I have been feeling an increasing level of frustration lately with regards to giving reports to the floor, be it ICU, med-surg, or OB. Yesterday I had one intubated patient who I had just finished titrating to keep him down. I was working diligently to get the versed and propofol to the correct doses to keep him comfortable, and to bring his fever down to stop him from shaking.
I had another patient - she was much less critical, though still important. She was admitted for postpartum hypertension. Her blood pressure was around 140/77 when I called report. We had treated her with magnesium to prevent seizure, placed a foley catheter, and given labetalol PO. The doctor had also ordered a labetalol drip. Additionally, he had ordered 24-hour urine collection.
I am an ER nurse, and I did not put the foley catheter bag on ice. To be honest, I am not an expert in preeclampsia. I am also a new nurse with just over one year of experience.
I am feeling SO FRUSTRATED as a new nurse while giving report. I am doing the very best I can to keep up with orders - and I feel like the floor nurses are never happy with what gets done in the ER.
I just honestly feel like there needs to be a larger discussion around how to give and receive report. Do you think there should be a time limit on how long we can give report on one patient. There are certain details that I sometimes wonder ... among the zillion things I have done for the patient in the ER ... why do the floor nurses ask 300 questions during report? Also, I just feel like I am getting the 3rd degree for everything I did or didn't do while in the ER.
How do you layout your report? What details do you offer? When an ER gives report to another ER nurse, it takes 3 minutes MAX - but giving report to the nurses on the floor seems to take an ETERNITY! What is the deal with that? When I get a patient ... I figure it out! I would really like to get better at giving report, but I hate feeling like I am getting asked for details that are minutiae. And I am really struggling with the attitude of many of the ICU nurses to whom I give report. Perhaps it is only at my hospital, but I don't think it is necessary to be condescending.
How about hosp to hosp report? That was fun tonight.. Dear nurse, the pt u know nothing about is now at your facility cuz I've been trying to give you report for 35 minutes
You're actually looking for ADPIE (the Nursing process). SBAR has been so trendy lately that we try to use for all sorts of things it wasn't meant for and isn't appropriate for. SBAR for is for communicating a single change in status. ADPIE is the overall process of patient care and provides a much better structure for capturing and organizing information on a patient. Typically when someone is using SBAR for report, they're actually just using ADPIE, it's just cooler to call it SBAR.
Omg! I said almost this exact thing to my nursing manager when they brought out the new "SBAR" format report sheets and she looked at me like I had four heads!
Yikes, the hostility is pretty strong. I work on the floor now and will soon transition to an ED position. It helps me on the floor if you tell me that you guys are in chaos - I understand and will receive a patient even without report to help. But most of the time it is a standard situation and then I get a call from the charge RN (who has never laid eyes on the patient) or someone who has only had the patient for 5 minutes (I know because they say "I don't know anything about them, I just came on shift and haven't seen them yet"). They read from the EMR which is jumbled and often incorrect- was that critical K+ corrected with meds or not- who knows because it shows ordered, cancelled, given, and then entry is corrected.
Also, I know that many questions are asked of the patients in the ED- it saves me effort and time of a septic patient or AFIB with RVR and SOB patient if you just tell me all the important stuff and then maybe reassure me about the issues you looked at and determined that it can wait- what are the big fires and what are not?
Tell me what you are worried about because I trust you to know what is a big deal. Tell me what you have already treated and what still needs to be done. I don't care that you didn't correct the K+, or hang the fluids, or get a urine sample, or whatever- I just need to know what got done and what still is on the hot list to be done.
And if you have multiple traumas rolling in and just need to clear beds, just say so and I will shut up and figure it out.
I've worked both sides of the fence, and I have to admit when I worked the floor, most ED reports really drove me nuts. For one thing, they seemed to have a knack for calling me while I was elbow deep in poop or right after having gowned up and walked into a C-Diff room. If I told them I needed a few minutes, they'd act all put out.
Then, they'd give me some rambling, incoherent report that didn't include anything I needed to know. Basically I had already looked the patient up in the system and could see everything they had told me anyway. If I had any questions, I'd get "Well, I'm covering for the primary nurse who is at lunch, so I don't know the answer to that" or "I just came on five minutes ago so I don't really know the patient". It really just felt like a waste of time in most cases.
Then I began working in the ED, and I gained understanding. It's a whole different world down there in those trenches!
This is why I think having a standardized report format is really important. Whether it's SBAR, ADPIE, or XQZH (I made that one up, don't ask me what it means) doesn't really matter.
Something that I found really helpful when calling report to the floor was to take a moment to grab a piece of scratch paper and write down all the pertinent information I wanted to pass on before I even dialed the phone. Now granted, there are times when you're so slammed that you just don't have that extra moment, but when you can, it's really a good thing.
Also, about a year in to my ED experience, we switched over to a new system where we would fax the SBAR sheets to the floor as soon as we got a bed assignment. Then the report phone call often went like this:
We record report into a messaging system, leaving your name and extension, and then the floor retrieves it, and calls back if they have any questions. They rarely do. It works well, because the receiving nurse can listen to it when she is able to and prevents the inevitable, nurse is elbow deep in poop when you call.
I'm just wondering. I've never worked a ms floor.. But is there not some sort of heads up that you're getting an admission, from the ER? I can't imagine the nurse to nurse report is the first you're hearing of the admit going into your bed.
All things can't be prevented because of the unpredictable nature of nursing, but is it unheard of to attempt to call the ER for report to see if the nurse can give you the low down? Like, hey nursey, are you free? I'm about to put on a hazmat suit to clean up cdiff.
I'm just wondering. I've never worked a ms floor.. But is there not some sort of heads up that you're getting an admission, from the ER? I can't imagine the nurse to nurse report is the first you're hearing of the admit going into your bed.
I spent several years on the floors in float pool and have now been in the ED for the past six months or so. Depending on the floor, YES...unfortunately this is absolutely possible that the first you hear of a new admit is when the call is transferred to you and the ED nurse says 'so you're the nurse taking Mr. XYZ?'. For those who have pointed out that empty beds mean admissions, let me add something: you can have no empty beds on a floor and still get admissions if the patient is appropriate/MD demands specific unit/needs monitored bed/chemo/locked unit etc. We would get about ten minutes lead time to figure out which patients could be moved to other floors, fight with the MD and the patient to get orders to do so, fight with the (uncooperative) accepting unit who refuses us the bed, have our charge fight with their charge and then fight with the house sup to get the transfer moving...
all while the ED called and called, yelling at us for refusing the admission we just learned about ten minutes before with no bed available. I've had a new admit just left in the hallway (with no bed available) and been told 'figure it out, your problem now.' Patient was aghast and it was embarrassing for all of us. *sigh. It happens - this and much more. If you want the floors to understand you, you have to extend some understanding as well.
JME: It's not your (ED's) 'fault' for sending the admission and it's a petty, annoying nurse who takes it out on you. What I wanted to know: when and why patient came to ER, what you worked up, anything you treated and what's left for me that's undone. Bonus if you can tell me the extras: are they escorted by 15+ family members, are super demanding, speak ___ language only, are they a man dressed as a woman (that was an unnecessary surprise that created quite a fiasco with the intended roommate at 0300), have they been hostile/combative toward you etc.
Knowing what your floors can see in the system is also important; if we were told anything prior to the call for report, it was only the name, age, gender and admitting dx. We used a different system than the ED and could not access nursing notes, orders, labs, etc at all. The report we received was all we had to work with until the packet arrived with the patient to the floor and sometimes only then did we figure out there was a serious issue with admission criteria, (say, to unmonitored bed or to floor which couldn't admin ordered drips.) Few nurses want to fight the admission just to fight it - unfortunately, once the patient is 'accepted' to the floor, it's not cool to be on the receiving end of a cluster...jam involving incident reports, calls to the MD and house sup for transfer, aforementioned fight with appropriate floor to secure bed, etc all while that patient waits for care and your seven, eight, nine, or ten other patients also wait for their care.
Of course, JME, but I hope it gives another perspective. It's interesting now to see things from the other side. I try to give the receiving nurses the report I always hoped for and take things up the chain if there's a problem. Can't we all just get along?
The thing is, that on the floor you expect to have all the knowledge about the patient as possible, and you have to have a doctor's order to sneeze.
In the ED, you get what you get and you go with the flow. You have a lot of autonomy to do whatever intervention is appropriate, and if you have a good team, you know the doctor will have your back. You get comfortable with that. That's what I love about the ED. I feel like I can get to do things based upon my nursing assessment, rather than being a handmaiden to the doctor.
One of the things that drew me to the ED was when I was working on the cardiac unit. I had just received a patient, a LOL with some new onset cardiac issues. I knew she needed an EKG, a CXR, basic blood panels, etc., but I couldn't order them until the cardiologist had been there and evaluated her and had actually physically written orders. In the ED, nurses have the autonomy to order what is needed that is appropriate to the presenting s/s.
I can't tell you how many "verbal orders" I have written on patients in the ED that would have required a physician to actually be physically present on the floor in the inpatient setting...things like "may access Portacath for blood draws" or "TPN for PICC occlusion"...those things are total no-brainers and would earn you a well deserved scoff if you held up patient treatment until a doc was available to physically write the order. It's important for ED nurses to understand that. We need to cut floor nurses some slack. It's not their fault that they need orders just to pass gas. That's the nature of the beast.
I split my time between ICU and the ED, and occasionally tele. I've never really noticed any difference in giving report to ICU/floors when I'm in the ED vs being anywhere else, the same issues come up no matter whom is giving report to whom.There are certainly different styles; many ICU Nurses write a full page of notes while getting report, I write down absolutely nothing.
Some things to keep in mind; I've never worked anyplace where the ED and inpatient floors used the same charting system, this means that floor Nurses can't access the ER charting, usually until it gets uploaded to their EMR which sometimes doesn't happen until the next day.
There are definitely some questions that are ridiculous, such as "where is their PIV?", but I've also experienced times where basic information that should have been communicated in the ED report and wasn't resulting in patient care delays and even harm to patients, so there's certainly times when we could do better in giving report in the ED.
I absolutely HATE when I get interrupted while giving report. Maybe if you actually listened, you would know the IV site with which fluids are running in, and not have to ask me 4 times. If I get interrupted more than twice, I say "if you have any questions my extension is ....." and hang up.
The exact wording of patient abandonment laws varies some state to state, but in general the rule is you have to ensure the receiving Nurse has received and understood the report before transferring care. If a Nurse has questions, no matter how ridiculous, and you don't answer them then that is patient abandonment.
Anna Flaxis, BSN, RN
1 Article; 2,816 Posts
I might have told a joke or two!