How do you handle patients "holding" in your ED?

Trauma Columnist · Jan 18, 2004

I work in downstate Illinois at a level one trauma center - 31 beds, 62K visits/year and lately the holding is getting ridiculous! Up to 20 hours sometimes. We too are facing the same difficulties - no extra help and way too many patients. If you find a solution, please share it with us!

RN~in~CT · Jan 18, 2004

I can certainly relate, but let me give this a different spin from a floor nurse's perspective. The problem our hospital has been having is we are full to capacity ~ I work on a general surgery floor, and we are taking medical overflows....our surgical overflows have been turp'd to other floors, etc. The ER and PACU have been "holding" pts simply because we have no beds for them. As soon as we get a discharge housekeeping cleans the room STAT, then one lucky pt gets a bed.

Problem is simply ~ too many pts...not enough beds...not enough staff.

RNin92 · Jan 18, 2004

RN~IN~CT:

Thanks for the response!

I worked the floors before I went to ER. I was on Tele/ICU.

I know that the problem is not just the floors. Our Med/Surg units actually are great!! They call right away to clean rooms and always take pts even if they are short-staffed.

Our ICU however is another story!!

There have been many days when we are holding 10-15 patients and the ICU does HAVE empty beds but their staffing is such that they only take 2 patients each. Period. End of story. No negotiating. That is part of the frustration.

But we have many, MANY issues that compund the obvious problems of too many patients.

We have docs who round and then discharge in the late afternoon.

We have an OR director who NEVER cancels elective surgeries no matter how many patients are holding in the ED and in the PACU.

It is a nightmare that has become a daily occurance and we are just so darn frustrated. And I am worried that it will take a death of a patient to cause any real change. As a nurse it is difficult to accept.

MAGIK GIRL · Jan 18, 2004

i worked in a hospital that could "cap of beds" because of staffing. one night, we had 20 boarders. THIS WAS A 34 BED ER!

who thought of that bright idea? i can understand their staffing issues but they refused to utilize agency nurses. the er was always staffed so we got stuck.

i also worked at a trauma center which had 60+ beds. had obs, emergent, peds er, etc. there were many times we had holds there also.

now i work in small community hospital in the er and we still get boarders!

i don't think there is an answer but i find it truley amazing that when a different shift comes in, suddenly there are beds available. i have also been in charge and told by the supervisor that there are no beds available. this was according to the computer. well, we sent some of our staff to do a "recon" and found about 4-5 empty beds on various floors. we called the sup and these beds were pts that were discharged many hours earlier in the day. the floors had "forgotten" to remove the pts names from the computer to free up the rooms!

i have come to the conclusion that you just have to go in and work your 12 and then come home. there is really nothing that can be done except renovation and more beds!

have a good one!

mg:D

RNin92 · Jan 19, 2004

Hey thanks for the reponse!

I just wonder how you get to the point in your nursing career that it's "ok" to "hide" beds and keep a patient in a noisy and cramped ER on a cart designed for a twelve year old!!!

Man...retire me before then!!!

I'll take the drunks and the crazies every day of the week as long as my ER teammates ae there with me!!

NeuroICURN · Jan 19, 2004

Ok, we got a floor nurse's opinion, now here's one from an ICU nurse's perspective! :)

I work in a major, inner city, Level 1 Trauma Center (that serves 5 states) and I work in one of the seven ICUs.

I can sympathize with the EDs dilemma here. Just recently, our hospital was SO busy, that there were pt's waiting to get into our ICU for 3 days in the ED and 2 days in the recovery room!!! Now is that crazy or what??? :eek:

The reason that we NEVER go above 2 in our ICU is because trust me, these people are usually SO VERY sick, that it would be impossible! Let me tell you, it can be too much to have those 2 pt's at times!!! ICU nurse's can back me up when I say I hate being the nurse that is double assigned, then one starts to go bad and you're so busy you can't see straight...but because that person is so sick, he/she will be a single assignment on the next shift! UGH!!! Just the other day I had someone that was so sick, that I didn't see my other pt. until noon! Thank goodness for a good staff that can help out when they see you're drowning and for the fact that she was mildly stable for that moment in time!

Also, there are many times when even the charge nurse is double assigned, so if you need a hand, you better hope that there's another nurse nearby that can either help you or pick up your other pt. for a while! So, in a way, there are times when you do have more than your two pts!

But once again, I do appreciate what our ED does. I know that these people didn't "magically" get that sick just because they came through our doors! Someone had to keep them alive before I got my hands on them!

Obviously your hospital has some serious staffing issues, but so do we all! Here's hoping that someday it will get better!

:kiss

ERNUTBALL · Jan 19, 2004

Originally posted by RNin92
Hey...

Just wondering how other EDs handle patients "holding" or "boarding" in their EDs.

In our ED we deal with holds rather simply, we get a hospital bed, put them in it, try to find a portable TV with some movies, get them a drink and hope they sleep well. We have the same issues as everyone else and no, we have not come up with some ingenious way of solving the problem. We have 16 beds in our ED and one night several weeks ago I came in at 1900 to find 12 holds. Our shift supervisors all do a great job getting us help when it is available, but when there is no one to call in, we are on our own. In addition, our Dept. Manager does not believe in going on any kind of divert without some direct intervention from God. I have seen our ER RN's having 2-3 holds plus a full load of regular ER patients.

RainbowSkye · Jan 19, 2004

I understand being busy and taking care of too many patients; I've been working in ER for twenty-five years.

However...if the ICU nurse is too busy to care for more than two patients (and I know that is the case), how the heck can anyone expect an ER nurse to care for those very same critically ill patients along with the regular ER case load?

We do the best we can.

athomas91 · Jan 19, 2004

i worked at a hospital that has found some remedy.... it was agreed upon by a committee consisting of someone from everywhere....that because the ED could not close and had to hold pt's in hallways etc...that there was no reason the floors couldn't do the same....so basically every third hold would be sent to the floor to be held somewhere up there...

ex: ER 2 holds, third hold upstairs, ER another 2 holds, third hold upstairs...

it worked well - you wouldn't believe how many beds they "found" when called w/ a hold....:roll

RNin92 · Jan 19, 2004

At least we are all sinking together I suppose!!

We are working on a lot of problems...some going better than others. And we do have a manager that will allow us to go on bypass (or diversion). But that's really not the answer either. Who hasn't had a OD dropped at the back door or a full arrest roll up in someone's van?!!?

I think athomas91 has the right idea...

Why is the ED hallway special?

At least on the floors the nurses who are trained in those areas are taking care of the patient.

And...the "backup" in those areas are other nurses with the smae training and competency.

Plus...I am not surprised about the "mystery beds" showing up.

Sad isn't it...

I know how busy and insane it gets in the ICU...but we are in a crisis everyday and sometimes you have to pick between 2 bad choices.

Better in the ICU with one nurse "tripling up" with the backup of other ICU nurses than being cared for in the ED with other ER nurses trying to help. We are trained for the acute phase NOT maintainance. Plus we are taking care of the ICU hold and a few telemetry holds AND our ER patients.

If the patient were YOUR loved one...which would you choose?

mercRN · Jan 19, 2004

One night before I went to night shift we had a bunch of admissions, not only for tele but for medical. We ended up, since the pt's were stable, moving as many as possible to the back block so it was quieter and then that nurse got to play m/s nurse. it is easier for one nurse to try and take care of a bunch of admissions and not have to worry about taking care of sore throats and ear aches. We still have to chart on these pt's every 45 minutes even if they are a direct admit. If we have a pt being admitted as an "medical observation" we will sometimes if we can admit them on our pediatric floor if they have room. They don't care for it but they deal with it.