I worked 7a-7p yesterday and my charge nurse told me at about 6:30p that we were getting an admit - we printed out her info from the ED even thought we both knew the pt wouldnt be coming up until after I'd left. Well at 6:53pm the ED calls and wants to give me report - I explain that I'd take "report" (most of the time they just say "Have you read the paperwork? Are you ready for them?" and no report). However, I did tell the nurse I wasn't the nurse that would be taking care of the pt - we were at shift change and havent even gotten a chance to start report. She finally asked if we were ready for the pt, so I put her on hold for a second to ask the nurse who was relieving me (who was also charge that night -- our night charges have a full group as well) AND the current charge if they wanted me to ask if they could wait a little.
They both agreed to wait till at least the nurse could get through report. I asked the ED nurse to wait 15-20 minutes, and she says "Ugh... yea, I guess I'll just tell my charge" and hangs up.
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?
[That should never happen, without knowing, you did say you were told a patient was coming...was it a miscommunication or do you think deliberate? If deliberate it should be written up!]
The way our ER ---> Floor admissions work is we get a slip with the patienst name/dx/doc and then that is shortly (usually 15 mins) followed by fax report, and sometimes a call "hey we're on our way up". The patient comes up 15 mins after report, unless something changes.
On that particular patient all I got was the slip.. no faxed report... no ER call. So really all I knew was her name and dx. I was also not told that she was advanced dementia and admitted at the end of the hall (50+ ft from the nurses station with no line of site). yeah, it was a GREAT night.
I think having an admitting nurse sounds great. We have an 'admitting unit' but they are only here M-F 8am-9pm. (No Wknds, No Holidays) because we never admit people after 9pm or on the weekends, right?
I think it would be great if ALL ER nurses were to follow a floor nurse around for a few shifts, and ALL floor nurses were able to follow an ER nurse around for a few shifts. It's amazing the perspective you get when you walk in someone elses shoes.
No, I don't like shift change admits, but there are things that both sides need to realize.
a. Your report is not more important than my getting report from the other floor nurses - these are all pts that need our care
b. If a pt comes up right before shift change, we are still to do a full assessment and sections of the paperwork - we can not 'fluff and buff' unless they arrive after 7am. We usually have accucheck and meds at this time, so we WILL be staying late.
c. Floor nurses have multiple patients too and at shift change are likely to be answering family members questions, taking patients medicines, assisting patients to the bathroom, etc. I for one am not going to tell a pt they must pee faster because ER is calling me with report. But I try to call back as soon as I can. (And NO, it would never be more than 30min unless we had a pt crashing). We can not plan our busiest time of the evening for when the ER might call with report.
d. While you have potentially three patients in the ER, I have five to six. You can probably keep a closer eye on them than I can. (of course this is depending on how busy the ER is)
e. When ER's are busy I have known stable admits that are being admitted to the floor being wheeled into the hallway so that the new ambulance can have that room - they are waiting in the hallway for the floor nurses
f. The hospital administration is pushing the ER nurses to get the patients out quickly and they are the ones getting in trouble if the pt waits in the ER too long (that is due to pt complaints about ER waits, but does not take into consideration the safety of the pts in situations where the ER could care for them better)
I guess my response to all of this is - if the ER nurses would make an effort to 'hold' shift change patients (at our request (so they know if we are busy or not (depending on how close to shift change it is)) when they are not busy (yes there are mornings when there are four nurses and two patients - I would think they could handle it), It would be so much easier to be gracious and have you bring up a pt when the ER is busy. It's a two way street - if you help us out when we need it (and you are able), we will try to help you out to help you free your room up as quick as you can. (i.e. there was one morning I even went down to get our ER admit because they were so busy). I think it is mainly the nurse in that aspect - there are a few of our ER nurses who volunteer to hold the pt if they know we are in report (when they can of course), then others who refuse even if it is the sole pt in the ER.
I am all for the admitting nurse, and / or staggering shifts, but until that point in time comes - if we can all try to see each other's point of view it would help tremendously.
It's not a secret that many (not all) ED nurses hang on to patients until they leave so they don't have to take another before end of shift. That puts the new shifts in both departments under the gun. Please just send your patient when THEY are ready to go, not when you are. Oh, and PLEASE do not ignore Med/Surg orders just because they are still in ED. We've had patients with stat blood transfusion orders 10 hours old and not started. Just because it says med/surg orders doesn't mean you ignore them entirely.
For the record, I could never do an ER nurses job...I would implode after one crazy night. Most nurses understand each others position; it's the lazy/negligent few who make it difficult for others. I've tried to give other nurses the benefit of the doubt until proven otherwise and it's helped me to judge a lot less.
I NEVER hold patients until shift change just so I don't get another one. Don't assume that is what happened when you get a patient at shift change. I get my patients up as soon as I see a bed assigned. Our charge nurses make a big push to get patients up, as we have big computerized boards that show how long the patients have been there, their bed assignments, etc.
Now if it is time for me to go home and I get a bed, I am happy to have the oncoming nurse hold the patient, but I want to give report seeing as how I know the patient. I don't like being made to stay late waiting to give report. I really do try and do what I can to alleviate some of the problems between the ED and the floor though!
We have the same issues in PACU. Our policy is we call the floor to tell the floor when the patient has arrived in PACU. Usually, the patients stay about an hour, with a few exceptions). Approximately 15 min before we are ready to bring the patient down, we call the floor again to notify them that we will be there in 15 min. So now, the floor has been notifiied twice.
We get to the floor with the patient, I kid you not, the nurses will watch us walk by, no one offers to help get the patients into the bed. I've had to put the call light on to get a nurse to come in MANY times. I've waited up to 20 min for someone to show up. There have been times I've had to leave my patient, go out to the desk and ask "who will be receiving this patient" only to hear "I'm not sure yet?". This is totally unacceptable!
There should be a nurse ready and waiting for us to come down, as we always give notice as to when we are coming.
I don't have the luxury of telling anesthesia "I'm sorry, we're busy and can't take the next post op right now" - and I don't want to hear that from the floors either!
I don't often have the luxury of waiting for the floor nurses to "get it together" and argue (yes, I've heard arguements as have the patients as to who will be taking my post op) as I often have other patients rolling into PACU all day. So time is of the essence.
Specializes in Cardiothoracic Transplant Telemetry.
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 understand what you are saying, and you obviously work at a large busy ED. Our ED is small and goes on divert regularly if there are more than 20 people checked in. One of the things that we see happening is that the ED nurses will want to call report up to the floor on a patient that they know is going to be admitted before they go home so that the oncoming shift doesn't have to do it. The problem with this is that the admitting doc usually hasn't seen the patient yet, and often the patient isn't ready to come to the floor for hours. In these cases we get no update on the patient's condition, any tests done, or even when they will actually show up.
What ends up happening is that the off-going ED nurse gives a minimal report to the off-going floor nurse, with information that is incomplete because the work-up on the patient is incomplete. The oncoming nurse gets a report sheet that basically has a set of vitals, a presenting complaint and maybe the results of the cbc. They then have to watch the door like a hawk to make sure that the transporter doesn't sneak the patient past the desk to the room without telling anyone, and we have no idea what we are getting.
When I get a patient to the floor, I am unable to get any medications for that patient until the orders are processed and approved by the pharmacy, and allergies are entered. I have had patients sent to the floor in active chest pain with no way of accessing meds to treat it, and patients sent to the floor vomiting from the 1mg of IV dilaudid they gave the narcotic naive patient for their nitro headache right before sending them to the floor. I would have liked a update on the report that I received 3 hours prior to these patients hitting the floor, but I didn't get that.
Sorry if I sound snippy, but can you tell that I have been a little frustrated lately? :redpinkhe
Specializes in Cardiothoracic Transplant Telemetry.
Now if it is time for me to go home and I get a bed, I am happy to have the oncoming nurse hold the patient, but I want to give report seeing as how I know the patient. I don't like being made to stay late waiting to give report. I really do try and do what I can to alleviate some of the problems between the ED and the floor though!
It is great for you to call report before you leave because you know the patient- but only if they are ready to come up. If they are going to be down in the ED for 2-3 hours receiving more tests and waiting for orders to be written, then the oncoming ED nurse has plenty of time to get to know them.
One of the things that I wonder sometimes is if the ED nurses see report as a inconvenience that they need to get out of the way. ED nurses never know what is coming in the door, so I think that they forget how much more prepared we can be to treat the patient with a timely and thorough report. I have always seen report as a necessary component to continuity of care, and I like to know what is going on, to myself and the other nurses on the floor, we see report as much more than a mark in a required box.
Specializes in Utilization Review/Case Management.
It's not a secret that many (not all) ED nurses hang on to patients until they leave so they don't have to take another before end of shift. That puts the new shifts in both departments under the gun. Please just send your patient when THEY are ready to go, not when you are. Oh, and PLEASE do not ignore Med/Surg orders just because they are still in ED. We've had patients with stat blood transfusion orders 10 hours old and not started. Just because it says med/surg orders doesn't mean you ignore them entirely.
Thanks
If this is the norm at your hospital, there is something wrong.
Our ED manager stresses the length of stay averages. Holding a patient in the ED for 10 hours after admission orders is unheard of where I work, unless there is no bed available at all. Then usually the pt. gets transferred if we can work that out. Also, if they do need to stay, we try to get as many of the floor orders done prior to transfer/on the schedule as we can.
However, we still might have 3 or 4 critical patients, and a few hall patients we are caring for. We have to do a full assessment, psychosocial and medication reconciliations, plus carry out all orders, initiate IV's, help them to the restroom, collect lab samples and discharge/admit/transfer for each patient, with the average being 10-15 patients per nurse in a 12 hour shift.
Med surg is tough, I know. I hated getting admits at shift change as well, because it seemed that PACU and ED all wanted to dump patients between 1700 and 1900, plus dinners, plus meds, fingersticks for the diabetics, family visits and "can you fluff my pillow and feed me dinner" from those who can do it for themselves. Then to top it off, the admitting/attending physicians would show up and discharge patients. (that is part of the problem, patients who could be discharged at lunch, but the doctor isn't there to sign the orders, therefore ED patients have to wait until that room is free and clean to be brought up).
It is a system wide problem, not just a nursing problem. The problem is that nurses are seem to be the ones that feel the pressure, and have to make it work.
The nursing staff needs to stick together and document the problems we have. We all need to be held accountable for the problem, work together and fix what we can.
Specializes in Clinic, formerly ED, ICU, PACU, ortho.
I work in the recovery room. Like the ED, the top excuses for not taking the pt. on the floor/ICU are 1)It's shift change (let's make this an hour ordeal) 2) the room is not ready (call housekeeping, or I will) 3) that pt. has not been assigned (ps-it is an empty bed, assign it at the beginning of the shift during "report" 4)we haven't heard of the pt (I called before and someone knew you were getting him) 5)the nurse will call you back (then doesn't) 6) can you hold him for a while (sure, pts come out of the OR, or through the ED, regardless of whether or not we are busy, but by all means, let us hold them for you).
Solution: "Let me talk to my charge nurse or the nursing supervisor, I'll get back to you." 90% of the time the nurse will call right back to take the pt. Imagine that.
There should be a nurse ready and waiting for us to come down, as we always give notice as to when we are coming.
Ha ha Ok, and shall I stand there with drinks and appetizers for you? Seriously....we have full assignments, often times 6 pts....I absolutely do not have the time to stand there waiting for my post op when I could be passing meds, assessing, doing dressing changes, doing my prev post op admit, an er admit, etc etc etc.
Stand there waiting....I have never heard anything more ridiculous in my life.
Bottom line, ALL nurses are busy. ALL of us, regardless of what dept we work in. We all have different stressors, but how about we remember the reason we are there....FOR THE PATIENT. Lets not be unrealistic. I often times miss lunch, bathroom breaks are a rarity, so forgive if I am not standing around simply awaiting your arrival.
Finally...somebody who gets it! I'd work with you any day :yeah:Medic2RN!!!!!!!
Thanks FlyingScot....I start my new ER job in August. It'll be an interesting change from the floor. I'm sure I'll have greater insight into this post at a later time.
:redpinkhe
KeechieSan
93 Posts
[That should never happen, without knowing, you did say you were told a patient was coming...was it a miscommunication or do you think deliberate? If deliberate it should be written up!]
The way our ER ---> Floor admissions work is we get a slip with the patienst name/dx/doc and then that is shortly (usually 15 mins) followed by fax report, and sometimes a call "hey we're on our way up". The patient comes up 15 mins after report, unless something changes.
On that particular patient all I got was the slip.. no faxed report... no ER call. So really all I knew was her name and dx. I was also not told that she was advanced dementia and admitted at the end of the hall (50+ ft from the nurses station with no line of site). yeah, it was a GREAT night.