Your Gettin a Patient - The Doors Open and In Rolls Your Pt.

[CarVsTree]

How does this happen???

Pt. arrives is seen in ED @ 2100 as a trauma alert. Primary/secondary survey, orders entered in CAPOE, plain films, CT scans done, etc.

I get a call from my AP (unit clerk) @ 0230, "you're getting a pt., report's in the computer." I knew there was no bed in the room, as I walk out into hall to get the bed to bring it to 17A, the doors open up and in rolls the pt. Fortunately, the pt. was A&O and could tell me his injuries. I stood there and read report in front of patient.

We won't even begin to talk about the crazy orders the first year put in... But in his defense, he was just hired a few days before to replace a first year that quit.

I don't mind short notice but how about 5 minutes... Hmmmm.... How 'bout 2 minutes.... 10 seconds just don't cut it.

[CarVsTree]

I am not condoning nurses that fail to provide adequate information as a matter of providing report with the floor nurse.

Also, it's noteworthy to indicate the downfalls of pre hospital communication between EMS and the ER. There are many unknowns before actual ABG's, X-Rays or other similar diagnostic testing are ordered and conducted in the ER. Pre hospital communication only serves to "outline" and/or "describe" the overall patient's condition prior to their arrival in the ER. In many instances the information provided may be "unclear" without any specifics pertaining to what is actually going on with the patient.

For example, EMS doesn't always have the opportunity to complete a head to toe assessment and report things like blood exhibited in the patients urine from a recent trauma etc. Sometimes, these things are "added surprises" once they arrive in the ER. EMS can't effectively report the "unknown."

Getting back on topic, my basic beef is how certain floor nurses "delay" to accept report from ER nurses because it's either:

A) Not a particularly good time for the floor nurse right now to receive the patient and they intentionally delay the admission process.

B) They are not their primary care nurse, the primary care nurse is on break right now etc..etc..etc... (I have heard it all..)

Hence the so called "communication" issue ER seems to have with the floor nurses and vice versa.

You would think some floors somehow thought they had the added option of refusing medically cleared patients if they don't happen to like certain facts about their overall condition.

Keep in mind this is really not the ER nurse's decision, (although they may have input to this decision) The decision to discharge the patient to the floor is actually the decision of the public medical officer representing the facility. (AKA The ER doc)

Also, "stabilized patient" might have a completely different interpretation to the average recent grad floor nurse and an ER doc.

It's not that ER nurses feel more "important" than floor nurses do etc.., it's just that some floor nurses (not all) don't effectively understand the meaning behind the medically cleared patient concept.

Receiving the patient on the floor is not somehow an optional issue unless an acute and drastic change in the patient's condition are suddenly noted. That is what I would consider as a reasonable expectation. However the ER may view anything else as excuses and/or unnecessary delays in the admission process.

This is probably why we have this ongoing admission war. It's a matter of understanding and no matter how I try to understand the floor nurses concerns, I am always perplexed in understanding how any such expressed concerns can possibly meet the criteria of outright refusing an admission they are receiving 89.9% of the time.

My Best.

Good post. I agree that delays from the floor can be a big problem. My hospital has solved that problem by requiring no delay report. Meaning if I'm up to my elbows in poop and can't take report (for trauma alerts where its phone report) patient comes up anyway. That being said as policy does not mean I can't say... "I'm in the middle of changing pt. can I call you back in 2 minutes?" This has almost always been met with "sure." I call back immediately after finished with la poop and take report. Occasionally, I've been told "can't we really need the bed." Then we all do what we gotta do.

I think we could go on and on with what could be done better by the other department! We all know we're ALL pushed to the limit in ALL departments. BTW, report isn't what I care about most when receiving a pt. What I like is 2 minutes to look ancillary results, labs, and orders. This is where I get my picture. Not to say report is of no value - that would be ludicrous. But when I've already looked at results in the computer, I can just hear the RN's assessment and go from there.

Cheers all!

[CarVsTree]

Also, it's noteworthy to indicate the downfalls of pre hospital communication between EMS and the ER. There are many unknowns before actual ABG's, X-Rays or other similar diagnostic testing are ordered and conducted in the ER. Pre hospital communication only serves to "outline" and/or "describe" the overall patient's condition prior to their arrival in the ER. In many instances the information provided may be "unclear" without any specifics pertaining to what is actually going on with the patient.

For example, EMS doesn't always have the opportunity to complete a head to toe assessment and report things like blood exhibited in the patients urine from a recent trauma etc. Sometimes, these things are "added surprises" once they arrive in the ER. EMS can't effectively report the "unknown."

This happens to EVERYONE who receives report from someone, whether you work in the ER, floor, or ICU.

[nursemike, ASN, RN]

Floor nurses have it easy in comparison. Give the ER staff a break. All they are trying to do in the ER is move stabilized patients to the floors. This makes more room available in the war zone. It's not like the ER can choose thier patients.

I'm a floor nurse, but before I was a nurse, I was a transporter. One of my jobs was bringing pts up from the ED. I routinely made several trips from the ED each shift, so I got a pretty good look at what it was like, even though I haven't worked there as a nurse.

All I can say about your comment is "Pffft."

In point of fact, as I told my doc, I don't really have any problems with my ED. Report is often given by any nurse with the time to give it, whether he or she actually knows the pt or not, and it's usually pretty sketchy. Well, the first thing I do with any admission is a full head to toe, so mostly what I need is what meds have been given--and I generally do get that. I'm also starting to learn their lingo--if I'm told the pts GCS is 4-5-6, I know longer wonder, "So is it a 4 or a 5 or a 6?" and I'm not surprised when they arrive upstairs and it's a 15.

I do sometimes ask whether they can sit on this one for 4-5 more hours, because I'll be off at 0730--but I sure they know I'm kidding. I have--but only twice--asked them to give me ten minutes because I was in the middle of something urgent, and they have. From my transporting days, I know how urgent it is to clear an ER bed, but most of our ER nurses started on the floors, and they're well aware of how "easy" we have it.

I know we're not supposed to get personal, but I'm thankful every day that attitudes such as that you expressed are pretty rare at my facility.

I don't know. It makes me wonder whether our administrators might not be quite as demented as they seem.

[teeituptom, BSN, RN]

That is why you have different staffing levels, a doc on the unit, stat preference for all tests, proximity to Radiology, transporters, an entirely difffernt Pyxis system in which you do not have to wait for a Tylenol to be profiled before pulling it.

The ER has EMTALA to guide your triage function. Your patient, triage nurse or EMS gives you "report." On the floors, we have something called "continuity of care" and we have no less need to know what has already been done for the patient.

We are certainly not "less than ER" nurses because we are not ER nurses, we too have protocols to follow and a different skill set.

One of them is that we are to get Report before each patient gets to the floor. Our complaint is that we are not getting Report or that we get insufficient Report or that the patients are coming before we even have the room cleaned.

In some cases, the patients may have been stablized and became UNstable on the way to the floor.

You need to stop making this about nurse vs nurse and understand that just like a person doesn't walk in off the street into a Trauma room, we should not be getting patients who have been treated by the ER without getting some form of Report.

Ive seen some just walk in straight to a trauma room

[Miss Mab]

ELTHIA SAID:

You imply that the majority of floor nurses are recent grads, then state that ER nurses "don't feel more important'. First off, I am proud to be a floor nurse, and I nor the majority of my coworker are not recent grads.

A medically cleared pt for my floor would

1. have a stable BP

2. have a stable HR, failing that be asymptomatic with the brady or tachy HR

3. have a decent pulse ox with or without O2

4. have chest pain less than 2/10 at time of transfer

5. If s/p cardiac cath, sheath removed and hemostasis at sheath site, PPP, can have femostop in place.

6. If on restricted cardiac drips, meds are within limits allowed by protocol for my floor, NO TITRATING.

Um, isn't that pretty much a home care pt.?

nowadays anyway...

also, what are these things called transporters you all speak of??

[nursemike, ASN, RN]

Thanks for clearing that up. I can understand the frustration of the floor nurses at not recieving report on a newly arrived patient or turning up unannounced. In the ER we are used to patients rocking up sick as dogs with no notice but its different. The ED is set up for exactly that sort of thing and we are used to working with limited information, whereas on the floors, its an intrusion into an already busy scene (and I don't mean that disrespectivily towards the patient) and floor nurses expect a report and expect time to prepare,as its the way it is supposed to be done. However, this understanding goes both ways and I myself have dropped onto a unit 'unexpectantly' 5/10 minutes early because it was a case of getting the patient out of the ER as quickly as possible because of pressures on the department at that time. Now, I appreciate that each unit has its own pressures but transferring a stable patient to make room for a trauma or a code, makes sense to us in the ED. Unfortantly, that means other units get the shortend of the stick sometimes.

What I still don't get is who transfers the patients to the floor? Is it orderlys? What if the patient goes off on the way?Just curious!

At my facility, each floor had people--usually just a couple of us--assigned to do transports, clean pt rooms, and other odd jobs--so if we got an admit from the ED, it was my job to pick them up. If they crashed on the way, I was to start CPR, get them off the elevator, and call the code team. But if there was any sense that that might be likely, a nurse from the ED (usually) came with me to monitor. Very rarely, we'd have to send the nurse receiving the pt, or the CN, because the ED just couldn't spare the staff.

I've heard we're changing that system, soon. We'll have a few employees housewide to do transports, and room cleans will be done by housekeeping. I'm sorry to see it--I thought my job was a valuable one, and I rather enjoyed that I got to interact with pretty much every department in the hospital at some point in my shift. But it does kind of depend on people being self-motivated, and I guess they've been seeing problems with that.

The thing that gets me is that I occassionally saw a few nurses with the attitude that "My patient is sicker than yours, so I'm more important/a better nurse than you." Like the time I was bringing an ortho admit up from the ED and a gang from the ICU slams my cart (with a patient on it) into the wall to shave half-a-second or so off their transit time to the CT scanners. Or like seems to be the attitude in some of the defensive posts on this thread. But, as I noted earlier, that's pretty rare at my facility. Most of the complaints about the ED are like my "Why do I always get a patient right at lunch time?" and I'm not blaming anyone, other than possibly God, and I'm willing to entertain the notion that even God has more important issues than whether I'm a half hour late getting lunch.

On some of my trips to the ED, it was urgent to clear "Hallway Bed 4" because ambulances were on the way and it truly did look like a war zone. Once in awhile, doctors and nurses had time to laugh and joke and the only patient other than the one I was getting had the flu. Once in awhile, as I was doing a terminal room clean, a nurse would say, "Clean slowly--I'm not ready for another patient, yet." but they were nearly always joking. Once in awhile, the ED had to just keep their pants on because the patient who was 3 days post-op from a minor fracture was now throwing a PE.

Again, thankfully, it's generally understood where I work that not many nurses have it "easy" very often, regardless of what department they work in.

[elthia]

ELTHIA SAID:

You imply that the majority of floor nurses are recent grads, then state that ER nurses "don't feel more important'. First off, I am proud to be a floor nurse, and I nor the majority of my coworker are not recent grads.

A medically cleared pt for my floor would

1. have a stable BP

2. have a stable HR, failing that be asymptomatic with the brady or tachy HR

3. have a decent pulse ox with or without O2

4. have chest pain less than 2/10 at time of transfer

5. If s/p cardiac cath, sheath removed and hemostasis at sheath site, PPP, can have femostop in place.

6. If on restricted cardiac drips, meds are within limits allowed by protocol for my floor, NO TITRATING.

Um, isn't that pretty much a home care pt.?

nowadays anyway...

also, what are these things called transporters you all speak of??

No that isn't a home care pt.

Home care pt's don't have chest tubes to low wall suction, aren't 24-48 hours post CABG/AVR/MVR/esphogectomy/thoractomy, don't have cardizem/amiodarone/dobutamine/dopamine/natrecor/heparin/integrelin drips,

don't have NG tubes to low wall suction.

Don't have a hemo or pnuemothorax.

Don't have PCA pumps or epidurals for pain control.

Pt's aren't home care pt's if they are having a NSTEMI, or STEMI ( at least I hope to hell not) or unstable angina.

ACS II and ACS III pt's go to my floor.

And they can have all that I have just listed and STILL have stable vital signs at time of transfer.

Anywho...

Why I love being a floor nurse...because today it may have taken almost 45 minutes, but with much coaxing and encouragement and teaching, and a few insulin syringes and a much abused orange, I taught a man to give himself his own lovenox shot for the first time.

While waiting for transport which was late picking up my pre op patient, I got him to shed some "jitters" by getting him to tell me WWII stories, and was able to turn the conversation into a review of Post op teaching by comparing cardiac rehab to "boot camp"

No matter how much anyone will put down floor nurses, I think that it is the balance of critical skills, with the ability to teach and to have one on one personal interaction with the pt as the reason I love floor nursing.

[UM Review RN, ASN, RN]

Ive seen some just walk in straight to a trauma room

Yes, and then you had 4 nurses, a couple of techs, a transporter and a doc rush in to do something about it.

That's completely appropriate. That's what the ER is for, and that's what the ER nurse does.

Whereas, when a Direct Admit came to me with 8/10 CP (and no tech--OK, I had a tech but she was "busy" and only dropped in after everything was done), I had to weigh the patient, put the monitor on, take vitals, do the EKG, draw blood, start an IV, hang fluids, give O2, ASA, NTG (3 of which relieved the CP :uhoh21:), give the stat meds (unable to pull them from the Pyxis, so I had to call Pharm and Lab and Xray to get it all stat) and do the admission paperwork.

I also ran up to the computer and entered the stat orders (the US was also "busy" and did not comprehend the emergent nature of the admission) and came back to the room to find the patient drinking a caffeinated beverage.

Guy's trop came back high (I can't recall the numbers, I just remember thinking, This dummy is going to pay for that long lunch with heart tissue for the rest of his shortened life) around the same time that the Doc showed up and Pt. was then transported to the Unit.

All the while the patient was wondering what all the fuss was about. :trout: That's why I'd love to ban Direct Admits.

My point?

Thank God, I had been forewarned that this patient was coming and I had plenty of time to get the room set up for him. (And time to get my other patients assessed and medicated.)

I had the scale, the EKG machine, the IV kits, the lines, the lab tubes, and the dinamap in there.

(And I'll bet you thought I was entering into the floor vs ER nurse p'ing contest, didn't you? )

But sorry, I still don't think there's any excuse (despite those of you who insist on trying to compare floor nursing to ER nursing, which is like comparing apples and oranges) to not give a good Report when transferring a patient from one unit to another in the hospital and to not give time for the receiving nurse to prepare for that patient.

[Crash_Cart]

Please don't get me wrong. I have all the respect in the world for floor nurses. Heck, I was once an old school Medical Orderly (Pre Med Student) and as such I have formally consolidated/trained on many floors myself for that matter. Medical, Ortho, OR, Psyc you name it, I have worked there at one time.

Some seem to be misunderstanding some key elements and valid points from an ER perspective I am making in this thread.

Sure ,we can all make some improvements to the patient care process we are attempting to implement into place however, I admit most floor nurses do a bang up job with the train wrecks we usually send them from the ER. I do have to give them credit for that. Thank god they are there for us in our time of need.

Just remember I don't really care what kind of nurse you are, we are all in this great big mess together. We all share the same common objective.

The patient.

My Best.

Charles - Emergency Department.

[nursemike, ASN, RN]

On the other side of the coin, the first time I had to call report on a pt I was sending to the ICU, I gave the kind of report I generally give at change of shift, and I could almost see the nurse on the other end gesturing, "c'mon, c'mon". They want the report we usually get from the ED--latest vitals, vitals before the event precipitating the move, last meds given, and don't seem to really much care how the pt pees.

Geez. Nursing is more complicated than it looked when I was transporting.

[TrudyRN]

In the USA, things are a bit different......

Nursing bosses, risk managers, and medical chiefs-of-staff and department heads need to get involved in teaching people the right way to avoid these very serious errors and sheer laziness in handing off an exsanguinating patient. Would calling it criminal negligence or attempted manslaughter be too serious?

Someone asked me earlier if RM should be involved in correcting this dumping problem. Yes!! Involve everyone who can possibly make this terror stop. If I were the bleeding patient or that person's relative, I'd have marched up to Admin and to the DON and then to my lawyer. What is wrong with people that they do this kind of thing? What is wrong with the one who didn't raise bloody Cain after this happened to her patient? Sorry if I sound critical but this person could have bled to death and such must cease. Now stop posting here and go plan how and whom to approach to change this type of thing and make it cease in your own hospital. Then come back and post how it is going.

[caroladybelle, BSN, RN]

Someone asked me earlier if RM should be involved in correcting this dumping problem. Yes!! Involve everyone who can possibly make this terror stop. If I were the bleeding patient or that person's relative, I'd have marched up to Admin and to the DON and then to my lawyer. What is wrong with people that they do this kind of thing? What is wrong with the one who didn't raise bloody Cain after this happened to her patient? Sorry if I sound critical but this person could have bled to death and such must cease. Now stop posting here and go plan how and whom to approach to change this type of thing and make it cease in your own hospital. Then come back and post how it is going.

Episode happened about 7 years ago.

The issue WAS written up and DON notified....please note the patient was a hospital employee, wellknown and well visited.

As to what was done, I do not know. However, after two more incidents of a port being perforated (another one in ER - proving that what ever followup that was done, obviously wasn't enough - and one in the ICU), ALL units were required to call an onco nurse to access ports. Just as after some chemo was inproperly administered in PP - onco nurses administer ALL IV/IM/SQ and most PO chemo.

But do ya think they staff us well enough to run all over the place, especially if there are any major chemo hangs in the ICUs???

I no longer work there and am a traveler now.

Why ever would you think that I hadn't done anything about - preforation of a port, much like chemo errors are sentinel events and always goes to RM......not that they will do anything , in some facilities, except to CTA. My understanding is all sentinel events go to JCAHO.