No success in refusing admits inappropriate to the unit...

[NBMom1225]

I work midnights on a general Surgery/Med-Surg/Tele unit in a +400 bed suburban hospital. Our unit does not have any negative pressure rooms, though there are negative pressure rooms on other units in the hospital that also have telemetry.

Lately, we have been getting patients from the ED that should not be sent to our floor, such as rule-out TB and rule-out meningitis, both of which are airborne precaution situations. We have tried arguing against receiving these patient with the ED, who states "well, they're just ruling it out", and going over their heads to the Hospital Nursing Supervisor...only to be told we have to take the patient. Our hospital has portable HEPA filter units, but they typically aren't sent up to the floor for several hours AFTER the patient has arrived, not for lack of repeated phone calls to the appropriate supply department, and we still feel this is inadequate since the room is not negative pressure.

Inevitably, whatever physician is on consult for Infectious Disease will see the patient on day shift the next day and puts in an order for the patient to be transferred to another unit with a negative pressure room. We have even tried calling the ID physician as soon as the patient is admitted to try to have the patient rerouted before they even get to our floor, but the ID physician (if they even return our call) will usually just state that they have not yet evaluated the patient and will refuse to place any orders until they do.

Has anyone else had to deal with this type of situation? Our staff feels this is putting our other patients at risk and is unacceptable, not to mention preventable if the ED physicians would just put in an order for the patient to be admitted to a negative pressure room from the start.

We are taught in nursing school to advocate for our patients, we should be able to refuse admits that are so obviously inappropriate for our unit! Does anyone have any suggestions for dealing with this sort of problem?

[MunoRN, RN]

While it's not the case everywhere, there are facilities where ED docs write admitting orders, particularly at night. I've heard many of these conversations between the ED doc and admitting Doc which often consists of nothing more than the patient's name, MRN, and relevant findings, there is often no discussion of where the admitting Doc wants the patient to go or what he/she wants for admission orders.

[NBMom1225]

I admit I don't know all of the details of who decides which unit a patient is admitted to, on the midnight shift it seems to usually fall to the ED docs to put in the order to admit to inpatient, or the covering hospitalist group which is often a PA or an NP on midnights. The bed coordinator somehow figures into this formula, who seems to assign the actual bed wherever they see fit, unless a specific unit/type of room is specified.

A big part of the problem is that the floor no longer receives ANY sort of report from the ED. It used to be a phoned RN to RN report; then it became a faxed report. Now that we have EMR we are told "you can just look it up"...I think this is the root of the problem. We may not even be aware one of our beds is booked, depending on the quality of the unit secretary (which we only have until 2300 if we have one at all), and the next thing we know transport is calling to say "room 1234 is on their way up"...most of the time there is no chance to look up their H&P, vitals, labs, nothing...and no opportunity to catch problems (like needing a negative pressure room, blood cultures ordered 6 hrs previous but not yet drawn, etc) BEFORE they arrive on the unit. This issue has been beaten to death at our facility, with the only answer from the higher ups being "it's all in the computer". Funny how transport can't take the patient down for a flipping Xray without the RN filling out an SBAR sheet, but it's fine for us to have no choice but to take the patient who's now on a gurney in the middle of the hall and know absolutely NOTHING about their previous/current state...umm, was the right side of their face drooping before they got here, or is this new?!

I'll just keep entering incident reports into the computer, emailing my concerns to management (they aren't the only ones who know how to make use of a paper trail ) and will definitely make use of the facilities compliance hotline!

And thanks all for the correction regarding meningitis as a droplet...at my previous facility droplet precaution patients went into negative pressure rooms whenever possible, which was most of the time, so that's where my mind went.

[NBMom1225]

@Bec7074...thanks for the link from the CDC! I just forwarded that info to my work email and will print it off next time I work and highlight the section that states "Initiate protocol to transfer patient to a healthcare facility that has the recommended infection-control capacity to properly manage the patient" if an airborne infection isolation room is not available...and post it on the notice board right in the middle of the nursing station...maybe even send copies of it to the bed desk coordinator and to the ED department

[Dixielee, BSN, RN]

Anyone should be able to clearly see that this is an attempt by the ED staff to cause massive outbreaks of communicable disease on each and every floor of the hospital Those lazy ED nurses want to get rid of the patients as fast as they can so they can go back to watching TV and eating free pizza. They don't really care what happens to the patients or the floor nurses as long as they can have their own way.

I think you should go to the ED, steal a copy of the schedule and write incident reports involving each and every ED nurse, physician, tech and clerks because this is clearly a conspiracy and you are just lucky to still be alive.

Those ED nurses could have turned those patients away at the door as soon as they saw they were coughing up blood, but they let them in so they could create havoc on your floor. I'm sure a good and complete write up and complete re-education of the ED staff is in order. Better still, they should just fire them all and start fresh. That will teach them.

We know our rights!! We should never have to take a patient who might not be appropriate for our floor! The nerve!!!

[Tragically Hip]

Dixielee, I may be dense here, but what was the purpose of all that sarcasm? Were some ED feathers ruffled?

If you could add some constructive information on the admitting process, that would be really cool.

[minnymi]

I admit I don't know all of the details of who decides which unit a patient is admitted to, on the midnight shift it seems to usually fall to the ED docs to put in the order to admit to inpatient, or the covering hospitalist group which is often a PA or an NP on midnights. The bed coordinator somehow figures into this formula, who seems to assign the actual bed wherever they see fit, unless a specific unit/type of room is specified.

A big part of the problem is that the floor no longer receives ANY sort of report from the ED. It used to be a phoned RN to RN report; then it became a faxed report. Now that we have EMR we are told "you can just look it up"...I think this is the root of the problem. We may not even be aware one of our beds is booked, depending on the quality of the unit secretary (which we only have until 2300 if we have one at all), and the next thing we know transport is calling to say "room 1234 is on their way up"...most of the time there is no chance to look up their H&P, vitals, labs, nothing...and no opportunity to catch problems (like needing a negative pressure room, blood cultures ordered 6 hrs previous but not yet drawn, etc) BEFORE they arrive on the unit. This issue has been beaten to death at our facility, with the only answer from the higher ups being "it's all in the computer". Funny how transport can't take the patient down for a flipping Xray without the RN filling out an SBAR sheet, but it's fine for us to have no choice but to take the patient who's now on a gurney in the middle of the hall and know absolutely NOTHING about their previous/current state...umm, was the right side of their face drooping before they got here, or is this new?!

I'll just keep entering incident reports into the computer, emailing my concerns to management (they aren't the only ones who know how to make use of a paper trail ) and will definitely make use of the facilities compliance hotline!

And thanks all for the correction regarding meningitis as a droplet...at my previous facility droplet precaution patients went into negative pressure rooms whenever possible, which was most of the time, so that's where my mind went.

I think the compliance hotline is a good idea. I've always been skeptical of using it even though it's supposed to be anonymous. I always figured they probably record the conversations and break out the tape when they're meeting with the nurse manager or whoever is the root of the problem. So, maybe it's only anonymous as long as they don't recognize your voice? I might just be paranoid though, but I've always wondered about that.

[MunoRN, RN]

While I understand your concern, you're unlikely to make much of a dent in the problem if this isn't against your facility's policy, which it might not be. My facility only places patient's on full TB precautions in the case of a confirmed history w/active TB or positive CXR for TB. There are other patient's that we rule out but are unlikely to be positive, which we don't place on airborne precautions and only our infectious Docs can place patients on airborne precautions for TB in patient's that don't yet have a positive test or CXR.

I'd be more concerned with your report process. It's one thing to fail to meet Joint Commission standards (which your report process fails to do), but in my state this is a violation of the practice act; patient abandonment is defined as a failure to confirm receipt and understanding of a patient by the handing off Nurse in any situation where a patient requires ongoing Nursing care.

[Bec7074]

@Bec7074...thanks for the link from the CDC! I just forwarded that info to my work email and will print it off next time I work and highlight the section that states "Initiate protocol to transfer patient to a healthcare facility that has the recommended infection-control capacity to properly manage the patient" if an airborne infection isolation room is not available...and post it on the notice board right in the middle of the nursing station...maybe even send copies of it to the bed desk coordinator and to the ED department

Welcome! Do work!

[sauconyrunner]

Anyone should be able to clearly see that this is an attempt by the ED staff to cause massive outbreaks of communicable disease on each and every floor of the hospital Those lazy ED nurses want to get rid of the patients as fast as they can so they can go back to watching TV and eating free pizza. They don't really care what happens to the patients or the floor nurses as long as they can have their own way.

I think you should go to the ED, steal a copy of the schedule and write incident reports involving each and every ED nurse, physician, tech and clerks because this is clearly a conspiracy and you are just lucky to still be alive.

Those ED nurses could have turned those patients away at the door as soon as they saw they were coughing up blood, but they let them in so they could create havoc on your floor. I'm sure a good and complete write up and complete re-education of the ED staff is in order. Better still, they should just fire them all and start fresh. That will teach them.

We know our rights!! We should never have to take a patient who might not be appropriate for our floor! The nerve!!!

DixieLee, I think you are responding to this as an ED nurse only. The OP is not saying these pts should not be admitted, the OP wants them admitted to a Negative Pressure room- which is the correct thing to do. We have Neg pressure rooms in our ED- and thats where we put those patients as well. (We are a really small facility...) I didn't really see any attacks in this post on any of the ED staff- except for some confusion about who writes orders. I'm an ex ED Nurse (12 years) and a New Infection preventionist. It really is an issue to not put these patients in the correct place. Places everyone, including the ED staff at risk.

[SoldierNurse22, BSN, RN]

I've encountered this as well. We had a patient who was r/o for Varicella with skin lesions. She was an oncology patient who had just finished her chemo and the docs put her on precautions, but we didn't have a negative pressure room either. My friend tried to talk sense in to the team in charge of the patient's care, but the docs seemed to think that because there was no diagnosis of the disease that precautions weren't necessary. We went over their heads to infection control and let's just say things happened. We talked to our ward leadership as well and between them and the folks at IC, we got her place appropriately. I think the message hit home when the docs saw us moving in and out of the room they had just been in without any PPE in respirators, gowns and gloves.

[redhead_NURSE98!, ADN, BSN]

Anyone should be able to clearly see that this is an attempt by the ED staff to cause massive outbreaks of communicable disease on each and every floor of the hospital Those lazy ED nurses want to get rid of the patients as fast as they can so they can go back to watching TV and eating free pizza. They don't really care what happens to the patients or the floor nurses as long as they can have their own way.

I think you should go to the ED, steal a copy of the schedule and write incident reports involving each and every ED nurse, physician, tech and clerks because this is clearly a conspiracy and you are just lucky to still be alive.

Those ED nurses could have turned those patients away at the door as soon as they saw they were coughing up blood, but they let them in so they could create havoc on your floor. I'm sure a good and complete write up and complete re-education of the ED staff is in order. Better still, they should just fire them all and start fresh. That will teach them.

We know our rights!! We should never have to take a patient who might not be appropriate for our floor! The nerve!!!

Oh God, get over yourself.

[nuangel1, BSN, RN]

i am an ed nurse we care for all kinds of pts.sometimes we don't even know the pt should be on precautions.the nursing homes don't always give us appropriate info.but i don't admit the pt the ed dr does.the ed dr puts diagnosis and type of floor for admit after he has talked to admit /accepting dr.it is the nursing supervisor who assigns where the pt gets admitted to.if the floor has an issue it is the supervisor they need to call .if the pt should be in neg pressure room but is not in one on your floor then file incident report tlk to supervisor call your manager at home go up the ladder talk to chief of medicine call id report to osha call your union if you have one .but stop blaming the ed we don't pick the floor /room .its not in our control .we have to move the pts .there are always more people who need our room.