Imput please: change of shift and admits.

TazziRN, RN · Nov 21, 2006

I don't know about PACU, but it wouldn't work in the ER. At my place we try to work with the floors and hold admits if it's around change of shift, but there are times when we just can't. There are even times when we have to send a pt to the floor with the house supe and report hasn't been called, because we're expecting a major injury accident pt, or a CPR in progress. I agree that if the ER is not inundated (which we often are, and in the larger ERs it's even worse) the pt should be held if at all possible, BUT.....my experience has been on the other side of the coin: we have to get the pt out because we're expecting something bad, or we have umpteen pts in the waiting room waiting to come back, and the floor nurse says "I'm going to lunch now" or "I have to (fill in blank) to Mrs. So-and-so". The room may be ready at 5, but the nurse may have had fifty things to do with her four other pts and couldn't bring the pt then. And I don't know about most ERs but the ones I've worked at do not start PCA pumps. We do, however give IVP meds, which your pt should have gotten.

I'm not saying this is what's happening. It sounds like, from what you said about the nurse in your post that there was no reason for the pt not to be medicated, but about not bringing the pt down right away.......there may have been things going on in the ER that you don't know.

dosamigos76, RN · Nov 21, 2006

Where I worked at, if the pt was in ER and orders included an IV or Foley, they HAD to have one BEFORE they were sent to the floor. Antibiotics HAD to be given within four hours of being seen in ER, so they usually had their first dose before we got them. Another nice thing was if telemetry was ordered they had better have it on and working before they came to the floor as well. If someone DIDN'T follow procedure, they were written up big time. It made a lot of difference when you're taking an admission on the floor and cut down a lot of the stress for everyone involved.

Cheryl

meownsmile, BSN, RN · Nov 21, 2006

WE also have a huge problem with this. 1500 and 1900 esepcially. We have patients brought to the floor from ER and bam,,, here comes OR to take them to surgery. We are lucky if there is 15 min to even see the patient. The patient should have been kept and readied for surgery in the ER.

Then there is the PACU/ER rush where of course they dont know what the other is doing and we seem to get both depts patients at the same time.

If we ask one to hold for a few minutes you would think we asked them to cut off their own right arm without anesthesia.

My solution, i usually let the one who has to give me report (ie PACU, sorry guys) wait. They have to stay with the patient until they pass report so its only logical that the PACU nurse is going to wait until i can get in there for report. I get the patient from ER in bed and a quickie assessment then im off to the surgical to get report. I dont make them wait long,, maybe 10 min at the longest, but thats the only solution ive come up with since noone wants to LISTEN to what we need from them.

wooh, BSN, RN · Nov 21, 2006

The room may be ready at 5, but the nurse may have had fifty things to do with her four other pts and couldn't bring the pt then.

But when the ER nurse is ready, the receiving floor nurse of course doesn't have fifty things to do with her other patients at the time?

It goes both ways, we're all busy!!

scrmblr · Nov 21, 2006

I can't speak for PACU...But I can say that if ER is busy it is insanely busy. If I have a pt with a bed ready at five I try really really hard not to transfer at shift change. But, sometimes, I will have other pt's to transfer or some seriously sick pt that needs cont care. I have no idea what the solution should be. Know that if I send you a pt at shift change it is because my life is hell in the ER.

starae · Nov 21, 2006

As a PACU nurse I must first say I'm sorry that sometimes this happens to you. Unfortunately, there are times when it can not be avoided. Our PACU usually gets slammed throughout the afternoon and it seems the patients are often ready to go around 6:30-7. Sometimes we can not hold them because there are several times a day we are holding up patients coming from the OR when we are full. Management does not take to kindly to hearing the patients are not moving because it is near change of shift. Also, the amount of time our patients spend in PACU is tracked and averaged. If they are staying there longer without a genuine need we have to answer for that. In our unit, we do start all the IVFs, PCAs, treatments, and IV meds that are due. I think this helps the floor quite a bit. I can say personally I have recently been on the floor and understand how hard it is to take a new patient while starting or ending the shift, and I empathize with you. It is usually not intentional and most of the nurses don't even notice that it is shift change.

Just wanted to present the other side of the story. It sounds like there also may be a problem to be addressed with safe staffing for night shift on your floor.

RunnerRN, BSN, RN · Nov 21, 2006

But when the ER nurse is ready, the receiving floor nurse of course doesn't have fifty things to do with her other patients at the time?
It goes both ways, we're all busy!!

You're right, all nurses are busy :) But I will say, there is a difference. The floor has a finite capacity. The ED cannot put more patients than you have beds (and in my hospital, we have more beds than we have nurses so we're constantly limited by the number of nurses working on the floor). We do not have a capacity at all. It doesn't matter how many CPs and traumas and strokes we're already doing, if another walks in the door, we're going to push someone into the hall and start the new one. I've had patients on nitro/heparin gtts in the hallway because we had so many sick ppl. We've also gotten to the point that we've run out of tele so had ppl on the Zolls (crash cart monitors) and dynamaps.

Sick people don't know what "shift change" means. All they know is that they hurt or don't feel right. Same thing goes with EMS pts.

No nurse in my dept waits until shift change to get patients to their rooms. And if I get a bed at 5 (a clean bed) and it takes me 2 hrs to get the pt up, you can be sure the poop hit the fan in the meantime. And if we aren't busy and a floor RN asks me to hold the pt for a little bit I will do my best. Now maybe in your hospital there IS a trend to sending admits up at shift change (does the whole hosp work 7a-7p?) It might be worth instituting a little study to try to change things and see if some education is in order.

Good luck! I know it is just as frustrating for you to get a mad rush of admits as it is for us to get stonewalled by the unit secretary :)

TazziRN, RN · Nov 21, 2006

I can't speak for PACU...But I can say that if ER is busy it is insanely busy. If I have a pt with a bed ready at five I try really really hard not to transfer at shift change. But, sometimes, I will have other pt's to transfer or some seriously sick pt that needs cont care. I have no idea what the solution should be. Know that if I send you a pt at shift change it is because my life is hell in the ER.

You said it better than I did, thank you!!

No, I'm not saying floors are not busy with the pts they have, but floors don't have to worry about where to put the code pt coming in the back door because the floor won't take the pt yet and the nurse taking the pt has gone to lunch. We try very hard to accomodate the floor nurses and hold pts if we need to, but we have a problem with floor nurses telling us "No" when we call and say "We NEED to bring the pt now!" Most ERs are closed/locked units, not visible to the rest of the hospital unless you're actually in the dept. "Insanely busy" only barely describes how bad it can get.

I'll back out now. This has always been a hot issue.

JMBM · Nov 21, 2006

I work in an ED. I know its hard, annemarieRN. Almost all of our nurses have worked on the floors and we know precisely how much it sucks to have an admit roll in at 1850. Its really tempting to lash out at the person who handed you the admit - be it the ED or PACU nurse. Now, there may be a few inconsiderate ED nurses out there who don't care about your shift change, but in almost every single case, the problem is not the nurse downstairs. In our shop, if we have an admit that falls sometime after 1830, we do our best to drag our feet until after 1930 to give the new shift a chance to get their feet under them. But just as TazziRN and RunnerRN have said, sometimes we just have no choice. We can't stop the ambulances from coming or the people from walking in the door. So why does an admit arrive at 1800 when a bed was ready at 1530? Nine times out of ten, it is due to the doc. We request a bed as soon as we know the patient will be admitted. However, we can't move the patient until the doctor writes admit orders. Many times, the admitting doc or resident on duty comes down, examines the patient, then spends 45 minutes writing orders - all after the bed was ready. The orders might then require emergent treatments or changes to prior treatments - things that need to be done before the patient goes up. Then three more chest pains roll in. All while the bed is ready. In the meantime, the charge nurse is yelling at you to get that patient upstairs to open the bed. Believe me, if we could have handed you that patient at 1530, we would have, but sometimes it just doesn't happen. So, annemarie, if an ED or PACU nurse is jamming you at shift change due to lack of consideration, I'm really sorry and that nurse needs an attitude correction. However, please know that most of us understand your situation and only hit you at shift change if patient care absolutely demands it.

k3immigrant · Nov 21, 2006

admitting a pt at the change of shift i think is an issue about safety.i once admitted a pt from ED that on report sounded ok.it was a change of shift so our policy is to tuck in the pt, check vital signs & do report but what happened was, the pt's BP on the floor was 70's, no good IV access(22G), O2 sat low 80's.ED nurse said, "oh the BP was fine before we left". To make the story short, 10 minutes later, we are coding the patient. The result was, unnecessary overtime for outgoing shift, wasting of a bed(the pt was not triaged right so from ED to step down then ICU) & everybody being stressed out.

transfer at the change of shift is not bad at all as long as ED nurse will assess pt that pt will not code just after the pt is transferred from the gurney to the bed & PACU nurses, at least the pain med was just given or at least the PCA was already set up & ready to hook for the receiving nurse or at least the order was already called/scanned/faxed to pharmacy so it's just to pull out from the pyxis & to set up.

all of us should think this way when giving a pt to another nurse, "how do i feel if i am the receiving nurse?"

Antikigirl, ASN, RN · Nov 21, 2006

Happens at our unit all the time too!

The part that gets me is family that follows that patient up during this time!!! They all come up to our floors and all the sudden they think it is eat/drink time, or time for the hotel services to start! Now they will put a kink into just trying to get that patient stable, info, and change shift! It is this that will have me swimming over my workday.

I feel that maybe family should wait in the lobby till the admit/transfer is done (one family member to help with questions as needed in the room) and the patient is settled in. Families don't care if it is change of shift, and get really nervous or anxious if there is an immediate switch of nurses...so I think they should wait in a lobby till all is settled with the admit, then they can come in. (plus it is always so much fun to try to get a patient all set up dodging all the family members, their personal items, the way they quickly set up the chairs in the exact wrong spaces...or get in the way or complain about transfering the patient to our beds...uhggggg!).

I have advocated for family to remain in our lobby on our floor till the patient is settled in, I also find it is a good policy for HIPAA because I am going to be asking questions the pt may not want everyone to know but feels obligated to tell me anyway. If family wasn't in the room, I could get my job done quicker without interuptions and be able to hand off care to the next nurse in an effective mannor.