No report from ED and patients waiting in the halls....

[Kharma711]

ED is in the middle of construction at my hospital and we all just received a notice from the DON which basically states:

ED wait times are too long and too many patients are coming through so...

1. As soon as discharge orders are written/ a bed becomes available, the ED no longer has to call report ahead of time. They have new options, bring the patient and give report at hand off or send the patient and call report after they have arrived.

2. The patient will be brought up as soon as the order is written and will be allowed to stay on the stretcher in the hall until the patient is discharged and the room is clean... even if the room needs TRU-D and the new patient is on some form of precautions (contact, respiratory, etc).

So basically, my understanding is that clearing out the ED is more important than patient safety....

9/10 times the patient is transported by a paramedic tech (who knows nothing about the patient) on a required portable monitor (I work on a step down unit).

These patients will need to remain on a portable monitor until the room/monitor is available. Often, we received less than stable patients from the ED. In my opinion, it is very unsafe for a potentially unstable patient to come to the unit and sit in the hall until their room is available.

Not only that, but we often have 4-5 patients (even though the "standard" is a 3:1 ratio... this means we may temporarily have 6 patients which is highly unsafe. Especially since we may or may not have report on the new patient sitting in our hallway.

To make matters worse, several patients come up with family in tow. We will be forced to send them to the waiting room for anywhere from minutes to a couple hours as we wait for discharge and terminal cleaning... only other option is to have them standing in the halls and potentially creating a hazard for employees and patients/family as they go about their way.

I am under the understanding that it is against regulations to have anything other than people in the halls of an inpatient unit as it is a safety hazard.

ED throughput is an important issue for my hospital and I understand that changes are needed. However, I see this as a huge problem, a customer satisfaction issue, and a serious safety hazard for all involved.

If a new admit that the nurse hasn't received report on were to code in the hall, it would be a disaster and potentially cause the death of a patient as the assigned nurse may not know anything about the patient and well, we are trying to code a patient on a stretcher in the hallway.

So, question is: what are your thoughts/opinions on this new policy? Is it really worth the risk to the patient to expedite ED wait times?

Our nurses are not being given any choice in the matter and may not even know they are getting the new patient until they arrive in the hallway...

[kbird03]

It won't work! Obviously! The powers that be must assume nurses are dragging their feet with discharges and getting rooms cleaned! They will learn quickly when that brilliant idea get implemented and families are complaining! I'm sure you would give them a heads up, but will they listen?! We now get patients with no verbal report from EC just a print out of Sbar, but must go to a clean room! My goodness common sense is lacking as you know.

[iluvivt, BSN, RN]

It violates THE JOINT COMMISSION rule that hallways must be kept clear and also the rules from the Fire Marshall.Also you are correct in that a break occurs in the continuity of care and it is not safe if you must wait for a report or can't get to the patient in a timely manner.What happens if the patient has to use the bed pan or urinal .....does that occur in the hallway too with no expectation of any privacy.

[Emergent, RN]

Sounds funky by first world standards. Obviously your facility is currently desperate (by first world standards)

[Kharma711]

It violates THE JOINT COMMISSION rule that hallways must be kept clear and also the rules from the Fire Marshall.Also you are correct in that a break occurs in the continuity of care and it is not safe if you must wait for a report or can't get to the patient in a timely manner.What happens if the patient has to use the bed pan or urinal .....does that occur in the hallway too with no expectation of any privacy.

The urinal/bedpan thing is just another aspect of what is a huge problem with this new system! The facility I work at is so broken it isn't even funny and this just takes it to a whole new level... those press ganey scores they worry so much about are going to suffer and then this will change... that or my scenario of a code in the hall... it's just rediculous to expect us to work under these conditions smh

[nutella, MSN, RN]

I wonder if this would be of interest for you :

http://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf

it is from 2011 but is from the Agency for Healthcare Research and Quality (AHRQ)

Especially look at Appendix A that lists other resources and what other hospitals have done to improve patient flow.

If you want to get to the bottom of this you could ask your manager who wants to implement this strategy some questions like:

- was there some research to identify the problem for ED overcrowding?

- if yes - what does it suggest?

- where there alternative ideas / solutions?

- how will this improve the root cause for the problem (hopefully somebody did a root cause analysis...)?

- who assumes responsibility for the patient who is on a stretcher while the nurse still has the other patient on the assignment?

- is this strategy congruent with safe staffing and safe practice standards?

- how will this influence patient satisfaction ? (great question since it often boils down to money /reimbursement - so if the pat is not satisfied and conveys this in the survey will the hospital loose more money???)

- are other improvement strategies under consideration like implementing a discharge lounge, improving the discharge process through streamlining discharge, improving cleaning times for rooms? opening of a clinical decision unit for times of high census in the ER with flow problems (flu season....).

So far I have encountered this idea of adding patients into the hallway only within a contingency plan to deal with mass disasters or similar that require to clean out the ER quickly. IMO it is not a solution to use such a plan to deal with a chronic problem with patient flow and throughput. I found other strategies much more efficient depending on the root problem. Discharge lounges can be a viable option if you have a lot of patients who do not get out right away after D/C and who have to wait for a ride but are otherwise ok. Standard D/C times with pressure to the MD to get the D/C process on the way early in the day, stat pager for housekeeping with priority cleaning to reduce those wait times, discharge nurse if the problem is that nurses do not have "time" to get going on the D/C paperwork and so on and forth.

If your safe ratio is 1:3 I would ask some more questions related to that.

If it comes to the hallway scenario and you encounter problems make sure all of the staff submits incident reports for anything related to it like unable to give medication in a timely manner, no privacy for toileting, and so on and forth.

[martymoose, BSN, RN]

So basically, my understanding is that clearing out the ED is more important than patient safety....

BINGO!!! you win a prize!!!!

I just heard my place wants to run at 110 % capacity.....

More pts= more possibilities for money.

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

Sounds to me like they want to transfer the ER wait times to Floor wait times. Their satisfaction scores increase while the floor scores plummet.

[NuGuyNurse2b]

yup, just moving numbers around basically. and then it will fail and another dumb idea drafted by the powers that be will be implemented. I feel like when they see that 'hire more nurses' is an option, they quickly find ways to not do that.

[Kharma711]

yup, just moving numbers around basically. and then it will fail and another dumb idea drafted by the powers that be will be implemented. I feel like when they see that 'hire more nurses' is an option, they quickly find ways to not do that.

The saddest part about this is that we can't get new nurses. There have been postings listed for my unit since I hired on a year ago... we have hired 5 nurses in that time. One of which quit in orientation, 2 transfers from other units, and the other two are currently in orientation. We have also lost 6 or 7 experienced nurses in that time... it's a lose-lose situation.

[loveu123]

As a nurse who has worked both floor and ED, I can understand your concerns. It is sad the way nurses are treated. We are understaffed in most EDs and have to transfer patients as soon as they get a bed. I get 3 or 4 patients in my rooms as soon as I transfer my other patients. We have EMS in our hallways with patients who can't breathe or bleeding and need to put them in a room right away. I do however disagree with sending a patient to the unit without report.. it is sad how both ED nurses and floor nurses are treated badly by Hospitals.

[gonzo1, ASN, RN]

JC reports state hand off is one of the unsafest times in pt care. For you to get a patient without report first is a gross violation. However, there are a couple of considerations. You have not assumed pt care until you get report. Make sure that you start charting, "report rec'd and pt care assumed at this time" on all your patients. That way when you don't get report you can chart, something like," pt rec'd into stepdown hallway. No report rec'd, pt on portable monitor. Will assume pt care after rec'g report."

If I were in this situation I would take care of the pt in the hallway, but the chart would reflect that no report was rec'd and pt care not assumed. This may protect you in court as the pt is being taken care of, but you have not assumed care. Since the pt is in the hallway they and their family will be asking all staff for help, and everyone will see what needs to be done and have to be involved in pt care.

If a pt codes in the hallway this will not be on you, if you follow ACLS quidelines, but rather on the hospital itself.

This won't last for long as pts and their families are going to be screaming. I would just go along with it for a while and make sure you educate yourself on JC standards of care as far as privacy and hand off and I don't know what else.

You are a brave soul for staying in such a position, cause I would be running for the doors as soon as my shift was over after having my first hallway pt. I have a feeling this will never actually happen. I have worked a few places where they said this was going to happen and it never has. Too many unanswered questions like how to use bedpan, urinal, hallway crowding and fire codes, no privacy and multiple privacy violations.