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?

[HiddencatBSN, BSN]

On 7/6/2020 at 5:31 PM, JBudd said:

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.

Was just going to say, I don’t remember the last time I haven’t eaten at the nurses station. We drop staffing at 3am regardless of whether our volume has dropped and there isn’t always float pool staff to cover the difference especially when the volume is higher than expected.

The ICU can’t create beds, but we can and do and we also have responsibility for a waiting room of patients who are varying levels of acuity from could-have-gone-to-pcp-in-2-weeks to as-soon-as-that-admit-goes-up-wipe-down-the-bed-and-toss-a-clean-sheet-down to we’re-starting-this-one-in-the-trauma-bay.

As far as communication and respect go, in my experience at multiple facilities, my personal politeness has nothing to do with how readily report is received. I have noticed that hospitals I’ve been at that have done away with report to med surg tend to be ones where there were issues with patient transfer being delayed from the time a room is assigned and the ones that continue on with phoned report seem to move patients more smoothly.

Currently my facility calls report. When the receiving RN sounds harried and asks for some time before I send up the patient I try to accommodate that. When the delay is because there’s no crib in the room and the waiting room is 6 hours deep during flu season and the patient has been held by mom sitting on the stretcher in the ER for the last however many hours, they can just as easily continue that arrangement for the time it takes for a crib to be delivered to the inpatient room in that room rather than in the ER.

I’ve done inpatient and know that things get hectic but delayed movement has ripple effects that can impact multiple patients.

[Jeckrn1, ADN, BSN]

On 7/4/2020 at 8:50 AM, 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.

The report does not have to be verbal, it can be electronic.

[Jeckrn1, ADN, BSN]

I once worked in a high volume ED and often when we tried to call report we got the nurse is not available then the charge is not available. They state they will call back in 15 minutes which 9 out of 10 did not happen and when you called back after 30 minutes you got push back. How we stopped that issue was we called the floor, asked for the nurse taking the patient. If not available the change nurse. If not available informed them the patient is on the way. Problem of delaying taking report stopped real quick.

[BeenThere2012, ASN, RN]

28 minutes ago, Jeckrn1 said:

I once worked in a high volume ED and often when we tried to call report we got the nurse is not available then the charge is not available. They state they will call back in 15 minutes which 9 out of 10 did not happen and when you called back after 30 minutes you got push back. How we stopped that issue was we called the floor, asked for the nurse taking the patient. If not available the change nurse. If not available informed them the patient is on the way. Problem of delaying taking report stopped real quick.

It troubles me to see this post turn into a “competition” if you will, of ER nurses having to defend their position for expedient hand-offs and Floor nurses defending their position of being forced to take a patient when they Too are overwhelmed or pressured.

Seems to me it is coming down to administrations causing all the pressure with not enough staff to handle the acuity of patients or the high patient loads nurses are forced to deal with. Once again, this is the same book...different chapter. Nurses end up arguing their side with one another, when in fact, it’s administrations refusing to provide adequate staffing.

[NightNerd, MSN, RN]

We get a written SBAR as a note in the computer. No official time limit before they can transfer the patient up, but it's usually at least half an hour. I actually like reading the SBAR; it's a good summary and I can quickly look up anything else I'm interested in while I'm in the EMR. Talking on the phone is annoying and distracting, LOL, so I have learned to prefer this. It does sound like your hospital is making a pretty sudden change without a clear presentation of the new practice to the people it will affect, which isn't okay. Whether written, verbal on the phone, or bedside, I think it's important to somehow hear from the ER nurse what the patient came in for and what's been done for them so far; anything else is something we can probably figure out on the fly, even if it's not ideal.

[OUxPhys, BSN, RN]

You know, after reading all the responses I guess this really wouldn't be too bad of a policy. If I find out I am getting an admission I already look up the patient to get an idea of what I will be dealing with. Still, it would be nice to get a quick call from the ER nurse to give a quick update (for example of any meds were given or if any drips were started).

[scribblz, BSN, CNA, LPN]

On my med surg unit myself or whoever is charge will get a phone call from the Nursing supervisor that they have an admission that needs to be placed.

IE. I've got a 93 yr old tele admit here with CHF exac with a foley and a lasix gtt. Now if I have no close beds to the nurse's station I might have to move some people around, and negotiate for a slight delay while I work that out. But that's between the supervisor and I, not the ED.

A good nursing supervisor should have a rapport with both the ED charge RN and the in patient charge RN to facilitate getting people into beds at a pace that takes into consideration how busy each are. Not to say there aren't nights they don't try to slam us every 20 minutes...but overall it works.

Once she assigns the bed they SBAR via fax which provides the scenario that brings them to the hospital, procedures and tests done in the ED, basic head to toe assessment, home med list and meds received in the ED. The ED charge nurse calls to confirm we received the SBAR and provide the ascom phone extension for the primary ED nurse for that patient. They generally roll up within 15 to 30 minutes after SBAR'ing.

I find it to be a pretty good system. I can call and ask any questions if I have them, but I don't have to interrupt what I'm doing to take report which totally works for me.

[explorereb96, ADN, BSN]

All we get from the ER is an SBAR which really is just basic. The GOOD ER nurses will at least put in their admitting diagnosis, small synopsis of why they came in, their IV site and any fluids rec'd, last vital signs, their monitor info, meds they were given and for what. Sheesh it only takes 5 mins. I am finding that this new way doesn't streamline anything but the ER, it makes the patient's upset and feel as if they are hastily handed off. I also noticed that these nurses aren't able to give a good, solid report since they never practice it. Most of the SBARs I receive now are useful only for the name and age of the patient. not worth the paper faxed up to us. heh why bother, just phone up and tell us I'm getting a 85 year old female to room 240 bed 2. I'll look up the rest.

[Deborah Cohen, BSN, RN, CNM]

I totally agree with the nurses who have a more global perspective. I have not worked ER but I've worked Intensive care. The triage is similar. If there are no ER or ICU beds you are on red alert. You can change the entire EMS system routing critically ill patients to more remote sites risking their lives. I've worked on the floor and I've been in situations where the ER nurse is trying to give report. Often times the floor nurse is in no big hurry to take it. Especially when it's the end of a shift. During this Pandemic it is essential that we free up beds. I think it's a good idea for some type of communication to happen but honestly if a patient is deemed stable enough to go to a med surg bed then the floor nurse has adequate time to read the chart or the info in the EMR. We have to learn delegation. Let your CNA go get vitals and situate the patient. In the meantime you can scan the chart and even ask the patient why they are there.

[CardiacRNLA, BSN]

On 7/5/2020 at 9:57 PM, LovingLife123 said:

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. 

I could have not said it better. Some of the worst report I received or charting I have seen is from the ED. They didn't know crap about the patient they supposedly were "treating." The only concern was sending them upstairs. Which usually screws over the floor once they are admitted. It becomes someone else's problem. Gimme a break. The ED isn't the only place concerned with throughput.

[CardiacRNLA, BSN]

2 hours ago, Deborah Cohen said:

I totally agree with the nurses who have a more global perspective. I have not worked ER but I've worked Intensive care. The triage is similar. If there are no ER or ICU beds you are on red alert. You can change the entire EMS system routing critically ill patients to more remote sites risking their lives. I've worked on the floor and I've been in situations where the ER nurse is trying to give report. Often times the floor nurse is in no big hurry to take it. Especially when it's the end of a shift. During this Pandemic it is essential that we free up beds. I think it's a good idea for some type of communication to happen but honestly if a patient is deemed stable enough to go to a med surg bed then the floor nurse has adequate time to read the chart or the info in the EMR. We have to learn delegation. Let your CNA go get vitals and situate the patient. In the meantime you can scan the chart and even ask the patient why they are there.

I am sorry but you could not be more misguided and wrong. You are just as guilty of not looking at it globally. Especially with the snide comment, "The floor nurse is no hurry to take it" about report. You think that floor nurses are the only ones that want to shirk report during change of shift? How about the multiple times, the ED charted and verbally stated INCORRECT things in report. Sent a patient to a med-tele bed just to move a patient upstairs and we on the floor have to fix it and move them to a higher level of care? This is a delay in care. And I saw it happening all the time.

Being "global" is not just focusing on the EDs needs. Being global is truly being global and looking at all the perspectives. I saw the entire fractured system needs work.

[JKL33]

3 hours ago, Deborah Cohen said:

I've worked on the floor and I've been in situations where the ER nurse is trying to give report. Often times the floor nurse is in no big hurry to take it. Especially when it's the end of a shift.

Probably because they don't have it any better than anyone else does. This is solidly a business and administration problem and we are wrong to hold it against our fellow coworkers. Maybe this would never have become such an issue if other toxic attitudes and practices weren't allowed and propagated by management, such as making the off-going nurse complete the admit on a patient that rolls up at 6:59 because it's "her" (or "his") admit. Just completing all the documentation isn't enough, either. They get crabbed at if they have to pass off anything to do with "their" admission (including getting the orders implemented) to the next RN, and also crabbed at if they try to do it themselves and incur OT. And crabbed at if they try to prioritize by skipping some useless part of the admission assessment. And on and on.

If it's that important to move patients up to the floors, then I guess maybe there should be separate admission RNs, a whole staff of them. They could be their own team. That's the kind of idea that actually gets put into place when people are serious about something. But what we have here is more corporate fantasies, where a few people will accomplish much with as few resources as humanly possible.

3 hours ago, Deborah Cohen said:

honestly if a patient is deemed stable enough to go to a med surg bed then the floor nurse has adequate time to read the chart or the info in the EMR.

Have you been paying any attention to the number of patients who inappropriately go to M/S beds? Or the fact that patients have to be at least a little bit actually sick to get any inpatient bed even if M/S is the right bed for the patient's condition?

While all of this is frustrating, I will repeat that it is most times inappropriate to look to coworkers as the underlying problem. Your comment is probably quite insulting to some here, as if M/S nurses don't understand that they are allowed to (try to) delegate vital signs to a (probably legitimately not available) tech.

3 hours ago, Deborah Cohen said:

ask the patient why they are there.

You can't be serious with this. On the one hand we shall give them no hint ever that we are busy because that is inappropriate and bad customer service and will encourage distrust. But your idea is that the staff RN should ask them why they're there because business people don't want to pay for a better way to get patients settled into beds?