New admits at shift change

I've noticed a pattern of the ED cleaning out their pts that need admitted RIGHT at shift change, which is a pain in the ass for us floor nurses - but is it really too much to ask of an ED nurse to wait a little bit?

YES, at least in my ER. Believe me, it drives us crazy too! All of a sudden we have beds! Then our charge and ER director starts pushing us to move them out! Sometimes we are told that the admitting doctor is on the way, so we'll know a bed is due to be cleaned but have no control on the timing-All of a sudden the swoop of physicians leave their offices and are now onsite in the ER. They don't want to go to the floor so they hold up our patients too! Then it's shift change-sometimes I think it's a conspiracy...the worst is when they start pulling our patients into the hallways and giving us medic patients. Who has time to call report when you are working up a new CP. Personally, I'd like to go back to faxed reports...I don't need to speak to anyone, unless it's ICU or CCU. I am very detailed in my written report and send all supporting documentation to the floor. I'd rather have my stablized patient sitting in your hallway, than in mine:D

Maisy

I'm an ER nurse myself. This is always an ongoing issue. I can understand both sides of it. I will always hold when we have the rooms and the time. The problem is patients are ready for admit when they are ready.Whether that be shift change or not. We don't purposely wait for that few minutes time frame. I always try to wait until after shift change when I can. However, when I have patients waiting on a room that we can't get back until this room is cleared out, then yes that puts us in a hurry. Also, we still have to report this patient to the next nurse so somewhere regardless of where the patient waits there is going to be a nurse holding it for a few minutes until one or the other is ready. Saying all that, this still does not excuse the attitude. When we can be respectful and learn to read each other it helps us understand the other side and what is going on at the moment. There are some nurses when they ask me to hold I know there is no way they can accept this patient right now. However some nurses ask me to hold and I don't hear anything back from them for 3 hours plus. Not Kidding.

On the rare occasion I ask the ER to hold someone for a few minutes, I always call back when I say I will (unless something happens, of course) and I always take the patient up, whether I'm ready for it or not.

We have certain nurses in the ER who will intentionally dump patients at shift change... because that means they don't have to pick up more patients. It drives us crazy and if the supervisor realizes what's happening, he/she won't give them a bed right away. It's a twisted little game.

If ER tries to call report at shift change, I'll usually take it and then just pass it on to dayshift. As long as they know it's coming, they can make assignments accordingly.

Thankfully, a lot of my friends from school work in the ER, so if I ask nicely and plead my case, they'll usually hold when I need them to.

Again, I am not sure holding is within the rights of those nurses. Many times it is not within our rights. Our charge will make us call the floor charge RN if nurse tells us to call back. They are on us every second to move, move, move. If we aren't busy-I'll hold if I am able, but 95% of the time it's not my call.

Maisy

I've noticed a pattern of the ED cleaning out their pts that need admitted RIGHT at shift change, which is a pain in the ass for us floor nurses - but is it really too much to ask of an ED nurse to wait a little bit?

Yes MeganAnne sometimes it is too much. What you are not understanding is that ER nurses cannot control when the bed is assigned, when the orders are written or how many patients need to be admitted. Believe me we would love to avoid admits at shift change if it was at all possible so we didn't have to take the crap dished out to us either. For every ONE admission you get there can be up to SEVENTY (no that is not an exaggeration) people waiting for my bed. We know it is an inconvenience to the floor, we don't do it on purpose and quite frankly I am getting a little tired of these threads blaming the ER. Your time would be much better spent trying to find a solution. Here's an idea. My hospital created an admissions nurse position whose hours are I think 5-5 (am and pm). She would do the admissions on most patients but in particular those who had to be admitted during shift change. When there were no admissions she served as a resource person to the floors (covered lunches, helped with MRT's, etc.) This has greatly reduced the squabbling. In addition if the situation arose where the admit nurse was unavailable the floor nurse receiving the patient was only responsible for a set of vitals (tech can do that) and a "breathing check". The on-coming nurse did the paperwork and assessment. Please can we avoid turning this into another "ER vs. Floor" thread. Sorry if this came across as grumpy...I just woke up and my inhibitor isn't warmed up yet.:bowingpur

I think it is really important for every floor to have a policy so that this situation is not so stress-inducing. I worked 3rd shift peds for many years. We got more admits from ER than any other shift. Any admit after 6:45 AM was settled in a room, made comfortable and the admit paperwork held for the next shift. We also worked that way on the beginning of our shift.

It was a very high priority to get patients to bed and not have them hanging around the ER. If all the admit paperwork had to wait, so be it.

I am not in support of NOT transferring pt. at report time. Let's be real, the receiving unit wants to count the 20 minutes before report and 20 minutes after report as report. This works out to be over an hour, several times per day.

I work in a PACU. Can you imagine us telling anesthesia they cannot bring their pts. out because we are in report. That would be kicked all the way up to the DNS. So, when the floors/ICUs try to stave off the pt., the PACU or ED RN is overwhelmed and care is compromised.

I really enjoyed reading this thread for some of the great responses out there from ER nurses! I have had this happen to me quite a few times in ICU where I'll get an admit at 6 but I just try to take a deep breath and get as much done as I can as the patient will most always need an a-line, triple lumen, foley, cultures sent, care plans started, and about 100 other things. When this happens I know I will be at least an hour late getting home. It sucks and it seems it really sucks for you guys (ER nurses) too. I also HATE leaving work for the next shift so I try to stay to do as much as I can.

I just chalk it up to its a 24hour facility and things can happen any hour of the day and thankfully it doesnt happen every day lol. In our case many of the times the nurses have no control over it and its usually a Doc who wants to get the pt up to our unit ASAP, no matter what time it is. It also seems that we, most often, get new admits at around 5-6 in the afternoon. I guess all I can say is I definately feel for ya in those situations because they definately are no fun. Do you get any help on your floor from other nurses when you are getting an admit at a bad time? It really helps when you can get help from others to make a bad situation a little bit better. :icon_hug:

I am not in support of NOT transferring pt. at report time. Let's be real, the receiving unit wants to count the 20 minutes before report and 20 minutes after report as report. This works out to be over an hour, several times per day.

I work in a PACU. Can you imagine us telling anesthesia they cannot bring their pts. out because we are in report. That would be kicked all the way up to the DNS. So, when the floors/ICUs try to stave off the pt., the PACU or ED RN is overwhelmed and care is compromised.

We change shifts twice a day; that leaves 22hrs to transfer pts. In the past month we have had a pt sent up, non responsive, with a bp of 60 palp, no report sent from the ED. One from PACU also severely hypotensive, hypothermic. Both went to ICU. Amazing what the ride up in the elevator does to the perfectly "stable" pt, must be the altitude. Anyway, both times the floor nurse was right there to assess the pt off the bat, but when they send pts when shes trying to get report and there is a delay in her seeing them, how safe is that? I have been told by PACU nurses, "well they have a PCA, you dont have to do anything with them" when I have asked them to wait 15 minutes for shift change. Huh? No clue.

Bottom line is sending pts to the floor at shift change is potential dangerous and the nurse receiving the pt is the one whose butt is on the line.

I cannot imagine what it would be like to work the ED. (Or maybe I can and that's why I don't work one. hehe) That kind of minimally controlled patient flow - with all the complaints about waiting unreasonably long times - is just NOT for me. So I just take the admission whenever it comes and go with the flow. Yes, it's irritating if it comes at the change of shift. Hopefully, the oncoming nurse will be where he/she can just step in there with me and take report while I get the patient connected to the monitors and assess the patient. That's the ideal.

Our beds are assigned through a computer application. We can see the time when the request for admission/transfer is placed and the time when the bed is assigned. What is fishy is when the bed was assigned for an admission through ED at around 1400 and it arrives to the unit at 1845. I just try to be Pollyanna-esque - smile and do my best to believe that the RN in the ED was busy with this patient and others and couldn't move him/her sooner. To be completely frank, it's easy to believe. I can't think of a single RN from the ED who looks as if he/she spends a lot of time sitting...

I really enjoyed reading this thread for some of the great responses out there from ER nurses! I have had this happen to me quite a few times in ICU where I'll get an admit at 6 but I just try to take a deep breath and get as much done as I can as the patient will most always need an a-line, triple lumen, foley, cultures sent, care plans started, and about 100 other things. When this happens I know I will be at least an hour late getting home. It sucks and it seems it really sucks for you guys (ER nurses) too. I also HATE leaving work for the next shift so I try to stay to do as much as I can.

I just chalk it up to its a 24hour facility and things can happen any hour of the day and thankfully it doesnt happen every day lol. In our case many of the times the nurses have no control over it and its usually a Doc who wants to get the pt up to our unit ASAP, no matter what time it is. It also seems that we, most often, get new admits at around 5-6 in the afternoon. I guess all I can say is I definately feel for ya in those situations because they definately are no fun. Do you get any help on your floor from other nurses when you are getting an admit at a bad time? It really helps when you can get help from others to make a bad situation a little bit better. :icon_hug:

You'd love working our unit, I have never seen a patient leave the ER without all of the things you mentioned you'd have to stay late to do. It's all done by us before patients hit the floor! We get the hairy eyeball if the patient has urine in their foley, or their wounds haven't been measured. (Can't do everybody's job). It's usually the same for the floors, they are fluffed and buffed-just waiting to be tucked in!:nuke:

Maisy

I work in an ER. If I can, I try to wait until I know shift change is over before I transfer a pt. But I can't always do that. Sometimes I have the DR or the charge breathing down my neck to get the pt out of there so we can get another one into the room.

What gets to me is when I call to give report and I'm put on hold for > 5 min while they try to find someone to take report. I don't have 5 min! The last time this happened I literally had one pt code while another LOL was trying to strip tease in the hallway. Obviously I hung up, called the code, threw a blanket over granny, and tried to contain the chaos. The floor called back and yelled at me for hanging up! If you can't take my call in a minute or less, just give me a ring when you're ready. It may sound insensitive, but when it's busy, I barely have time to give report at all.

Another time I brought a pt up to ICU. As we were transferring her the nurse made a nasty comment about how I hadn't emptied her foley before transfering her. I did feel badly about it, but when I was caring for her she was on the verge of death and her foley was the least of my worries. In the ER we understand that the floors provide better care for seriously ill, time intensive pts, so we try to get the really ill ones upstairs as fast as possible. We basically stabilize them and transport. This makes sense b/c ICU ratio is 1:1 or 1:2. I still have 3 other pts despite my seriously ill one to care for in the ED.

I always try to be nice and considerate. I don't mind calling back later and holding pts if necessary. I actually do that pretty frequently. It just isn't always possible.