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]

Yeah, if there was a policy in place for covering pain before the initial orders were written, that'd go a long way to improving PG scores. And our patients would get better support/care too..........which is the overall purpose anyway right?

Its a tough one though. That'd be difficult to do I think.

[traumaRUs, MSN, APRN]

I can give some perspective as an advanced practice nurse: we are to move patients in and out as rapidly as possible. On my first visit to the patient, I do the assessment, order labs and get things rolling. Labs/xrays take about an hour, CTs about two hours so when I get the results from the ordered tests, I determine a plan: either discharge or admit. I put in for a bed immediately, discuss the plan of care with the ER MD, he calls the attending MD and the bed request cycle begins. If I see a critically ill/injured pt, I order a bed immediately upon seeing them with the caveat that the results of labs/xrays might change my plan of care.

However, my focus and job is to see, treat, street or admit.

[eriksoln, BSN, RN]

I can give some perspective as an advanced practice nurse: we are to move patients in and out as rapidly as possible. On my first visit to the patient, I do the assessment, order labs and get things rolling. Labs/xrays take about an hour, CTs about two hours so when I get the results from the ordered tests, I determine a plan: either discharge or admit. I put in for a bed immediately, discuss the plan of care with the ER MD, he calls the attending MD and the bed request cycle begins. If I see a critically ill/injured pt, I order a bed immediately upon seeing them with the caveat that the results of labs/xrays might change my plan of care.

However, my focus and job is to see, treat, street or admit.

I love it, they should teach that in school. See........treat.........admit/street. STAS.........eh, IDK/

[twinmommy+2, ADN, BSN, MSN]

No, I have never seen our ed hold pt's whether that be nurses or otherwise. We have to make beds for the masses trying to enter through the door and we cannot say no to anyone. Usually during the busy hours there is an ambulance en route who has already spoken for that bed, so we have to get them up asap, not to mention the how many people that are in the waiting room also needing the very same bed. It in no way ever helps us to hold on to someone.

Now, does the nurse that had your patient have a more critical patient that needs attending to? If thats the case then that nurse will hopefully be asking for someone to take their patient upstairs (or the charge nurse will be asking for them).

[eriksoln, BSN, RN]

No, I have never seen our ed hold pt's whether that be nurses or otherwise. We have to make beds for the masses trying to enter through the door and we cannot say no to anyone. Usually during the busy hours there is an ambulance en route who has already spoken for that bed, so we have to get them up asap, not to mention the how many people that are in the waiting room also needing the very same bed. It in no way ever helps us to hold on to someone.

Now, does the nurse that had your patient have a more critical patient that needs attending to? If thats the case then that nurse will hopefully be asking for someone to take their patient upstairs (or the charge nurse will be asking for them).

I will certainly be more sympathetic towards ED nurses who call me, panting with anxiety, saying they need to move the pt. NOW. I'm only one person, but still, it makes a difference.

[classicdame, MSN, EdD]

another reason could be housekeeping. If they have several rooms to clean before ED patients can be transferred to the floor, they may turn in all the room numbers at one time - right before they go home.

[eriksoln, BSN, RN]

another reason could be housekeeping. If they have several rooms to clean before ED patients can be transferred to the floor, they may turn in all the room numbers at one time - right before they go home.

Yes, as a floor (M/S) nurse, I have had situations where housekeeping just wont get up there and do the room. I've called one, the charge nurse twice and the CNA went off the unit to find them, but still the room is dirty. It shouldnt take a phone call to the supervisor to get a room cleaned.

Guess, just as this thread promotes working as a team with your ED, it also should show us housekeeping's role in pt. satisfaction.

[ERnewbieRN, BSN, RN]

I definitely have never held onto a patient in the ER for a few reasons. First and foremost, it negatively affects patient care. No one wants to be laying on a hard ER stretcher in the noisy chaotic ER for any longer than absolutely necessary. Orders that I simply do not have time to initiate (besides, obviously, stat/now orders) get neglected when I have that one patient being admitted and 3 other rooms being changed out over and over again with new patients that I must attend to. Then, the charge RN always wants to know why people aren't getting their patients moved. They almost never have to ask me, however, because getting these people out of the ER is usually one of my top priorities, barring sicker patients. It benefits me in no way to keep these patients here while I'm trying to deal with new ones, and the pressure's on to get the admitted ones out of there so we can get people back from the waiting room.

Reasons I would keep admitted patients for longer than expected: 1) I have one or more critical patients that require my attention and simple prioritization skills dictate that I must attend to these criticals first. 2) The supervisor notifies the floor that they are getting a new patient, but neglects to inform ER that the patient has received a bed assignment. I annoy the crap out of supervisors asking about bed assignments when it's been an hour or more. 3) There is a delay on transport's end and I do not always feel comfortable leaving the ER to bring the patient up myself... depending on the acuity level of my other 3 patients.

With this being said, the only times that I personally have ever tried to call report at "shift change" (and I've never called later than 0545) is when the supervisor doesn't give us the bed assignment til then. As soon as I get the assignment I IMMEDIATELY try to call report. However, this has only gone over once or twice, since no one wants to take report at shift change. Understandable, but now that patient has to be reported off to 2 different nurses: the oncoming ER nurse, and then the oncoming floor nurse. In my opinion this is breaking up the continuum of care.

I'll get off my soapbox now. Just trying to let the floor nurses see where we're coming from down in the bowels of the hospital. :)

[Magsulfate, BSN, RN]

I see holding a lot where I am at, in the LTAC ICU. When we're getting a patient from another ICU, they'll hold them until 6:30 and then transport them via ambulance, which usually means they get there right after night shift starts. Since it is a different facility, I have no control over it and REALLY, I don't mind. lol

When I worked acute care ICU, I never seen them hold an ICU patient in the ER. They always wanted to get rid of those types. It was always like "Here they come! REady or nooooot! " POOF and there they were... lol Wow, they must have been calling report from right outside our icu doors! lol

When it is a lateral transfer, that is when I see the most lag.

[Chixie]

Our doctors are notoriously slow to do meds for discharge so we will have mr smith in bed 4 sitting there for 5 hours waiting to go home. Meanwhile the a+e department have been told that we have an 'empty' bed and they start pushing for their patient to come up to us even though mr smith is still sat on his bed waiting.

Or we have to wait for housekeeping to get a wiggle on to high clean the side rooms (infection control) and despite telling a+e this they still send the infectious patient up who then ends up sitting in the hall spreading heaven knows what until housekeeping do their job.

While i appreciate that you want to get the patients out of a+e please dont shout at me because housekeeping are slower than slow.

[eriksoln, BSN, RN]

Our doctors are notoriously slow to do meds for discharge so we will have mr smith in bed 4 sitting there for 5 hours waiting to go home. Meanwhile the a+e department have been told that we have an 'empty' bed and they start pushing for their patient to come up to us even though mr smith is still sat on his bed waiting.

Or we have to wait for housekeeping to get a wiggle on to high clean the side rooms (infection control) and despite telling a+e this they still send the infectious patient up who then ends up sitting in the hall spreading heaven knows what until housekeeping do their job.

While i appreciate that you want to get the patients out of a+e please dont shout at me because housekeeping are slower than slow.

Yeah. As a travel nurse, I dont really have the knowlegde of who is who to be assertive and get housekeeping up to clean the rooms. Sometimes my charge nurse is at a loss too, after 3 stat calls and one face to face, if the housekeeper doesnt want to do it, they wont.

I've had more assertive ER nurses get ahold of the right people to get the room cleaned. That helps me a lot. When I'm staff and know the ropes, I dont need that support as much, but it still helps. A call to the supervisor from an ER nurse is just more effective than a call from a M/S nurse. It shouldnt be that way, but it is.

[MIA-RN]

I work in the ED and I never try to hold a patient. Shift change doesn't matter in my ED...we get patients as we empty rooms. It's not uncommon to come into a shift in the ED and have a couple 'established' patients and then have a few more that were just placed in beds that the off-going nurse doesn't know anything about. That's just the pace. We call report on the admits as soon as we find we have a room. If I am calling report and realize that its shift change, when I am working 12's I tend to forget about the 8h evening shift, I just apologize and call back in 15 minutes. I understand about getting rooms clean, and I also understand how we get backed up in the ED. Its the process, not the nurses.

It's not fun getting a patient when you have just gotten there and have yet to see everyone on your assignment, I remember that from my M/S days, but it's just how the flow goes. I took them as a floor nurse and I send them as an ED nurse...none of the timing has anything to do with nursing.