How does your hospital book beds?

[mappers]

One of these days, I'm going to ask someone at my place who is "in the know". This is a common frustration on our floor.

It often seems like we will go all day without a single admission and have open, clean beds. Then after 3:00 pm we will suddenlty get 3 -4 bookings at a time. Then ER will bring them all up at the same time...right around 6:00 when we are getting ready for shift change at 7:00.

Our hospital has what is called "bed huddle" which is when all the charge nurses for the day get together to discuss staffing. They meet at 12:45 for 3:00 pm, 4:45 for 7:00 pm, etc. We post our census, what we "earn" and what we have. Our hospital system has a system wide in house "agency" so we list what agency nurses are available. Then the blood bath....er discussions begin on who gets pulled where, etc.

It always seems like this influx of new bookings happens after bed huddle which is frustrating. So at 12:45, we earn 4 nurses based on our census and our 5th nurse gets floated to another floor. Then we get 5 bookings and now we earn that 5th nurse...but it's too late and we have to suck it up for four or eight hours (depending on the time). You know those people have been in the ER for several hours. Really? You didn't know they were coming to the floor 20 minutes ago? (And I don't know who the "You" is in that question, ER, House Supervisor, I just don't know.)

One day, we had open beds all day. It was really slow. Then we got 3 in a row. The ER transporter brought them all up back to back. We complained a little, and he starts saying "They're really swamped down there it's going to get worse!" We say, "Why didn't you bring them up sooner then! We've been ready all day!" We found out the patients had been in the ER since early that morning.

We have an Admission Nurse who works out of the ER. She will go to the floors to help admit patients on busy days. She is worth her weight in gold, let me tell you. She came up that day because she'd already started the admission on one of the new patients and was finishing it up. I asked her and she said ER had been waiting on bedbooking all day, that it isn't ER's fault.

So I'm assuming it goes something like this (I've never worked in ER, so I'm guessing). ER doc decides to admit a patient. Nurse calls bed booking saying we need a tele bed or M/S bed, etc. Bed booking looks at their giant board of all the beds, picks a unit and calls them. We take the admission, let them know if the room is clean, etc.) They call ER back and let them know the room. Now there is some type of process that goes on with admitting, getting them into the computer as an inpatient and I really don't know how that works. Then patient is brought up.

But it seems to take HOURS to do this. And why the feast or famine? AND we have a sister unit that is similar in acuity as us. Telemetry M/S, they focus on strokes, we focus on cancer, but we get everything. It seems like they'll get 10 admissions one day and we get 3 or vice versa when our censuses (censii??) are similar.

I'm not blaming ER. I know it is busy and if you have a critical patient that you're trying to stabilize and get to the cath lab or the unit, you are not going to focus on getting that stable COPD patient to my floor. I get that.

I really want to know from the perspective of someone who has been there and done that. I believe that when I get frustrated with a process I usually need to learn more about the process to understand why things are happening the way they are.

[GM2RN]

Your frustration is shared my many other nurses at other hospitals. I work in the ED in one hospital, and it's actually my job at another hospital to "book" the beds, so I will share my experiences as soon as I'm able. For now, I need to sleep...gotta be up and ready for work in a couple of hours.

:)

[mappers]

Thanks! I really would appreciate learning "the other side" so as not to be so frustrated. Have a good day at work!

[nursej22, MSN, RN]

This is a long-standing issue, and only seems to be getting worse, I think because of the high ED census. You have a couple of systems/processes at odds with each other and the higher ups with the power to change things don't see the issue.

ED docs traditionally do their dispos at the end of their shifts, which for us is an hour and a half after we have set staffing. We have tried several things to move pts out of ED earlier like transitional orders, written report, and an electronic Bed Manager program. We still get 3 to 4 admits right at 7 pm.

Our manager has given us to okay to slightly overstaff, that is we always have enough staff to take at least 3 admits at 7am, 3pm, 7pm, and 11 pm. If we are still overstaffed at midshift, there is always a volunteer to leave early. This seems to work much better that staffing strictly by the floor census and our manager says we are always under budget.

A couple of years ago the hospital tried to adjust staffing every 4 hours but that was a miserable failure. It seemed like we were always in crisis mode and breaks were missed. When management had to pay overtime for missed breaks and people staying late to chart, they loosened up a little.

[LoveMyBugs, BSN, CNA, RN]

Just know from the ER side that we don't plan on bringing them all up at once, we want to get them up to the floor as soon as we can. A lot of on the ER end is waiting to transport as soon as the MD says he is ready.

Say we get a pt in and as soon as he has assessed the pt the MD decides he is going to admit, he then orders a ton of stuff.

So we get started on getting a room

Then doc needs to confirm the addmission with the pts PCP or get the hospitalist to agree to admit

Then there is more waiting for test results

I have seen a pt go from a medical bed to a telly bed to based on labs go to a ICU bed, then get changed back to a medical bed again, all before the MD is ready for the transport

It is never on purpose to bring patients up to rooms close to shift change

[canoehead, BSN, RN]

It's a combination of problems. The ER docs always have someone they're observing and decide to admit at the end of their shift. The docs in offices arrive after office hours to write admission orders. Perhaps the people on the bed board are waiting for the last minute so they can juggle patients to result in a maximum number of patients distributed into the beds/resources available.

[mappers]

I'm seeing some terminology and processes that I'm not familiar with, so I'm going to ask for some clarification...

"ED docs traditionally do their dispos at the end of their shifts, which for us is an hour and a half after we have set staffing."

What's a dispo? I'm assuming it is like a discharge except from the ED to inpatient??

So what I think I'm reading based on the past few posts (canoehead, lovemybugs, nursej22) is that doctors wait until the end of their shift to send patients to the floor? Is their shift the same as nursing (ie 7a - 7p?)

And we frequently have patients who come from the ER without orders and we have to call the primary or hospitalist for orders. Does this not happen everywhere?

I guess I don't really know how a patient gets from ED to Floor. This is the kind of stuff I sometimes wish they'd teach us in orientation. How does a hospital actually work? All the moving parts. They don't teach that in nursing school. After two years, I'm slowly starting to figure it out. I think a lot of the b*tching that goes on between floors and units would lesson if people really knew how all the various parts worked.

[SonorityGenius]

After reading your post very carefully, it seems that the ER is doing appropriate by booking them and waiting for the beds; you are doing everything ok by giving beds whenever booking calls.

The answer is in the middlemen; the Admitting/Bed Booking that is SLOW AS MOLASSES at your place!

[HamsterRN, ADN, RN]

This is also an issue at our hospital and it is mainly due to the work schedules of the ED docs. They tend procrastinate on writing admit orders until they've got about an hours left in their shift, then they suddenly write put out a small stack of admit orders, resulting in the sudden influx. We bought a computerized "bed manager" program that was supposed to help fix the problem, but it doesn't remind the docs to write orders any earlier.

[mappers]

I think I see one vote ER Docs fault, one vote...just the nature of the ED process, and one vote bed-booking. I don't think I ever would has thought about the ER docs being the hold up. Learn something new every day.

[Fribblet]

This is also an issue at our hospital and it is mainly due to the work schedules of the ED docs. They tend procrastinate on writing admit orders until they've got about an hours left in their shift, then they suddenly write put out a small stack of admit orders, resulting in the sudden influx. We bought a computerized "bed manager" program that was supposed to help fix the problem, but it doesn't remind the docs to write orders any earlier.

ER docs do not write admission orders.

[HamsterRN, ADN, RN]

ER docs do not write admission orders.

Our do, occasionally the admitting doc will see them in the ED prior to transfer, but typically our admission ordersets are filled out by the ER docs and signed by them. Do you guys not transfer a patient to a floor until the admitting doc has seen the patient and written orders? That would be a dream come true for us.

Our ER docs change shifts at 7P 11P and 7A and we get most of our admits in the 1 hour prior to these times, according to the ED staff it is because this is when they write all their admit orders.