ER nurses not calling report anymore...

dansamy · Sep 10, 2013

I think it's an outpatient vs inpatient thing. ER & OPS are outpatient services. When the patient is admitted, they need inpatient orders.

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CodeteamB · Sep 10, 2013

It's actually pretty common and there are some posts in this thread that refer to the same problem. Regardless, I think you're confusing how things should be with how they actually are, and it's how things actually are that determine the safety issues that affect patients. This is just one of many examples where systems aren't perfect, making some sort of verbal component to report all the more important.
So your report does have a verbal component?
There's a lot of evidence that it can't be done as safely as including a verbal component to report. Do not believe the evidence? Find it to be insignificant? What sort of adverse events are required to buy 3 minutes of your time?

It may be common to have a charting system that doesn't communicate from one area of care to another, but since there are systems that allow for continuity I would say that choosing one that doesn't is ill advised, and, yes, behind the times. Again, a systems issue, not nursing at the ground level.

As I stated before in this thread, the verbal component is me speaking to a nurse (either receiving, or charge) on the floor and ensuring there is no extenuating circumstances (eg a code on the floor, or improperly reported room status) that would prevent safe reception of the patient. I personally also state the name and diagnosis of the patient, and will relate anything truly unusual, but many nurses do not.

It actually takes me 3-5 minutes to enter report into our system, what I save is the 15 minutes waiting on hold and answering questions that can easily be found in the typed report. Like I said, it works for us. I have worked both floor and ER jobs prior to and after the institution of computerized report and I prefer the latter on both sides of the equation. As a floor nurse I receive a vastly more accurate and full report (mandated fields) and am able to reference the same later. As an ER nurse it saves me time, aggravation, and yes, triggers me to include all pertinent information. Win-win IMO.

MunoRN, RN · Sep 10, 2013

Then it is a quirk of your state DOH regs and doesn't add much to a discussion among nurses ranging all over the US and beyond. Nonsensical when you think about it. "Different level of care" ... so the ICU patient's order for Lipitor, prescribed because he's been on it for a decade and unrelated to the ICU critical illness that resulted in admission ... needs to be reordered when that patient has sufficiently recovered to be moved out of the ICU to the floor? Wasteful.

Medication Reconciliation on transfer isn't limited to my State's DOH, it's also a CMS requirement, and also a JC core measure, so it applies to the majority of Hospitals in the US. I agree it can be a little silly, but doesn't change the fact that this is a common requirement.

I'm not seeing where the Dilaudid example has much validity -- surely working in the ER you agree that pain med orders in the ER are overwhelmingly one time dose orders.

It's 50/50 in my experience, although I don't think I was arguing that prn orders are the majority of orders, when it is a prn order in the ER, it can't be followed after transfer without a new order.

Are you under the impression that a floor Nurse, in the rare cases where pain meds are ordered as more than x1, can continue to give the med ordered in the ER?

CodeteamB · Sep 10, 2013

I think it's an outpatient vs inpatient thing. ER & OPS are outpatient services. When the patient is admitted, they need inpatient orders.
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The inpatient orders are written in the ER by the inpatient physician, and the ER nurses are responsible for carrying them out until transfer of care is achieved. It is likely at my place of work that by the time the patient makes it upstairs the inpatient orders have all been completed or started.

MunoRN, RN · Sep 10, 2013

It may be common to have a charting system that doesn't communicate from one area of care to another, but since there are systems that allow for continuity I would say that choosing one that doesn't is ill advised, and, yes, behind the times. Again, a systems issue, not nursing at the ground level.
As I stated before in this thread, the verbal component is me speaking to a nurse (either receiving, or charge) on the floor and ensuring there is no extenuating circumstances (eg a code on the floor, or improperly reported room status) that would prevent safe reception of the patient. I personally also state the name and diagnosis of the patient, and will relate anything truly unusual, but many nurses do not.
It actually takes me 3-5 minutes to enter report into our system, what I save is the 15 minutes waiting on hold and answering questions that can easily be found in the typed report. Like I said, it works for us. I have worked both floor and ER jobs prior to and after the institution of computerized report and I prefer the latter on both sides of the equation. As a floor nurse I receive a vastly more accurate and full report (mandated fields) and am able to reference the same later. As an ER nurse it saves me time, aggravation, and yes, triggers me to include all pertinent information. Win-win IMO.

I agree that the ideal report consists of complete and accurate information, particularly where that can be communicated to the receiving Nurse by having the data "in hand", but that's still only half of it.

Things get lost without the verbal component, there is a wealth of evidence to this which is why a verbal component is strongly advised or even required by practice and safety groups.

Our systems can always be better, but I don't think it's a reasonable excuse to tell a family who lost a loved one that even though a verbal report might have avoided an adverse event, that doesn't matter because there are systems issues as well. There will always be systems issues, that doesn't mean we have an excuse not to use the most basic safety precautions.

MunoRN, RN · Sep 10, 2013

The inpatient orders are written in the ER by the inpatient physician, and the ER nurses are responsible for carrying them out until transfer of care is achieved. It is likely at my place of work that by the time the patient makes it upstairs the inpatient orders have all been completed or started.

I applaud you're willingness to initiate the floor orders, although that's actually pretty rare. "Those are floor orders, not my orders" is the more common view.

A little irrelevant, but who writes the inpatient orders varies, in many facilities inpatient orders or at least temporary orders are written by the ED doc.

CodeteamB · Sep 10, 2013

I applaud you're willingness to initiate the floor orders, although that's actually pretty rare. "Those are floor orders, not my orders" is the more common view.
A little irrelevant, but who writes the inpatient orders varies, in many facilities inpatient orders or at least temporary orders are written by the ED doc.

Thanks for the applause

But it's not out of the goodness of my heart, it is an expectation of my job, and any ER nurse who refused to do "floor orders" would not remain employed for long.

It's pretty clear that you and I work in very different systems. A patient can be admitted to hospital (care accepted by inpatient physician and all orders in) and have to remain in our ER another 12 hours (I once saw a patient waiting for a high demand, low turnover unit in the ER for 3 days over a long weekend). It is necessary that we start orders. We all have our own challenges and things that can be improved upon. Hence why ER flow and efficiency are the watchwords where I work, which drives the need for innovation in things like report.

Altra, BSN, RN · Sep 10, 2013

Medication Reconciliation on transfer isn't limited to my State's DOH, it's also a CMS requirement, and also a JC core measure, so it applies to the majority of Hospitals in the US. I agree it can be a little silly, but doesn't change the fact that this is a common requirement.

You are misinterpreting med rec, possibly just for the sole sake of argument. It must be done on admission, and on discharge. Not just because the patient moves between hospital units, for cripes sake.

Edited to add: to expand on the above paragraph ...

JC & CMS of course require med rec. That DOES NOT include a complete overhaul of every med ordered every time the patient changes units within the same facility. That is ridiculous.

MunoRN, RN · Sep 10, 2013

You are misinterpreting med rec, possibly just for the sole sake of argument. It must be done on admission, and on discharge. Not just because the patient moves between hospital units, for cripes sake.
Edited to add: to expand on the above paragraph ...
JC & CMS of course require med rec. That DOES NOT include a complete overhaul of every med ordered every time the patient changes units within the same facility. That is ridiculous.

The most wide reaching med rec requiremt, the CMS meaningful use requirement, is for admission, transfer, and discharge; all 3. In the different facilities I've worked at, and with systems projects with about 20 hospitals over 5 states this has always been true.

dansamy · Sep 10, 2013

The inpatient orders are written in the ER by the inpatient physician, and the ER nurses are responsible for carrying them out until transfer of care is achieved. It is likely at my place of work that by the time the patient makes it upstairs the inpatient orders have all been completed or started.

Right. It works that way at my facility too, but the ER orders are d/c'ed because the admitting orders are initiated. Now when they arrive to our unit, it takes a few minutes for pharmacy to put their orders into our pyxis.

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Altra, BSN, RN · Sep 10, 2013

The most wide reaching med rec requiremt, the CMS meaningful use requirement, is for admission, transfer, and discharge; all 3. In the different facilities I've worked at, and with systems projects with about 20 hospitals over 5 states this has always been true.

Transfer between from one facility to another ... not within the same facility.

MunoRN, RN · Sep 11, 2013

Transfer between from one facility to another ... not within the same facility.

Yep, within the same facility.

From the JC requirement:"Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation

is done to avoid medication errors such as omissions, duplications, dosing errors,

or drug interactions. It should be done at every transition of care in which new

medications are ordered or existing orders are rewritten. Transitions in care

include changes in setting, service, practitioner, or level of care.

From the CMS requirement:"The EP who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. "