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!

[maria87]

I work in an ER and came from the night shift on a med surg tele floor where 7-8 pts was expected. Things I quickly realized after transitioning to the ER is the all of my pts on the floor had a diagnosis, I knew who had PNA and that they had already begun antibiotics, were being treated by respiratory, who was having an MI, how bad it was and at what stage of the MI they were in, they had received asa, had multiple ekg's depicting a NSTEMI (I.e. More stable), and knew they were on a monitor that would alarm if something changed.

Now on working on the ER, in my 4 hours as greeter, or the first face you see in your hospital stay, I enter no fewer than 50 chest pains. Chest pains that turn out to be heart burn, gastritis, MI's, and aortic aneurysms. I have no way of knowing which is which. When I get a new pt I rush in to get the first ekg, blood work and continuous monitoring, and I do this while caring for 3-4 other pts that I know equally little about.

That pt pt you received and shipped to ICU likely had an ICU consult in the ER in which the ICU dr. rejected the pt. With no other option but to admit to a MS floor, in which a hospitalist accepted and agreed with that placement, the nurse probably did rush them out because it was best for the pt. The stretchers are hard and uncomfortable, the ER is loud and full of germs, and the department is ill equipped to hold an admitted pt often not carrying their regular medications or specific antibiotics.

If it is not said in your hospital already perhaps you should start it, but nursing is a 24 hour job. My major issue with what you said is that you've no idea if your other pts were even alive. Really? What kind of report did you get from the previous nurse. What were your coworkers doing while you were tied up with a critical pt? Do you not have support staff that was rounding?

I have been on both sides, if a floor calls and ask me to hold a pt for a limited time so they can handle a crisis or settle their last admission because it's that kind of day, I do as often as I can. But this month in particular that has not been the case. Everyday my ER has been holding approximately 20-30 admitted pts, every single day. That leaves less than half of our department to see new pts, for which we are still responsible for. Working pts up in hallways, recliners, pulling "more stable" pts out of rooms to put in more critical ones.

I understand and the pressure you are under and I urge you to shadow an ER nurse for a day so you can see where they are coming from. I am not saying they are without their faults just that we are all nurses who need to work together and I think understanding one another is a great step towards that.

[Steffy44]

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

Amen. Our hospital requires ALL septic patients go to either PCCU or CCU depending on how septic. Our problem has been our hospital closing one med surg floor to enhance productivity (make them more money)! All it has done is caused the other 3 floors to burst at the seams. They only open the other floor when there is finally no where to put anyone. Then PCCU and CCU start flushing out people to floor status when they aren't really ready to be floor status. End result is half of them get a MET call and transfer back down. It's incredibly frustrating.

[Sour Lemon]

My major issue with what you said is that you've no idea if your other pts were even alive. Really? What kind of report did you get from the previous nurse. What were your coworkers doing while you were tied up with a critical pt? Do you not have support staff that was rounding?

When you work in a place with these types of ratios, your co-workers are trying to keep their own heads above water and deal with their own crises. And each CNA may have 20-40 mostly HEAVY patients, so if those CNAs haven't run out into the parking garage crying yet, they're still not able to help as much would be ideal. In fact, management will sometimes take pity on them and assign a few of each nurse's 8-9 patients as "total nurse care" ...meaning they have no CNA assigned, at all.

The reality is that the patients who are not in a current crisis and not constantly on their call lights often get "forgotten" about- sometimes for hours. When you create a few seconds in your mind for them, the most you can sometimes do is hope they're still alive.

And the nurse reporting off? They've been working under the same circumstances and their minds are a mass of chaos during report. Your charge nurse also has 8-9 patients- so don't make the mistake of thinking that they have time to help, either.

I have never worked in the ER, but I can imagine that the ER nurses at these places are just as over-extended.

[nursemcsleepy, BSN, RN]

I think the real problem is that you have nine patients on a tele floor! That seems insanely unsafe, and makes me wonder how unsafe the ratios are in the ER.

[Kaitef0716]

Speaking as an ER nurse the rush comes from our throughput times. Like someone else had mentioned we get audited like no other on how fast or slow so many different things happen in the ER. Especially this time of the year with having to board patients it really slows down our workflow and fills up our waiting rooms. We should only be having 3 patients but when boarding and high census is going on we might have as many as 6 or 7 patients a few of which might be ICU patients which makes it very unsafe for us and easy to miss if someone is starting to become unstable. Once we have a patient stabilized they go to the floor. A severe sepsis pt might be on 3 or 4 different abx and 4 liters of fluid but our job in the ER per sepsis core measure protocol is to get the fluids started and start at least 1 abx and the rest the floor can finish. As for receiving an unstable pt just tonight I had a pt for Chf who had been fine the whole couple hours I had her and I was just about ready to tx her to a cardiac floor then all of a sudden she went into vtach and a fib rvr and we had to put her on all kinds of drips n send her to ICU. She was literally fine the whole time for me but in a second just changed so sometimes it happens.

[Daninurse69]

I myself have worked as an ER nurse in 3 different facilities and I have to say to you that we do not like sending patients up on top of each other or at change of shift. I have had the floor say to me, " I can not take that patient right now". The sad truth is when a sick patient or one whom thinks they are sick (patients with no PCP so let's get it checked at the ER) comes in through those doors we can not at to them hold on we can not take you right now; we must triage them and place them with a priority then go on to the next one that walks through those doors. I have said all along that we as ER nurse's should work a shift in each unit as well as each nurse from another unit work in the ER. There is seldom times in the ER that we have nothing to do. Hope this clears some things up and believe me we do feel bad when we send the unit multiple patients or very sick ones. We as nurses all have to remember we all have a patient load. Imagine have a code in one room while getting a chest pain patient in another along with someone SOB due to severe CHF or asthma. We as nurse's will continue doing our best for those they put their lives in our hands. God Bless.

[GM2RN]

I myself have worked as an ER nurse in 3 different facilities and I have to say to you that we do not like sending patients up on top of each other or at change of shift. I have had the floor say to me, " I can not take that patient right now". The sad truth is when a sick patient or one whom thinks they are sick (patients with no PCP so let's get it checked at the ER) comes in through those doors we can not at to them hold on we can not take you right now; we must triage them and place them with a priority then go on to the next one that walks through those doors. I have said all along that we as ER nurse's should work a shift in each unit as well as each nurse from another unit work in the ER. There is seldom times in the ER that we have nothing to do. Hope this clears some things up and believe me we do feel bad when we send the unit multiple patients or very sick ones. We as nurses all have to remember we all have a patient load. Imagine have a code in one room while getting a chest pain patient in another along with someone SOB due to severe CHF or asthma. We as nurse's will continue doing our best for those they put their lives in our hands. God Bless.

I agree that whenever possible nurses should have to experience other departments to gain a better understanding of one another's jobs. I used to work the float pool, so not only do I know what it's like to work other floors, but I've also had the "pleasure" of getting dumped on with the assignments that the other nurses didn't want because I wasn't regular staff on that floor.

I also agree that we need to be understanding of the need to hold patients for a brief period if there is a code or some similar emergency on the floor, and I don't mind when I know it's legit. But, the nurse asking for extra time, for whatever reason, needs to understand that it's not just me that she is putting off. My patients may have been in the ER waiting for admission for several hours and it can be a big deal to tell THEM that they have to wait another 15 minutes even, so I can be as understanding as I need to be, but please, floor nurses, don't take more time than necessary for my patient's sake.

[PANYNP]

Agree with above, and my intent is not to bash my beloved ED colleagues, but my experience, over the past 37 years, has been that Nursing, rather than physician providers, drives the timing of admissions from ED to the floors or ICUs.

It's been a nursing ritual, at many hospitals where I've worked as a staff nurse, that these admissions are batched to arrive at change of shift. Once in a while we would call the house supe/clinical resource nurse and plead to have the admissions held for 2 hours, so we could see our other patients prior to becoming involved in the assessment and processes involved with patient admissions.

So, small consolation, this has been going on for a long time. The icing on the cake is discharging a patient in order to take an admission.

The implementation of Observation Units in larger hospitals' EDs has mitigated some of this admission-transfer chaos.

This is an important area for research related to near-misses, errors, nursing retention, and patient-family satisfaction.

[GM2RN]

Agree with above, and my intent is not to bash my beloved ED colleagues, but my experience, over the past 37 years, has been that Nursing, rather than physician providers, drives the timing of admissions from ED to the floors or ICUs.

It's been a nursing ritual, at many hospitals where I've worked as a staff nurse, that these admissions are batched to arrive at change of shift. Once in a while we would call the house supe/clinical resource nurse and plead to have the admissions held for 2 hours, so we could see our other patients prior to becoming involved in the assessment and processes involved with patient admissions.

So, small consolation, this has been going on for a long time. The icing on the cake is discharging a patient in order to take an admission.

The implementation of Observation Units in larger hospitals' EDs has mitigated some of this admission-transfer chaos.

This is an important area for research related to near-misses, errors, nursing retention, and patient-family satisfaction.

I don't remember your previous post but I don't recall thinking that you were bashing anyone.

I know what you mean about admissions being batched, or at least having that appearance, but how do you mean that it is a "nursing" ritual?

Admissions or room assignments tend to happen at shift change for three reasons that I can think of: one is admissions that occur early in the morning because of ER doctors not wanting to bother the admitting doc with admissions in the middle of the night so they wait until a "reasonable" time in the morning to call with several admissions at once; another reason is because some ER doctors are lazy with their admissions and hurry to get several done at once just before shift change so that they don't piss off the doc coming in on the next shift; last would be due to most discharges occurring during the day just in time to have rooms assigned to ER admissions just before shift change.

[AnnoyedNurse]

As far as the ED dumping patients to the floors and ICU's- my general rule of thumb is properly communicate with the nurse what my situation is and try and understand what her situation is. There have been times when I really needed a 15 minute break and I expressed this to the nurse when getting report. I ask her, are you able to hold this patient for 15 minutes while I take a bathroom break or run down and get a cup of coffee...most of the time, if the ED nurse can, she'll hold the patient. If I'm working on an unstable patient, i'lll tell her- I need 15 minutes to hang my drips here and intubate this patient and I'll be ready for you- and if she can, she'll hold the patient. ICU's and ED's usually have a bad relationship. I try to get to know the ED nurses- and I'm always honest- when I say I need to do a,b, or c before I can take the patient, they know I'm being honest and will do what they can. At other times, they can't but they'll say they'll move slowly and sometimes they'll send their charge nurse to help manage the patient on arrival to the ICU air my resource nurse would manage my current patient until I landed my new admit. As nurses, we have to communicate and utilise all of our resources. I've even had a house sup do some stuff for a patient while I landed my ne admit. It's never never easy- but communicating makes it less of a war zone and creates a team environment.

Nursing ratios are terrible. Ancillary staff ratios are even worse. But not every nurse on the unit is dealing with a crisis at the same time- routine med pass for non urgent meds can wait so that a nurse can help her colleague who is dealing with an emergent situation. It's about working as a team, prioritisation, knowing when to ask for help, and knowing when a fellow nurse is drowning and offer assistance.

What at frustrates me most are the nurses who are willing to help during an emergency Because it's fun, but refuse to help when a patient needs to be cleaned. Remember, basic nursing care, although not fun, is still a very very important aspect of our jobs, and we need to help eachother out when a nurse happens to have a C-Diff patient with High ICPs, several BM's and a couple bouts of emesis.

We have to be able to look at the big picture- in essence, we need to become experts at triaging our admitted patients, perfecting the observation assessment, prioritising, working as a team, and know when to ask for help. I recently resigned from a hospital because the ratios were terrible and ancillary staff were so inundated and unable to help with turns and toileting took care patients.

As nurses, we have to continue adjusting and if we fail, then our patients are the ones who are hurt the most. My suggestion, find a hospital that values nursing ratios and adequate ancillary staff. With enough hands and resources, the suggestions I have made are much more doable than if the facility is chronically understaffed. Also, you need to become an expert at completing incident reports. Whenever there is an issue without a safe solution, report it.

[ThePrincessBride, MSN, RN, NP]

Nine patients? That sounds ridiculously unsafe.

I have had this issue of ER sending up patients that med surg nurses couldn't take and now are no longer even required to give report to the oncoming nurse.

Those ER nurses are constantly being pushed to turnover the ER beds so I don't blame them. I blame management for poor staffing.

[ThePrincessBride, MSN, RN, NP]

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.

On my unit it is fairly common for floor nurses to end up with seven patients.

That is so unsafe. I think more states need to follow California and have a max of five patients per nurse. Really, I think more than four is when quality of care starts to decline. Five is doable. Six is tough. Seven or more? Nuts.