OK ED nurses, fill me in on the real story.

[eriksoln, BSN, RN]

OK, another thread made me start thinking about something thats always irritated me. Admissions coming right at change of shift. It happens regardless of where they are coming from.......ED, Critical Care unit pt. now going to M/S.......from M/S to rehab. It seems some sort of flood gate opens right at shift change and the halls fill with pt's going from one unit to another.

Now, this is too consistent to be a coincidence. I can tell you, hours before the pt. comes to me, when the pt. will come. I'll find out around 5PM a pt is supposed to come to us, and I know they will start calling report about an hour and a half before the next shift change, then half an hour before the change........here they come.

I can even tell what type of pt. I am getting depending on when the transfer. If they transfer within an hour of the order to transfer being written.......well, that pt. is a major PIA. If they come a half hour before shift change, their nurse liked them and held onto them.

So, seeing all this evidence, I cant arrive at any other conclusion other than people hold their pts to avoid admissions. I think this is especially true of ED nurses. They are the most predictable of them all. Good pt's transfer at shift change, PIAs whenever the order is written.

I had someone who worked ER for a couple years tell me this is not possible in the ED. He ageed Critical Care units in the hospital definately hold pts, but not the ED. He explained why, basicaly said the ED physician had more to do with it than the nurses.

So is it true? If you work in the ED, do you see nurses holding onto pts? Or am I just showing syptoms of my touch of paranoid schytzophrenia?

[DebanamRN, MSN, RN]

I don't see our nurses holding onto patients. The charge nurse won't allow it. She/he watches the board for beds popping up. The charge nurse goes to the ER nurse with the admission to make sure report is called and the pt is put up for transport. When the transporter shows up, up the pt goes. Or sometimes, we take them up. Usually we have quite a few people in the waiting room waiting on one ER bed, so they gotta go when they gotta go. I think it depends on the dynamics of your particular ER, however, if patients are being held onto.

[froggg123]

I am an ED nurse and at least at my hospital we would catch a fit if we even thought about holding a pt., when it is decided that a pt. is going to be admitted we cant just transfer them to the floor we have to wait for a room assignment (even if you know you are getting my pt in no way indicates that I know there is a room available for them) now we also have to wait for the admitting doctor to write admission orders and if they write for any stat test (like CTs or Xrays) then these have to be completed before they go to the floor and we dont have control over how long this takes.

ED nurses are not like floors, in that we dont "fill up" you only have a certain amount of rooms on your floor, we dont hold because if our room is filled they will give us pts in the hall, so really there is no benefit to holding anyone it just makes more work for us.

Lastly, if you know you are getting an ED pt. and you want report, the phones work both ways, call me and ask me if I am ready to give you report or if there is something that the pt is waiting on.

[eriksoln, BSN, RN]

To debanam:

Actually, someone in another thread was just commenting on how a lot of times the unit refuses report until shift change. That adds to it to, but doesnt explain the ones that report has been called to the unit for over an hour..........and......here comes shift change.........and...........here comes pt. down the hall.

[eriksoln, BSN, RN]

I am an ED nurse and at least at my hospital we would catch a fit if we even thought about holding a pt., when it is decided that a pt. is going to be admitted we cant just transfer them to the floor we have to wait for a room assignment (even if you know you are getting my pt in no way indicates that I know there is a room available for them) now we also have to wait for the admitting doctor to write admission orders and if they write for any stat test (like CTs or Xrays) then these have to be completed before they go to the floor and we dont have control over how long this takes.

ED nurses are not like floors, in that we dont "fill up" you only have a certain amount of rooms on your floor, we dont hold because if our room is filled they will give us pts in the hall, so really there is no benefit to holding anyone it just makes more work for us.

Lastly, if you know you are getting an ED pt. and you want report, the phones work both ways, call me and ask me if I am ready to give you report or if there is something that the pt is waiting on.

Ah, that is exactly what the guy I worked with (now a M/S travel nurse, was an ED nurse when he was staff) said. It makes sense that you wouldnt want to hold pt's either if thats how it is for you. He went on to say that the only one who stood to benefit from holding a pt. was the ED physician, but I dont remember how.

So you dont mind me calling? huh. I never did, always afraid of catching you in the middle of something too critical to be interupting you in. Guess the secretary would tell me that though if it were the case.

I still dont know why the flood gates open at change of shift. :bugeyes:Maybe its all in my mind. lol

[MAISY, RN-ER, BSN, RN]

Even if you wanted to hold a patient, it is impossible! Our float nurses call report if we can't. Bed management gives out our beds and they watch how long it takes to call report! In the past the floor nurses refused assignment, the charge nurse and managers protected them-now, no one is protected....they go to hallways, they go anywhere but the ER! The ER is always flipping patients, and now everyone suffers but the patients are doing well!

The other thing that happens is that our discharge time is not enforced therefore patients are still in the beds the ER patients will get. The other reason is that staffing does not allow it, nursing ratios are low so there is no one take the patients.

Just some ideas, but you never know!

[Spidey's mom, ADN, BSN, RN]

I agree - you can't hold a patient no matter what. We work very hard to get the ones admitted out of there. We get everything ready and then send an SBAR and then call the nurse. Then transfer or the nurse takes them up, depending.

Nope - can't hold them. At least where I worked.

steph

[FlyingScot, RN]

At my ER we had a computerized bed tracking program. It relied on the floor charge nurses inputting what beds were empty. Oddly enough there were never any empty beds. So the nursing supervisor started to do bed rounds near the end of the shift. She'd find the empty beds ( some that had been there all shift)and make the charge nurse put them in the computer. Once they were in we'd finally get the bed assignment usually at about 1815. We then had 15 minutes to get them up. Basically the floors were their own worst enemy. If they had released the beds earlier then the admissions would have been staggered. Holding patients didn't work to our advantage. They'd just slap a piece of paper on the wall with a big letter on it and call that a bed (be it a chair or a cot). The "reports been called but the patient took an hour to get here" complaint is valid if it truly is a regular occurrence. What usually happens though is you call report and the admitting doctor shows up in the ED and refuses to let you move the patient before he has completely assessed them and written the orders or something ugly rolls through the door and you end up having to do CPR for the next 20 minutes. Believe me ER nurses DO NOT WANT TO HOLD ADMITTED PATIENTS.!!! Sorry for the caps but we can't seem to get the floor nurses to understand that. We can only move the patients when we get a bed assignment and for some reason they all seem to come at the end of the shift. Not our call...that's somebody else's doing. You need to complain to the bed assignment people. Also, the ER tends to have staggered shifts so very few actually work a normal 7-7 schedule. For me it wouldn't have been a benefit if I took a patient up just before shift change as I still had 3 hours to go.

[loricatus]

Any place I worked it was impossible to hold on to patients. If I am too busy to call report the CN would do it. Once informed that a bed is assigned, clean or not, I am pushed to call report ASAP. It seems that it is more important to the CN that report is called, than it is to take care of an emergency patient. So, it I hold a patient in the ER, it is because I am trying to care for more critical patient.

Personally, I would rather get rid of the admitted patient as soon as I can because I don't want to deal with the admission orders. Once the ER doc admits the patient, the ER orders are no longer valid (unless the hospital has bridge orders in place) and the admitting doc has to do an assessment and write orders. This interim is a PIA for the ER nurse. However, I do suspect that ER docs do wait to decide on admissions when they get nearer the ends of their shifts, which would make it appear that it is the ER nurse that is holding the patient. That is, unless the ER doc wants that patient out.

Another holdup could be transport. Once the report is called, the patient goes on a wait list for transport. If the transporters are responsible for taking patients to tests/studies, in addition to floor transports, the backlog could be immense. near the end of the transporters' shift, you may also see a surge of activity.

There are just too many factors in play here for there to be a single answer to your questions.

[eriksoln, BSN, RN]

At my ER we had a computerized bed tracking program. It relied on the floor charge nurses inputting what beds were empty. Oddly enough there were never any empty beds. So the nursing supervisor started to do bed rounds near the end of the shift. She'd find the empty beds ( some that had been there all shift)and make the charge nurse put them in the computer. Once they were in we'd finally get the bed assignment usually at about 1815. We then had 15 minutes to get them up. Basically the floors were their own worst enemy. If they had released the beds earlier then the admissions would have been staggered. Holding patients didn't work to our advantage. They'd just slap a piece of paper on the wall with a big letter on it and call that a bed (be it a chair or a cot). The "reports been called but the patient took an hour to get here" complaint is valid if it truly is a regular occurrence. What usually happens though is you call report and the admitting doctor shows up in the ED and refuses to let you move the patient before he has completely assessed them and written the orders or something ugly rolls through the door and you end up having to do CPR for the next 20 minutes. Believe me ER nurses DO NOT WANT TO HOLD ADMITTED PATIENTS.!!! Sorry for the caps but we can't seem to get the floor nurses to understand that. We can only move the patients when we get a bed assignment and for some reason they all seem to come at the end of the shift. Not our call...that's somebody else's doing. You need to complain to the bed assignment people. Also, the ER tends to have staggered shifts so very few actually work a normal 7-7 schedule. For me it wouldn't have been a benefit if I took a patient up just before shift change as I still had 3 hours to go.

Why sorry for the caps? Oh.......thats supposed to mean you're yelling at me. :madface:Are you yelling at me? lol

No, I'm starting to get a better picture of it. And thats what I wanted. A better understanding of why it happens (the flood gates opening at shift change). I'm starting to think I shouldnt insist the ER does it that way because it benefits them.

I think U R right about the bed tracking computer games some floors play. I overhear stuff sometimes and a lot of charge nurses always talk about "(fill in the blank with whatever unit) hides beds so they dont have to get admits. They shouldnt be able to do that, now we are going to get twice as many admits. Why doesnt that hospital supervisor round on their floor?" Yeah, the lengths people wont go through to avoid a little work. I was at one hospital where it was so bad, one unit would send an aid to the other units to see how many dirty/empty beds there were.

Dont get me wrong, I'm just trying to do some fact finding. When I'm on the clock, I co-operate with ER nurses. When they call, I take the report. I'm not stupid, you guys are your own little cliche just like we in M/S are. You talk to one another. You know which nurses try to put off admits and which ones are helpfull. At my last job, the nurses who abused the kindness of the ED nurses got the ED to the point where if they didnt take report, it was a call to the supervisor. On the other hand, if you were the cooperative type and asked for a few minutes to attend to something that was urgent, they'd let you go, leave you alone for a whole half hour while you calmed down the dementiated lady crawling out of bed. I make sure I am known as a cooperative type.

[MAISY, RN-ER, BSN, RN]

My thing is we need to work together for continuity of care. I make sure my orders are started if I got them before I received the bed....I also medicate for pain, feed and do whatever else if I can. No one wants a cranky patient in pain no matter where they end up. In my ER I can pull meds and get meals and frequently do just so everyone is happy! Gingerale and graham crackers along with an 1 hour wait for pharmacy input is no fun for either the receiving nurse or the patient who just wants to be settled! I am like you, am friendly with my MS nurses, and try to accomodate their needs too!

Wouldn't it be nice if we were just all nurses, and not ER, M/S or whatever?

[FlyingScot, RN]

Why sorry for the caps? Oh.......thats supposed to mean your yelling at me. :madface:Are you yelling at me? lol Dont get me wrong, I'm just trying to do some fact finding. When I'm on the clock, I co-operate with ER nurses. When they call, I take the report. I'm not stupid, you guys are your own little cliche just like we in M/S are. You talk to one another. You know which nurses try to put off admits and which ones are helpfull. At my last job, the nurses who abused the kindness of the ED nurses got the ED to the point where if they didnt take report, it was a call to the supervisor. On the other hand, if you were the cooperative type and asked for a few minutes to attend to something that was urgent, they'd let you go, leave you alone for a whole half hour while you calmed down the dementiated lady crawling out of bed. I make sure I am known as a cooperative type.

You are one smart cookie for figuring this out. ER nurses are so grateful when somebody actually takes report on the first call that they will go out of their way to make the admission as smooth and easy as possible for the admitting nurse. Patient looks a little pale+ might need a transfusion down the road+ nice admitting nurse= well lookee there the ER nurse put a second line in just in case. Not nice admitting nurse...baby you are on your own. I generally had no difficulty getting the floor to take my patients as they got an accurate report and a clean, pain-free (unless a FF who couldn't be pleased) patient. But if it took more than two phone calls, reasonably spaced, and still no report then you bet I'd call the supervisor because obviously something terrible is happening on that floor because there was not one nurse available to take report. And I can say with some authority that in many cases if there was any holding of patients going on it was being done by the ER docs who did benefit from their rooms being full. Unfortunately we had little control over it even though we complained bitterly to management about it on a regular basis.

And BTW I wasn't yelling at you I was just trying to get the attention of the floor nurses.