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

[eriksoln]

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?

[eriksoln, BSN, RN]

Oh, I know you're not. Tone is not easy to pick up on keyboards and comp. screens but that wasnt the tone I envisioned. This is great, I love finding out real answers to things that go on at work. I knew I joined here for a reason.

Next thread...........those pesky Case Management people.:sofahiderJust kidding. Dont throw daggers at my personal spots.

[kmoonshine, RN]

In our ED the time that an admit bed is called for, to the time a bed is assigned, to the time that report was called is tracked. If I don't call report, the charge nurse does. I try to keep up on all my pts; it would be easier for me to hold onto them for a bit! But just as they roll out the ED, in comes a new ambulance...

[mypixiedust]

I have worked tele, CCU, and the ED. I can tell you, I use to have the same complaint about ED nurses waiting till shift change. In my experience in the ED, we do not wait. As soon as a bed is assigned, report is called. Lots of time the UC will tell me that she hasn't even told the nurse she was getting that pt yet. In the ED so much is happening so fast that you want to get that pt upstairs. The faster you get that pt upstairs, the faster the next patient gets seen, and the faster the waiting room is empty.

Many times, I have had a pt waiting for there bed assignment, and we pull them out in the hallway to make room for the next emergency, so it doesn't benefit holding a pt. You could end up with 5 or more pt's.

I use to say the ED nurses didn't know much about their pt too. For instance, I wanted to know a pt's full hx, meds, etc. As an ED nurse, you are moving pt's so fast that those details may not be a priority to the reason a pt was seen.

I think it would be nice if nurses could take a day and float through the hospital to see the important roles everyone plays. Remember as a nurse, we should always put the patient's best interest first. As soon as a ED doc tells the pt they are to be admitted, that pt will constantly ask "when am I going upstairs." After awhile it gets annoying.

[canoehead, BSN, RN]

I've worked in 4 different EDs and so far there is no one that feels holding onto a patient benefits the ER nurse. We just get the next patient in a chair, or in a hall.

The biggest holdup I've seen is when the admitting doc decides to finish office hours, then come over to the ER and write the admission orders on all his patients. So the floors start getting all the admissions that have built up that day at about 5pm, and it doesn't stop until he is done. By 5pm families and patients are restless and uncomfortable and the waiting room is backed up. We REALLY need to move them along, so the floor nurses get no mercy. I remember bringing a patient upstairs at that hospital and the charge nurse said we sent them 5 admissions in 30 minutes. I was embarassed to be bringing up another, but those patients had been waiting 5 hours or more each on stretchers in the ER.

I agree it's not right. I want my admission outta there ASAP because floor orders are such a drag to keep track of (regular meds- ewwww!). It helps if there is more than one doc writing all the admission orders, and if he is available all day.

[eriksoln, BSN, RN]

I have worked tele, CCU, and the ED. I can tell you, I use to have the same complaint about ED nurses waiting till shift change. In my experience in the ED, we do not wait. As soon as a bed is assigned, report is called. Lots of time the UC will tell me that she hasn't even told the nurse she was getting that pt yet. In the ED so much is happening so fast that you want to get that pt upstairs. The faster you get that pt upstairs, the faster the next patient gets seen, and the faster the waiting room is empty.

Many times, I have had a pt waiting for there bed assignment, and we pull them out in the hallway to make room for the next emergency, so it doesn't benefit holding a pt. You could end up with 5 or more pt's.

I use to say the ED nurses didn't know much about their pt too. For instance, I wanted to know a pt's full hx, meds, etc. As an ED nurse, you are moving pt's so fast that those details may not be a priority to the reason a pt was seen.

I think it would be nice if nurses could take a day and float through the hospital to see the important roles everyone plays. Remember as a nurse, we should always put the patient's best interest first. As soon as a ED doc tells the pt they are to be admitted, that pt will constantly ask "when am I going upstairs." After awhile it gets annoying.

All excellent points. And you beat me to the one I was going to put in here too. I think you are right about how it would improve things for everyone if floor nurses went to the ED once early in their career to just see things.

And about the pt. being put in the hallway, when you do that, you've just capped the PG scores from that pt. No hope of getting top marks there no matter how well everything else goes. Thats not good for anyone, floor or ED nurses.

I appreciate everyone taking the time to educate me on this. Instead of coming at me with "You dont understand, just shut up and take report" stuff everyone really made an effort to talk things out. My attitude towards ED nurses is different now.

[Medic2RN, BSN, RN, EMT-P]

Right now I work in two different hospitals: one in the ED and the other on the floor in an ICU stepdown. Magically, the same thing occurs - transfers right around shift change.

When I'm in the ED, I want to get rid of that admitted patient asap, but I can't do anything until bed control assigns me a room. It's very frustrating waiting. I try the best I can to get that patient to the floor quickly after an assignment is made. I think some hospitals have certain times when bed control is updated. That's the only thing I can think of....

When I'm working in the stepdown, the same thing happens - admits right at shift change. Come to think of it, ICU transfers happen around that time too.....hmmm.

My gripe regarding the whole situation is how nurses treat each other. The ED nurses think the floor nurses are trying to avoid work by delaying receiving report. The floor nurses think the ED nurses are trying to avoid work by holding patients until their shift is over.

When will we stop blaming each other and start sticking up for ourselves collectively? Perhaps we'd find solutions when we stop pointing fingers.

[WalkieTalkie, RN]

My gripe regarding the whole situation is how nurses treat each other. The ED nurses think the floor nurses are trying to avoid work by delaying receiving report. The floor nurses think the ED nurses are trying to avoid work by holding patients until their shift is over.

I used to work in the ER as a tech and now I'm a nurse in the ICU. Regarding this, I've actually had one of the ER nurses call me and ask if he could bring a patient up at 0645. He said "do you want her now?" I said "no, but I will take her because that would be crappy to make her wait!"

Sometimes you just have to suck it up!

[eriksoln, BSN, RN]

Right now I work in two different hospitals: one in the ED and the other on the floor in an ICU stepdown. Magically, the same thing occurs - transfers right around shift change.

When I'm in the ED, I want to get rid of that admitted patient asap, but I can't do anything until bed control assigns me a room. It's very frustrating waiting. I try the best I can to get that patient to the floor quickly after an assignment is made. I think some hospitals have certain times when bed control is updated. That's the only thing I can think of....

When I'm working in the stepdown, the same thing happens - admits right at shift change. Come to think of it, ICU transfers happen around that time too.....hmmm.

My gripe regarding the whole situation is how nurses treat each other. The ED nurses think the floor nurses are trying to avoid work by delaying receiving report. The floor nurses think the ED nurses are trying to avoid work by holding patients until their shift is over.

When will we stop blaming each other and start sticking up for ourselves collectively? Perhaps we'd find solutions when we stop pointing fingers.

I think thats been going on to a certain degree in here anyway. Hey, I'm only one person, but I'm one less person who thinks ER nurses play games with the transfer times.

Now, in the future, like the guy I mentioned who I met traveling, I will speak up and say "hey, its not really like that" when someone says that around me.

Cant change the world all at once. But, like I said, everyone here changed my mind about what was going on. Then I talk to a few people and they change their minds.............and so on.

[Medic2RN, BSN, RN, EMT-P]

I used to work in the ER as a tech and now I'm a nurse in the ICU. Regarding this, I've actually had one of the ER nurses call me and ask if he could bring a patient up at 0645. He said "do you want her now?" I said "no, but I will take her because that would be crappy to make her wait!"

Sometimes you just have to suck it up!

Yup, I understand.....I suck it up every single minute I'm at work.

[Babs0512]

I have found it the other way around. Often the floor "puts of" taking report. Statements like "the bed isn't cleaned yet" or "the other patient hasn't left yet" are typical responses.

You're right, these things often happen near change of shift - partly because by the time the ER doc makes a decision and notifies the PMD, the PMD won't come over till his/her office hours are through for the day. So, patient ends up waiting, taking up an ER bed. Doc finally comes in to admit. Papers go out to admitting, and come back close to shift change.

There is a name for that, ahhhh, oh yes, Murphy's Law. Good ole Murphy is seen a lot in my life!!

Blessings

[eriksoln, BSN, RN]

Well, as someone from the other end, on the floor, I can be witness to the fact that a lot of times the whole "bed isnt clean" thing is often true. Multiple stat bed clean calls places by the charge nurse, another hour goes by, no sign of housekeeping.

Its annoying. That situation kind of lets me know how you guys feel when you try to call report and get the run around. Like I mentioned before, some ED nurses who dont have time to fool around will get the supervisor involved 1st time they call report and its not taken. It gets that way with us and housekeeping sometimes. We have to go all the way up the ladder to the supervisor just to get a room cleaned. It shouldnt be that way.

Now, as far as waiting for the attending to write initial orders goes, thats something that maybe should be brought up in quality control commitee meetings. Maybe there should be a time limit for them to do it, otherwise pt. goes to unit and they can do it there.

That last subject is a sticky one. As a unit nurse, my biggest pet peeve is when you get a new ED pt. and have no ability to manage pain. They've been in the ED for hours and have received multiple doses of pain medication and only get marginal relief. Then they come to the unit with nothing. It takes even a good, aware nurse a long time to get initial pain medication/management orders. Again, the pt. has only been on the unit a couple hours and our chances at top rankings on PG are capped/ruined.

I dont think there is much an ED nurse can do about that. Thats more of a gripe about the process than the ED nurses. But, its a tough situation for myself as the unit nurse. I've been pegged for not covering pain in surveys once or twice because of this very specific issue.

[MAISY, RN-ER, BSN, RN]

Here is an example of why we have these problems: Yesterday acting as a float I attempted to call report to telemetry. Patient had been downgraded from ICU-charge RN gets on the phone and advises that she was going to call and argue that the patient could be medical. After explaining how her vitals needed to be monitored and considering her over night status of ICU admit she agreed the patient should be monitored-I was asked to wait a minute for the receiving RN because she liked taking her own report and was giving a peg tube med-I said no problem....I waited and waited.....finally I called the floor back and was told C had gone to lunch....WHAT! the secretary told me the covering nurse had no time for report and I would have to wait as the charge had also gone to lunch.....Lunch what a concept.....THE REPORT WAS FAXED AND THE SECRETARY ADVISED IF THERE WAS A PROBLEM WITH THAT THE NURSE MANAGER COULD CALL ME! My issues was two-fold, I waited because I could I did not have a patient assignment and felt the RN should get a verbal report. Two, the in you face rudeness required was unbelievable, not only ignoring me but going to lunch when you know a patient is coming and you have a covering RN!

As for pain control, I agree there is a problem. Sometimes the ER will only do maintenance. Sometimes we don't have admitting orders when a patient gets their room(we don't have to send although try). Mostly it is because the doctors write short orders. If I have a Ca, chronic or intractable pain or whatever I try to get mild, moderate, severe pain orders along with benadryl, tylenol or anything else for that very reason-this includes drip orders, I will send to our pharmacy for preparation. The problem is that many doctors do not write this way unless prompted, and many nurses unless having worked with CA patients don't know to ask! The other problem facing those with a pyxis is that it takes forever to be updated when the patient reaches the floor! Perhaps pharmacy and administration need to be reminded of continuity of care.

Just my:twocents: