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!

[NickiLaughs, ADN, BSN, RN]

Not all ER's are as busy as yours. The day that I received my patient, that was actively dying, the ER only had 3 patients. The ER nurse dropped my patient off and he had a RR of 45 rpm.

That's not normal? Kidding....lame I hate lazy anybody. And that applies to all departments

[MrNurse(x2), ADN]

Throughput and ER wait times are the buzzwords in customer service based healthcare. ER docs see a patient and may take 30 - 45 minutes to decide to admit. This means the patient has at least an hour before admission to deteriorate. The ER nurse may not be on top of that patient, either and a quick peek in the room would not warrant follow up for sepsis. This gives the probability to encounter this scenario. I have called many an RRT on patients that have just been rolled in from the ED. There is no way I could work ED, not my personality, and I credit those that effectively juggle the multitude of orders that are being written on their patients. Most ED nurses are awesome, but the few who just triage and roll are the ones who send RRT's to the floor.

[brillohead, ADN, RN]

I think that for safety's sake, there needs to be a moratorium on admissions for an hour before and two hours after each shift change.

Sending a patient up at 0700 or 1900 is simply not safe -- either the patient is a trainwreck and the nurse will be busy dealing with the admission paperwork, the admission assessment, and the constantly-popping-up new orders/meds while the patient's other five patients get ignored, or the other five patients get their assessments and meds at shift change, but the new admit gets ignored.

NOBODY is safe or satisfied in EITHER scenario.

While the ED might want to turn over the bed and get another patient in there, and the patient may want to get off the ED stretcher and into the not-very-comfy-but-still-better-than-a-stretcher bed, it's not going to be safe to send that person right at shift change.

[emmy27]

I think that for safety's sake, there needs to be a moratorium on admissions for an hour before and two hours after each shift change.

Sending a patient up at 0700 or 1900 is simply not safe -- either the patient is a trainwreck and the nurse will be busy dealing with the admission paperwork, the admission assessment, and the constantly-popping-up new orders/meds while the patient's other five patients get ignored, or the other five patients get their assessments and meds at shift change, but the new admit gets ignored.

NOBODY is safe or satisfied in EITHER scenario.

While the ED might want to turn over the bed and get another patient in there, and the patient may want to get off the ED stretcher and into the not-very-comfy-but-still-better-than-a-stretcher bed, it's not going to be safe to send that person right at shift change.

The problem is, the patients in the lobby stubbornly refuse to stop deteriorating for two- wait, I just re-read that- SIX hours a day.

It would be great if hospitalist shifts could be staggered in a way that moved discharges earlier in the day and reduced the number of bed assignments made at 1830 (a chronic problem in every hospital I've worked in). But holding the patients in the ED and subjecting them to an additional change of care there (we're changing shift in the ED at 1900, too) does not improve safety for that patient- it only reduces it for the one who hasn't been seen at all yet.

I've been on both sides of the equation and I heartily agree that getting OR sending a patient at shift change is not ideal (nothing sucks more than finally dispatching a patient to the floor at 1850 and then having night shift look at you like you're lazy for not having the patient that just landed in your clean bed two minutes ago primped and pressed already). But holding them in the ED does not solve anything- it just delays care for another patient.

I will say that as both a floor and an ED nurse I've seen PLENTY of delaying tactics regarding taking (and occasionally calling, but less often, as ED is subject to being assigned additional patients if things get bad enough, so there is less motivation to delay) report after 1700 in the hopes that the new admission would fall on the next shift, and that only makes things worse for everyone. If the floor nurse is truly busy when report is called, there needs to be a backup plan in place for the charge or another team member to take report, and if the admission requirements are so onerous that they make it impossible to safely accept a patient, there needs to be either a floating admission nurse or a policy allowing the receiving RN to delay complete admission paperwork till the following shift for admits received after 0600 or 1800 (both solutions I've seen work effectively on real units).

Holding patients longer in the ED is never the answer, because there are other people who are literally receiving *no* care at all until that bed is freed. If you think a decompensating septic patient arriving on the floor with a line, a detailed H&P, and an admitting doc on call is frustrating, imagine what it's like to pull one from the lobby and realize they're septic as hell and have been slowly worsening for hours, missing a golden window of potential intervention, because there was literally nowhere to put them. That happens.

[blondy2061h, MSN, RN]

The problem is, the patients in the lobby stubbornly refuse to stop deteriorating for two- wait, I just re-read that- SIX hours a day.

9 hours a day if you have people on 8 hour shifts! Is PACU also not going to send their admitted patients up during this time frame?

[brillohead, ADN, RN]

Getting a transfer is a lot different than getting an admission, paperwork and time-wise.

Also, my ED's waiting room is often full of "headache x 5 months" or "vomit x 1 occurrence 20 minutes PTA" or "lady partsl bleeding" (not pregnant, just got their period) or "ankle pain -- fell down stairs three days ago". The trauma rooms are kept open for ESI level 1-2 patients to get taken back immediately, and the level 4-5 folks can sit and wait for hours as far as I'm concerned while the level 3s go in ahead of them. We have an urgent care center they can go to for stuff like the sniffles or constipation, otherwise they can GOMER!!!

[Cowboyardee]

Throughput and ER wait times are the buzzwords in customer service based healthcare. ER docs see a patient and may take 30 - 45 minutes to decide to admit. This means the patient has at least an hour before admission to deteriorate. The ER nurse may not be on top of that patient, either and a quick peek in the room would not warrant follow up for sepsis. This gives the probability to encounter this scenario. I have called many an RRT on patients that have just been rolled in from the ED. There is no way I could work ED, not my personality, and I credit those that effectively juggle the multitude of orders that are being written on their patients. Most ED nurses are awesome, but the few who just triage and roll are the ones who send RRT's to the floor.

Here's the thing. Sending that patient quickly to the floor where an RRT is called is actually a better outcome than having the patient continue to decompensate in the ED while they wait for a bed. The real problem in this situation, as before, is that an unstable patient was sent to the floor instead of an ICU. Of course, it would be better if they were sent to the ICU in the first place - but your beef there is with the ED physician or hospitalist. Sending them to the floor quickly gets them seen by more staff and gives the hospital another opportunity to reevaluate the patient's level of care.

The big boogeyman to avoid in this situation isn't a patient going to the floor, being identified as unstable, calling an RRT and transferring to a more appropriate level of care. It's the patient continuing to decompensate unnoticed in EITHER the ED or the med-surg unit and getting inadequate medical attention. I see plenty of that as an ICU nurse and RRT responder. We don't much enjoy getting clobbered by the ED either, but the truth is we're better equipped to handle sick patients than they are - so send em over. Likewise, the med-surg units are better able to handle stable patients than the ED is, and present another opportunity to reevaluate the patient's condition.

[Artsy_RN]

I'm curious to know what the history/labs/vitals were for the pt upon admission. So nothing was evident to the ER, admitting, or bed management that the pt was going into septic shock prior to being admitted? Was a lactic acid even drawn in the ER? Need more info to determine whether or not the pt was assigned the improper acuity level of care...

As far as the ER nurses rushing pt's to the floor, we have no choice but to send the pt up if the bed is ready. Sometimes I would like nothing more to hold an admit for a few minutes so that I can catch my breath. But the charge nurse has already assigned the room and an ambulance is waiting with their next train wreck right outside the room waiting to fill the room.

[LessValuableNinja]

I've been in ERs that stagger shifts. One had 7-7, 10-6, 3-11, and 10-10. I didn't do any data modeling, but in those environments I never (really) saw end of shift patient dump syndrome. This place is a nice place to break from the dreaded "personal statement" without getting too far out of nursie mode. Thanks AN!

[emmy27]

I've been in ERs that stagger shifts. One had 7-7, 10-6, 3-11, and 10-10. I didn't do any data modeling, but in those environments I never (really) saw end of shift patient dump syndrome. This place is a nice place to break from the dreaded "personal statement" without getting too far out of nursie mode. Thanks AN!

We have staggered shifts at my current ED and there are still a lot of patients going up between 1700 and 1900- and it's not because that's how the staff RNs like it (nobody likes to play phone tag, get chewed out by the floor, or get a brand new patient from the lobby right before their relief arrives) but because that's when the BEDS are assigned.

I truly believe the key determining factors are hospitalist scheduling and culture, along with a determination from senior management to get beds cleaned and assigned in a timely manner and hold all units to a high standard of calling and receiving report in a timely fashion (one hospital had a 30-minutes-from-assignment-to-arrival-in-room rule with a detailed incident report due from all participants in the process any time it wasn't achieved and hey look, suddenly patients were making it to the floor on time).

The ED is continuing to be slammed (hall beds and extra patients, anyone?) regardless of whether we hold a patient or not. Our motivation to keep a patient with a bunch of admit orders past when they can reasonably go to the floor is very low.

[morte, LPN, LVN]

bottom line, not enough hands to do the work at an acceptable level of care...

[nursej22, MSN, RN]

bottom line, not enough hands to do the work at an acceptable level of care...

Amen! Not enough housekeepers, hospitalists, pharmacists, PTs, as well as nurses and assistants.