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.
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?
I agree with all of this.
We have 1 ED tech for the entire dept. and no separate transport staff, so we often have to transport ourselves, sometimes making it difficult to get patients to the floor in a timely manner.
You also have to look at this from the patients' viewpoint. Most of the time they have been in the ED for several hours before they even get a bed assignment, so it's not fair to them to make them wait any longer than necessary to go to the floor.
I also have worked the floor and have to say something about how assignments are done. I really don't understand why, when given extra staff in anticipation of new admits, the patients are split between all but that extra nurse, and he/she is expeted to take all of the new admits. It is totally wrong to dump on 1 nurse like that. Plus, the floor doing this then wants to wait an hour between each patient so admission paperwork can be done. This adds hours to patients' wait time when you have 2 or more patients going to the same floor. I'm sure not everyone does this, but I have seen it done frequently, and have even been on the receiving end of this kind of decision and had to take all of the new patients. The practice of dumping on nurses who are not core staff or are called in to help is just wrong and it should stop for the good of all.
Just wanted to chime in that I think it's great to learn how the different departments work in relation to others. Sometimes it doesn't make the problem better but I think it helps morale to understand the reason behind certain problems. And increases a feeling of being on the same team instead of an "us vs. them" mentality.
First of all, I want to say thanks to everyone for not turning this into a back-biting, accusitory thread. I wanted to convey in the OP that I really was looking for information, not venting, and I think that worked. Love to see information sharing instead of snapping at each other.
Someone asked how big my hospital was...around 250 beds. We are in a metorplitan area but are one of the more "suburban" hospitals. We are also part of the largest hospital system in the city.
To the person whose hospital only staffed transporters during the day....what the heck?? Aren't ERs open 24-7? It's one thing to not staff at night in an area that is definately slower at night (OR for example where you aren't doing outpatient/elective surgeries at night), but the ER? I mean is night different than day there? Especially since Dr's office are closed and you're getting all those people who can't wait until morning. That sucks for you!
As far as the "extra" nurse taking all the admits, sometimes that happens on our unit, sometimes not. Yesterday we got an extra nurse at 3:00 (I'm not really sure why, I don't think we "earned" her). At first she just did tasks, then she ended up taking two admits. I don't think it was that bad for her...But I wanted to say, on our floor the charge nurse does most admissions. She gets all the initial history, etc done, sometimes does the RN assessment, sometimes doesn't, usually calls the doc for orders if we don't have them. It depends on how busy we are as to how much of the initial orders she/he gets done. So if we have an extra nurse who is taking admissions, a lot of time, the charge is doing half the work anyway. I understand that this is unusual at our hospital. On other floors, the charge doesn't do admissions. (Which kind of makes me wonder what they do, but anyway.)
My sister has been a nurse a lot longer than me. I remember her talking about an 11a - 7p shift back in the dark ages when there were 8 hour shifts. She said this person was there to cover lunches/dinners and shift change. To help take up the slack during these times. Anyone else remember this?
first of all, i want to say thanks to everyone for not turning this into a back-biting, accusitory thread. i wanted to convey in the op that i really was looking for information, not venting, and i think that worked. love to see information sharing instead of snapping at each other.
someone asked how big my hospital was...around 250 beds. we are in a metorplitan area but are one of the more "suburban" hospitals. we are also part of the largest hospital system in the city.
to the person whose hospital only staffed transporters during the day....what the heck?? aren't ers open 24-7? it's one thing to not staff at night in an area that is definately slower at night (or for example where you aren't doing outpatient/elective surgeries at night), but the er? i mean is night different than day there? especially since dr's office are closed and you're getting all those people who can't wait until morning. that sucks for you!
there are many times when it will be relatively slow on days, and we get slammed with patients right around 7p and stay that way until after nidnight, sometimes until 3-4 in the morning. one thing that makes it so bad is we have only 1 doc after 11p, and if he/she is a slow one it makes for a really tough night.
as far as the "extra" nurse taking all the admits, sometimes that happens on our unit, sometimes not. yesterday we got an extra nurse at 3:00 (i'm not really sure why, i don't think we "earned" her). at first she just did tasks, then she ended up taking two admits. i don't think it was that bad for her...but i wanted to say, on our floor the charge nurse does most admissions. she gets all the initial history, etc done, sometimes does the rn assessment, sometimes doesn't, usually calls the doc for orders if we don't have them. it depends on how busy we are as to how much of the initial orders she/he gets done. so if we have an extra nurse who is taking admissions, a lot of time, the charge is doing half the work anyway. i understand that this is unusual at our hospital. on other floors, the charge doesn't do admissions. (which kind of makes me wonder what they do, but anyway.)
if that one nurse gets only 2 admits then it's not a bad night for that person. the problem is, you can never know how many admits you will get. just a few nights ago i became aware of a situation on the cardiac tele floor where they had a nurse with no patients from the beginning of the shift. they gave her all of the new admits and there were many that night. i can see it if the extra nurse doesn't get there until 3 am, but not if they are there from the start of the shift.
so if your charge nurse is doing all of the admission paperwork, how long does it typically take for one admission, and do you have the ed hold patients while each one is being done?
my sister has been a nurse a lot longer than me. i remember her talking about an 11a - 7p shift back in the dark ages when there were 8 hour shifts. she said this person was there to cover lunches/dinners and shift change. to help take up the slack during these times. anyone else remember this?
No, we don't have the ER hold patients while admits get done. When an admit comes up, the charge will do the Admission Hx, Screenings, etc. Takes 15 - 30 minutes depending on if the patient, sometimes longer if they haven't been there before and have an extensive history. If it's a person who we really need to assess for skin issues, etc, (say a nursing home patient vs. a walkie, talkie 20 something) she'll have the RN getting the patient come in and do all that with her and then the RN finishes up the assessment. Sometimes the charge will do the assessment, sometimes the staff nurse will. Sometimes the charge will call the doc for orders, sometimes the staff nurse will. Sometimes the charge nurse will start the IV and draw labs (if necessary) sometimes the staff nurse will. It really depends on how busy everyone is.
If more than one Admit comes up at the same time (or close together) several things might happen.
* The Charge will check on both patients and make sure that they are not in distress, etc assess which one is more urgent and then admit one and then the other. The 2nd might have to wait an hour or so, but if they are comfortable and someone is checking on them, it isn't really a big deal.
* We also have a nurse who is an "Admissions Nurse" that works out of the ER. She can be paged to do an admission if we are getting slammed and often helps. Since she is out of the ER, she usually knows when we are getting slammed and has half the admission done before the patient comes up. (We
* If a staff nurse happens to be in good shape with their team, the staff nurse might just go ahead and do the admission. I've done this several times.
Direct Admits are harder since they don't have an IV, don't have any labs done, etc. There is just more you have to do for them. If I'm getting a direct admit, I'll work with the charge to get things done.
It seems to work well for us, which is why it really puzzles me when I hear nurses from other floors say their charge never does Admissions. I have to wonder what they do then, unless they take a team. But I don't think they take a team. I know charges have other responsibilities, but ours have the same ones and still have time to do most of the admissions.
Oh..and if we have a nurse who is there at the beginning of a shift, they get a team. These "extra nurses" are people who show up mid-shift for whatever reason. Sometimes they get a team, sometimes they don't. Just depends on the business of the unit.
No, we don't have the ER hold patients while admits get done. When an admit comes up, the charge will do the Admission Hx, Screenings, etc. Takes 15 - 30 minutes depending on if the patient, sometimes longer if they haven't been there before and have an extensive history. If it's a person who we really need to assess for skin issues, etc, (say a nursing home patient vs. a walkie, talkie 20 something) she'll have the RN getting the patient come in and do all that with her and then the RN finishes up the assessment. Sometimes the charge will do the assessment, sometimes the staff nurse will. Sometimes the charge will call the doc for orders, sometimes the staff nurse will. Sometimes the charge nurse will start the IV and draw labs (if necessary) sometimes the staff nurse will. It really depends on how busy everyone is.
If more than one Admit comes up at the same time (or close together) several things might happen.
* The Charge will check on both patients and make sure that they are not in distress, etc assess which one is more urgent and then admit one and then the other. The 2nd might have to wait an hour or so, but if they are comfortable and someone is checking on them, it isn't really a big deal.
* We also have a nurse who is an "Admissions Nurse" that works out of the ER. She can be paged to do an admission if we are getting slammed and often helps. Since she is out of the ER, she usually knows when we are getting slammed and has half the admission done before the patient comes up. (We
* If a staff nurse happens to be in good shape with their team, the staff nurse might just go ahead and do the admission. I've done this several times.
Direct Admits are harder since they don't have an IV, don't have any labs done, etc. There is just more you have to do for them. If I'm getting a direct admit, I'll work with the charge to get things done.
It seems to work well for us, which is why it really puzzles me when I hear nurses from other floors say their charge never does Admissions. I have to wonder what they do then, unless they take a team. But I don't think they take a team. I know charges have other responsibilities, but ours have the same ones and still have time to do most of the admissions.
The charge nurse on the floor at the smaller hospital I'm at does not take a team unless there are too many patients for the other nurses, and is supposed to help the other nurses with whatever they need, except that when I floated to the floor I almost never got any help, and I never even knew for a long time after I stopped working the floor that the charge didn't take a team. Matter of fact, now that I think about it, I can remember only one time when I got help with my med sheets and that was it.
At the larger hospital, the charge nurse does take a team but it is supposed to consist of fewer pts than the other nurses. Even though I haven't worked the floor at this one, I know from my dealings with them that the charge also helps with admissions and other things as necessary.
begin on who gets pulled where, etc.
GM2RN
1,850 Posts
I agree with all of this.
We have 1 ED tech for the entire dept. and no separate transport staff, so we often have to transport ourselves, sometimes making it difficult to get patients to the floor in a timely manner.
You also have to look at this from the patients' viewpoint. Most of the time they have been in the ED for several hours before they even get a bed assignment, so it's not fair to them to make them wait any longer than necessary to go to the floor.
I also have worked the floor and have to say something about how assignments are done. I really don't understand why, when given extra staff in anticipation of new admits, the patients are split between all but that extra nurse, and he/she is expeted to take all of the new admits. It is totally wrong to dump on 1 nurse like that. Plus, the floor doing this then wants to wait an hour between each patient so admission paperwork can be done. This adds hours to patients' wait time when you have 2 or more patients going to the same floor. I'm sure not everyone does this, but I have seen it done frequently, and have even been on the receiving end of this kind of decision and had to take all of the new patients. The practice of dumping on nurses who are not core staff or are called in to help is just wrong and it should stop for the good of all.