Just wondering how it works at your hospital when you are full to the gills.
Last weekend we were full, people in the halls, long line at triage, ect. The problem is we were boarding admited pts for ICU and tele. It was not because there were not rooms it was because they were short staffed. Why can't the floors work short staffed when we have to? We were over our ratio but that doesn't seem to matter. We keep filling the hallways, trudging through without lunch or anything. I just don't get it. I'm not even asking you to use your hallways just fill the rooms!!!! Why is it expected that the ER house all the pts when we are out of rooms, short on staff, no breaks just so the floor nurses can stay in their ratios?
The ER is not set up for long stays. We don't have comfortable beds, no tv's, no phones in the rooms. Dietary does not deliever trays. Pharmacy does not send daily meds. We have to do each of these things ourselves on top of the regular ER pts.
I'm not saying this to start a "Er vs Floor" war, but I personally work in an ICU, and I don't care if we have empty beds or no, If there's not adequate nursing staff to care for that pt, then they're not hitting my unit til there's a nurse available. My manager is responsible for my unit, and the ER manager is responsible for hers. It's up to me to protect my nursing license, and I won't put pt's in danger by taking unsafe pt assignments.
Maybe it would help to speak to your unit manager about your concerns.
I totally understand your thinking and really I agree with you. No one should have unsafe numbers and put patients in danger. It just seems when EVERYONE is full it is the ER that gets stuck with the out of control numbers. Talking to our manager really doesn't help. If the floors can't take them what do we do? We can't refuse patients that come in through the door like you guys can.
It seems I'm getting a lot of replies from floor nurses. I'm curious to here from other ER nurses how your hospital handles things when the ER is overflowing with patients. I'm not trying to start a debate just find out what we can do differently so we are not so overwhelmed when this happens. The other night we litterally had 10 patients in the hall on cardiac monitors. Only serious patients end up in the hall, all others are waiting in the lobby. We were boarding over a dozen ICU/tele patients plus had a full load of ER patients. When half of our rooms have boarders it really slows down the flow of the ER. Patients wait hours in the lobby, ect.
I work both ER and ICU (Primarily ICU) so I can see it from both sides...the patients in your hall?? Are they true ICU or maybe truley even a MS patient or are the majority pts that will they eventually be sent home after labs/x-ray/ etc etc??
I know on occassion we have had to house true MS pts in the ER and it sucks for everyone, pt- staff alike..but if there is not a nurse avail to take care of them they are better off down there. Who knows what is going on up on the floor? Maybe a pt is going down fast and is requiring multiple ICU nurses attention.
Over Labor day weekend we were already a light staff--no house supervisor--and we had 2 ICU deaths with in 1 hour and we got an admit during that hour...the admit was basically put in a room and had to wait--would they have been better off staying in ER at least hooked up to tele with the door open for that hour vs sitting in a dark ICU room while we were busy with the critical/dying and rooms and halls full of grieving family?
PS we have been known to divert to another hosp when we were in fact just too full and could NOT care for any more.
Most of the ones in the hall at least this round were tele/icu. We had Med/surg beds this time. Typically if they are not critical they wait in the lobby for an open room. We only put pts in the hallway if they are too sick to wait in the lobby for a room.
I do understand floors get busy, have codes ect. I have no problem holding patients for circumstances like that but usually that is not the case. This last weekend it was just plan short staffing on the floors. Open beds everywhere but no nurses.
We do divert ambulances when we get crazy and we did do this over the weekend. However we are the only trauma center in the area so we can't divert those. You also can't send away someone that walks through the door. So diversion helps slightly but does not make a huge difference in the big picture.
Well, I know in our hospital, they have to abide by the acuity. Or at least the maximum numbers for the floor. Even if there is an empty bed (the max is 23, but there are more beds, since you have to take into account pediatric patients that can't bunk with adults, or numerouse isolations) If the policy says X # of pts per floor, or per nurse.... and the supervisor willingly goes over that, knowing it is in hospital policy, they may be held accountable. ... At that point, even though there are beds on the floor, I have protested, and refused to take admits from the ED.
Is is a safety issue, but also a matter of not setting precedence. If you start accepting patients over your policy and safety limits, before long, they will change the policy and up the limits per staff memebers, since they have seen in the past that you can handle it!
Agree. But the ER nurses have no such safety valve. Patient arrives .. by law, they must be seen.
I'm not saying this to start a "Er vs Floor" war, but I personally work in an ICU, and I don't care if we have empty beds or no, If there's not adequate nursing staff to care for that pt, then they're not hitting my unit til there's a nurse available. My manager is responsible for my unit, and the ER manager is responsible for hers. It's up to me to protect my nursing license, and I won't put pt's in danger by taking unsafe pt assignments.
Maybe it would help to speak to your unit manager about your concerns.
Again I'm not disagreeing with you in principle, but you're comparing apples & oranges. Your unit is closed - you have the ability to decline to take a patient at a certain moment in time. Not so for the ER.
I work both ER and ICU (Primarily ICU) so I can see it from both sides...the patients in your hall?? Are they true ICU or maybe truley even a MS patient or are the majority pts that will they eventually be sent home after labs/x-ray/ etc etc??
When we're holding, it's the already admitted patients that are in the hallways to free up more private areas for new incoming patients that still need to be examined.
I know how hard it is but we have to understand that everyone is working, not just one area. I cannot put a patient on my floor when I don't have a nurse. I try as much as I can to help everyone get the patients to our beds when they need to come. I don't hide beds or alter my census to keep patients out. We need to remember that everyone is working and we should always be working together.
That is a nice principle but it is not reality. I would not ever claim that inpatient unit nurses are working "less hard" or any similar nonsense ... but the situations are not comparable. Inpatient units are viewed as having a maximum capacity and staffing, physical plant layout and all other resources are designed according to that theoretical "maximum." There is no maximum in the ER ... and too many hospitals ignore the problem.
Diversion is not the solution. It has no impact on walk-in patients and please understand that "walk-in" patients are not necessarily ambulatory & only mildly ill. MIs, evolving respiratory arrests, patients with suicidal/homicidal intent, GSWs, other major traumatic injuries, and acute abdomens ... all can and do show up at the front door of the ER.
Specializes in Management, Emergency, Psych, Med Surg.
The emergency department has to take everyone who arrives, no matter what. It almost always causes a back up and this is a very stressful and often dangerous situation to be in. And you are right...divert is not the answer because if you are on divert, chances are the other hospitals are as well. I know one thing, it is going to get worse before it gets better. With people out of work and no insurance, more and more will be coming to the ED.They will be sicker because with no insurance often they wait too long before they decide to see a doctor and I don't know many doctors out there who are giving free care. On our med surg floor where I work, I try very hard to get my beds turned over so that I can take some of the load off the ED. It will be interesting to see what happends in 2009.
The night we had the fire on the Med Surg floor, and had to evacuate all the MSP and CCU patients to the ER. we did close the ER. (Which is state reportable) and the next nearest hospital had already started to divert patients due to a large MVA that had happend that night and flooded their ER with trauma patients.
But with all of our medical and CCU patients in our ED allong with every portble monitor, med carts, chart racks, and all available staff....what a zoo! we had 4+ patients packed into one patient ER bays! This happend about 11pm, so when family members started hearing the news on the scanners or word of mouth, they started showing up in the ED!
Usually when our ED is full to overflowing, your frequent flyer patients, or those that just didn't want to make a dr appointment for a sinus infection, end up just leaving before being seen. We have had people leave, drive 30 miles to the next nearest hospital, see the wait in that ED, and come back to ours, and expect to get their place back in line to be seen!
That is the reason I could never work ER. People like that, and pain med seekers. It gets worse all the time. I think they need way more urgent care centers. And educating the masses as to what is an emergency, and what is just something that can wait till you get into your MD.
One place I worked at years ago opened up the out patient dept (after hours and on w/e), put the stable pts there and staffed it accordingly with ER nurses. Freed up alot of beds, and maintained proper and safe pt to nurse ratios for everyone, bought time for the floors, ICU to get beds available. I wonder if this could work on a daily basis, like a holding area, short term admission. But NOT be included in the bed census for inpatients. It would certainly be better than in the halls. Although the back log of inefficiencies really impact the abilities of the floors to accept new patients and until those are addressed we are destined to remain as we are.
While everyone has valid points, the problem lies with administration and their need to maximize profit. The hospital I work in and I would venture to say the majority of hospitals staff the oncoming shift with the current patient census. This means you get exactly the number of staff for what is there at that time (the current shift) and does not account for new admissions. I have yet to see a hospital not have admissions on every shift so this makes absolutley no sense from the nursing or patient care stand point. It does, however, make sense to the powers that be that want to minimize staffing pay and make and their budgets look better.
Ratios are a good thing but this does create bottlenecks in the ER to which administration refuses to alleviate by staffing better. Change that to staffing smarter. I secretly think the suits like to keep us at each others throats for issues that we have no power over. When I first started nursing many years ago administration told us in a meeting that nurses were their "biggest liability" and to keep our jobs we all had to work harder and more cost efficiently. We are not liabilities, we are ASSETS and without us there is no hospital, no business. We do have power if we all stand together. We need to pick our battles, hold our ground, and embrace all our fellow nurses in the trenches with us. We are in this together and it will get worse before it gets better.
"I secretly think the suits like to keep us at each others throats for issues that we have no power over."
I think you are right in some cases. I see it a lot in our hospital. Night staff against day staff.... specialty units against Med Surg. even the different levels on a floor. RN against LPN against CNA. and management in a lot of cases doesn't do anything to encurage peace amung the ranks.
Specializes in Management, Emergency, Psych, Med Surg.
There are alternatives as suggested above. Use day surgery and outpatient beds. BUT you still have to find nurses to staff it. When I used to be in management at the director level I had staffing issues all the time. There are many times when staff is just not available. You may have bed space but you have to have people to provide the care.
If it's not an emergency then waiting to be seen is the norm where I work. We have a large ER. 65 beds with 6 quick care nonemergent beds. Quick care is staffed with 2 rn's 2 PAs and one of the docs from another team works both teams. We also have a 7 bed pediatric unit which has 2 rn's staffed open 11a-11p. There's 3 trauma rooms and a resuscitation room as well, along with 6 chest pain center beds. There's also 4 immediate cares throughout the county run by our hospital. Don't get me wrong, it's busy and it can be frustrating, but the serious patients get treated first and we've never had a 4 hour wait ever I don't think. There's also an after hours clinic. Our staffing is great and we have an oncall system where we sign up for 2 shifts per month. There's never been hallway patients in our new ER....that's scarey to even think that....
Non-emergent patients are educated that there is a wait and they choose to stay or not... There's always that person who attempts to give the triage nurse or even the nurse taking care of them inside a hard time. Most of us just educate the patients based on policy. Granted....there are a few who still blahblahblah to us....most of us smile as we come out of the room with a montra....you'll be seen based on the environment presenting in the ER at this present time. Some leave...some stay....doesn't matter to me either way. Your boil on your rump is not an emergency to me...my trauma,stroke,MI,etc is...feel free to watch the flat screen tv in your room while you wait. I'll be back in once the doc has seen you and written orders.
Non-emergent patients need educated..plain and simple. We do it on a regular basis and it makes life much much better. We always brainstorm between triage and the command center....
we now have a policy if the patients tell us they are going to leave, we go get a doc to see them right away, most of the docs just treat them. only a few will saythis isn,t and emergency and we will see you as soon as we can. So lets reward the selfish rude pts, while the other pts have to wait for them, after all they are most important in the press gainey. And on the press gainey subjecy, are any of you being told the some insurances co, Blue Cross, Mass healthwont pay for things if our press gaineys do not go up to a certain percent? I can see not paying for hosp acquired infec, cut off wrong leg, but the food sucks, the nurses didn.t pay enough attention to me! what kind of crap is this. I think the administrators ar making some of this stff up, if they can nick pic, what will the agree to pay . I just transferred to the birthing center and someone was out of controll that there was no turkry wrap left, she was carring on and speaking to the nurse manager. I thing she orderd a turkey wrap out to be delivered.. so its the same there. I thinkk we should statr some type of nurse ganey. we could survey alll the hospitals around ustelllour fewwlo nurses which ones are good, rate them on many things.pass them out to the patients as they come. so after 18 years I left the ED, my job was removed, forcing everyone to work 3 12"s cant do 1 or 2 which i wanted to do. so i saw a position in birthing center and got it. I am enjoying itand I know longer limp to my car after work, so it is all for the best .. BUT I MISS THIS.......why is it soooo hard to leave it. wish me luck, i will have to live though u guys for my er fix. guess I will pop over to ob and make some new friends:typing:typing
Specializes in Management, Emergency, Psych, Med Surg.
Please refer to the CMS (Center for Medicare Services) site. Some hospital aquired illnesses will not be covered such as UTI, hospital aquired pneumonia, stage 3-4 decub ulcers (you need to do a complete skin assessment when pts come in so you can document that they came in with a decub), some post op wound infections, any post op infection of hip or knee surgery, injuries that require care due to a hospital fall, etc. Go to the site and it will give you the details. You might also note that when Medicare/ Medicaid make a change in their reimbursement, private insurance changes soon follow.
bjaeram
229 Posts
I totally understand your thinking and really I agree with you. No one should have unsafe numbers and put patients in danger. It just seems when EVERYONE is full it is the ER that gets stuck with the out of control numbers. Talking to our manager really doesn't help. If the floors can't take them what do we do? We can't refuse patients that come in through the door like you guys can.
It seems I'm getting a lot of replies from floor nurses. I'm curious to here from other ER nurses how your hospital handles things when the ER is overflowing with patients. I'm not trying to start a debate just find out what we can do differently so we are not so overwhelmed when this happens. The other night we litterally had 10 patients in the hall on cardiac monitors. Only serious patients end up in the hall, all others are waiting in the lobby. We were boarding over a dozen ICU/tele patients plus had a full load of ER patients. When half of our rooms have boarders it really slows down the flow of the ER. Patients wait hours in the lobby, ect.