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.
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.
I could be wrong, but I don't think docs holding up the process is the norm. In larger hospitals with lots of admits, docs would never get it all done in the last hour or two if they did this.
I think the confusion about this is because ED docs often do the physical writing, after receiving verbal orders from the admitting docs over the phone, so it is perceived as the orders originating with the ED docs.
However, if an ED has a hospitalist working, that doc does write 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.
Admitting docs never see pts in my ED. Pts also never go to the floor without written orders.
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.
Sounds like the software used by your facility is similar to ours. One difference is that all units do not have the same access that I do as the bed managment person. It's done that way to cut down on the resistance that we used to get when one floor would question why they were getting a patient when there were open beds on another floor and they were feeling picked on. This still happens on occassion, but much less than it used to.
The only specialty units that have any say-so in approving bed assignments are OB and peds. Otherwise, I assign the pts and the floors must take them.
I agree that some experience is helpful in this position, but I started the job with only 6 months of ICU experience and I've been doing the job for almost 2.5 years now. In addition to assigning beds for ED admits, I handle all of the direct admits and ED to ED transfers that come to our hospital.
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.
Ummm...any nurse that did this in my ED would do it only once...
OP, you sound like you are on the sister unit to the one I used to work on!!! I understand completely, and we used to have the same thing happen, day in and day out!!! Are you in Kentucky??
OP, you sound like you are on the sister unit to the one I used to work on!!! I understand completely, and we used to have the same thing happen, day in and day out!!! Are you in Kentucky??
Yep..... Lets just say....the POPLAR trees are big around here.....
I'm not sure, but I don't think the people in bed booking for our hospital are nurses. And that is a problem IMO. The House Supervisor of course is there and oversees, but the people who call the floors, I'm pretty sure they aren't. (Based on some of the funky "diagnoses" we see.)
We have recently run into problems where people come to the floor, have been assigned a room with a roommate and we find out they need to be in isolation. I'm not sure where the communication is with that.
Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
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.
I'm not sure, but I don't think the people in bed booking for our hospital are nurses. And that is a problem IMO. The House Supervisor of course is there and oversees, but the people who call the floors, I'm pretty sure they aren't. (Based on some of the funky "diagnoses" we see.)
We have recently run into problems where people come to the floor, have been assigned a room with a roommate and we find out they need to be in isolation. I'm not sure where the communication is with that.
I agree that it coud be an issue if they aren't nurses. Sometimes the docs request isolation with the bed order, but often they don't. So it's my job to look through the pt's chart when I get the admit order to see if isolation is warranted. I also have the discretion to not put a pt in iso even with a doctor's order if I determine that there is no medical necessity for it. On rare occassions, a pt that needs iso will fall through the cracks and be put in a room with another pt. This is either due to the necessary information not available to me in the pt's chart, or we get too slamming busy that I just miss it. When it happens, we have to adjust and make other accomodations.
I'm curious; how big is your hospital? My impression is that is small to medium, but I know I could be wrong.
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.
Yes, it's true, for several reasons. For one thing, as one poster already mentioned, sometimes they want to observe the patient a bit before deciding whether or not to admit. That might include running additional tests; it might also mean deciding whether to admit the patient to general med/surg, tele, stepdown or critical care. ER doctors usually try to finish up on ALL of their patients before leaving, instead of turning them over to another doctor, and that means that sometimes they don't get admitting orders and diagnoses completed until shortly before they go off duty. Another consideration: night shift ER doctors will often hold off on calling a patient's PMD until 6 am or so, unless it's absolutely necessary to call earlier. And that means that we don't get access to admitting orders until the night shift is almost over.
As far as the ER staff goes: we WANT to get those patients out of the ER and upstairs. In my hospital, length of stay is tracked as a quality measure; the longer those patients lie on our uncomfortable carts, and the longer other patients sit in the waiting room, waiting to be taken back on one of those uncomfortable carts, the worse it reflects on us.
It's important to remember, too, that sometimes we, the nurses, are just too busy to get back to the patient to prepare him/her to go upstairs. If I have a patient who's just been assigned a room, and the paramedics come in with a patient that's assigned to me, I have no choice but to get that patient checked in. Most of the time, I get patients up to their assigned inpatient bed as quickly as I possibly can; but sometimes there's a delay that I can't do anything about.
One last consideration: my hospital doesn't have transporters 24/7. They come on duty at 6:30 am, and leave at midnight----so, unless we have ER staff available to take patients up, we have to try to work our transports around their schedule.
Having been on the other side (working on the floor), though, I know how frustrating it is to get "dumped on" while you're running like crazy trying to finish up your shift. For a while, I experimented with giving the patient a history to fill out while s/he waited for a room, just to speed up the admission process, but the idea wasn't well received by my coworkers (although the floor nurses loved it). When I worked on the floor, we also trialed having a day shift nurse come in an hour early to start admissions, but that didn't work well, either. Has anyone else come up with ideas for this problem?
begin on who gets pulled where, etc.
Lets just say....the POPLAR trees are big around here.....
Learn something new every day.
GM2RN
1,850 Posts
I could be wrong, but I don't think docs holding up the process is the norm. In larger hospitals with lots of admits, docs would never get it all done in the last hour or two if they did this.