ER rushing patients to the floor

[freckles23]

So I wanted to run something by everyone. I realize at my hospital, the ER try to push their patients out of their unit and onto the floors. I work on a med surg tele floor. Last night I walked into work and right off the bat had an admission. Well this admission was very unstable and was going into septic shock and my first hour was stuck attending the needs of the patient. This meant I was neglecting all of my other 8 patients. Were they alive? I couldnt even tell you. So a few hours later I transferred the patient to ICU. So yes this patient was my admission but the ER is so quick to rush patients onto the floors that they end up sending unstable patients to the floors and then cause chaos to us because then we need to do the documentation for the assessment and then all the transfer work for a patient we only saw for a few hours. Idk if this is more of a management issue on getting patients up to the floor quickly but it is very unsafe and it is a reoccuring theme at our facility. I understand patients statuses change and stuff happens but it feels like it is getting out of hand. My one co worker walked into work when I did and right off the bat had a patient that passed away on shift change (thats just bad luck I guess). But I really just wanted to know what is the real reason behind this? Last night was too much for me and my stress and anxiety level is thru the roof when I need to go to work. I left work at 10 this morning and am going back at 7 for another 13 hours so I dont know how I am going to manage this night. Just needed to vent! Thanks for listening!

[AliNajaCat]

We don't get to choose which patients and what their conditions are that show up for care. The ER's job is to stabilize and transfer, and they should be doing it. I think the problem may lie in the communications between the units. There should be a telephone report including an ETA before the patient leaves the ER, and there should be an agreed time to send/receive. You should have a standardized report sheet for the ER nurse to complete and hand to the floor nurse, so everybody knows what's bee done and what needs doing when.

The best way to get this sort of thing going is to have some informal and then formal discussions between the staffs, facilitated but not run by the nurse managers. When you both have a better understanding of each other's jobs and constraints, you'll be able to be more collegial.

[AJJKRN]

As a Med-Surg nurse, honestly it looks like your ratios play a much bigger role than being factored in.

"My eight other patients..."

So what are the ED's ratios???

FWIW, often the pressure to meet throughout times and whatever else that is coming through the ED doors keeps the admits on to the floor steady. Besides, why did the ED MD or the accepting hospitalist accept the patient as floor status in the first place? This is a process issue. Yes the ED RN can advocate for the patient to go to ICU but ultimately the MD's and the house officer are allowing these transfers.

Eight other patients...nope...not ever would I work in that environment!

[quazar]

As a Med-Surg nurse, honestly it looks like your ratios play a much bigger role than being factored in.

"My eight other patients..."

Yeah, that made me raise an eyebrow, too. I'm not a m/s nurse, but I was under the impression that 5-6 is standard/high, but 8 is ridiculous and dangerous. Especially on a med/tele floor. Geeeeeeeeeez. Scary scary. That's the first and biggest problem, IMO.

[Wile E Coyote, ASN, RN]

That's some steep m/s ratios, as pointed out.

For the ED's part, they get near constant barrages about their disposition times. Door to triage time, triage to provider time, door to cath lab time, admit order to transfer time, etc.

This pressure is likely the primary driver behind these rapidly assigned beds.

[nursej22, MSN, RN]

IMHO, the push to move out of ED by 4 hours has really created some unsafe situations. And at least at my old place of work, combining fairly new nurses who were unable to recognize "really sick", and a team nursing approach where no one person really knows what is going with the patient has made for some scary situations.

Personal story, a loved one drove himself in after a hard fall from his bike, short of breathe, severe chest pain. 1 hour in waiting room, during which he got an X-ray. Fx ribs, partially collapsed lung. Chest tube inserted, but the nurse seemed mildly irritated when I pointed out that his continuous glucose monitor was alarming. She was only able to assist with the chest tube, not pain meds, not blood sugar control, just chest tube. And it did occur to her to tape the connections

Our cardiac tele floor begged for a standardized report sheet, got one, but it never got filled out. Near impossible to have any kind of phone report because nurses at each end were always already on a call, or tied up in an iso room.

And just one sickie arriving at shift change? Try 3 on a daily basis: one ED acute STEMI waiting for the cath lab, one post-op thoracotomy with an epidural, de-satting, and a direct admit in fulminant pulmonary edema. And a discharge hopping from foot to foot for paperwork so they can leave.

Yeah, no thanks.

[KatieMI, BSN, MSN, RN]

Because ER's job is to stabilize and transfer appropriately, and that's what they are doing. Justdoingtheirjobs. Where I am, same thing happens also with OR/PACU, diagnostics and others, with sometimes predictably bad outcomes. Higher turnover = more patients =>> more muneys charged, who cares if the guy ends up in ICU as a result. Plus, doing so undoubtely makes better customer service experience

Common tendency nowadays is to demand more and more with less and less opportunities to do so safely and successfully. Just wondering how many poor souls end up in ICU or ECU (Ethernal Care Unit) before it comes to the end.

[XNavyCorpsman]

I had the ER drop off an actively dying patient to me at the IMCU where I used to work. Pt died 6 hours later.

[Here.I.Stand, BSN, RN]

My question is who are these admitting docs who are sending unstable pts to the floor vs ICU?

[ED_Murse]

The association between length of emergency department boarding and mortality. - PubMed - NCBI

On the floor, you have a set number of patients. In the ER they just keep coming in. The majority of research shows that the longer admitted patients stay in the ER the worse their outcomes are.

Its hard to comment on that case, maybe the pt was stable when they left the ER.

[Jules A, MSN]

My question is who are these admitting docs who are sending unstable pts to the floor vs ICU?

Excellent point. We attempt to have some control over our admissions so although the psych unit is a bit unique because we typically don't take anyone too physically fragile we absolutely manage our admissions. Patients are not sent within a certain time of shift change, during set visiting hours, if we have someone having an acute meltdown etc. The accepting provider as well as our RNs review the prospective patient's diagnostics to ensure the ED isn't trying to shove someone our way who is medically unstable. If I'm in house in some cases I will also go down and assess the patient myself when there is a disagreement on the patient's status, usually involving full blown DTs, which require medical floor admission. Unfortunately when a patient comes in to the ED with a psych history or substance abuse the tendency seems they end up on the fast track to inpatient psych often with only a minimal peek at the somatic presentation. I get it because they can be disruptive in the ED and often are not in danger of physical decompensation which puts them further down the list but this fact makes the accepting provider and accepting RNs insight so important.

[blondy2061h, MSN, RN]

Probably the rush was that patients were getting more and more backed up in the ER. I'm not trying to justify it, because sending an unstable septic patient off to be a med surg nurse's 9th patient isn't justifiable. I'm just saying the ER was probably crawling with patients and that's where the rush came from. It wasn't until I did house supervision that I saw how amazingly this chain reaction of delays in each area can domino and cause chaos for the whole building.