suppose that if "looking in the patients chart" is "standardized" within the institution it would comply with "JACHO" standardized critical content....but I don't think reviewing the computer chart was what "JACHO" had in mind for improving critical handoff information.

All of the hand-off communications solutions that were developed by the Center and the leading hospitals can be found on the Center website. The targeted hand-off solutions from the Center, which are described using the acronym SHARE, address the specific causes of unsuccessful hand-offs. SHARE refers to:

• Standardize critical content, which includes providing details of the patient’s history to the receiver, emphasizing key information about the patient when speaking with the receiver, and synthesizing patient information from separate sources before passing it on to the receiver.
  
• Hardwire within your system, which includes developing standardized forms, tools and methods, such as checklists, identifying new and existing technologies to assist in making the hand-off successful, and stating expectations about how to conduct a successful hand-off.
  
• Allow opportunity to ask questions, which includes using critical thinking skills when discussing a patient’s case as well as sharing and receiving information as an interdisciplinary team (e.g., a pit crew). Receivers should expect to receive all key information about the patient from the sender, receivers should scrutinize and question the data, and the receivers and senders should exchange contact information in the event there are any additional questions.
  
• Reinforce quality and measurement, which includes demonstrating leadership commitment to successful hand-offs such as holding staff accountable, monitoring compliance with use of standardized forms, and using data to determine a systematic approach for improvement.
  
• Educate and coach, which includes organizations teaching staff what constitutes a successful hand-off, standardizing training on how to conduct a hand-off, providing real-time performance feedback to staff, and making successful hand-offs an organizational priority.
  

[herring_RN, ASN, BSN]

When I work on a monitored unit an ER RN brings the patient. Report has been by phone so I look over the patient and chart and have time to ask questions.

For medical-surgical patients there is always a telephone report. I can call with any questions if needed.

The above is since we have a ratio of 1:4 in the ER with critical care patients 1:2 or 1:1 and critical trauma 1:1, the triage and radio RN has no patient.

Before we had a staffing law or a union a tech sometimes brought a patient while I was discharging one. Once I found a patient lying flat on a gurney, nasal cannula in the nose but not attached to O2, foaming at the mouth.

Within minutes that patient was intubated and going to ICU.

The bed from the previous patient was still dirty. The tech had taken the portable O2 back to the ER. I hadn't even been told a patient was coming. The charge nurse had been called by the supervisor.

We had to change such conditions. I cannot fault an individual nurse when they system is unsafe for patients and staff.

Not giving report is in violation of CMS requirements. It can be reported and investigated. Scroll down to find the one for your region: CMS Regional Offices - Centers for Medicare & Medicaid Services

Or report it to the Joint Commission: http://www.jointcommission.org/about/JointCommissionFaqs.aspx?faq#296

Hand off requirements: http://www.jointcommission.org/center_transforming_healthcare_tst_hoc/

[martymoose, BSN, RN]

I think our place stopped letting us take report because we'd ask too many questions. This way we can get dumped on, and too bad if it's an inappropriate admission.Once the pt's there , they stay.

[GM2RN]

I think our place stopped letting us take report because we'd ask too many questions. This way we can get dumped on, and too bad if it's an inappropriate admission.Once the pt's there , they stay.

What do you mean by "inappropriate admission?"

[uRNmyway, ASN, RN]

What do you mean by "inappropriate admission?"

I assume pp means a patient that is inappropriate for that particular floor. Higher acuity, longer projected length of stay than the floor accepts, etc.

[nrsang97, BSN, RN]

What they meant by inappropriate admit was one that should have been on a different unit. For example a pt admitted to a med floor and was on a levo drip.

One night ER didn't mark in the meds given and meds ordered section in their chart that a pt was on a pitocin drip following a fetal loss. This pt lost her baby at 24-26 weeks. On pitocin due to bleeding. There was no phoned report. Pt is septic. Upon getting notification that the pt was coming labs were checked and the pt had a critical WBC >30. ABX started No blood cultures done.

Upon arrival to the unit RRT activated immediately. BP in the toilet, pt pale, lips white. This pt should have been in the ICU not on a med surg tele unit. Preferably on OB , but her BP would necessitate a RRT call anyway. We have had pt come up non responsive intubated and immediately sent to ICU.

I am still shocked that DNV (we do not use JCAHO) allows this for handoff.