I know that various problematic aspects of holding ICU pts. in the ER due to a lack of unit beds has been discussed here before, but here's where I'm struggling ...
At my hospital, orders for a pt. that goes to the unit are written by a resident when they get to the unit. So when a pt. is held for hours in the ER ... I really have no orders. Our ER docs have "washed their hands" of these pts., so to speak, and yet these pts. have continuing needs for pain control, control of HR/BP, etc.
Along the same line, any suggestions for nursing home residents who are seen in the ER, discharged back to their home facility, but end up waiting hours for transportation back ... these people are technically discharged, but they get hungry, need their glucose checked, have pain, etc. etc. ...
Any suggestions? I did search through other "ICU hold" threads ...
We always do the ICU orders though, if a pt's sick enough for the unit, then they're too sick for the ER nurse to say "we don't do admission orders," I'm surprised to hear that not everyone does the unit orders.....med-surg pts however, the most important/highest priority orders are done, the rest wait.
This is what we do as well. We do not have anyone come from the ICU or floor to care for patients admitted with no bed, we have to do it. Sorry to the floor nurse who is mad that I didnt give the 9 pm colace to your patient, we have bigger and more important things to do down here. The ICU patient will get thier orders done, and the high priority things that med/surg patients get will get them. Sometimes if we have enough staff we will designate one nurse to take an assignment of admitted patients and do only those patients and no new ER ones. I actually did this assignment last week and it was probably the easiest one I had in weeks. A lot of downtime at night with nothing to do for them.
We sometimes send a patient to the unit without admission orders (if they're a fresh patient and can get there quickly, we'll ship them up. We'll give report, and the docs with follow us up and finish their orders up there.
If a patient remains on your unit, then whatever meds/interventions that are orders, need to be done. Just because your ED doc didn't write the other, it's still YOUR patient.
We recently had some staff develop an admission tool to assist with this. It has a section to list their daily meds, when FSBS are due, when labs are due, any consults that may be coming, etc. This helps us get it written down for us and future staff when a patient had what meds. I have found it *really* helps to make sure you're on track. Face it- if you have a patient and are not giving those meds that are ordered on the admission orders (if they're due), it's a med error.
in our er, if you end up holding a unit pt/med surg, you're expected to take care of that pt as well as your 3-4 other er pts. if you call to get someone to come down from the icu or med surg floor to help out the answer from administration is that they are already short staffed. now i don't know about you guys... but i'm gonna be a little more concerned about the code or trauma ems just brought in than i am whether or not my med surg pt got their 2100 ambien...
Reading the posts related to holding patients in the ER concerns me more than a little bit. I have worked ER for 14 years and what all of this boils down to is this, we are held to providing a standard of care. If admission orders are not taken off and started in the ER when the patients can be there for hours, then the standard of care is not being followed. Believe me, I have had my share of med/surg admits, ICU admits etc be held for hours or even over night. It is a pain in the CAN!!! But when you are called to court, the attorneys will have a field day with the excuse that admission orders are taken off on the floor, not in the ER. It is the responsibility of the nurse to see that the patients receive the standard of care no matter the location in the hospital. Now for those with residents in your hospitals ,I agree, get them off the butts and have them write orders.
Sounds like your hosp. has some policy changes to work on. In our E.R. when a service accepts a patient like the ICU team ect, they come down , see the patient, write orders, if there is an emergency and they are not there the E.R dr.s take care of it and the ICU team is paged in the mean time. I forgot how long they have, but they have a certain amount of time to write there orders. If they are busy , they write the basics and do the long orders upstairs. The E.R nurses go by the orders they have, and If the patient isn't going up within 2 hours, then they (transcribe) do the orders themselves or someone who isn't busy does them. A lot of the medication issues are the pharmacy fault, they don''t send them, they say they did, they never got the order .There are lots of excuses.
This seems to be an international problem, I work in th ED of a small hospital with a 6 bed ICU (in reality a high dependency unit) and 9 bed CCU (mixed soft/hard wired). Regularly we sit on pts, but also we regularly have to have pts mediacally retrieved out to a bigger teaching hospital.
The dept of health is /has bought in regulations for how long pts are kept in ED's. The DOH feels that no pt should be in ED longer than 8 hrs after admission (by specialist), if they are there longer there is a monetry penalty that the hospital gets hit with. Of course nusing staff are made to feel that its their responsiblity (HA). All it does is increase the pressure on ED staff from another point.
In my experience, ICU orders were written on the patient, and an ICU float nurse was sent down to take care of the patient. This was a problem at a hospital that I worked at last summer, where one day in particular there were 5 ICU overflow patients overnight in the ER. Add in the monitoring, A-lines. vents, etc, and it is impossible for an ER nurse to take care of one of these patients and all of the ER patients they would have also.
In Arizona they passed a law that if an ER is holding ICU patients, they must be staffed the same as if they were in ICU, so the ER nurse ends up with only 2 ICU patients if they have to hold in the ER. Also, if the patient is going to be held in the ER, the admitting physician goes to the ED and writes orders, the ER nurse and clerk use light green and light blue highlighter to highlight over the orders that are completed during the course of the time the patient is being held in the ER. This makes it easy for us in the ICU to tell which things have been done for the patient at a quick glance, it also is a more effective way for orders to be carried out and continuity of patient care to be provided.
We sometimes send a patient to the unit without admission orders (if they're a fresh patient and can get there quickly, we'll ship them up. We'll give report, and the docs with follow us up and finish their orders up there.
If a patient remains on your unit, then whatever meds/interventions that are orders, need to be done. Just because your ED doc didn't write the other, it's still YOUR patient.
Yep, it's still my patient. That was my point. ALL of our unit pts. go up without orders. I can and certainly do keep bugging our ER docs for pain meds & resp. interventions, and continue to titrate the drips.
This problem needs to go up the food chain to Administration. I have been on the receiving end of an ER/ICU turf tiff and ended up getting an entirely different and much sicker patient. I was on ortho.
The last vent I looked at was probably 10 years ago. I agree that ER should be considered critical care. I hope it won't take a sentinel event to make your hospital realize how much danger they are putting their clients into.
As stated previously, Arizona law limits an EDRN to 2 ICU patients and no other patients. This can cause quite a backup out in the ER waiting room.
We push the ED doc's for orders when we have a room assignment. The good experienced ED doc's give you orders for the floor as soon as they decide that the patient is being admitted.
We have a unit secretary that puts the orders into the computer. We ship a copy of the med orders to pharmacy and we have a decent turnaround. Also, many of the meds are in our Pyxis system in the ER already.
I do agree with the EDRN who said that she's going to treat the trauma code before giving the floor patient their 2100 ambein. We call that TRIAGE...you take care of the person who needs urgent care first.
I work in a 14 bed ER. Our admit pts. have orders written when they are admitted. We do the admission orders but that puts a strain on the entire ER. If we are holding an ICU pt. that is generallly a 1 on 1 pt. So that takes away a nurse that could be taking care of Er pts. I have seen us hold as many as 7-8 pts. during the night waiting on beds. That to me is dangerous business. Not only for the admit pt. but for the emergency pts. and thwe nurses as well!
NYCRN16
392 Posts
This is what we do as well. We do not have anyone come from the ICU or floor to care for patients admitted with no bed, we have to do it. Sorry to the floor nurse who is mad that I didnt give the 9 pm colace to your patient, we have bigger and more important things to do down here. The ICU patient will get thier orders done, and the high priority things that med/surg patients get will get them. Sometimes if we have enough staff we will designate one nurse to take an assignment of admitted patients and do only those patients and no new ER ones. I actually did this assignment last week and it was probably the easiest one I had in weeks. A lot of downtime at night with nothing to do for them.