Dangerous ER Admits

[nialloh]

I need advice. Our ER is dumping patients onto floors with little consideration to patient safety. My floor is medsurg with tele (which is how management can get around RN/pt ratio limits). We get fresh MI's, strokes, and all drips except nitro, with a ratio of 8:1.

The problem is that the ER is always sending pts with no orders other then call DR for orders, and usually before the labs have resulted, so don't know how bad the pt is, or even if stable. They mostly don't even give report, but drop the papers on the desk and run (some of the older nurses do give report in fairness). I have lost count of how many pts we sent to ICU after getting them from the ER. More then once we sent 2 in one shift. Once they even sent someone after she had expired, sorry, but that's a little to stable for me. The s++t hit the fan over that one, and they were good for a while, but are now back to their old tricks.

Most of this started when we got a new DON. In north Jersey, hospitals frequently go on bypass. In an effort to stop this, the DON canceled the 1/2 hour rule (1/2 hour from being told there is a pt in the ER to when they can send. To give us a chance to get ready). The ER called and sent at the same time, ready or not. After being swamped a few times with sometimes 3 admits in a ten minute period (with no orders), our nurse manager was able to get us a 15 min wait (even now we don't always get it). God help us if we try to go over 15 min.

The other day I got a pt with an active occipital bleed. The ER wasn't busy, and her primary said to admit, over the phone. Neuro said not to admit, as he was sending to NY, ER to ER. They admitted anyway. Neuro hit the roof, but didn't want to transfer to ICU as she was too unstable, and wanted as few moves as posable. I had her for 5 hours before transporting. I hardly saw my other pts.

What I need to know is what I can do to stop this. It is dangerous and life threatening. We have tried complaining, but are ignored. I'm going to write a letter of concern to management about the bleed, but if I'm the only one writing these letters, will they be listened to, or will it bite me in the back.

Sorry it's so long, and thanks for letting me get it off my chest.

[pickledpepperRN]

An Incident report every time too. Try to hand them to the hospital attorney or risk manager.

Thank you for advocating for your patients.!

[purplemania, BSN, RN]

do you have a risk management nurse? Quality improvement? Safe harbour act with your state BON? I would use all three.

[nialloh, RN]

Update : This is the letter written and sent :

Statement Of Concern

It is necessary to bring to your attention an ER practice that is inconsiderate, inappropriate and down right dangerous. It is no longer unusual to receive a patient from the ER without notification, doctors orders, stat meds administered, oxygen or resulted lab work. On occasion we have received patients without IV access or pulse (expired).

Due to the indifferent attitude of the ER staff the following statement was heard, when a little leeway was requested due to overwhelming patient loads from multiple admissions (from the ER):

"There is no more half hour"

Even when the ERs total load is two patients, they still send patients to floors within 15min or less with no regard for the floors ability to care for them because:

"We don't want them to get used to making us wait"

It is obvious the welfare of the patient has become second priority to transferring them out of the ER.

Frequently a patient sent to our unit has to be transferred to ICU, because the stabilization that was never received in the ER and attempted on our unit, failed. Due to the ERs eagerness to transfer patients out of their unit, many patients have been sent to our unit despite their ICU acuity. As many as three admissions from the ER to our unit have been sent to ICU within the same shift. This indicates there is a problem with the admission acuity assessment in the ER. It has become obvious that if the ER is not sure where the patient should go, they are sent to our unit, e.g.

-, A neurologist's instruction that a patient with an active occipital bleed remain in the ER, was ignored. She was sent to our unit. The patient's condition was so unstable the neurologist refused a transfer to ICU since any further movement could cause more damage. It is unknown how much, if any, damage occurred on the unsanctioned move from the ER. The patient was transferred to ******** ************ hospital during that shift.

- An acute MI patient with positive Isos was received from the ER with no monitor, nurse, oxygen or phone call to see if the bed was ready. The patients O2 sat upon arrival was 79% on RA.

- Patient sent to our unit prior to primary MD completing assessment. MD followed patient to floor, completed assessment and then sent patient to ICU.

The above incidents are just a small sampling of a 30 day period.

This statement of concern is not intended to malign all the ER staff. Many ER nurses will actually give report to the receiving nurse on the floor, although it is more likely to find the patient in the hall on a stretcher, and the paperwork placed on the nurse's station, while the nurse goes back in the ER without ever having announced her presence on the floor.

It should be obvious that this practice of getting the patients out of the ER by whatever means necessary is not in the patients best interest. It is a dangerous practice that will eventually cost someone their life, a floor nurse their license and the hospital a major lawsuit. It is unacceptable practice for any hospital to give the ER "carte blanch" on admitting patients to the hospital with no regard for the floors ability to facilitate that patient.

These issues must be addressed immediately

We were told that much of what was being done was policy and wouldnt be changed.

What really happened is we nolonger get slammed, we get report, and the patients go where they are ment to.:) So it looks like all has worked out ok.

[jadednurse]

Nialloh, good for you!

Just curious, to whom did you send that letter ?

Good job of standing up, for your license, for your patients, for your unit!

[nialloh, RN]

The CEO and DON got copys mailed to them with return conformation. It was kept inhouse. It was really a cya letter.

[gwenith, BSN, RN]

Good work Nialloh and a positive example of making sure management DOES know the situation. All too often nurses assume that management knows and that is where the problem is coming from. We have to ensure that they know not just the problem but the full impact and outcomes of what is happening. Once you do that action gets taken.

Once again - good for you!!!

[Rapheal]

Good job!!!!!!!!!!