How can we make the process of report from ER to floor better?

NurseOnAMotorcycle, ASN, RN · Oct 24, 2012

There is a never ending war between the ER and the floors. The floors hate us because we give them higher census, they hate doing admissions, they hate that we bring them during meals, med times, shift change, whatever.

They don't care that we are taking care of 3 critical patients and 2 demanding ones because they are already taking care of 6 themselves. They want us to dump the patient to a different floor and start a whole new argument all over again because they don't feel like taking another patient.

I've been a floor nurse who argued about having to take a patient. We had endless excuses and reasons prepared in advance JUST IN CASE admitting tried to send us a patient. Now I'm a emergency room nurse trying to keep new onset afib's who had to wait a WHOLE 15 MINUTES from dying in our waiting room while their stable co-patients are drinking/laughing/waiting for an in-house bed.

No good answer. Face to face, over the phone, or SBARR... our reports will always be seen as inadequate, our care will always be seen as not enough by the floor nurses. Would be nice if they shadowed in the E.D. once in a while to see our side of things.

happyinillinois · Oct 24, 2012

Level of care assignments are made by the ER MD in conjunction with a Case Manager. Criteria has to be met in order to move to a higher level. Sometimes the only bed available is what they are gonna get. A voice report from the staff ER nurse to a staff floor nurse isn't going to change the level of care.

happyinillinois · Oct 24, 2012

What are we supposed to do with the patient (s)? You don't understand, someone who is ready to go up has been pulled from the room and is waiting in the hallway. We now have a new patient in that spot. Our rooms are full. Charge is screaming get them to the floor. Multiply this by several nurses and you can see the problem. We have shift change too. All the while patients keep rolling in by ambulance and walk ins. You can't turn them away. Sometime take your lunch and walk down to the ER. Notice the chaos and volumes of patients. You will see why they need to go up ASAP, so the next in line can take their place.

Barley · Oct 24, 2012

"Face to face, over the phone, or SBARR... our reports will always be seen as inadequate, our care will always be seen as not enough by the floor nurses. "

I disagree. On our medicine floor, we'd be elated if we could do face-to-face, over the phone or SBAR. Our system typically consists of the ED nurse calling to verify we "received report" in the form of a faxed 10-15page "summary" of care delivered in the ED. The typical, honest response is "no, I haven't received it yet" because they call immediately after sending the fax, and we haven't had time to even pick the papers up, let alone read through the 10-15pages, trying to sort out what is and what is not relevant. It would be so much easier and effective to get some sort of verbal report, receive the ED nurse's recommendations for priority care areas (which are not included in the faxed report) and have the opportunity to ask them questions.

We do verbal phone reports for transfers between other floors, and I don't understand why things are different with the ED.

pattyweb · Oct 24, 2012

Hey, I was wondering how your facilities give report to the floors/ICU/CCU. Currently our process isn't working and we are getting a lot of inappropriate admits to our med/surg floors. I have had a ton of rapid responses where the pt ends up in stepdown ICU/CCU, ICU/CCU, or life flighted out or transferred by EMS to our larger sister hospital. Currently the report process is that the floor staff is to look up in the computer and be able to "read " the ER charting. However that is totally incomplete, the chart isn't updated so floor RN's can see VS, etc until after the pt is admitted on the unit. There is no opportunity to ask questions. They get a call from transport saying the pt is coming and then the pt is in the unit 15-30 minutes later. Our charting is in two seperate systems. ER uses one system and the floors use a different system to look at labs, and test results. What is your report process?

Do you work at my facility?? No, to be honest we went from verbal report to a printable or electronic chart accessible report several yrs ago. I hate it. I can, however, read the ED nurse's charting at anytime from when the pt is assigned until whenever, and do frequently call the ED if they do not seem stable enough for my med surg floor and I don't see any charting to reflect a plan of care (for example hypertensive pts that I would end up calling a rapid on). The ED nurse pages our charge prior to transfer, and we know we have about ten minutes before the pt arrives, giving us a little warning, and sometimes reminding us to look at charting once again. Still not perfect, but the verbal report never was either.

Runner1989 · Oct 24, 2012

Level of care is determined by hospitalist and ED attending. My report whether verbal or EMR review will not change pt level of care. We do EMR reviews and call once the floor has had 20 minutes to view the chart, we ask if they have questions and they go up. We only accompany a pt to the ICU as RN's. our techs take our med surg and step down pts up. This works well for us. I mean there is always going to be room for improvement, we are human. However, this is a level one trauma and it is so busy sometimes we are trying to get people upstairs or wherever they need to go because we have many more rolling in through the ambulance bay or from triage. I don't think you will understand until you see the chaos first hand.

FlsunshineRN · Oct 24, 2012

I completely agree sserrn! We dont have a protected "shift change" anymore because we are so overloaded with pts and shift change on the floor can last up to an hour.

nrsang97, BSN, RN · Oct 24, 2012

Our problem isn't that NO ONE will take report ( well it could possibly be since I am RRT and not a floor nurse or ICU nurse). It is virually NOT getting report. I want to make the report process better. Esme is on track with what I am speaking of.

There isn't an opportunity to ask questions. There isn't a way to see the complete chart (including most recent VS), etc. ER states that they sign out the chart but the floor still can't see it. (IT is looking into that)

I did like the idea of SBAR forms and a call back number for questions. I worked at a facility that did that yeas ago and it worked. I had the opportunity to call and ask if that K of 3 was treated or did I need to get orders with admission.

I do not want this being a war with ER vs ICU vs ER vs Floor. I just want to improve communication between the staff.

I know that the ER is completely different than the floor or ICU. For safety report has to be better. Too many transfers to ICU/CCU or stepdown from the floor. Our bed managers aren't nurses either. I believe that will change soon.

I have tried to read the ER charting and it is all over the place with its format and so frustrating to read if you don't work with it all the time.

nrsang97, BSN, RN · Oct 24, 2012

Level of care is determined by hospitalist and ED attending. My report whether verbal or EMR review will not change pt level of care. We do EMR reviews and call once the floor has had 20 minutes to view the chart, we ask if they have questions and they go up. We only accompany a pt to the ICU as RN's. our techs take our med surg and step down pts up. This works well for us. I mean there is always going to be room for improvement, we are human. However, this is a level one trauma and it is so busy sometimes we are trying to get people upstairs or wherever they need to go because we have many more rolling in through the ambulance bay or from triage. I don't think you will understand until you see the chaos first hand.

I understand it is a whole different world down there. I am not saying your shift isn't chaotic, but I just want better communication. There isn't even a call to see if they can gt the chart and ask questions. My concern is communication.

TheQueenBee · Oct 24, 2012

First I must say that in my facility we do no yet have computer charting. We call the admissions department with the floor selected by the admitting physician, pt name/DOB, admission diagnosis and any other pertinent information (hard of hearing, isolation precautions fall risk). They they call the desired floor to get a bed. The Telemetry floor and the ICU can see our cardiac monitors but otherwise know nothing about the patient.

Once we have received a bed assignment we fill out what is called a SHARQ (I can't remember what it means right off the top of my head). The SHARQ starts out stating why the patient presented to the ER, the admitting diagnosis the admitting/attending physician, check boxes for past medical history smoking/alcohol use. A section for meds, labs, radiology findings, and the most current set of vitals.

This form is then faxed to the floor receiving the patient The u]purpose is to cut down on phone calls and to help speed up the admission process. So far most everyone agrees they are quick easy to use and do help get the patient to the floor in a timely manner. For patients that are going to the ICU we still give a verbal report.

ecerrn · Oct 24, 2012

In my perfect world, the admitting doctor chooses the appropriate floor for admission, and the nurse does not get blamed when they say...we don't take heparin drips on this floor....adding another two hours to the patients stay in the er. In my perfect world, when the floor is notified of the admission, the nurse drops what she is doing and calls me for report....I will drop what I'm doing to give report. Once we both agree this is the right patient and the right floor, I will give a basice report and take the patient to that floor, then I will have a face to face with the patients nurse to fill her/him in any extra little particulars that may or may not come in handy during the patient stay....especially those things I don't want to discuss over the phone where there is ample opportunity for any one to eavesdrop. I don't believe the entire process running amok is solely on the shoulders of nursing....I think it is a system wide failure that has never really been addressed fully by administration....we're always functioning around a faulty system. Otherwise why do so many have the exact same complaints?

Esme12, ASN, BSN, RN · Oct 24, 2012

Our problem isn't that NO ONE will take report ( well it could possibly be since I am RRT and not a floor nurse or ICU nurse). It is virually NOT getting report. I want to make the report process better. Esme is on track with what I am speaking of.
There isn't an opportunity to ask questions. There isn't a way to see the complete chart (including most recent VS), etc. ER states that they sign out the chart but the floor still can't see it. (IT is looking into that)
I did like the idea of SBAR forms and a call back number for questions. I worked at a facility that did that yeas ago and it worked. I had the opportunity to call and ask if that K of 3 was treated or did I need to get orders with admission.
I do not want this being a war with ER vs ICU vs ER vs Floor. I just want to improve communication between the staff.
I know that the ER is completely different than the floor or ICU. For safety report has to be better. Too many transfers to ICU/CCU or stepdown from the floor. Our bed managers aren't nurses either. I believe that will change soon.
I have tried to read the ER charting and it is all over the place with its format and so frustrating to read if you don't work with it all the time.

The whole focus of your thread has just been answered.......

Our bed managers aren't nurses either.