New protocol - No report from ER to floor...

[justjRN]

I work med surg and our hospital recently started new protocol that ER does not call report to floor patient is being admitted to. We are told we will be getting ER patient such and such and what they are generally being admitted for and to expect them within 10 minutes of notification they are coming. We are to look up any other info (our entire report basically). It sucks for us and it sucks for the poor patient who has questions etc when they get to the floor and we know nothing yet as it usually takes about a good 15 mins UNINTERRUPTED (which is nearly impossible as we are working short most times anyway) at a computer looking up history, labs, notes ,iv's, meds given in ER, new orders etc to put together why they are there/plan. Many of us have complained how unsafe it is and even many near misses that have happened because of it. But of course.. it falls on deaf ears. I was told it's understandable but they don't see it changing anytime soon...?!

So- I wanted to vent and to also see if this is the process anywhere else out there?

[Guest219794]

12 hours ago, Elaine M said:

I always thought you had to give some sort of report when transferring patients. Imo throwing a chart at someone when you being a patient to a floor isn't report. It may prevent back up in an ER but I think there are better ways to do that.

Absolutely. Nobody should throw a chart at anybody. What would have been great is if there had been training in how to best utilize the technology to get the information you need.

It sounds like management changed he admission process and provided no training in how to receive PTs without a verbal report. That reflects a complete failure of leadership.

If you are knowledgeable about how to effectively glean information from a chart, but you are getting patients with incomplete charts, that is also a failure in leadership.

I just finished a shift. Late in the day, I gave report. Every single piece of information I gave was easily accessible in the chart. Most of it I got from the chart literally 2 minutes prior to calling, and while I was actually talking to the floor.

The fact that I did not have these facts stored in my head, or on a paper brain sheet is not because I am a slacker. I am CEN certified, regularly get excellent evaluations, and function as a preceptor. I know how to do my job.

The traditional verbal report is the single worst possible way to transfer information. It is like the game of telephone we played as kids because we know that information gets distorted when passed on verbally.

No doubt it is frustrating to be expected to do a job and not be given the tools to do it well.

[JKL33]

On 7/4/2020 at 5:20 AM, hherrn said:

Regardless of whether it is frustrating or best practice, it is done with the big picture in mind. The big picture is that this is a better choice than backing up the ER. 

On 7/4/2020 at 10:10 PM, hherrn said:

The traditional verbal report is the single worst possible way to transfer information. It is like the game of telephone we played as kids because we know that information gets distorted when passed on verbally.

You have made a good case for this change in practice and I had to think about it for a couple of days before responding. My concerns remain.

I don't have a problem with using EMR summaries for report; that's fine. But the hand-off and acceptance of care is actually still an official thing, an actual process...it's there for a reason...regardless of the fantasies of corporate types. I have no idea why we would make excuses for its breakdown.

In healthcare we are fond of excusing bad changes by pointing out that current ways are problematic. When commonsense "happy mediums" are never chosen and are avoided much like deadly poison, we should ask why. Well, the reason is because there is a promoted reason (aka excuse) about why a change is being made, and then there is the real reason it is being made. The real reason has precluded the happy medium.

You see, this is a little bit about not backing up the ED, and a lot about removing M/S nurses from the process of interaction. It's about being able to get patients into M/S beds regardless of the patient's status or the general floor's ability to care for them. It's about sending them up as fast as possible whether they are staffed to care for them properly or not. The game of telephone thing would be a legit concern if that were the only method of information sharing for the patient's entire stay. But a report from an ED nurse (who should have a very good idea of what has gone on so far) is no game of telephone. Game of telephone would be Day 5 M/S nurse reporting what happened in the ED based on days' worth of verbal transmissions of the ED story.

The fact that caregiving in the ED is now fractured and the ED nurse doesn't know much more of the story than anyone else may be a sad fact but is not a defense of the issue we are discussing (or anything else).

There are numerous other ways we could be improving ED back-ups. For example, no execs in my area are interested in investing in a truly robust method of completely separating the not-sick out of the ED loop. I suspect because ED billing. No one is interested in limiting the care and charting burdens associated with these not-sick patients, either. Again with the ED billing. So we continue with the full "triages," (after the patients have already been immediately roomed, of course) the full med recs, multiple screenings and the full head-to-toe assessments on patients with very simple and straightforward needs. Then we say that we need to cut M/S out of the loop to get patients upstairs faster because ED back-ups? Well, that's a little disingenuous at that point.

Respectfully, I believe that verbal report (even if it just consists of two people reviewing the same summary screen together for 60 seconds) has an important function. Attempts to eliminate it are not because it is so highly ineffective, but for business purposes that do not serve patients' or nurses' interests.

[EDNURSE20, BSN]

At my old hospital this was standard. I work float pool, so saw both sides of it. Most of the time it wasn’t an issue, as long as there was a good admission note from the Dr. But if I had questions/concerns I would just call the ER and speak to the nurse to clarify.

[mi_dreamin, BSN]

When I worked the floor I usually looked at my pt's labs/admission note, and any test results once I knew they were coming. It took me 5 minutes and then I knew what questions to ask, e.g. I see ancef was ordered, was it given?

I think that would be my concern with no face-to-face or verbal contact. I don't need to know the whole story, but there was almost always something that wasn't documented in the EMR that I needed to know. Otherwise I wouldn't have minded no formal report.

[BiscuitStripes, BSN, RN]

Is this in CA by chance?

[Lepetitpitbull]

Created an account just to comment. From an ER perspective this is a tempting policy. But while I do think patients should be sent up when the bed is ready, I also think the med/surg nurses should then call for report and the patient should be sent to regardless. I rarely give any information in report that could not be gleaned from reading the chart, but is important that the receiving nurse have a conversation where they can ask questions. I'd imagine they would like to know how they ambulate at baseline vs now and that can take a little digging if there's no verbal report. But imaging, ivs, labs, all that is black and white, plain as day in the chart.

[CommunityRNBSN, BSN, RN]

On 7/4/2020 at 5:20 AM, hherrn said:

Emergent made good points about good use of EMR. As an ER nurse, one of the things I have noticed is that despite advances in record keeping, many units use the same type of communication I saw as a student in 2002. A lot of verbal communication and handwriting. This is not how modern industries keep track of critical information.

I work outpatient but I had to chime in. Do you know how many times a week I PRINT something off a patient’s medical record and FAX it to a hospital or a specialist? Dozens of times a week. We aren’t even talking 2002– more like 1992. It’s an enormous problem and absolutely compromises safety. In our case, errors are made in sending things all the time (wrong phone number, fax offline, illegible handwriting). In the hospital, nurses are writing things down on scraps of paper, then typing them into charts.

[Tweety, BSN, RN]

The ER gives us a verbal report, but we are not allowed to obstruct the transfer by saying "I'm busy let me call you back". When they call report the patient is usually already on the way. If by chance we miss report we can call them, or the electronic chart usually has all the most of the information we need.

I think it's important though to get a hand off from someone whom has laid eyes on, listened to and taken care of the patient.

[LovingLife123]

I’m sorry, but telling me I can get all my info from the chart is the biggest load of crap I’ve ever heard. Not one ED person charted on my patient’s ICD. Not one.

I get real tired of hearing crap from other depts about my unit. Everybody thinks we just sit around in the ICU all day and yuk it up. I’m sorry the ER is backed up, or you had to hold a patient in PACU a little longer. I’ve got 4 different departments clamoring for my one bed.

Am I not entitled to shove lunch down? Do I not get time to clean my room and set it up? I get so tired of ED and PACU getting crappy about things out of my control. And sorry, but the ED is terrible at charting and giving me any info on my patient. Good thing I didn’t send my patient to MRI with the lack of charting and info.

[BeenThere2012, ASN, RN]

On 7/3/2020 at 7:15 PM, NewEnglandRN16 said:

I worked at a hospital that used an SBAR report. When they assigned the room the charge nurse would get the patients name via pager. When the patient is ready to come up to the floor the charge nurse gets a notification that the SBAR is ready. They are to bring the patient up after 30 minutes when the SBAR is notified to be ready. This allows time to review SBAR and get ready. There are situations that require a nurse to call report. The only issue we deal with is often times we get notified SBAR is ready but the ER hold their patient until shift change. This has caused a lot of issues for the floor nurses and they are not allowed to admit patients during shift change 30 minutes before 30 minutes after.

Well at least you are giving the floor the 30 minutes. As we all know, since you never know when or how many will come, you can’t make any sort of a good plan or time management adjustments when you have no idea what to expect until they get there. Makes no sense to me other than another “dump” situation we nurses experience all the time. Having said that, I realize ER nurses have little to no warning for their patients coming either. However, the triage protocols help control the flow to some degree. It troubles me how we nurses have such little control over the flow of our work. Where I work, we often get patients without any report. It’s not the policy but it happens frequently.

“Oh I thought so and so already gave report!” At that point, it’s too late and you have no choice but to scramble and hope nothing important is missed.

[Guest219794]

On 7/5/2020 at 10:35 AM, JKL33 said:

You have made a good case for this change in practice and I had to think about it for a couple of days before responding. My concerns remain.

I don't have a problem with using EMR summaries for report; that's fine. But the hand-off and acceptance of care is actually still an official thing, an actual process...it's there for a reason...regardless of the fantasies of corporate types. I have no idea why we would make excuses for its breakdown.

In healthcare we are fond of excusing bad changes by pointing out that current ways are problematic. When commonsense "happy mediums" are never chosen and are avoided much like deadly poison, we should ask why. Well, the reason is because there is a promoted reason (aka excuse) about why a change is being made, and then there is the real reason it is being made. The real reason has precluded the happy medium.

You see, this is a little bit about not backing up the ED, and a lot about removing M/S nurses from the process of interaction. It's about being able to get patients into M/S beds regardless of the patient's status or the general floor's ability to care for them. It's about sending them up as fast as possible whether they are staffed to care for them properly or not. The game of telephone thing would be a legit concern if that were the only method of information sharing for the patient's entire stay. But a report from an ED nurse (who should have a very good idea of what has gone on so far) is no game of telephone. Game of telephone would be Day 5 M/S nurse reporting what happened in the ED based on days' worth of verbal transmissions of the ED story.

The fact that caregiving in the ED is now fractured and the ED nurse doesn't know much more of the story than anyone else may be a sad fact but is not a defense of the issue we are discussing (or anything else).

There are numerous other ways we could be improving ED back-ups. For example, no execs in my area are interested in investing in a truly robust method of completely separating the not-sick out of the ED loop. I suspect because ED billing. No one is interested in limiting the care and charting burdens associated with these not-sick patients, either. Again with the ED billing. So we continue with the full "triages," (after the patients have already been immediately roomed, of course) the full med recs, multiple screenings and the full head-to-toe assessments on patients with very simple and straightforward needs. Then we say that we need to cut M/S out of the loop to get patients upstairs faster because ED back-ups? Well, that's a little disingenuous at that point.

Respectfully, I believe that verbal report (even if it just consists of two people reviewing the same summary screen together for 60 seconds) has an important function. Attempts to eliminate it are not because it is so highly ineffective, but for business purposes that do not serve patients' or nurses' interests.

Excellent points regarding some of the throughput issues faced in an ER. The assessments and screenings you refer to are irrelevant and inaccurate. ENA and ACEP both push to streamline patient care and reduce all this wasted time.

But, the issue in your OP is a bit different and has to do with time from decision to admit and actually moving the patient to the floor.

What would you recommend to meet that goal?

Also- thanks for listening and communicating well. This thread could easily go off on track into unit vs unit nonsense.

[Guest219794]

When I worked ICU we had remote coverage at night. EICU where a doc at a remote site monitoring a large group of PTs they had never seen. I was shocked at ho wquickly they could make critical decisions on PT's they had not seen. ICU nurse to nurse reports were close to 15 minute each, and these remote docs could make important decisions in 2 minutes. That is when I started focusing more on the doc's documentation to learn more about my PTs. Frankly, they are better at it than us.

I can read an ER doc summary, basic hx, and course of care in in 3-4 minutes.

In a perfect world, receiving RN would have an opportunity to review the chart- 5 minutes should do it. ER nurse could give a brief verbal presentation covering the big picture and nuanced issued not well covered in EMR. Receiving nurse could ask questions about issues not in the EMR.

This would be done in a certain time frame. X minutes. If either side can not meet their obligation, a brief variance report will be filed with periodic reviews to ascertain personnel vs system issues.