Patient Safety

[Rashandap]

The hospital I work for has a goal for admitting patients from the ED. All patients admitted via the ED, the hospital wants these patients to be on floor, in the bed within 60 minutes of informing ED and my med/surg unit that this patient was being admitted. This is a great goal, because so many times patients have to linger in the ED for hours, and most of time may not be very comfortable on stretcher as they would be in a bed on the floor.

Here is the problem: about 2 weeks ago, I came into work, my nurse:patient ratio is 1:6. I was sitting at the nurses station with night shift nurse receiving report. The unit clerk this hands me a index card to inform me of a new admit from the ED. I took card a set it aside and continued receiving report and reviewing the last 24 hrs of orders. When we were on the last patient, the other day time nurse took answered phone from ED. The nurse told the ED nurse that the nurse who would be getting patient was in report, she was about to say could you hold on when the ED nurse started screaming at her, yelling saying getting the patient up to floor in 60 minutes was a priority over getting report for patients already on floor. I took the phone from the nurse I would be working with, and I talked to the ED nurse. He proceeded to tell me how he needed to get that patient up to floor now, and how getting patient up in 60 minutes were more important. He said if somebody doesn't take report I will just be bringing patient up. I told him I would be receiving patient and I needed him to hold on as I was in middle of report and I had not even gotten the fax they are required to send for me to review and ask any questions. He just continued to be very rude so I told him again to hold on, he just wouldn't he said what ever I was doing could be postponed and I could look at sheet after taking report. Finally I just told him that NOTHING is more important that patient safety and that unless I was given oppurtunity now to review patient data I would not take patient right now, I told him if has a problem he could call my charge nurse, and I gave him the extension and hung up.

This scenario keeps happening at the hospital I work for. Most times when the ED is not busy, they take their time bringing the patient up and I usually have to chase down the nurse to get report. When it is busy they want everyone up to floor immediately.

My problem is I feel like I am being rushed to take patients and I end up having more questions about patient from nurse in ED, but for the most part after they fax transport/report sheet you will see ED techs bringing the new patient. The techs of course can not really answer any questions I have for the previous nurse.

So since I have not gotten adequate report I don't except responsibility for patient, I tell the ED tech and my charge nurse (well charge nurse in training) that I cannot safely take care of patient. The reason I did this was patient safety. On a previous occassion around change of shift, I got a patient from ED, I got the info as I was going for lunch. When I came back there was no transport/report sheet, no chart, and I couldn't find the index card, so I went back to taken care of the patients I had before. Around 630p light goes off in room at end of hall, which is were the new patient. I went in to room and the patient and her husband were in the room, I asked how long they had been and he said an hour. Apparently when ED tech brought patient up they just left her in her room, and her paperwork so nobody new she was there. So I had to hurry somewhat to at least get her vitals well that patient O2 Sats were 80% on room air. So I had to get some O2 on her. The girl was in severe pain (sickle cell crisis) and was ordered a dilaudid PCA. So I had to call IV team to get a line in her. IV nurse start a new IV Lock only to then find out patient has a mediport.

I think sometimes that as nurses so much is put on our shoulder in terms of giving patient care, providing support for patient and family, that things like being in a rush to get patient up to floor or anything else should trump patient safety.

[SCRN1]

One thing I think is good about that policy is it keeps the ED nurse from keeping a patient in a bed there until shift change so they don't have to put another one in it. Now before I get flamed for saying that, let me add that I don't think all ED nurses do that. But it happened quite frequently at a hospital where I used to work. They would wait until just before or just after shift change to send up patients. Some of the patients would tell me around midnight when they were just coming up to the floor that they'd been down in the ED since earlier that morning. There was no need in that since we had an empty bed all day they could've been in and the other people sitting out in the waiting room could've been seen instead of waiting so many hours. The supervisors were aware of this happening too, but never did anything about it. Where I'm currently working, it still happens sometimes. But not like at the other place.

I'm with you about wanting to get report first...and to be able to assess them before getting a new admission. It could've been several hours since the last nurse was in their room. What if they're a surgical patient and they're laying in there in a pool of blood and you come on and don't get to them for quite a bit later because of getting a new lengthy admission? Is the ED nurse going to get blamed for that patient not being assessed? No, YOU are.

[Altra, BSN, RN]

Let me give you the perspective of the other side ...

1) That ER nurse will be held accountable for whether or not the pt. got up to the floor within the 60 minutes mandated by your facility's policy. He/she can document, "Floor RN in report, not ready to accept pt." until the cow/pig/other assorted nursery rhyme character flies over the moon, but it will not matter. What will be looked at by management is, did the RN meet the goal of getting the pt. to the floor within 60 minutes.

2) Just a thought - some day you might actually ask an ER RN with whom who are friendly, "when you're not busy, do you take your time getting pts. to the floor?" Be prepared for either utter confusion (what does it mean to be "not busy"?) or a hysterical belly laugh. The very nature of working in the ER is to stabilize pts. & move them out ... to make room for the teeming mass of humanity lined up behind them. There can be many reasons for delay in getting the pt. to the floor, but I feel confident in saying that the ER nurse's desire to hold on to the pt. is not one of them.

3) What is your charge nurse's response to your refusal to accept the pt.?

Do a search for threads on this topic - there are many.

[TazziRN, RN]

One thing I think is good about that policy is it keeps the ED nurse from keeping a patient in a bed there until shift change so they don't have to put another one in it. Now before I get flamed for saying that, let me add that I don't think all ED nurses do that. But it happened quite frequently at a hospital where I used to work. They would wait until just before or just after shift change to send up patients. Some of the patients would tell me around midnight when they were just coming up to the floor that they'd been down in the ED since earlier that morning. There was no need in that since we had an empty bed all day they could've been in and the other people sitting out in the waiting room could've been seen instead of waiting so many hours.

And quite often it's the doctors who hold up admits.......no orders are written, or the admitting doc needs to see the pt and doesn't show up until after office hours.

Walk a mile in our shoes, please.

[rn undisclosed name]

Since I don't work in the ER I don't understand what in the world takes so long to get patients up to the floor. When I am told they are faxing report I expect the patient to be en route up to me. I can't tell you how many times the patient shows up hours later. If there's a delay - fine. Let me know. I am not just sitting at the nurses station twiddling my thumbs waiting for this patient to arrive on the floor.

I think something needs to be addressed regarding getting patients up to the floor and quite honestly I don't think patients should be sent up to the floor as a nurse if just coming on to start her shift. Admissions are involved and the other patients need to be seen. Some hospitals state no admissions 1 hour before or after shift change. I think that sounds fair.

[rn undisclosed name]

And quite often it's the doctors who hold up admits.......no orders are written, or the admitting doc needs to see the pt and doesn't show up until after office hours.

Walk a mile in our shoes, please.

Tazzi can you please explain about admitting docs needing to see the patients. I have very rarely had a patient that I admitted who was seen by the admitting doc. Yeah, they're seen by the ER doc but the admitting doc hardly ever. I don't know maybe this is different from hospital to hospital. Many times the patients are just assigned to whoever doctor's turn it is to accept new admits. When the patients get up to the floor that is when I get orders from the admitting doc. Just trying to understand.

[Rashandap]

Let me give you the perspective of the other side ...

1) That ER nurse will be held accountable for whether or not the pt. got up to the floor within the 60 minutes mandated by your facility's policy. He/she can document, "Floor RN in report, not ready to accept pt." until the cow/pig/other assorted nursery rhyme character flies over the moon, but it will not matter. What will be looked at by management is, did the RN meet the goal of getting the pt. to the floor within 60 minutes.

2) Just a thought - some day you might actually ask an ER RN with whom who are friendly, "when you're not busy, do you take your time getting pts. to the floor?" Be prepared for either utter confusion (what does it mean to be "not busy"?) or a hysterical belly laugh. The very nature of working in the ER is to stabilize pts. & move them out ... to make room for the teeming mass of humanity lined up behind them. There can be many reasons for delay in getting the pt. to the floor, but I feel confident in saying that the ER nurse's desire to hold on to the pt. is not one of them.

3) What is your charge nurse's response to your refusal to accept the pt.?

Do a search for threads on this topic - there are many.

I am totally in favor of the Hospitals Policy to try to get patients up to the floor within 60 minutes if a bed is ready. That being said, getting the patient up to room in 60 minutes is not more important that patient safety. I feel it is my duty to make sure any patient in hospital is provided safe, adequate care. To do that I need to get a basic report from the nurse before the patient arrives on the floor, so if anything I can start getting things together that I may need to care for patient. What if a patient coming up to floor had C. Diff or MRSA that is something I need to know before I go into patients room.

ED nurses are not the only ones who hold on to patients until change of shift so they don't get a new admit. This particular day it was rush, rush get that patient up to floor. Yet later on that same day @ 130p I was told I was getting another admit from ED. @ 200p I called ED for report, and to get fax since it had not been sent, the nurse was at lunch so they took my number. I again had to call nurse around 5p because patient still had not been brought to floor nor had I got fax. At 6p I finally got fax but it was completely inadequate, the last vital signs time on patient was from noon, it is now 6p. An even those vital signs were incomplete, with no temperature or O2 sats.

Why was getting the patient up to the floor in AM a rush, but later that same day the next patient can wait six hours, to right before my change of shift. When these patients come on to the floor in addition to a head to toe assessment, I have to make sure orders are put in, I have to enter patients clinical pathway, as well as appropriate care plans. I usually have to call MD for orders, because at my hospital MD's are not required to write orders for patient before they get up to floor.

[Bluehair]

On a previous occassion around change of shift, I got a patient from ED, I got the info as I was going for lunch. When I came back there was no transport/report sheet, no chart, and I couldn't find the index card, so I went back to taken care of the patients I had before. Around 630p light goes off in room at end of hall, which is were the new patient. I went in to room and the patient and her husband were in the room, I asked how long they had been and he said an hour. Apparently when ED tech brought patient up they just left her in her room, and her paperwork so nobody new she was there. So I had to hurry somewhat to at least get her vitals well that patient O2 Sats were 80% on room air. So I had to get some O2 on her. The girl was in severe pain (sickle cell crisis) and was ordered a dilaudid PCA. So I had to call IV team to get a line in her. IV nurse start a new IV Lock only to then find out patient has a mediport.

Hmmm. Did you happen to think to fill out an incident report on this? That sounds like they were on the verge of patient abandonment. If nothing else, they missed the point of trying to get the patient to their room within 60 minutes. It's so they can get care, and if the receiving nurse doesn't even know they are there than that seems to defeat the purpose.

You get a written report? It was my understanding from JCAHO standards that report (hand-off communication) is supposed to include the opportunity for asking questions. You can hardly ask questions when you are a) being yelled at, or b) can't get in touch with the nurse.

Our hospital has a similar goal, and the purpose is to improve patient care as well improve patient satisfaction ( a goal at our facility since the upcoming HCAPS surveys will be tied to Medicare reimbursement in the near future...).

Our ED doc's can not write admission orders, the hospitalists or primary care MD has to do that, and they usually won't write 'em until they see the patient. A few will write the basic 'admit to floor' with diagnosis and come see the patient on the floor for the rest of the orders to help move things along more quickly. The wait for admission orders in ED can take HOURS! Then they order tests they want done before the patient goes upstairs. I sympathize with the ED nurses, it's a mess!

Yes, there are always waiting hordes in ED's across the country. But I agree with you that we also have to maintain the safety of the patients we have (as well as maintain our own license!) before taking on more. Shift change has long been shown to be the time of day when the most errors occur (or are found), so bringing patients from ED right then does not seem to be the best idea. Some ED nurses (please don't flame me guys, I know it's not all!!!) have come right out and told me they don't care what is going on in ICU, we are bringing this patient up now anyway, and brought a new admit right when we were receiving a code blue pt. from the floor. Did they stay and help with the code, or help get the new patient settled and put on the monitor? Nope. Not safe practice in my book.

In a perverse way it's comforting to know our ED is not the only one to seem to prefer that last hour to bring us admissions!

[TazziRN, RN]

At the hospitals in our area the admitting docs sometimes say they want to see the pt and write the orders, but when they say "I'll be there in a bit," they actually mean "I'll be there after I finish with my office pts." Other times the ER doc writes the covering orders, but they're busy seeing other ER pts and we can't get them to sit down long enough to write the orders. We cannot send pts to the floor without orders.

[Altra, BSN, RN]

I think something needs to be addressed regarding getting patients up to the floor and quite honestly I don't think patients should be sent up to the floor as a nurse if just coming on to start her shift. Admissions are involved and the other patients need to be seen. Some hospitals state no admissions 1 hour before or after shift change. I think that sounds fair.

Is it fair to the patient w/chest pain & nausea who arrives in triage at 1830 if all ER beds are full and in a "holding pattern" with no movement of pts. out until 1 hr. after shift change?

This is an issue with no easy answers.

[TazziRN, RN]

Is it fair to the patient w/chest pain & nausea who arrives in triage at 1830 if all ER beds are full and in a "holding pattern" with no movement of pts. out until 1 hr. after shift change?

This is an issue with no easy answers.

:yeahthat: :yeahthat: :yeahthat:

[BrnEyedGirl, BSN, MSN, RN, APRN]

the most obvious answer to this is the same thing we all c/o all the time,.staffing issues!!!! I work in a local trauma center (one of two in the city),..we have 13 Trauma beds,.and 18 beds on the ED side (we also have a Fast Track but I won't "count" them for the purposes of this conversation),.....it is not unusal for us to have all 18 ED beds full w/4 hallway beds on the ED side,..all 13 trauma beds full w/8 hallway beds,.45 people in the waiting room who haven't even been brought back yet,.then the radio calls,.."MVC car vs semi truck,.4 class 1 taumas enroute,.ETA 7 minutes",.....so now what the heck do we do??? We have 6 RN's and 2 techs,.4 ER DR's Well,.we do what ER's do,.we triage,...the little old lady in 7 w/ CHF had her lasix, foley in,.sats ok w/O2 gets moved to the hallway,..the back pain X6mo goes back to sit in the waiting room to wait for Xray results,..the kid w/the runny nose et fever goes w/ the guy with back pain,.gotta stay w/the guy with the high BP et chest pain,..gotta stay w/ the altered mental status et new facial droop,..security is called to watch the 4 meth OD's,........ things get backed up folks,..way backed up,.but again what do you do?? Need more nurses, more techs,.more Dr's!!