Holding patients in ER

Katnip, RN · Oct 2, 2004

We have the opposite policy. We are to chart each time we call and if they will not take report, it goes to our charge nurse. You can bet they don't refuse too often.

As a matter of fact, our bed control people came up with a new policy that if the receiving nurse truly cannot take report at the time because she's at lunch or in the middle of a procedure, the receiving charge nurse must take the report and be ready to take the patient within minutes of getting report.

When I worked IMCU at another hospital, it worked the same. We took report immediately.

It really does move patients faster, but I know the floor nurses are probably pulling out their hair.

If we aren't busy, and don't have 30 people in the waiting room and 5 ambulances and a fire truck at the door (our EMS uses firetrucks when all the ambulances are busy...like yesterday), we will try to hold a patient for 15 minutes for the floor nurse to prepare.

RN34TX · Oct 2, 2004

My Manager has told us we are "not to chart" when we have an unsuccessful attempt at calling report to the floor or ICU. We are a very small facility and have no nursing supervisor or even a charge nurse to intervene when the floor refuses to take report. We are especially vulnerable at change of shift. I have offered to participate on a committee to look into the causes and am still waiting for our first meeting after 2 months have gone by.
In the past, I have always charted 1. The time I called for the bed assignment 2. The time or Times I have attempted to call report & 3. The time I actually transfered the patient.
Anyone else out there had this problem? What do you put in the chardt?

Yes!!

I document every phone call attempt and refusal to take report and the times each incident occurred. I work ICU, not ER but it happens here as well.

I try to send stable patients to the Med/Surg floors and I often get the run around:

1. "The nurse taking that patient is at lunch."

2. "They are in report right now."

3. "The room's not clean yet." ---4 hours later!

I understand if the room isn't clean yet but I feel that they are jacking me around a lot of the times. And since when is it acceptable to say that the nurse is in report or at lunch?

If I'm at lunch, another nurse will take report for me. Change of shift, although inconvenient, is not a valid reason to not take report.

I get change of shift reports from the ER and Med/Surg floors all the time and that's just the way it goes. I never refuse to take report.

If I don't have an immediate need for the ICU bed, I even ask the receiving nurse if he/she is caught up or behind and if they need me to delay sending the patient to give them some time to get ready. I understand that sometimes it gets hectic and the last thing you need is another patient sent to you.

But a lot of times, we really need that ICU bed with a stable ready-to-go-to-the-floor patient still occupying it.

Sadly, I've had to get the supervisor involved a few times when I've waited 4 plus hours to give report and send a patient. There shouldn't be a need for that but there will always be some nurses who will try everything to get the least amount of work for themselves and put it on everyone else around them.

Tweety, BSN, RN · Oct 2, 2004

I don't work in the ER, but know as a supervisor, like the above we have the opposite policy, so we have some documentation later if there is a complaint from the ER or from patients or families.

We have a policy floors are not allowed to obstruct ER transfers. If no one is available for report, it's faxed, 30 minutes are allowed and the patient is brought up. Most of the ER nurses though are flexible and understanding if there are truly problems. Personally, I know I'm going to get an admission and stalling it benefits no one, even if it is shiftchange (which is not a myth at my facility, it's common).

Management is very keen on keeping the ER doors open, and floors and ICU "jacking around" is not accepted.

needsmore$ · Oct 3, 2004

my manager has told us we are "not to chart" when we have an unsuccessful attempt at calling report to the floor or icu. we are a very small facility and have no nursing supervisor or even a charge nurse to intervene when the floor refuses to take report. we are especially vulnerable at change of shift. i have offered to participate on a committee to look into the causes and am still waiting for our first meeting after 2 months have gone by.
in the past, i have always charted 1. the time i called for the bed assignment 2. the time or times i have attempted to call report & 3. the time i actually transfered the patient.
anyone else out there had this problem? what do you put in the chardt?

when we used to phone report- i always charted times called (attempted) and whether receiving unit was able to accept pt. this is because one of the #1 complaints by ed patients is the length of time they have to wait to be sent to the in-patient unit. i also charted when consultants/attending or admission doc was called to come see the patient and write admit orders (our ed physician group does not have admission priveledges as they feel their responsibility ends when the pt leaves the ed). when administration gets called by patients/ or their families about their complaints-at least they know through my charting that the ed is not to blame. (we seem to be blamed for everything else these days). now, we have a computerized bed tracking system. it works with the discharges and housekeeping. when we have an admission, we notify the "bed czar" as we call her, she assigns the room and we check the tracking system for availability ( clean and ready) we then fax report to the receiving unit, give them a courtesy call to let them know report was faxed and send the patient up. no more phone tag- it's working well for us, as the availability of the beds are documented by housekeeping and not by in-patient nurses.

anne

laurakoko · Oct 3, 2004

I TOTALLY agree with not holding up the ED. I have worked in almost every place in the hospital and I can understand each end. I have most of my experience (and 10+years) in med surg, and the taking of report from the ED. It is true, the nurses on the floors aren't usually available to take report right away, we're not just sitting around the nurses' station, making excuses not to call back. We usually are busting at the seams taking care of patients, and on the rare occasion eating, or peeing :chuckle. We have implemented a system at my hospital that is working, as well as promoting teamwork. If the ED, or any dept calls to give report, a nurse, (not always the charge nurse), will take the report, notify the nurse taking the patient, and greet the patient in the room. It takes a total of about 5 minutes, and settles a great deal of problems! Patients are usually happy, and ALL the nurses stay happy. Now the room not being clean......that is an issue of itself. I can call the service to clean the room, and ASAP, but it doesn't always happen, they are just as short staffed as we are!!! :)

mattsmom81 · Oct 3, 2004

Sadly this jacking around that occurs around transfers and ER admissions is usually due to a lack of teamwork on the units and everybody dumping work on someone else. It reflects an overworked burned out staff and I see it more and more in my agency travels.

There are times when I have truly been so bogged down in ICU, have several emergencies, have been playing 'musical beds' and trying to run a unit in spite of itself, and I have not had a minute to set up my room...which can be deadly for an unstable new admit. If people would work together, and truly help each other, things would run smoothly but more and more there is chaos and a dumping mentality out there. I am so appreciative of working with a helpful team when I find them today.

More and more ER's are holding patients and I am so appreciative of teamwork there too...I've had ER nurses ignore 2 pages of ICU admission orders to the patient's detriment, conversely I've had ER staff manage ALL the orders and even start the admission history/ asessment for me if they have time..I about kissed their feet!!!. It makes such a difference 'who' we work with in nursing doesn't it.

I try to understand other dept's perspectives and hope they will try to understand mine, as someone who does NOT jack around with transfers/admits.

jannecdote · Oct 3, 2004

These posts remind me of the days I worked hospital med/surg. I've seen nurses who were so overwhelmed they couldn't or didn't want to take report, ER waiting until change of shift to send someone up to dump it on the next shift, floor nurses who told housekeeping to take their time cleaning a room because they didn't want the patient and shift change was two hours away and they were going to try every ploy possible to postpone an admission, etc.

I remember being overwhelmed on some occasions, but usually I was so focused all day on getting done on time that I did, and I got to where I would just help the other nurses with their admits or do everything except the RN assessment. But ya know, trying to help backfired after a while because I started getting all the end of shift admissions. The charge nurse knew I was caught up and would not raise a stink about taking an admission. There is no such thing as one-sided teamwork. It's a good way to run off a good nurse.

I never griped about it back then, it's not my style , but I can see why these problems still exist.

As an agency nurse, I worked an ER holding area and I think it's a great idea. We admitted the patients, got the admit orders done, etc. It took a load off of ER and the floor nurses too. And most importantly, it was advantageous to the patients.

RNin92 · Oct 3, 2004

This is a problem that just will not die.

I have never understood the whole mentality of not taking report. Even when I worked in critical care...Isn't the JOB taking care of patients?

And in the ER, when we are pushing so hard to get our paitents up to the floors...isn't is just so we can bring in MORE patients to take care of?!!?

It would be so helpful if everyone's focus remained the patient and not the workload.

And in answer to the original post...

The only reason your managment dos NOT want you to document in the chart is because it may bring some lawsuit down if there is a bad outcome for a patient and it is related to the "holding" problem. But if you don't document SOMEWHERE you will have no backing in that lawsuit to show that you did all you could.

Rule #1-Protect thine own a$$ before protecting thine boss'

:rolleyes:

Tweety, BSN, RN · Oct 3, 2004

I have never understood the whole mentality of not taking report............
It would be so helpful if everyone's focus remained the patient and not the workload.

To help you understand, also realize that the nurse on the floor may have other patients that need tending to. In order to properly give the ER care when they arrive it might be helpful to tidy up some situations in the assignment first? Sometimes truly, honestly reallly really I can't drop what I'm doing and run to the phone and take report. Or sometimes honestly, truly I need 30 minutes to hang blood, pick someone up off the floor, send someone to the OR or to ICU. The point being you really don't know what's going on the other end. Granted a llittle teamwork on the end would be nice. But with the staffing and ratios on my unit, usually everyone else is just as crazy.

To me it's being very patient focused, both on the ones I already have and on the one's arriving, to ask the ER to wait a bit. But as I said before that option isn't given us anymore.

O.K. end of lecture. j/k

Sorry, but it would be nice to have some understanding on both ends. I've had the benefit of seeing all sides. And yes, I know the ER doesn't have the option when they are in the weeds and an ambulance arrives, I've heard that line too. :rotfl:

But I also agree. This is an issue that just won't die. Back to the original topic please. :rotfl:

Katnip, RN · Oct 4, 2004

I heard some of our bed control nurses and charges that we might make it policy not to transfer up to the floors during shift change. Not a bad idea, because if you're a floor nurse just coming on you really do need to get report on and at least eyeball the patients that are already there before worrying about what's coming up.

And Tweety is right. If you're up to your elbows in somebody's wound you can't run to the phone and take report. There are a lot of reasons to be stuck in the middle of something, and that's totally understandable.

RNin92 · Oct 4, 2004

No question about it...life can be just as busy on the floors as in the ER.

That is just not the point.

It isn't a "pi$$ing" contest to see who is busier...

It is a patient who needs the expertise of the inpatient nurse to manage and maintain their care.

When I was the charge nurse on the floor if my nurse was busy when the ER or OR or wherever called report, I took report and settled in the patient.

What do you do when a direct admit comes in? No one says hold the patient until I am not so busy.

The fact remains that a patient needs caring for...and there are many options to do so...it should not ALWAYS be keep the patient in the ER.

At our hospital we used to hold patients during shift change, too. Until it was recognized that shift change was at 0700, 1100, 1500, 1900,2300,0300, and 0700 again. You start to throw in lunches and dinner and "I need 30 more minutes" and the "good" time to transport a patient is non-existent.

We know only "hold" the patient between 0700-0730 and 1900-1930. We call report during those times we just don't actually transport until the magic 0730 and 1930.

Of course we still have all the other issues...