Hourly Rounding in an ER

[green34]

This is a bad idea in my book. First off, they want the PCTs/Nurse Extern/Unit Clerks/Phlebs/Paramedics do hourly roundings.

First off, the unit clerks should not be doing the hourly roundings unless they bring back the 2nd clerk in which case that clerk could do the hourly rounding easily. It is way too often that they try to get me to do something like draw blood when I am a unit clerk and the night doctor starts flipping out because they can't find me and they need to admit/call a doctor/whatever. 2nd, the nurses rarely answer the phones and instead will let it ring. 3rd, the nurses do not enter orders into the computers at the moment. After they switch to electronic charting, it'll be easier as the doctors enter their own orders and I can see having unit clerks round then.

PCTs are run ragged. They have to do EKGs, stock, transport patients, and clean rooms. On night shift, we really should have a 2nd pct/nurse extern/phlebotomist but we don't. RNs will not do EKGs most of the time. I can tell them "hey, so and so is upstairs with a patient, can you get your EKG" and they will wait for the PCT to come back.

Paramedics - Usually they are triage. They flip out when no one covers triage, but then they also want them to do stuff in the back. I went on lunch once and came back to find out they left 3 patients sitting out there the entire time I was on lunch. Seriously, we can't win. They tell us to stay in triage and then flip out we're not helping in the back. When we help in the back, someone falls/becomes violently ill/something bad happens and we get yelled at for not being up there.

Phlebotomists start the IVs for nurses, do ekgs, and run patients up to the floor. They are also run ragged.

The next biggest issue I have is we're minimum staff. If we were at the previous staffing levels before people quit/were injured/became very sick out of all the positions, we would be better off. However, we're not. Hourly rounding could be passed onto the nurse extern/pct or the 2nd clerk. However, they eliminated the PCT and the nurse externs only work weekends and we're down to one that works every third.

The next issue is that how long will an hourly round take? When we have 20 rooms full and you have 1 person doing the rounds, it can take more than the hour to get around. We have usually between 2-30 rooms/hall carts full. It seriously makes no sense. Not to mention it is supposed to help update people but the pct/phleb/unit clerk will not know exactly what that person is waiting for whether it is test results (usually), radiology, doctor needs to get time to do a pelvic, medication, whatever. Oh and it's also to check the level of pain.

Not to mention any of the patient that do decide to use the bathroom we then have to track down the RN to figure out whether the patient needs a bedpan/commode/allowed to walk down to the bathroom/sample/whatever.

I guess I really don't like the idea of hourly rounding being given to one person. It wouldn't be so bad if it was on even hours, an ancillary member does the odd number rooms and the RNs do even and switch it that way. Some facilities do it that way on the floors and it seems to work. I think it would work out a lot better that way if they divide up the hourly rounding because the RNs are not going to do the rounding at my facility (less than 5 will take up their patient when the pct is on a transport instead of waiting for the pct to take the patient up and instead will sit and talk).

I guess I am ragging on the RNs right now, but there are some things that is ridiculous. The entire dept right now has low morale because we're short staffed. The RNs just found out that they are going to every other weekend and will probably be furious for the next few months as about 1/3 of our staff is retiring, quitting, or leaving for the new hospital.

In itself it is not bad and should be done, but how they are presenting it to be run will be bad and lead to more problems.

[funtimes]

I dont work in an ER, and maybe I'm being naive, but wouldnt patients be checked on at least hourly anyway regardless of whether there is some sheet that has to be signed stating that? The only difference now is someone has to sign a sheet or chart that it was done.

This is done at night on all the inpatient units I've worked on, but its usually a responsibility shared between the RNs and the techs.

We had sheets on the doors that had to be initialed every hour. Of course inevitably you'll find some people who will often ignore the sheets until the end of the night, and then initial them at the end of the shift.

[dansamy]

I hate hourly rounding. Let's wake our patients up every hour all night & ask them if they need to pee!

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[turnforthenurse, MSN, NP]

I hate hourly rounding. Let's wake our patients up every hour all night & ask them if they need to pee!

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I don't wake them unless I have to. I make sure they are BREATHING and chart something along the lines of, "pt asleep, no distress noted at this time. call bell within reach."

[dansamy]

I don't wake them unless I have to. I make sure they are BREATHING and chart something along the lines of, "pt asleep, no distress noted at this time. call bell within reach."

Some people sleep so lightly that opening their door awakens them. I really hate hourly rounding.

(I don't work in the ER. I work on a peds/adult med/surg unit. I can usually do vital signs on a sleeping toddler, but usually the parent wakes up.)

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[hikernurse]

The thing is, as an RN, I have always checked on my patients all the time, one way or another. Charting that is the big time waster. When my elderly parents have been in the ER (generally for several hours), they've had someone come in hourly, introduce themselves, then they are never seen again. What's the point of that?

The only people rounding should be those with the ability to actually care for the patient, the nurse or tech. I think it's nuts to have ancillary staff rounding--not because you aren't valuable (!), but because you have other tasks that are necessary to do as well and having to spend time to hunt down a nurse/tech is a time-waster.

And just a thought, I certainly don't know your unit, but when I was a tech, I had no real idea of what the nurses actually did--even when I was in nursing school. I know there are times RNs can look like they are doing nothing, but they really are involved.

[MendedHeart]

Hourly rounding is evidence based. At my job, we share the responsibility with the CNA. We do it on the odds, they on the even. It works good.

[Best_Name_Ever]

Hourly rounding is evidence based. At my job we share the responsibility with the CNA. We do it on the odds, they on the even. It works good.[/quote']

We do the same at my facility.

[green34]

There are a lot of people addicted to their phones or shopping in my unit. More so on days than nights.

I think the biggest issue is cutting the staff down to a bare minimum and then throwing something like this on top of them. They've eliminated the 2nd shift unit clerk, 2 nights out of the week we do not have a patient care tech on nights, sometimes we do not have a paramedic or a person who can actually function as a paramedic, Saturday and Sunday we used to have a nurse extern and supposedly they are hiring more of them (one graduated last December, one finished in June, and one in December), and we have a full time phleb that is off due to injuries. This may change when we get our actual manager back and it may be why no one has been hired in the last six months to a year (they had an ANE position posted, but he ended up on medical leave before then).

Oh, we've lost at least four nurses due to health issues or quitting to go somewhere else they have not replaced. They are 2nd or 3rd shifts. Not to mention we have at least four leaving in October to go to a different new facility.

Hourly rounding is evidence based. At my job, we share the responsibility with the CNA. We do it on the odds, they on the even. It works good.

Is it a department on the floor or in the ER?

At the moment, I can almost guarantee they will not want to do the "even hours/odd hours" split even though I did suggest it because it'll put too much on the nurses. So they will send a unit clerk who is supposed to be putting in the admissions, calling the other doctors, entering orders, answering phones, tearing down charts, go round to 16+ rooms to help the patient to the bathroom and so on. Even with a tech, the tech is not that familiar with the patients as they will help sometimes but usually they are stocking or taking patients up to the floor.

Another thing that is slightly frustrating is that hourly rounding is good for the floor. It is excellent for the floor. However, when it is the ER, not so much. A pct can take notes on which patient needs a commode, bedpan, can ambulate. With the ER, some patients can be discharged so quickly. When the patient wants an update, you still have to go tell the nurse to go give them an update as the patient may be waiting for test results, imaging, lab work, ekg, etc. You still have to track down the nurse and find out who is NPO. Granted, 90% of the patients are NPO till close to discharge.

The theory is good, but I don't know if it is practical to apply it to the ER. Also, I do not know if they will take my suggestion of RNs and ancillary staff switching odds/evens into account. I don't think so.

Honestly, it would probably help if we had a PCT that could be dedicated to hourly rounding from 11 am to 11 pm. By the time the pct came back around, it would be time to start again most nights.

[MendedHeart]

This is on the floor, however, in our ER, the nurses have a.1:4 ratio and there is a floater. The nurses are required to do a q2 reassessments so tgey have to go in anyways every two hours, and then the techs are checking on them too. In my ER each end has a nurses station with the ED rooms surrounding so its easier to keep an eye on patients.

[green34]

Ours varies from one to four to one to six. Usually quickcare and night time it's one to six. The charge nurse in theory does not take patients but they do to help with ratios or move patients along.

Also, about a fourth of our ancillary staff is injured or they've quit. Same thing with nurses. Oh and another two or three are retiring before the end of the year on top of the ones leaving.

I do not know why they are not hiring people now before they have a skeleton crew. They will be bumping people off orientation early it seems. I don't know if it is because the manager is out on sick leave and the acting manager is more concerned about her facility (she's the one who will take over the new facility). The nurses that are leaving for the facility, their last day is in October. Orientation is twice a month. So pretty much we will have no nurses for nights or thirds and very few ancillary staff.

[Starfish714]

We also do hourly rounds (RN's even hours, PCT's odd hours) at our hospital, and it does help out with patients calling out/needing things, plus we know how they are doing at all times :). I only see this as a positive idea.