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

Nurses General Nursing

Published

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?

Specializes in Critical CarE, WOCN, DELEGATION, CASE MANAGEMENT,.

I'm not trying to insult anyone with my comments. I think you are missing the point. We aren't talking about your world on your floor in any given day. This is City, County, Statewide emergency response. I am quite certain that floor nurses are barraged with demands from all sides. I'm going to take a chance and reiterate that triage and delegation are paramount. You don't need to read nursing notes in the EMR. Read the Physician report. Look at the labs. What is the admitting dx? I'm sorry if you don't agree. You say that patients are coming to the floor sicker. I'm sure they are. Then just imagine what is landing in the critical care bed. We are all stressed. We are short handed. We work overtime. We can't leave or we're charged with abandonment. We have no voice. Let's face it, the system stinks. But it's what we have. Nurses have no collective bargaining power. We need to stop pointing fingers at each other. We need to respect what each of us has to do and come together.

On 7/20/2020 at 5:52 AM, Deborah Cohen said:

I think you are missing the point. We aren't talking about your world on your floor in any given day.

I'm not missing any point and I work in the ED.

On 7/20/2020 at 5:52 AM, Deborah Cohen said:

This is City, County, Statewide emergency response.

Maybe you jumped in because covid, but this "no report" thing has absolutely nothing to do with covid. It's been a must-try management experiment for a very, very, very long time in various places and varying iterations. If management is implying that a change like this is because covid they are being opportunistic. I assume we will be seeing quite a bit of covid opportunism for a long time to come.

On 7/20/2020 at 5:52 AM, Deborah Cohen said:

We need to stop pointing fingers at each other.

Well that sounds familiar. ?

1 Votes
59 minutes ago, Deborah Cohen said:

I'm not trying to insult anyone with my comments. I think you are missing the point. We aren't talking about your world on your floor in any given day. This is City, County, Statewide emergency response. I am quite certain that floor nurses are barraged with demands from all sides. I'm going to take a chance and reiterate that triage and delegation are paramount. You don't need to read nursing notes in the EMR. Read the Physician report. Look at the labs. What is the admitting dx? I'm sorry if you don't agree. You say that patients are coming to the floor sicker. I'm sure they are. Then just imagine what is landing in the critical care bed. We are all stressed. We are short handed. We work overtime. We can't leave or we're charged with abandonment. We have no voice. Let's face it, the system stinks. But it's what we have. Nurses have no collective bargaining power. We need to stop pointing fingers at each other. We need to respect what each of us has to do and come together.

It's possible that you missed the point JKL was making. Or at least the main point.

The main point is that this is system problem. The result of making nurses try to take care of patients in this clearly inadequate system is conflict between units.

In no other field are people realistically expected to do more in less time. It is simply impossible. In manufacturing, they know how long it takes to assemble a widget. If somebody expects a widget to be assembled, then painted in that same amount of time, they know that either, or both, tasks will be skimped on.

Yet in nursing, you are expected to provide the same level of care to your 5 floor PTs despite an admit, or to your 4 ER PTs despite boarding PTs.

When faced with this impossible task, nurses focus on what looks like the immediate cause- Floor won't take the PT, or ER is trying to dump the PT. The cause is not your peers from another unit, it is management having clearly impossible and conflicting goals. You don't do more with less. You do more with more. But they don't want to pay for more, and they sure as hell don't want to get their old scrubs out of the closet and role model how to do it.

3 Votes
On 7/5/2020 at 7:45 AM, EDNURSE20 said:

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.

This is the same way my hospital operates too. The ED nurse writes a progress note (using a template) in SBAR format and includes their phone number at the end of the note for the floor nurse to call if they have any questions. And the floor nurse has 15 minutes, upon being notified by the manager, to review the note, patient's chart and any other relevant information and then call bed control to confirm that the room is ready for the patient to be admitted into. Also while reviewing the patient's chart, if the floor nurse spots any discrepancy, e.g., the patient would be better suited to a different department based on several factors (diagnosis, symptoms, level of care needed etc), the manager is to be then made aware.

In a perfect world this method would work perfectly however hospitals are not perfect sometimes things do get missed - think missed orders, missed labs, missed meds etc. For example the ED nurse might release all the orders and acknowledge them but not complete them all. And because this information might not have been communicated to the floor nurse, one of those orders could be missed unintentionally.

The point is, in nursing school we were a taught to rely on evidence based research. That is the basis of our practice. The latest evidence based research states that a significant amount of errors take place due to poor communication or lack of communication during the nursing hand-off.

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?

I worked in a level 1 years ago who did this. Only difference was an SBAR was faxed to the floor as well.

As someone who’s worked every unit in the hospital, save the OR, this is best practice. Provided the SBAR is sent. I would recommend this as something your hospital can do to improve the measure. We also got report on any level 1 traumas (we were the trauma/transplant unit, half M/s tele, half SSDU).

When I went to ED years later, the pushback we got on patients was insane. Nurses will say anything to keep the admit off the floor. They’ll spend 20 minutes looking for reasons to not take the patient. I know this because it’s something I saw when I worked the floor as well. The only thing I can say is that we are all busy. But there are some nurses who think they’re the only busy one, and they take it out on everyone. I’m not saying you’re one of those people, but it’s a hard wall to hit when you need to get an ED pt upstairs.

The fact is that it’s almost always safer to get the patient out of the ED and onto their unit. ED nurses are turning rooms like a waitress turns tables on a busy Friday night. They have a full waiting room, full hallways, and the endless slaughter of EMS bringing people through the door. They don’t get to review the chart and tell the ambulance “I’m sorry but I can’t take this patient right now, I have a lot going on.”

The Us vs Them mentality of units is really insane to me. Everyone needs to work together to get this *** done. If you have a nurse refusing to take a patient? Do you know the amount of time it takes the ED to get a patient up to the floor can affect their ability to be reimbursed? Those minutes count. And the ED RN has her charge nurse down her throat as to why the patient isn’t gone while simultaneously fighting the floor nurse to get the patient up there.

This usually happens when the ED is losing on that metric. EDs are black holes of hospitals as it is, rarely making money. Usually they cost the hospitals money. So, your administration is going to do anything they can to change that. Or at least stop the hemorrhaging.

Im not saying it’s right or wrong. It just is.

I’ve worked almost every system there is, and I would say there’s no system that should be taking you 15 minutes to look up a new patient. So, you guys could improve on that front. As for the ED, they need to be sending an SBAR with the patient somehow, OR they could put on in the chart. It would make a big difference.

As for the ED RNs who are dumping patients on the floor covered in urine or feces? Clean them up. Stop doing it. You know who you are, and you know it’s wrong. When I worked the floors it happened to me at least once a shift. It’s so disrespectful to the patient. Just because you can do it, you shouldn’t.

Also, I went to home health this year after 2 major spinal surgeries. I miss the hospital very much, but I don’t miss this stuff. I kind of love my autonomy and the ability to work alone.

1 Votes
Specializes in Tele/Interventional/Non-Invasive Cardiology.
On 7/21/2020 at 12:27 PM, NurseCocoBSN said:

I worked in a level 1 years ago who did this. Only difference was an SBAR was faxed to the floor as well.

As someone who’s worked every unit in the hospital, save the OR, this is best practice. Provided the SBAR is sent. I would recommend this as something your hospital can do to improve the measure. We also got report on any level 1 traumas (we were the trauma/transplant unit, half M/s tele, half SSDU).

When I went to ED years later, the pushback we got on patients was insane. Nurses will say anything to keep the admit off the floor. They’ll spend 20 minutes looking for reasons to not take the patient. I know this because it’s something I saw when I worked the floor as well. The only thing I can say is that we are all busy. But there are some nurses who think they’re the only busy one, and they take it out on everyone. I’m not saying you’re one of those people, but it’s a hard wall to hit when you need to get an ED pt upstairs.

The fact is that it’s almost always safer to get the patient out of the ED and onto their unit. ED nurses are turning rooms like a waitress turns tables on a busy Friday night. They have a full waiting room, full hallways, and the endless slaughter of EMS bringing people through the door. They don’t get to review the chart and tell the ambulance “I’m sorry but I can’t take this patient right now, I have a lot going on.”

The Us vs Them mentality of units is really insane to me. Everyone needs to work together to get this *** done. If you have a nurse refusing to take a patient? Do you know the amount of time it takes the ED to get a patient up to the floor can affect their ability to be reimbursed? Those minutes count. And the ED RN has her charge nurse down her throat as to why the patient isn’t gone while simultaneously fighting the floor nurse to get the patient up there.

This usually happens when the ED is losing on that metric. EDs are black holes of hospitals as it is, rarely making money. Usually they cost the hospitals money. So, your administration is going to do anything they can to change that. Or at least stop the hemorrhaging.

Im not saying it’s right or wrong. It just is.

I’ve worked almost every system there is, and I would say there’s no system that should be taking you 15 minutes to look up a new patient. So, you guys could improve on that front. As for the ED, they need to be sending an SBAR with the patient somehow, OR they could put on in the chart. It would make a big difference.

As for the ED RNs who are dumping patients on the floor covered in urine or feces? Clean them up. Stop doing it. You know who you are, and you know it’s wrong. When I worked the floors it happened to me at least once a shift. It’s so disrespectful to the patient. Just because you can do it, you shouldn’t.

Also, I went to home health this year after 2 major spinal surgeries. I miss the hospital very much, but I don’t miss this stuff. I kind of love my autonomy and the ability to work alone.

You don’t think you are perpetuating the US vs THEM mentality. Almost your entire post is a big sob story for the ED. You think floor nurses don’t have charge nurses breathing down their necks? What about administrators who literally go room to room making sure your charge nurse isn’t “lying” about not having an empty room to fill with ED patients.

And then having your MDs furious when the one empty bed you went to an ED patient just to get the patient out instead of a post-cath or EPS patient? Like you said everyone is busy not just the ED.

But my favorite is when an administrator told us we could take an active CVA patient on the our post- procedural. 4:1, no RT having floor because nurses should be able to take care of everyone.

Again, our fight isn’t with each other. We need to mobilize against administration who care more about having a pretty lobby and Alexa in rooms instead of providing safe care.

2 Votes
Specializes in Cardiology.
On 7/21/2020 at 12:27 PM, NurseCocoBSN said:

I worked in a level 1 years ago who did this. Only difference was an SBAR was faxed to the floor as well.

As someone who’s worked every unit in the hospital, save the OR, this is best practice. Provided the SBAR is sent. I would recommend this as something your hospital can do to improve the measure. We also got report on any level 1 traumas (we were the trauma/transplant unit, half M/s tele, half SSDU).

When I went to ED years later, the pushback we got on patients was insane. Nurses will say anything to keep the admit off the floor. They’ll spend 20 minutes looking for reasons to not take the patient. I know this because it’s something I saw when I worked the floor as well. The only thing I can say is that we are all busy. But there are some nurses who think they’re the only busy one, and they take it out on everyone. I’m not saying you’re one of those people, but it’s a hard wall to hit when you need to get an ED pt upstairs.

The fact is that it’s almost always safer to get the patient out of the ED and onto their unit. ED nurses are turning rooms like a waitress turns tables on a busy Friday night. They have a full waiting room, full hallways, and the endless slaughter of EMS bringing people through the door. They don’t get to review the chart and tell the ambulance “I’m sorry but I can’t take this patient right now, I have a lot going on.”

The Us vs Them mentality of units is really insane to me. Everyone needs to work together to get this *** done. If you have a nurse refusing to take a patient? Do you know the amount of time it takes the ED to get a patient up to the floor can affect their ability to be reimbursed? Those minutes count. And the ED RN has her charge nurse down her throat as to why the patient isn’t gone while simultaneously fighting the floor nurse to get the patient up there.

This usually happens when the ED is losing on that metric. EDs are black holes of hospitals as it is, rarely making money. Usually they cost the hospitals money. So, your administration is going to do anything they can to change that. Or at least stop the hemorrhaging.

Im not saying it’s right or wrong. It just is.

I’ve worked almost every system there is, and I would say there’s no system that should be taking you 15 minutes to look up a new patient. So, you guys could improve on that front. As for the ED, they need to be sending an SBAR with the patient somehow, OR they could put on in the chart. It would make a big difference.

As for the ED RNs who are dumping patients on the floor covered in urine or feces? Clean them up. Stop doing it. You know who you are, and you know it’s wrong. When I worked the floors it happened to me at least once a shift. It’s so disrespectful to the patient. Just because you can do it, you shouldn’t.

Also, I went to home health this year after 2 major spinal surgeries. I miss the hospital very much, but I don’t miss this stuff. I kind of love my autonomy and the ability to work alone.

You say the us vs them mentality between floors is insane to you but you openly are calling out nurses on the floor for finding reasons to not take a pt. I work on a step-down, which has a specific set of criteria for admission, so yeah....I do look at the pt's we are getting as charge nurse because we often get patients that are not appropriate for our floor, whether they belong on a med floor or if they need the ICU. It isn't right that we have to admit the pt and all the work that comes along with it to just end up transferring the pt to the unit or the med floor shortly after all so the ED can get pt's out of there. It takes away time for seeing our patients and it frustrates the patient being admitted.

Let's also not forget that it is oddly coincidental that the ED calls report right before shift change a good chunk of the time. That's how it was at my last job and how it is at my current job at least.

On 7/21/2020 at 12:38 PM, CardiacRNLA said:

You don’t think you are perpetuating the US vs THEM mentality. Almost your entire post is a big sob story for the ED. You think floor nurses don’t have charge nurses breathing down their necks? What about administrators who literally go room to room making sure your charge nurse isn’t “lying” about not having an empty room to fill with ED patients.

And then having your MDs furious when the one empty bed you went to an ED patient just to get the patient out instead of a post-cath or EPS patient? Like you said everyone is busy not just the ED.

But my favorite is when an administrator told us we could take an active CVA patient on the our post- procedural. 4:1, no RT having floor because nurses should be able to take care of everyone.

Again, our fight isn’t with each other. We need to mobilize against administration who care more about having a pretty lobby and Alexa in rooms instead of providing safe care.

My favorite is when bed control at my old job thought we could take all drips "because we were a step-down".

1 Votes
Specializes in Tele/Interventional/Non-Invasive Cardiology.
4 minutes ago, OUxPhys said:

You say the us vs them mentality between floors is insane to you but you openly are calling out nurses on the floor for finding reasons to not take a pt. I work on a step-down, which has a specific set of criteria for admission, so yeah....I do look at the pt's we are getting as charge nurse because we often get patients that are not appropriate for our floor, whether they belong on a med floor or if they need the ICU. It isn't right that we have to admit the pt and all the work that comes along with it to just end up transferring the pt to the unit or the med floor shortly after all so the ED can get pt's out of there. It takes away time for seeing our patients and it frustrates the patient being admitted.

Let's also not forget that it is oddly coincidental that the ED calls report right before shift change a good chunk of the time. That's how it was at my last job and how it is at my current job at least.

My favorite is when bed control at my old job thought we could take all drips "because we were a step-down".

LOL! Yup! Sounds about right! A few times I had to float down to the ED just to work overflow. And MANY of the nurses down there flat out told me they called report right before change of shift so they could get rid of their patients and not get another one so they could leave on time.

Specializes in Critical CarE, WOCN, DELEGATION, CASE MANAGEMENT,.

I'm not trying to insult anyone with my comments. I think you are missing the point. We aren't talking about your world on your floor in any given day. This is City, County, Statewide emergency response. I am quite certain that floor nurses are barraged with demands from all sides. I'm going to take a chance and reiterate that triage and delegation are paramount. You don't need to read nursing notes in the EMR. Read the Physician report. Look at the labs. What is the admitting dx? I'm sorry if you don't agree. You say that patients are coming to the floor sicker. I'm sure they are. Then just imagine what is landing in the critical care bed. We are all stressed. We are short handed. We work overtime. We can't leave or we're charged with abandonment. We have no voice. Let's face it, the system stinks. But it's what we have. Nurses have no collective bargaining power. We need to stop pointing fingers at each other. We need to respect what each of us has to do and come together.

Specializes in Critical CarE, WOCN, DELEGATION, CASE MANAGEMENT,.

I'm reading everyone's comments here and they're all valid and true. I think we form an opinion based on the perspective we're coming from at the time. Even though cross training isn't the topic of this post it would help for all nurses to see how the other half lives. As the front line bottom of the totem pole employees we are at the mercy of administration and policymakers. It's obvious we are all stressed and at times do things to lighten our load. I found that the more experiences I have and all the different places I have worked have changed my views about a lot of all these situations. I wish I had gotten my MSN and gone on for NP. That way I could bill for my services and not be at the mercy of an employer. Then all of this nonsense wouldn't be my problem. What can I say? All I know is that we have more power together.

On 7/21/2020 at 12:27 PM, NurseCocoBSN said:

I worked in a level 1 years ago who did this. Only difference was an SBAR was faxed to the floor as well.

As someone who’s worked every unit in the hospital, save the OR, this is best practice. Provided the SBAR is sent.

Where can I read more about this being best practice? Are you referring to just the SBAR aspect (which can be done either verbally or in written format and is simply an organized/systematic method of reporting so that important items are concisely covered)? I'm willing to change my opinion on the matter but not on the basis of an unsupported statement. Is there some research showing that non-verbal reports with un-closed loops are best practice?

On 7/21/2020 at 12:27 PM, NurseCocoBSN said:

I’ve worked almost every system there is, and I would say there’s no system that should be taking you 15 minutes to look up a new patient.

I doesn't take 15 minutes to look up a patient. Not on purpose, I'm sure, but you're confusing the issue. This isn't about how long it takes to perform a task. It probably takes me under a minute to start an IV, but that certainly doesn't mean that every patient slated for an IV gets it within 60 seconds of order in-put.

But since time is of the essence, I still have a problem believing that it's faster for someone to write a report and send it and someone else to pick it up and read it than it is to verbally convey info. And verbally conveying info is an immediate opportunity to ask questions. Many of the concerns being voiced about delays in being able to give report can be successfully mitigated by calling the assigned floor RN directly. This is also an interruption of what they're doing, but it is necessary and (I believe) more brief than the written SBAR process or the "it's in the chart" process.

In the floors and units we have gone the other way with reporting and now it isn't good enough to give verbal report at the nurse's station; instead it's bedside report with both RNs and the patient that has been promoted as being safer and having other various benefits. Why are we wasting time doing all of that if we could just all tell each other that everything's in the chart?

I hope I'm not just being "traditional;" I've continued pondering this while following this discussion and I don't think I am. I think there are real benefits to making actual contact with one another, and I definitely think there are serious detriments to just sweeping away nursing basics that were in place for a reason.

It occurs to me that one other thing underlying this issue (which I was reminded of while reading some of your comments about reimbursements, etc.) is this idea of high quality + extreme efficiency + low cost. It is a lie. That's why you don't get 5-diamond quality food at McDonald's drive-thru and you don't get your food in 3 minutes when you sit down in a 5-diamond restaurant. We are killing ourselves and doing a lot of funky things in this profession because of what is essentially a fantasy. Something (amongst these three desired items) has to give and my opinion is that it should not be quality/safety.

1 Votes
Specializes in Pediatrics Telemetry CCU ICU.

We have SBAR faxed to the floor after bed control and charge agree on the room. Fine, if the SBAR had more than a name on it. And, if the charge nurse actually tells the assigned receiving nurse that the patient is coming. It makes for a cluster*** for everyone, including the ER nurse I call because she/he hasn't written anything but a name. If I want to work ER I would have sought that unit. Now that our unit is a mini ER . I always hear the saying from the ER staff "welcome to our world, we never know what's coming through the door either, it's become a guessing game of what was actually done for a patient downstairs. The point I am trying to make is that from a patient expectation the ER "no one knows anything that wrong with me yet." By the time they get to the floor their expectation is "well they have it somewhat worked out so I should at least have this and that." Amid call lights and our in house patients screaming for attention as an unknown admit comes up with high expectations of having food and drugs available to them as promised by the ER staff. We didn't even know you were coming, what you are here for, or what orders you have. That explanation alone takes time while you are trying to get them in the bed safely. They look at you like you are stupid and some even say so. Sorry, I don't have telepathy maam'. Even with all of this, I don't mind. I just want ONE thing from the ER staff and that is please stop the practice of promising things to these patients things you KNOW damn well we can't provide right away. The explanations to these patients alone take away precious time we can be using to actually get the admits done and our other patients do not have to suffer. It's passing the proverbial buck. Just tell them that even though they are going to the floor, we still have much work to do before they are settled. (example....it's after 730pm, nutritional services are closed...yet ER is promising that the patient can get a hot meal once they get to the floor). One of the other hospitals that is within our area went back to providing report after at least 3 deaths attributed to ER transport bringing up patients, and left them in rooms, on a Cardiac Step Down unit. The nurses in all cases were not even aware they were receiving patients. The charge nurse had a full assignments of their own, no unit secretary, change of shift, all nurses and techs were at bedside shift report. No monitors placed on the patient. Ridiculous. It just seems that it doesn't have to be a circus but they MAKE it that way.

2 Votes
+ Add a Comment