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.
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.
Our ER docs place a pt up for admission, but must then find a doctor willing to admit and oversee care. When that MD has been identified, 1 of 3 things happen:
1. A resident is sent down to see the patient and write orders
2. The primary nurse takes phone orders from the admitting attending
3. The admitting attending comes and sees the patient in the ER and writes orders.
We do not send patients to the floor without written orders and an attending MD assigned. ER doctors do not write admission orders as they are unable to coordinate care of a patient out of the ED. (I'm sure they are capable, but that's not what they do.)
If the ED staff is telling you that the ED MDs are writing orders you are either misunderstanding or being lied to. I've never heard of an ER MD willing to accept responsibility for the care a patient receives on the floor. Theoretically, if something happens the MD would have to leave the ER and care for the patient up stairs. Considering how many patients are admitted through the ER, that would mean the ER MDs were responsible for just about every patient in the hospital. That would leave the ER in chaos. It doesn't happen.
Our ER docs place a pt up for admission, but must then find a doctor willing to admit and oversee care. When that MD has been identified, 1 of 3 things happen:
1. A resident is sent down to see the patient and write orders
2. The primary nurse takes phone orders from the admitting attending
3. The admitting attending comes and sees the patient in the ER and writes orders.
We do not send patients to the floor without written orders and an attending MD assigned. ER doctors do not write admission orders as they are unable to coordinate care of a patient out of the ED. (I'm sure they are capable, but that's not what they do.)
I think this is what happens with us (sans the resident part, we don't have those.) I think a primary nurse actually calls the admitting doc to get an order to admit. Whether the doc gives more orders than that depends. We will often get a patient where it says "Call for orders." And admitting is assigned, so something has been done so far. But as far as ordering fluids, diet, meds, consults, etc, we often have to do that from the floor. (Not always, but often.)
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
Our ER docs place a pt up for admission, but must then find a doctor willing to admit and oversee care. When that MD has been identified, 1 of 3 things happen:
1. A resident is sent down to see the patient and write orders
2. The primary nurse takes phone orders from the admitting attending
3. The admitting attending comes and sees the patient in the ER and writes orders.
We do not send patients to the floor without written orders and an attending MD assigned. ER doctors do not write admission orders as they are unable to coordinate care of a patient out of the ED. (I'm sure they are capable, but that's not what they do.)
If the ED staff is telling you that the ED MDs are writing orders you are either misunderstanding or being lied to. I've never heard of an ER MD willing to accept responsibility for the care a patient receives on the floor. Theoretically, if something happens the MD would have to leave the ER and care for the patient up stairs. Considering how many patients are admitted through the ER, that would mean the ER MDs were responsible for just about every patient in the hospital. That would leave the ER in chaos. It doesn't happen.
Writing admitting orders and acting as the primary once the patient gets to floor are not the same thing (although they should be). Yes, I am sure that it is the ED docs writing the orders, it is in their handwriting, has their signatures, and has their EMR number as the physician signing the orders. All our admission ordersets have at the top "Care will be transferred to Dr. _______ on transfer". There is obviously some involvement of the admitting MD, they can refuse to admit the pt or ask the ED doc include particular orders, but for the most part the admitting Docs are unaware of exactly what the admit orders are when I call them (since they didn't write them).
Part of the difference might be that we are not a teaching hospital, we don't have residents. Our admitting MD's are often family docs who, unlike residents, aren't expected to come in at odd hours to see an otherwise stable patient, which is why the ED docs write their admission orders.
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
Patient disposition has so many factors involved.
I can tell you that the larger the hospital, the slower the traffic becomes. Sometimes it can come to a halt. Depending on what is occuring--staffing issues, acuity issues, multiple traumas...being a bed manager is a GIANT HEADACHE.
To put it simply:
We have ONE department to manage the board, and a computer software program accessed by ALL units--with the exception of super specialties who MUST approve admissions--they put in the requests, and the computer lists all requests by name and types of beds needed.
Two people work the 7a shift. One person works the 7p shift. The nurses that "man" these departments are nurses who have accrued many years of experience--particularly ER and ICU and most especially, the skill of triaging people. No new grad will ever work there. That's part of the department policy, and it's mandatory they have 5 plus years. It is a difficult job--and can be horrible.
The nursing supervisor who is the DOE (doer of everything) oversees any major glitches, otherwise they stay out of the bed management department's way.
Each floor has a staff charge/supervisor--some in the role of assigning beds. They all have phones to keep in contact with bed management AND they "crunch" every shift--mostly every 8, and in the event the hospital has stagnated and the ER is backing up--every 4.
There is constant communication, and there is a list of criteria of what each floor will take. By the time an ED patient has met criteria admission--the hospitalist/internal med will have been contacted (and they respond IMMEDIATELY), decided the type of bed and patient should go to--generally-- within 1-2 hours, and all admission orders. All of this is the "expected" route of transfer.
We also have 24 hour (7a and 7p NPs) available to facilitate the flow. These are nurses with multiple years of experience, and NONE of them with direct entry background. My hospital doesn't hire DE-MSNs for these types of position and generally promote the nurses who've obtained their masters after these nurses have worked high-acuity areas for at least 5-7 years. They can also write admission orders and get things moving.
However...
You never know how many sick, ICU patients come in through the ER or the FLOOR. I worked ICU triage before and had many occasions when I wondered if the full moon was in place--codes everywhere, code rescues everywhere, and stat STEMIs and CRANIEs needed beds...no staff.
The same with the floors...
The same with the ED...
The same in L & D
The same in NICU
The same in PEDIATRICS.
There are days when all he** breaks loose and you just want the day to end.
And then there are days when the 48 bed ICU has 12 patients and they nurses are BEGGING you for patients...
So....I think your post is clear on one thing There seems to be a lack of communication and lack of procedural policies to help facilitate moving patients in your place of work. Perhaps that is a good place to start in finding out why you have the pattern that you do.
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
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
AMEN.
Many people take it so personally as if you woke up that very day and decided...
"Oh my, I know Sally on 4 Medical-Surg is working 7-3 today. I think I will make throw her off kilter and bring up a patient at 2:30 just because I am an evil elf full of mischief and my life's one and only purpose is to make Sally miserable...Yay!":devil:
I concur that it seems like bed assignments are finally made at the wrong time all the time...
What kills me is when people do not want to take report at shift change... it comes down to "Do you want report from the person that knows the patient the best, or do you want report from the oncoming nurse that knows only whats been told to him/ her."
I feel bad for the floor nurses when bed assignments are made @ 0530 because they have to do all their admit stuff, plus whatever AM orders that doc has placed, but down in the ED we don't have much of a say. We get our butts reemed for not moving pts. upstairs quick enough, and we get hell from the nurses upstairs for waiting so long to admit a pt. when in all actuality, we may have just gotten the bed assignment at a god awful hour.
Many people take it so personally as if you woke up that very day and decided...
"Oh my, I know Sally on 4 Medical-Surg is working 7-3 today. I think I will make throw her off kilter and bring up a patient at 2:30 just because I am an evil elf full of mischief and my life's one and only purpose is to make Sally miserable...Yay!":devil:
Yeah, and if I'm not bursting with happiness when the ER calls report (or if Deity Forbid I can't hold the phone in one hand while I clean up a code brown with the other hand and actually tell them they'll hae to call back!) the ER thinks I'm upset that I had to stop waxing my legs and painting my nails to take a patient.
Our ED docs have a pre-printed transitional orderset they can use to send pts to the floor, and then the admitting doc or hospitalist can come up and the complete admission orders.
Or the admitting doc will see the pt in ED and write orders there. We do not accept patients without orders.
Dispo is short for disposition--will pt be dc'd or admitted? If admitted, to where and with what orders.
When I was floated to ED I was told that it's best to wait until the end of the shift to take pts to the floor, and then take your last break just before you go home because that's when the donuts come in. If you take them up too soon you will have to bring back another patient from the waiting room.
I experienced this with a family member. He came to ED about 6 pm, I left my unit to sit with him having been told he would be admitted. At 11 pm, I was told they would be moving him to my floor, the delay had been because they were waiting for a bed(not so, he went to my unit and they had been expecting him for 5 hours). In that five hours no other tests were done, no meds were given. He had labs drawn on arrival and a CXR. They kept him npo, he got to the floor at 1145pm, with orders to be npo after midnight. This was for an 85 yo with a near syncopal episode on a hot summer day, no fluids, no IV.
Our cardiologists will always time and date their admit orders they write in ED. Pts often come up with 3 hour old orders, with now and stat meds ordered but not given. Stuff like heparin drips for acute MIs, metoprolol for HTN, lasix for CHF.
So yeah, there are many factors why patients always come in bunches and part of it is that is the culture, at least at our hospital. And there does not seem to be any big push to change it, other than buy an expensive computer program that doesn't get used, or use a written report that's less than perfect.
What kills me is when people do not want to take report at shift change... it comes down to "Do you want report from the person that knows the patient the best, or do you want report from the oncoming nurse that knows only
Well, if it's shift change, more than likely the person that knows them best will be giving report to the person leaving.
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.
I'm surprised to hear that it's considered "traditional" to dispo at the end of the shift. Neither of the two hospitals where I work do this. Pt's are dispositioned throughout the shift and go to the floor as soon as possible.
At the smaller of the two--a mid sized hospital with a 29 bed ED--docs advise the nurse caring for the pt, or the charge nurse, as soon as they know the pt will be admitted. The charge has already been in communication with the supervisor who has informed the charge of what beds are available in the hospital, so they know how to plan where the pt will go.
The docs sometimes know as soon as they see a pt that they will be an admit, but the pt generally can't go to the floor until all test results are back, and the ED doc has spoken with an admitting physician and received orders. The written orders are given to the unit secretary to inputs relevant orders and sends a page to pt registration to inform them of the need for a bed. Registration then pages the floor with a bed request and they are supposed to page a room to the ED within 30 minutes. Often 30 minutes is exceeded for some reason, but that's the process. Pt's are then transported to their rooms as soon as possible--no intentional waiting until shift change.
Throughout this process, the ED charge, the supervisor, and the charge nurses on the respective floors are all in communication as to the census in the ED and the number of possible admits, so there are no surprises on the floors. Staffing is done based on actual floor census as well as any anticipated admits. Obviously you can always predict what will come through the doors of the ED, but this process works fairly well for this hospital. We do have our challenges with some nurses intentionally not giving out timely bed assignments because they don't want new patients, or not wanting to take new patients right before shift change, but it's not due to docs holding admits until the end of the shift.
At the larger hospital--a 40-something bed ED--it's my job to assign the beds. There are two of us per shift on nights unless someone calls in sick and there no one to fill in. Even with two of us it can get crazy busy at times.
At this hospital, as soon as the doc knows a pt is to be admitted, he/she puts an order in through the computer system with the diagnosis, name of admitting physician, and the type of bed requested. The order shows up on my computer screen and I start to look for a bed.
I can "see" all of the beds in the hospital with the software that we use, and I have to have a bed assigned within 30 minutes of receiving that order. There are times when this can't happen; for instance, if there are no ICU beds available or we are out of tele beds, but for the most part it's doable.
After I decide where the pt will go, I call the floor to inform them that they are getting an admit, then I complete the order by assigning the bed in the computer. The assignment shows up on the tracking board in the ED so they know where the pt will be going once written orders are completed.
The initial bed order happens fairly early in the process so it's not unusual for bed assignments to change. The doc may decide to order tele, the pt may end up needing to go to ICU, ICU pts may be downgraded and go to tele, all of which will necessitate a bed assignment change.
As with the other hospital, the supervisor is in communication with us and the floors, so there are no surprises. This does not mean, however, that they are always staffed to take every pt that is admitted, but it usually works out because staff can be called in or pulled from other floors. When extra staff cannot be had, nurses are often required to take more pts than they would normally, or there are holds in the ED until the next shift if it is determined that it would be unsafe for pts to go to the floor.
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.
The admitting docs where I work rarely come to the hospital in the night. The ED docs talk to them on the phone and get their orders.
As for the bed board waiting until the last minute, that never happens where I work.
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.
Some docs work 7-7 shifts, but where I work, shifts vary depending on anticipated census levels. I suspect this is the same at most hospitals unless they are quite small.
I agree that it would be helpful if everyone knew how all of the various parts of the hospital work.
begin on who gets pulled where, etc.
Fribblet
839 Posts
Our ER docs place a pt up for admission, but must then find a doctor willing to admit and oversee care. When that MD has been identified, 1 of 3 things happen:
1. A resident is sent down to see the patient and write orders
2. The primary nurse takes phone orders from the admitting attending
3. The admitting attending comes and sees the patient in the ER and writes orders.
We do not send patients to the floor without written orders and an attending MD assigned. ER doctors do not write admission orders as they are unable to coordinate care of a patient out of the ED. (I'm sure they are capable, but that's not what they do.)
If the ED staff is telling you that the ED MDs are writing orders you are either misunderstanding or being lied to. I've never heard of an ER MD willing to accept responsibility for the care a patient receives on the floor. Theoretically, if something happens the MD would have to leave the ER and care for the patient up stairs. Considering how many patients are admitted through the ER, that would mean the ER MDs were responsible for just about every patient in the hospital. That would leave the ER in chaos. It doesn't happen.