How does your tele and ER work together?

Pill Hoarding Hussy · Mar 29, 2005

I have been a tele nurse for almost four years. I am getting ready to start a new job as staff in the ER. Tonite being my last nite on tele I was vividly reminded by my coworkers of the very poor relationship our tele has with our ER. The tele nurses always seem to think the ER should have done more for the patient prior to receiving them and the admission always seems to come up at shift change. On the other hand our ER is very busy and short-staffed. They are using alot of ancillary staffing ie agency and registry that are not completely familiar with our docs and procedures. There is new management who used to work in the ER and they are trying to make amends but say it is going to take time. The er always complains that they are too busy and need to get the pts up to the floor asap. Are any of you facing this at your workplace? Needless to say I didn't get many kudos on my transfer! :chair:

how does my floor get along with the ED? appalingly poorly. the admissions always come at change of shift, the pt could have been in the ED for 6+ hours, but all of a sudden at 0630 it is VITAL that they come up to the floor RIGHT NOW! the ED does not care what else is going on on your floor, how unstable the admission they just sent is, that you only have 2 RN's, a CNA and a new grad orientee. they do not care who is crashing, what your staffing is like, all they care about is getting people out of their faces.

the sick part of it is that they apparently can strongarm you and do as they please. i don't know if this is just my hospital or everywhere, but mgmt. does not back up their floor RN's. perhaps they think they do not need us... or perhaps cycling as many pts as possibe through the beds as fast as humanly possible to make that $$ is more important than safe pt care on the floors.

sorry, this turned into a rant... but you did ask.

congrats on your new job, i hope it is educational and fulfilling.

just try to remember what it was like when you were just a floor RN! :chuckle

Spacklehead, MSN, NP · Apr 5, 2005

how does my floor get along with the ED? appalingly poorly. the admissions always come at change of shift, the pt could have been in the ED for 6+ hours, but all of a sudden at 0630 it is VITAL that they come up to the floor RIGHT NOW! the ED does not care what else is going on on your floor, how unstable the admission they just sent is, that you only have 2 RN's, a CNA and a new grad orientee. they do not care who is crashing, what your staffing is like, all they care about is getting people out of their faces.
the sick part of it is that they apparently can strongarm you and do as they please. i don't know if this is just my hospital or everywhere, but mgmt. does not back up their floor RN's. perhaps they think they do not need us... or perhaps cycling as many pts as possibe through the beds as fast as humanly possible to make that $$ is more important than safe pt care on the floors.
sorry, this turned into a rant... but you did ask.
congrats on your new job, i hope it is educational and fulfilling.
just try to remember what it was like when you were just a floor RN! :chuckle

Unfortunately, the ER staff cannot control how many patients come through their doors, so usually as soon as they get a bed assignment for the floor, they like to get that pt. up ASAP since there are many other patient waiting for that ER bed. Also, a pt. may be in an ED for 6 hours before they come up to the floor because they are stuck waiting for labs and test results and, most importantly, an admitting physician! At the hospitals I've worked at, I know that if the staffing on the floors is bad, it is usually the same in the ED. As far as admissions always coming at change of shift, I cannot attest to how your ED works but in mine, it seems like we'll be calling the floor for 2 hours prior to change of shift and the nurse will not accept report - therefore the pt. goes up as soon as the new nurse comes on. I also think there needs to be some consideration that once the floor's beds are full, no more patients are admitted to that floor, however, once the ER's beds are full, we utilize our hallways and any space available. Yes, we can go on divert, but we cannot turn away walk-ins. Therefore, we have to keep your holds and everyone else coming through the department. I used to think along similar lines as you when I was a tele. nurse for 2 years, however, my view drastically changed when I became an ER nurse. I now have great respect and understanding for both the floor nurses and the ED nurses.

neneRN, BSN, RN · Apr 5, 2005

Ditto what softballmama said.

gotta say, I don't think any place is busier than the ER (as busy as, in some cases, but not busier)

As a floor nurse, you don't have to care for pts in the hallways that double or even triple your workload. Once your rooms are filled, that's it. If we can't get the pt upstairs, we still get additional pts, only the new ones are treated in the hallways instead of rooms. Last week, I simultaneously took care of 3 vented pts in my rooms, while in my hallway I had a subdural bleed waiting for ICU placement and a sepsis with a pressure of 60 in my other hall.

The ER nurses have no control over when a bed is rec'd. (at least at my hospital) The doc admits, an admission coordinator finds a bed, and then we wait. The beds are invariably given to us to call report on about 1/2 an hour before shift change. It's amazing to us in the ER how all of a sudden at shift change we're flooded with beds. We are pressured to have the pt out of the ER within 15 minutes of receiving the bed to make room for those still waiting in the lobby or rolling in the doors via EMS.

Once a pt gets to your floor, do you need to immediately start a line, draw labs, do an EKG, hook up to monitor, give stat meds/IVF/treatments, assess and determine acuity on EVERY single pt? Well, i do have to do this on every pt that I see. By the time the pt gets to the floor, they are, in general, stabilized with all the aforementioned already done. Even the dreaded 5 page admission assessment is done by admission nurses down in the ER. If the pt waits more than 2 hours for a bed after being admitted, then we call the admitting and get floor orders, so on most pts, that's done too. Yet I still constantly get the run around when I'm trying to call report and get the pt upstairs.

It's not that we want to get the pt out of our face, but when a pt who has been out in the hallway for 24 hours on one of those horrible stretchers, or we've got a MRSA in the same room with someone who doesn't, or when an intubated pt has been in the ER so long that he's been extubated and downgraded from ICU- yeah, we get frustrated-the pt needs to go.

I don't mean to offend any one or make it sound like I think the ER is always right- but this is going to be a sore topic for a lot- and it's something that's always going to be a problem for both sides. I should also add that I rarely ever have problems with the ICUs- they take report quickly and we take the pt right up. The unit nurses are also great when we're holding ICU pts forever and have to start following their unit protocols (another long vent), they'll answer questions and even come down to the ER (gasp! always a shocker to see a non ER nurse in our area) to help.

Pill Hoarding Hussy · Apr 5, 2005

Ditto what softballmama said.
gotta say, I don't think any place is busier than the ER (as busy as, in some cases, but not busier)
As a floor nurse, you don't have to care for pts in the hallways that double or even triple your workload. Once your rooms are filled, that's it. If we can't get the pt upstairs, we still get additional pts, only the new ones are treated in the hallways instead of rooms. Last week, I simultaneously took care of 3 vented pts in my rooms, while in my hallway I had a subdural bleed waiting for ICU placement and a sepsis with a pressure of 60 in my other hall.
The ER nurses have no control over when a bed is rec'd. (at least at my hospital) The doc admits, an admission coordinator finds a bed, and then we wait. The beds are invariably given to us to call report on about 1/2 an hour before shift change. It's amazing to us in the ER how all of a sudden at shift change we're flooded with beds. We are pressured to have the pt out of the ER within 15 minutes of receiving the bed to make room for those still waiting in the lobby or rolling in the doors via EMS.
Once a pt gets to your floor, do you need to immediately start a line, draw labs, do an EKG, hook up to monitor, give stat meds/IVF/treatments, assess and determine acuity on EVERY single pt? Well, i do have to do this on every pt that I see. By the time the pt gets to the floor, they are, in general, stabilized with all the aforementioned already done. Even the dreaded 5 page admission assessment is done by admission nurses down in the ER. If the pt waits more than 2 hours for a bed after being admitted, then we call the admitting and get floor orders, so on most pts, that's done too. Yet I still constantly get the run around when I'm trying to call report and get the pt upstairs.
It's not that we want to get the pt out of our face, but when a pt who has been out in the hallway for 24 hours on one of those horrible stretchers, or we've got a MRSA in the same room with someone who doesn't, or when an intubated pt has been in the ER so long that he's been extubated and downgraded from ICU- yeah, we get frustrated-the pt needs to go.
I don't mean to offend any one or make it sound like I think the ER is always right- but this is going to be a sore topic for a lot- and it's something that's always going to be a problem for both sides. I should also add that I rarely ever have problems with the ICUs- they take report quickly and we take the pt right up. The unit nurses are also great when we're holding ICU pts forever and have to start following their unit protocols (another long vent), they'll answer questions and even come down to the ER (gasp! always a shocker to see a non ER nurse in our area) to help.

i did not mean what i posted to be a personal attack on er nurses.

i am just stating that the relationship btw our floor and our er is very poor, with little to no communication. we do not receive phone report, we receive only a triage sheet and a vital sign sheet faxed to our floor. no record of what meds were given, no admission assessment help aside from drug allergies. maybe i am just feeling a little burned right now b/c the last shift i worked i took an ed admit that coded 20 min after arriving on the floor. when i read the triage sheet my spidey senses started tingling, i was wondering about icu placement, had the clinical supervisor go scope out the pt in the ed, was assured we could handle it, and he was sent (after i was threatened with disciplinary action by an ed nurse for delaying the admission process).

i know that no one can see the future and sometimes these situations are not avoidable. i just think there is a lot of room for improvement in the way er and floor nurses regard each other and communicate with each other. there seems to be no respect on either side. i too have cared for pts in the hall b/c the admission coordinators did not believe us when we said we were not ready to take the pt. not all floor nurses are lazy!

neneRN, BSN, RN · Apr 5, 2005

No, I know that floor nurses are not lazy, and I agree that communication between floor nurses/ER nurses could use improvement in probably any institution. I think the biggest problem is that both sets of nurses have one-sided views of the situation. I only know what happens in the ER- I've never worked the floor; likewise for nurses who have never worked ER. They are entirely different kinds of nursing, with different focuses and priorities and unless you've worked both, these problems/tensions will always be there.

We give phone report and the entire ER chart- including triage sheet, order sheet, nurses notes/VS, flow sheet listing all meds/interventions, all lab results- goes with the pt to the floor. Even all of the previous medical records are ordered on every pt in the ER and sent upstairs. Sounds like your ER could use a revamp on the giving report process.

Hrtnurse14 · Apr 7, 2005

Thanks for all the input from both sides. I have now been on orientation in ER for a little over a week after having been on tele I have gotten a taste of both sides. I do see at times that pts come up at change of shift because that is ER's change of shift too. But more often than not the ER nurse is running around like a chicken with her head cut off trying to keep up with the non ending stream of patients. I keep reminding myself I accepted the job to work in ER so I have little control over my acuity and patient load at most times. This is a transition, but one that I am enjoying because I am learning so much and it is challenging. Floor nurses choose to work in a more controlled environment for their own reasons. Floor nursing is necessary for a good outcome to a patient so the intake and the appropriate level of acuity is necessary when accepting and receiving patients. As far as ICU accepting patients easily, when you only have a couple of patients it is much easier to take report in a timely manner. I am trying to use my tele skills in er to get a patient's plan of care on track quicker. For example, I suggested Natrecor on a CHF pt right away. Suggested a patient who vagaled in ER should go to tele instead of a med bed because her b/p was low and she was still symptomatic. All we can do instead of complaining is try to use our head and skills in a positive manner i guesss.Thanks again for all the posts. It was nice to see that I don't work at the only place with problems between the two floors.

Peg804 · Apr 7, 2005

Just have to add my two cents. I work in an ED that never has a q""""" time. We treat patients in the hallways, the support room, triple up the cardiac, trauma, and ortho rooms-what a joy-and you know where HIPPA goes. I have worked the floors-don't want to do floor nursing, love the ED and as of now will never leave. I think that all floor nurses should come and see what goes on in the ED. As others have said-on the floors , when your beds are full, they are full. As Team Leader I get to enjoy the brunt of the screaming and cursing from the patients and their families who have been in the waiting room for 5 hrs. My name is on the nasty comment cards when we have no place to put people. Our policy is that we fax report to floors and the patient goes up in 30 minutes. What happens is about 5 minutes before pt can go up we get the call-bed is not cleaned, we;re having patient go bad, or what I love-the nurse is on break. BREAK!!! I haven;t had in break in longer than I can remember, and I haven't seen the BR all shift. Didn;t anyone notice the bed was not cleaned. Maybe we can swap crisises??? We cannot send pt to the floor 15 minutes before shift change, so when do we get the beds- just over the 30 minute waiting period. Why, cause the supervisor does not want the floors mad at him-the gutless wonder ohh!!! did I say that??? Sometimes I could just scream, and of course we loose all these fights, no the cannot take the patient early, and then there is the ICU and Heart Hosp. We have to call report to them, well with the internal caller ID they know it is us, I have been hung up on and put on terminal hold (by mistake of course). No WE WILL CALL YOU WHEN WE CAN TAKE REPORT. Well you know where that goes. Still love the ED-just wish the rest of the hospital understood us.

kris19620 · Feb 7, 2006

I see by all the replies we are all in the same boat. I work in the ER and find that many times I am greeted with hostility from the floor nurses. I do believe that this is from a lack of understading on how it is in the ER. It is NOT personal when we send pts. up. We dont know whats going on upstairs any more than the floornurses know whats up with us. And even if we do know, what can we do? We are being told to get the patients up! It would actually make for an easier day to keep the same pts. all day. Instead of the constant turnover. So please dont take it personal. I know that it seems that at times we are sending up everyone at once. I find that this happens a lot with the physicians as they are trying to disposition all their patients before they go off shift. It really has nothing to do with nursing. Believe me we are not treated special anymore than you floor nurses. Lets face it we all work very hard and dont get half the credit we deserve. We ALL need to remember it is NOT personal. Its management who will need to look into a smoother transition possibilities. In the meantime we are all just doing what were told.:roll

carachel2 · Feb 7, 2006

I've been on both sides. When I worked CCU/tele, I could SWEAR they held them down there until right at shift changed and then dumped them.

Now that I am in the ER , I realize nothing is farther from the truth. Holding a tele/CCU patient in the ER makes us MORE busier. We want them OUT ! When those little ladies need to start peeing (and have no indication for a foley) and eating and sleeping it is more time consuming for us than if we got in a new patient.

We have strict time guidelines that say once a bed is actually assigned, we have 30 minutes to call report and get them moved out and we try *very* hard to accomplish this. If the bed is not assigned until 6:00 then I know there is going to be a problem. The problem comes, however, when you are sitting down and about to call report and a fresh MI/shock,etc. rolls into one of your available beds. It is kind of frowned upon for you to sit and let everyone else do "all of your work." So in I go, assess, start lines, do EKG, start drips and POOF...one or two hours has gone by.

I don't know how to improve relationships among the groups. I do all orders that were given by the ER doc and will attempt to wade through admitting orders if the time is there. But the critical new patient who has not been stabilzed takes priority over calling to see if Mrs. X's collace has arrived from the pharmacy.

I think the mentality of the tele/med -surg floors also shoots them in the foot. I remember working CCU/tele and if you got an admission at 6:30 pm by golly, you stayed and finished *everything* without even a thought to passing it off to the oncoming shift. In the ER, if I have orders to do an EKG, start a line and a drip at 6:45, I will start doing everything and the oncoming shift takes the next order in line. There is no feeling of obligation to stay over and finish every single little thing...there is a great handoff of care and no feelings of hostility towards those who do not stay and do it all.

Please assure your colleagues that holding people in the ER makes MORE work for the ER nurses and we do everything we can

HappyNurse2005, RN · Feb 8, 2006

OK, how about if you are going to take care of tele pt's then know your rhythms.

Had an ED nurse (where I imagine, they are supposed to be able to read a strip, right?) call report to me. WHen i asked about the pt's rhythm she said "Oh could be sinus, could be afib im not sure" ????

carachel2 · Feb 8, 2006

OK, how about if you are going to take care of tele pt's then know your rhythms.
Had an ED nurse (where I imagine, they are supposed to be able to read a strip, right?) call report to me. WHen i asked about the pt's rhythm she said "Oh could be sinus, could be afib im not sure" ????

Well, that shouldn't be the norm, but more than once I've had to give report on a patient I didn't even know.