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!

[registered.nobody]

As an ER RN myself, I too am rushed to get patients to the floor once they get a bed so that we can transfer care and see more patients. Every RN must use nursing judgement as to which patient is stable enough to go up. However, there are times when a patient is in life-threatening condition and they are going to be only so good before they go to a bed. For instance, a severe code sepsis. But if the patient is decompensating and I feel that they are critical, it is my responsibility to go to the admitting doc and try to get the patient to the appropriate level of care.

[Horseshoe, BSN, RN]

Almost all of these conflict and problems would be eliminated with proper staffing of nurses, aides, and ancillary staff. And that will never happen until the PUBLIC calls for it. As it stands, they don't understand that this is the problem. To them, it just looks like the staff who are present are uncaring and incompetent.

[LadyFree28, BSN, LPN, RN]

Almost all of these conflict and problems would be eliminated with proper staffing of nurses, aides, and ancillary staff. And that will never happen until the PUBLIC calls for it. As it stands, they don't understand that this is the problem. To them, it just looks like the staff who are present are uncaring and incompetent.

Exactly.

Where I work, we can not send patients up at change of shift; the EARLIEST (and do mean earliest because I have sat on a kid for 3 additional hours because the nurse was "too busy" or being constantly hung up or "room is not clean" on while juggling being assigned to the trauma room and other critical kiddos) is 0800 or 2000; depending on the house supervisor, we may get beds at the change of shift, instead of well in advance-sometimes it is dependent on discharges and Peri-Op admissions, and throw in no nurses because this place cares about the bottom line and drove nurses away, screwed themselves over and don't plan to replace the too many nurses that left. Obviously the moves makes for unsafe staffing.

Despite working in an area where the poverty-level is the 5th highest in the nation, responses to the delay range wildly from unreasonable to understanding, with the average knowing that more nurses are needed; I direct them to call my CEO and not necessarily my director; partially because she and the MD director have been working to prove that TPTB more nurses and to be more attractive in retaining the good doctors that we have and can have; they rely on CEDOCS to attract throughout and overcrowding, which in itself is a HUGE safety issue, especially when a Level 1Burn Level 1 trauma, an respiratory distress needing CPAP and a unresponsive investion roll in within 5 mins of each other. It's not safe to leave a Pt who is sick and needs the proper interventions for the appropriate floor to be sitting in the ED, especially if I'm going to be in the trauma room for the last three hours of my shift.

I will spare the story when the suits came around, nervous and demanded that pts be placed in rooms without a nurse assigned, making them wait another 30 mins to arrive-that God my coworker, an wonderful support staff member informed me she was instructed to room the patients; and all but one was totally enraged and rightfully so.

My public is not stupid...they get outraged; they call the heath department on the hospital and the ED; I try to advocate for the outrage for them to utilize all the information at hand and focus their energies on the person sitting at the top and their elected officials, despite their disillusionment-they have the power because mangement can be VERY sensitive to bad publicity, and can elicit change; the other solution that I felt was beneficial but requires a lot of work and unit is forming a union, balancing the power, and forcing these corporate style decisions to take a backseat, along with public pressure can make a difference.

[Floyd Nightingale]

"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."

Mmmmmkay. Better to hold that pt in the ED and watch them die down there? Like the ED staff has nothing better to do?

[GM2RN]

Almost all of these conflict and problems would be eliminated with proper staffing of nurses, aides, and ancillary staff. And that will never happen until the PUBLIC calls for it. As it stands, they don't understand that this is the problem. To them, it just looks like the staff who are present are uncaring and incompetent.

Because we aren't allowed to tell patients we are working short-staffed or that we just don't have enough help...ever. I have had patients comment on occasion about me having to do "everything" because they thought we had people to transport to radiology or draw blood, etc. Sometimes we do, but if they aren't available if falls to the RN to see that orders get done.

[emmy27]

"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."

Mmmmmkay. Better to hold that pt in the ED and watch them die down there? Like the ED staff has nothing better to do?

I was wondering about this, too. What course would you suggest the ER take with a full code patient six hours from death?

[cjcsoon2bnp, MSN, RN, NP]

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.

Respectfully, I have worked on the floors and in the ED and there are major communication barriers between the ED and inpatient units. I have no desire to ship out unstable patients or dump patients on the floor nurses "just to free up a bed". Please keep in mind that when you say you're not ready for an admission because it's change of shift, this means that this admitted patient is using the last telemetry bed while a new high risk chest pain patient sits in a hallway or in a wheelchair without cardiac monitoring and isn't receiving potentially life saving treatment.

Secondly, it is just not realistic in an acute care setting to have multiple hours blocked out of the day before and after each shift change where patients cannot be admitted. I have worked in the floor and the ER and we in the ER are not able to tell septic patients or overdose patients walking into triage that they will have to come back in an hour or so because we are doing shift change.

The real problems here are (a) insufficient staffing with nurse-to-patient ratios that are out of hand on the inpatient and critical care units, (b) the persistent mindset (on some but not all inpatient units) that all admission documentation must be completed immediately and fully before another admission can be accepted (many nurses struggle to hand off some tasks to the next shift or accept that nursing is 24/7), and © the increasing amount of documentation that is being expected of healthcare professions (often duplicative, redundant and steals time away from patient care).

!Chris

[wyernurse]

The admitting provider decides what unit the patient should go to. The nurse in the ER should be an advocate for the patient and common sense says the patient is too unstable the nurse needs to speak with the admitting provider. For me that would be a red flag. Communication is the key. Getting a good hand off is helpful as well, asking the right questions can help and alert you to concerns prior to the patient getting to the floor.

[FranEMTnurse, CNA, LPN, EMT-I]

Due to miscommunication between units, and the mega rush, when I was critically ill, the CNAs did NOT look at my chart, nor were they told that I had vomited up 1&1/2 liters of systemic blood in the ER due to a tachycardia incident. I was stabilized in the ER, I felt that was NOT enough. I was unable to sit up due to hypovolemia, and laid flat for a week before my doctor called in a Pulmonologist to check on me. The Pulmonologist checked me when I was raised up, and diagnosed me with pulmonary hypertension. I was then placed in TCU. the very nixt morning, a cheerful little CNA raised my head in the high fowlers position for personal hygenic care when I told her, I was unable to sit up because I felt like I would pass out. She began to cry, and that made me feel bad for her. (I don't like to make people cry, I would much rather make them laugh) After that incident, black urine began flowing into my foley bag. I was going into acute kidney failure. I was placed on IV Lasix The following day, and thankfully, my kidneys recovered. I was unable to see my family for a week, and was so lonesome, longing to see them and instead was hearing the sounds of beds moving, loud nurses giving their reports, and telemetry units making their beeping sounds. This is what miscommunication can cause, and even worse. Thankfully, my doctor at least did act on the triggers he saw and saved my life.

[Chaya, ASN, RN]

Ah, yes, that change of shift dump. I do get it, really. I understand totally that it is necessary to free up space for incoming patients. However-and this should be a HUGE factor with the current emphasis on accountability, continuity of care, and prevention of

re-admissions; change of shift admissions specifically create those black holes where there may be significant time lags before an oncoming caregiver is identified. Report may be called to the floor to and from off-going staff who are no longer available for clarification. Critical ( as in Sentinel Event level) information is omitted ( in my experience omitted details have included patient with wound evac device, insulin pumps, life threatening med allergives and numerous patients needing imminent warfarin dosing). You get the idea. When I worked med- surg and we had those meetings about reducing errors and improving continuity of care between care levels I always raised this issue; not because of the inconvenience factor but because it creates a particular point of vulnerability in terms of the increased number of opportunities for errors in the system (as in, "falling thru the cracks"). Ideally, don't create the situations that allow these "cracks"!

[Wuzzie]

Ah, yes, that change of shift dump. I do get it, really. I understand totally that it is necessary to free up space for incoming patients

Just by calling it a "change of shift dump" indicates that you really don't get it. The ED is not dumping patients at shift change. First, most EDs do not follow the traditional 7-7 shifts for the majority of their staff so that rules it out right there. Second, the reason that it seems like this is because, in my experience the people who assign the beds (and they usually are 7-7) wait until just around 6pm to finally do the actual assigning. Guess what happens to the ED nurses that transfer a patient just before shift change...THEY get another patient. I really wish people would stop demonizing ED nurses. They are doing the best they can following the rules that are pushed upon them while dealing with a NEVER ENDING stream of patients coming through the doors. They can't please anybody!

[mamanrs937]

Also, as an ER nurse for many years, keep in mind that the ER doors never close. Once the floors are full, they are (generally) full. So when the ER staff calls with report, they are ready to move because they have to move. Squads don't wait, and the waiting room can get pretty ugly, like when you're babysitting a chest pain on a portable monitor because there are no monitored beds in the back. I could go on and on.