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

allnurses Guide · Jul 6, 2020

It isn't perfect, but it works. We are told to have our patients out of the ER in 15-30 minutes within receiving a room assignment. There is a place where we can look to see if the floor nurse has checked the EMR review. We are expected to keep charting up to date and ready to go in a few minutes notice.

I have had clinical supervisors put in for transport without asking me if the pt is ready! I have had to cancel transport if I am in the middle of something that can't wait. So yes, communication is essential..... but the narrative from the ER chart generally says it all.
The floor nurses have called me to clarify stuff, or I have called if there is something acute I think needs to be passed on. Generally if I call, that nurse has reviewed the chart so well that I don't have much to add.

And no, I haven't had a lunch break (officially off the clock for 30 minutes) in a long time. Nights are like that. Getting people moving is essential.

NurseSpeedy, ADN, LPN, RN · Jul 6, 2020

On 7/3/2020 at 8:02 AM, justjRN said:
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?

The hospital I used to work started this in 2017 I believe. Safe-not really. Going to change-probably not. It stunk. Patients showed up with drips not charted and not sure how much they got or the bed since the IV got ripped out during transport and the sheets were soaked with bodily fluids and IV drip fluid (cardiac meds with a titration ordered). Not sure how effective the meds are since not sure when it started flowing or when the IV came out. Total mess but it was all about how it looked on paper. Time from admission order to time to floor. Record times I’m sure. Not so great for patient safety or satisfaction.

Closed Account 12345 · Jul 7, 2020

I have several thoughts on this.

1. Know your Board's definition of patient abandonment. In my state, care must be transferred to a receiving RN. However, dumping a patient in an RN's assigned room, and this certainly is dumping, doesn't constitute a transfer of care. The receiving RN must be given an opportunity to accept/decline care of a new patient assignment. A facility's policy can't lower the standard of abandonment.

Let's say the receiving nurse is at lunch when a patient is dropped off in her room. The transferring nurse doesn't notify the charge nurse or nurse providing break coverage. Three hours later, the floor nurse realizes there's someone in a room she thought was empty. The patient is in the floor with a head injury. The responsibility lies fully with the nurse who dropped and ran without safe communication.

2. Joint Commission states "A handoff is a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient-specific information from one caregiver to another." Joint Commission notes that handoff allows for discussion between the sending and receiving nurse; the receiving nurse must have the opportunity to ask questions and have them answered to determine if he/she is willing to accept the patient's care.

Rolling a patient into one of my assigned empty rooms doesn't mean I've accepted that patient's care. Providing me with a detailed beside report doesn't mean I've accepted a patient's care. It is my responsibility to determine, based on the report received, whether or not I can safely accept a new patient's care. That is when my duty to the new patient begins. Now, might saying "I don't accept this patient's care at this time" result in employer repercussions (barring Texas Safe Harbor situations)? Maybe. You're going to end up with an angry ED nurse and manager, maybe an angry charge nurse and floor manager. You could be written up; your job could be threatened.

However, I'm more concerned with protecting patient safety (and my license) than I am with protecting my job or people pleasing. The reality is that some patients require care beyond my scope of practice. The reality is that a receiving Med Surg nurse may already have 5 other patients, 2 of whom are going downhill fast, 2 of whom are fresh post-op patients, and 1 of whom has dementia and keeps trying to climb out of bed. Can this nurse safely accept a new patient with respiratory distress and a glucose of 400 from the ED when she knows the patient next door is about to code? No, she can't, and she has a right to say so. Accepting the new patient's care at that point endangers the well-being of her existing patients and the new patient. It means she almost certainly can't meet the standards of practice in the care she is providing.

I was an ER nurse; I understand the importance of opening beds to serve the greatest number of patients. There are certainly floor nurses who drag their feet on new admissions for a variety of illegitimate reasons, including convenience. That is a leadership problem that should be addressed in their unit. There are also plenty of legitimate reasons to decline a new admit. Ultimately, it is the unit manager's responsibility to ensure adequate staffing of the unit based on patient acuity and safe ratios. That way there's always someone available to accept a new patient if a room is available.

3. Medical records existed prior to modern patient handoff standards. There's a reason handoff was created. The majority of sentinel events are related to communication failures. Yes, the information is available in the chart. When does the M/S nurse described in bullet point #2 have time to review the new patient's chart? Thankfully, most EMRs provide a patient summary/e-Kardex that can be reviewed in about 1 minute... but the nurse still needs the opportunity to ask the sending nurse questions before deciding if she will accept the new patient. When I worked in the ED, we called the receiving unit to say "Will you let the nurse receiving John Doe know that we're coming up in 10 minutes? I sent a copy of the patient summary, and I can be reached at extension 1234 if she has any questions before transfer." That system worked well because a) it didn't waste time providing a lengthy report; b) it gave the receiving nurse a chance to ask questions or decline the admission; c) it gave the receiving nurse a heads up that I was coming so she could meet me in the room if possible. If the receiving nurse wasn't available to review the faxed summary, the unit secretary was required to give it to the charge nurse instead, and she would temporarily accept the patient. The ED nurses were instructed to document report provided, transport to the floor, AND "Patient care accepted by ____." That's when our own responsibility for the patients ended.

4. First, I would have a sit down conversation with your manager. Present factual information and objectively list your concerns. Hopefully, the two of you can work together to find a suitable solution. If nothing is resolved, and you're truly having patients dumped on you without receiving a proper handoff, you should complete an incident report for each patient dumping occurrence at the end of your shift. Copy and paste Joint Commission's requirements for patient handoff into your report. Copy and paste your Board's definition of abandonment, if it's relevant. List any patient concerns that arose during the shift that would've been prevented if you'd received report. Do it every time. Make risk management aware of this dangerous process, and make it known that you're not willing to take the fall when a patient is harmed as a result.

OUxPhys, BSN, RN · Jul 7, 2020

So for those saying just read the chart why don't we do that for every area? Why should the ER only get that privelege? When Im busy id love to tell cath lab or one of the medicine floors "In slammed over here, just read the chart in the room".

Guest219794 · Jul 7, 2020

On 7/6/2020 at 4:47 PM, LovingLife123 said:
I don’t need every, single detail. But the patient having a implanted defibrillator is important. My point was, it wasn’t in any note. So you all saying look in the notes in crap, because there is nothing in the notes.
The ER getting crappy because I’m transporting a patient to their new room to make room for the patient from the ER is unacceptable. I can’t make floor beds open up faster, I can’t make housekeeping clean the room faster.
I don’t give a crap when their last BM was, what their skin looks like, any of that small stuff. But I want a basic report. Don’t tell me the ER doesn’t have time. I’ve gotten a lunch break twice in the last two weeks. I don’t have time.

I could easily have a pt with an ICD and not know it if it was not related to the chief complaint. If I did know it, I would not have written it in a note.

So, how did you ulimately learn about the ICD if not from the chart? Did it go off by surprise?

JKL33 · Jul 8, 2020

On 7/6/2020 at 5:02 PM, simba and mufasa said:
Crowding, Boarding, and Patient Throughput 
ER is a catchment area, get patient, stabilize and move them out. An ER is not a holding area, and nurses do not have time to take care of the patient as done on MedSerg/ICU or any other area. Throughput is the name of the game. Working as an ER nurse has opened my eyes literally and figuratively. The constant push of report by nurses on the receiving units can be detrimental to the patient. An emergency department (ER) is “crowded” when the need for services exceeds the department’s available resources for timely patient care. I understand that nurses on the receiving floors are frustrated.
Crowding causes a variety of deleterious patient care and outcomes, including increased patient mortality, increased rates of medical errors, increased numbers of delayed or missed orders, increased total length of stay, decreased door-to-imaging times for stroke patients, poorer outcomes increasing ambulance diversion (I.e., when an ED closes to ambulance traffic) and patient offload time (I.e., the time that EMTs and paramedics spend waiting for an ED bed to open so that they can return to services. Have been there done that. I have been on the receiving end and have sabotaged a transfer at times but the caseload on the units is real, its a slippery slope, profits before safety and a hostage situation for nurses where they are left bickering at each other instead of administration that directs everything with a remote control. Form a nurse practice council so self governance and autonomy.
And yes, have called the floor for report without fully knowing the patient. if the patient is septic, who cares about the skin, as an ER nurse, the concern is to stabilize and ship them to the unit. and then the full assessment can be done.
Dr Madenya

This is good information for nurses never exposed to the ED.

But...true as much of it is, it is not an excuse for administration seeking to remove long-standing protocols that have an important purpose and are in everyone's best interest. I have given two examples of things (1. resources used on low acuity patients and 2. General charting burdens) that in my mind would have to be addressed if admin wants to be taken seriously about ED overcrowding concerns. If throughput is the real, primary concern then step up to the plate and cut some of the actually burdensome BS. The answer is not to leave everyone still struggling with the pace and the care/documentation burdens and then cut big holes in safety-net-type things (like basic, concise report) instead of addressing these bigger things that would significantly improve unnecessary care burdens in the ED (and thus could be reasonably expected to significantly improve throughput).

Quote
Form a nurse practice council so self governance and autonomy.

It is a wonderful idea but I have not seen it produce the kind of results it sounds like it would. Definitely not autonomy.

Chronic Care Coordinator · Jul 8, 2020

Interesting post!

Valid comments from all!

Here is my perspective, having being a floor nurse, an ED nurse and an administrator from management!

Floors are generally swamped between sick pts, emergencies and staffing issues. It is important for staff to document and give management a protest of assignment in unsafe situations. Floor controls discharges,bed cleaning and accepting pts to the unit. Once the unit reaches capacity,no more admissions from the ED.

The ED is generally a mad house with controlled chaos! They cannot close their doors to emergencies and have to keep accepting patients. So they "Stick them, fix them and move them out" to the floor to make room for the next emergencies. Sometimes, the care is perceived as "not stellar" by the floor' cause the pt came in poop, drenched, not fed,IV dry----the list goes on and on. The ED nurses-some are thorough,some are not.Sometimes they get crashing pts and might not do the last peek beneath the sheets even if they are stellar nurses.

When I worked in the floor, I saw a lot of games being played by some not all nurses. "I am not taking an admission at 5pm as I have meds, dressings and charting to do". Meanwhile the pt is an 85 year old on a stretcher in the ED for 36 hours waiting on a telemetry bed (imagine your loved one on that stretcher). Calling report from the ED-no one picked up the phone or put you on hold as they were busy or dare I say didn't want to talk to you and accept the pt.

So we piloted a sheet in the ED along with the floor nurse's wish list. We did it as a team having reps from every floor and ED-all nurses.

It had the pt's report in easy to read format(Name,medical record number, diagnosis, med/surg history, meds given,IVS/transfusions and heplock gauge and site, any tubes(NG,Foley) or attachments(colostomy,illeostomy),implants (AICD,Pacemaker),allergies,Code status and barriers-Hard of hearing,language etc,signature (legible) and extension. Takes 3-5 mns to fill out.

This sheet was faxed and the ER secretary paged the charge nurse on the floor's beeper. Every charge nurse carried one including the ED charge nurse. The floor had 30 minutes to call back( hold for another half hour as we are running a code on another pt).Both teams attempted to work with each other. Few weeks before the project started ,floor nurses spend 4 hours in the ED with an ED nurse observing the flow. It is also working well (better than before)because the entire bedboard is online and everyone is involved when a pt is discharged, so that beds can be cleaned and made ready. In case of issues, administration steps in.

As an administrator, I make sure protocol is followed, both parties are polite with each other and reach out to resolve in real time (if possible) by connecting the second party on a conference line. Sometimes, I would ask the ED to hold off or even move the pt to a different available bed on another floor, if the first floor is having a major issue or a prolonged code.

At the end of the day, working together makes it much more of a peaceful day within your control. We all want the same things-staff practice safely, pt get good care and go home feeling what you did was productive and not a finger pointing session. In this Covid stress and racial injustice climate let us be kind to each other! We work hard enough and should build each other up and not tear each other down.Together we are stronger!

JKL33 · Jul 8, 2020

24 minutes ago, spotangel said:
Takes 3-5 mns to fill out.

This is seriously more time than I usually spend in total on the verbal report process.

Some of the stuff you're writing down is both inconsequential and very obvious upon first glance (NG, foley, location of IV site, ostomies, etc)

I promise I'm not picking on you!! - but <groan>. This is terrible, terrible. Filling out another piece of paper with stuff that is in the chart is the 2nd worst solution ("look in the chart 'cause they're coming up!" being the 1st worst solution). Actually, writing out another paper just might be worse than telling them to look in the chart. Sorry...?

Wuulie · Jul 8, 2020

My hospital started doing this as well. The ICU and tele units get report, but the regular med/surg units do not. I do not see a problem with this personally. I have worked both ends of the spectrum (I've worked ICU, ED, gen/surg, and tele). More often than not, the ED nurse just reads from the EMR anyways while giving report. The ED is such a busy, task based environment, that the nurses don't often have any more information to give that cant be found in the ED physician note or MAR. Ideally, the patient's stay in the ED should be short, so the ED nurse hasn't had a lot of time to gather information. The floor nurse has literally hours to be an investigator and gather information. Requiring the ED nurse to give report delays things by more than the time it takes to give report. It delays it by the time it takes for the ED nurse and the floor nurse to finally get a hold of each other. This delay is more harmful to hospital flow and patient outcomes than the 10min it requires from the floor nurse to look up ED notes. Floor nurses need to realize that patients that are ready to be transferred to the floor, just sit in the ED and kinda get ignored because the ED nurse is busy with the 5 other patients that just came in. The patient might as well be transferred to the floor at that point--even if it means waiting for the floor nurse to look up orders and notes.

Wuzzie · Jul 8, 2020

7 hours ago, JKL33 said:
Some of the stuff you're writing down is both inconsequential and very obvious upon first glance (NG, foley, location of IV site, ostomies, etc)

Yes, but you would not believe how many times I got asked what side the IV was on. Ostensibly it was so they could have the "pump on the right side of the bed" but, come on, the poles have wheels! ??

JKL33 · Jul 8, 2020

“I usually put them in the left AC so that’s probably where it is”

?

Guest219794 · Jul 8, 2020

This is a good thread with some good ideas from both sides. I really encourage people to avoid any posts that can be perceived as "us vs them" I know my first reaction can be defensiveness.

It is just refreshing to be on this site and have a productive conversation sharing ideas.