Overflow in the er

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So I'm doing some research for my BSN program and am looking at the way hold patients effect the er. This includes increased wait times decrease in patient happiness and an increase in nursing workload. I know our hospital has been trying but when you have 6-7 patients that you are caring for. 3 of which are holds with all floor orders in that you have to do. I was just wanting to get a feel for how the above effects moral and your care for your patients.

It's not unusual for pts to board for a couple of days and actually be discharged from the ED as admitted patients without ever having made it to a floor.

Same here. Its horrible. I worked a short shift this morning, 48 boarders in the department. 8 were Intermediate care, 3 ICU. The longest boarder has been in the department 1 day 18 hours on a stretcher that is now in the hallway with a portable monitor on the counter since they are tele. There were 28 patients in the waiting room when I left.

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Specializes in Emergency Room.
I have had boarders for an entire shift recently at my per diem job. Four beds occupied by boarders, and our fresh patients in hallway beds. It's not pretty. It's not unusual for pts to board for a couple of days and actually be discharged from the ED as admitted patients without ever having made it to a floor.

We've had that too lately, but thankfully, our Director will usually arrange to have an additional nurse come in to take an assignment of just the admit holds. This helps tremendously, not just because it relieves us of the burden of constantly switching from "ER nurse mode" to "inpatient nurse mode" but it also keeps us from having to constantly switch charting systems in the computer. The ER is on Medhost while the rest of the hospital is on Cerner. Since we don't get much Cerner facetime, we tend to be slower with our documentation than someone who floats up on the floor or has worked the floor in the past. The extra nurse makes a world of a difference.

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
Same here. Its horrible. I worked a short shift this morning, 48 boarders in the department. 8 were Intermediate care, 3 ICU. The longest boarder has been in the department 1 day 18 hours on a stretcher that is now in the hallway with a portable monitor on the counter since they are tele. There were 28 patients in the waiting room when I left.

Sounds familiar! :) One thing that is nice is that at least for admitted patients, we can usually get a hospital bed for them to at least get them off of the stretcher.

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
We've had that too lately, but thankfully, our Director will usually arrange to have an additional nurse come in to take an assignment of just the admit holds. This helps tremendously, not just because it relieves us of the burden of constantly switching from "ER nurse mode" to "inpatient nurse mode" but it also keeps us from having to constantly switch charting systems in the computer.

We also have an admissions unit and a CDU - all usually full as well. At least we don't have to switch charting systems, we continue to chart in our ER software but have to check the inpt system for any order changes.

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Yes! This.....ugh give me 5 full workups but please pleaseeeeeeee no admits :/

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Specializes in ER, SCTU, PACU.

I just finished a paper for my grad school class on this! I copied my list of references below if you need some additional materials. Definitely echo everyone else here, I hate admission holds. If I wanted to be an inpatient nurse I would have applied for an inpatient nurse position. ED nurses like rapid turnover and instant gratification, figure out what's wrong and how to fix it in just a couple of hours. 4-6 hours in the ED is pushing it. We've held for 3-4 days in my ED this season. Floor nurses definitely are not stepping up to the plate to take on extra patients, but in the ED we stretch until we break, and when we break it's ugly.

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Thanks for the references I had a felling I knew how most people would feel on this topic thanks everyone

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Specializes in Emergency Nursing.

This post is a bit eye opening for me, as we do not hold patients in the ER. Pretty much ever. The facility's policy requires the floor to take ED report as priority over their oncoming shift report, and there is a one hour admit order to bed protocol. If we go over that one hour time limit, we have to chart the specific reason for it, and it's regularly addressed. We also are not expected to perform admitting orders in the ED. Those are considered orders for the floor nurses to complete. Now, if we aren't busy, and I know the floor is busy, I have no problem throwing in a foley, or an NG, getting a type and screen started, or even ordering a tray to be received upstairs, but we aren't required to complete them, by any means. Holding patients in the ED would mean poor care, not only for the hold pts, but also the pts in the waiting room, who now must wait even longer for a bed. I would hate this process. At the facility I used to work, psych admits were notoriously long, sometimes 8-10 hours, but these were stable patients, for which we had specifically trained psych techs, and an area of the ED set up for this process. It was still frustrating to have to utilize your float nurse this way, but we never held medical or trauma pts in the ED.

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This post is a bit eye opening for me, as we do not hold patients in the ER. Pretty much ever. The facility's policy requires the floor to take ED report as priority over their oncoming shift report, and there is a one hour admit order to bed protocol. If we go over that one hour time limit, we have to chart the specific reason for it, and it's regularly addressed. We also are not expected to perform admitting orders in the ED. Those are considered orders for the floor nurses to complete. Now, if we aren't busy, and I know the floor is busy, I have no problem throwing in a foley, or an NG, getting a type and screen started, or even ordering a tray to be received upstairs, but we aren't required to complete them, by any means. Holding patients in the ED would mean poor care, not only for the hold pts, but also the pts in the waiting room, who now must wait even longer for a bed. I would hate this process. At the facility I used to work, psych admits were notoriously long, sometimes 8-10 hours, but these were stable patients, for which we had specifically trained psych techs, and an area of the ED set up for this process. It was still frustrating to have to utilize your float nurse this way, but we never held medical or trauma pts in the ED.

Your floors always have available beds/nurses? Usually my department holds patients in the ED because there are no available beds or inadequate staffing not because the floor nurse wont take report.

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.
This post is a bit eye opening for me, as we do not hold patients in the ER. Pretty much ever. The facility's policy requires the floor to take ED report as priority over their oncoming shift report, and there is a one hour admit order to bed protocol. If we go over that one hour time limit, we have to chart the specific reason for it, and it's regularly addressed. We also are not expected to perform admitting orders in the ED. Those are considered orders for the floor nurses to complete. Now, if we aren't busy, and I know the floor is busy, I have no problem throwing in a foley, or an NG, getting a type and screen started, or even ordering a tray to be received upstairs, but we aren't required to complete them, by any means. Holding patients in the ED would mean poor care, not only for the hold pts, but also the pts in the waiting room, who now must wait even longer for a bed. I would hate this process. At the facility I used to work, psych admits were notoriously long, sometimes 8-10 hours, but these were stable patients, for which we had specifically trained psych techs, and an area of the ED set up for this process. It was still frustrating to have to utilize your float nurse this way, but we never held medical or trauma pts in the ED.

But if there were no open beds where did you put them?

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Specializes in Emergency Nursing.

We do typically always have available beds. At most, we will hold a patient for 30 minutes while a nurse is called in. In 1.5 years I can only think of one medical pt whose admission was held because of lack of beds, and it was an ICU pt we considered shipping for this reason. But, they were able to move some pts around upstairs and we got the pt up in about 1.5 hours. We have held 2 psych pts overnight, waiting for a psych bed because we don't have inpatient psych at our facility, but that's it. It's a smaller facility with a lot of support for the ED.

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Specializes in Med-Surg, Emergency, CEN.

I think I'm kind of jealous now. :wideyed:

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