Hey ER, what takes so long???

ritarunningfeet · Feb 7, 2007

What is your hospital policy on who writes the admission orders? Because the small er I work in the er physician writes the admitting orders and then the accepting dr has to see the pt within 24 hours to write more orders. This works quite well as far as speed in getting to pt out of the er and to the floor. However, the large hospital I work in, the accepting physician has to write the orders. Sometimes they will give the orders over the phone which I like because then you can request your bed right away. However some to the drs let the in house residents write the orders, and that is slow as molassas in january. Ex. Last night they called the residents for admission before 10pm, and they said they would come and write orders, I called them at 1 am as they hadn't showed up yet, and was told they had 5 pts to admit, FINALLY at 4 am...6hrs after being accepted by the admitting dr. The orders were written and we could request a bed. So you see it may or may not be the ER that is being slow, sometimes it depends on who is giving the admitting orders. But it probably depends on who writes your orders?

Trauma Columnist · Feb 7, 2007

Hi there. Okay, there are good reasons:

1. In order to admit, the admitting MD must be contacted. They don't always return calls quickly.

2. Even though census is down, are the beds clean and staffed?

3. May take awhile to see if pt needs admit or not. This one sounds iffy at best. Maybe ER tried to send back to NH but they refused?

4. Labs sometimes do take awhile. They can be drawn 5 hours ago but if it takes 2-3 hours to get results, that can be delay.

5. If pt is not emergent and sounds like this one wasn't, yes she may sit while other, more ill patients are dealt with first.

Hope this helps.

DOBOY · Feb 7, 2007

i don’t know about your er but i can give you a quick break down of what happened labs take any where from 45 to 90 minutes, then the er physician has to see the pt or at least view the chart 30 minutes, the pt’s dr. is paged, wait for them to call back, and then wait for them to come in, 30 to 60 minutes, the dr. then usually talks with the pt, writes orders, dictates orders, and then leaves the chart in dictation for the nurse to have to find later 60 to 90 minutes easily. this is all based on you having no other pt’s being admitted, your er dr. is on the ball, and no critical pt’s come in. i have found though the biggest problem is getting the private dr.s to do their jobs and quickly.

Jen2 · Feb 7, 2007

There are several threads where this issue has been brought up. I cannot speak for your particular hospital, but I will tell you what goes on in our hospital.

Scenerio 1. Patient comes in with post op-complications. They need to be seen by the ER physician since the surgeons do not magically live in our department. Before we are able to consult the surgical service, there is a workup we must do since calling the service and simply saying that the wound is red will not warrant a visit. So we work the patient up call the hopefully admitting service with the results and wait and wait and wait. We wait until they are out of surgery, done doing rounds etc. etc.. Once we consult on a patient it sometimes takes that particular service up to 2-3 hours to come and see the patient. The service finally comes and sees the patient and decides to admit them. The ER physician cannot admit a patient. There must be an accepting service.

Scenerio 2. Patient comes in as a stroke page and neurology is at bedside evaluating the patient. We start workup and everything comes back to be "stable" from a neurology standpoint. Therefore neurology will not admit the patient to their service. The patient still needs to be admitted so the ER must then consult medicine to see if they will admit the patient. Well before the medicine team will come and see the patient, they want urine results. We get the urine results and wait and wait. Medicine then finally comes and sees the patient. Medicine does there eval and decides to admit the patient. Admission cards get put in and we wait for the H.O. to call us and give us a bed.

Scenerio 3. Trauma comes in and is scalped because their head went through the windsheild and a tib-fib fx that needs to be reduced. Admission cards get put in right away by the trauma service and we get a bed right away. However, before we can take them upstairs trauma needs to staple the head lac, we have to wait for plastics to come and suture the face, and have to wait for ortho to reduce the fracture. Can't just send the patient upstairs with a bleeding head wound and an unstable fracture with possible vascular compromise. All of these things takes time.

Scenerio 4. Have a very stable patient call report and start packing the patient up to bring them upstairs. Charge nurse comes in the room and tells you to hold on, EMS is at the door with a cardiac arrest. Work the cardiac arrest and then take the stable patient upstairs.

Try and notice what time rounds are done in your hospital. It seems as if in our hospital rounds are done by the services before noon. However, discharges are not made until later in the day. If a patient is not discharged until 5:00 in the afternoon, then this will put a patient being put in that bed at the floors shift change. Sometimes we get into a war with different services where no one wants to admit the patient to their service or the patient has multiple complaints and several differnet services needs to see the patient. I have also noticed that in my hospital a few of the nurses on the floor will have discharge orders for a patient and sit on them for as long as they can to avoid getting a new patient. Often times we are given a bed number while there is still a patient in that room upstairs, and if that patient gets discharged at 6:00pm there will be an ER patient in it as soon as it is clean. Usually right at shift change. I understand that not all nurses on the floor do this and it is not done intentional, when you have 6 medicine patients and are teamed with an LPN that has 6 patients, discharges are the furthest thing in your mind.

Don't know if I explained a little to you or not, but that is what this board is for, so that we can learn and try to understand each other better.

nuangel1, BSN, RN · Feb 8, 2007

Hi there. Okay, there are good reasons:
1. In order to admit, the admitting MD must be contacted. They don't always return calls quickly.
2. Even though census is down, are the beds clean and staffed?
3. May take awhile to see if pt needs admit or not. This one sounds iffy at best. Maybe ER tried to send back to NH but they refused?
4. Labs sometimes do take awhile. They can be drawn 5 hours ago but if it takes 2-3 hours to get results, that can be delay.
5. If pt is not emergent and sounds like this one wasn't, yes she may sit while other, more ill patients are dealt with first.
Hope this helps.

excellent explanation and very true.in our er we can't get a bed till pt has admitting md the drs don't always call back or the oc dr may refuse pt for some reason then we need to find another admit. dr .also just because bed is assigned doesnot mean when we call or fax report the bed is ready .and pt can go up.sometimes its the floors that has the prob;em staff or nurse is busy or a code etc its not only the ed.

neneRN, BSN, RN · Feb 8, 2007

And the list goes on and on, and that's why every ER in the country has the same problems!

The one that kills me is when I've finally gotten a bed upstairs for the patient after 8 hours in the ER and called report, the admitting MD all of a sudden shows up out of nowhere and wants to examine the pt and write orders before they go upstairs....an hour later you get the chart back and can send the pt.... unless they examine the pt and find one more test that HAS to be done BEFORE the pt goes upstairs, like an abd CT with 3 hours of drinking contrast.

What time the labs are drawn in the ER isn't always a good indicator of the timeline...yeah, the labs may have been drawn 5 hours ago, but the ER doc may have just seen the pt 1-2 hours ago. The nurse will do labs, EKG, etc. before the doc sees the patient. Say I draw my labs at 2:00, and the patient is seen at 4:30...okay the lab results that I triaged are on the chart, but any other labs I may not have read the doc's mind on are just getting added on, so add another 1-1 1/2 hours for those results.....

Our docs take a long time to dispo pts, I may give the doc a chart with everything complete, ready for dispo...then I don't see the chart until 3-4-5 hours later when they've finally admitted the patient. Depends on the doc, they may call each admitting doc one at a time, or if they know they have 3-4 pts they're presenting to the same doc, then they may wait until ALL of those 3-4 charts are complete so they can make one phone call and do it all at once. If those 3-4 pts all came in within an hour or two of each other, its gonna add on time to wait until all of those charts are complete. Sometimes admitting docs don't call back; its not rare that I have to track down an admitting doc that the ER doc has been paging for over 2 hours. Sometimes you'll finally track down the admitting doc, and you'll get, "I've never seen that pt, its not one of mine" or "I haven't seen that pt in 3 years, he's not mine"...so then the ED doc starts the paging game all over again or has to admit it to whoever's on service call. Service call doc tries to turf any pt he can because service call doc for the day has to admit all pts without private docs, and this includes a lot of uninsured, indigent, homeless, etc., so they're NEVER happy....and on and on- my point is, a lot goes on that is COMPLETELY not nursing related and completely beyond nursing control that you just don't know about....

UKRNinUSA, RN · Feb 8, 2007

if only we could whip these docs into shape!

when I rule the world.............................

RunningWithScissors · Feb 8, 2007

I have found though the biggest problem is getting the private Dr.s to do their jobs and quickly.

OK, now I see where the problem lies; I sure do know how long it takes for these boneheads to answer a page (esp. if they are on unassigned call, I'll bet!)

Thanks for the replies.........still would like to know why there is predictably one or 2 admits every nite in the magic change-of-shift window..............

neneRN, BSN, RN · Feb 8, 2007

I'd like to know too, and I'm in ER! Our admissions coordinator always passes out a handful of beds a half hour before shift change...she's not a nurse, so she doesn't care/doesn't have any reason to hold them....the ER nurses hate it...the floor nurses hate it...ER nurses think somehow the floor nurse has made it happen....Floor nurses think somehow the ER nurse did it....who knows?

LeesieBug · Feb 8, 2007

I guess I never understand the question of "why do patients get sent up at shift change?". ..That is just when they are ready. The ER personell are not twiddling their thumbs waiting 'till shift change. And once the pt is ready, we aren't allowed to sit on them because its shift change...we are supposed to get them up ASAP.

Pt care and the work needed to be completed in order to get them going generally does not fall into a nice clean schedule. Just as I am sure pt care on the floor does not always fit into a nice clean, tidy schedule....stuff happens.

If it makes you feel better, I get new pts at shift change everyday;)

Seriously,though, thanks for putting up with shift-change admits. I know it must be frustrating

EmerNurse, BSN, RN · Feb 8, 2007

One thing about the shift-change thing... I work nights and long about 5am, our ER docs start hollaring for admitting doc call-outs. The reason? The next ER doc comes on at 7am, and they don't want to hand-off too many patients to the next doc. Same thing happens around 1700 for the 7pm doc coming on.

The on-coming docs don't want to be responsible for the "almost admitted" patients. So the off-going doc wants them out of the ER, or at LEAST admitted (as in, we can't send them up yet because it's 0630 (can't send between 0630 and 0730 technically) but because they're admitted, they're off of the ER doc's list.

That's one reason for the close-to-shift-change admits. It drives ER nurses just as crazy. Here I am winding up my shift, and suddenly I'm taking admitting orders on 3 of my patients at 0645. And most of the time, at least one of them will be a NH patient with 45 meds and they'll all be diabetic. I have to transcribe all those orders before I can go - so much for getting out on time. And then on the floor, that patient is sent up when they've barely gotten report on thier other 7 patients!

It's a horrible bit of gripe for ALL of us!