Post op Admissions During Shift Change?

I<3H2O, BSN, RN · Nov 6, 2010

I work on a rural 35 bed med-surg unit. NOBODY holds patients for us during shift change. The only way we can get them to hold the pt. is by not picking up the phone for report. Even then, the ED and the PACU has been known to just show up on our floor with the pt. without giving report. It is a busy time at shift change. There should be NO new admits post op or otherwise until at LEAST 30 minutes after shift change. That way, the nurse can get report on the current pts. go and see them all and then get the new pt. so that the nurse can spend some time with the new admit.

A fresh post op is sometimes very time consuming. I have had post op TURPs that I didn't leave the bedside for >1hr due to the amount of bleeding and subsequently pt. being sent back to OR.

I wish more departments would hold the pts. for just a bit but they just don't at my facility.

nurseraphael · Nov 6, 2010

I work Charge on a busy 32 pt med/surg floor. We discourage pacu from giving report during change of shift, but they need their rooms opened when more cases are coming out of the OR . . . I work 12 hour nights and often these admits are trying to get cleared out by 8pm so the RR nurses can go home. I will ask if they can hold til 7:45 then send them up. the ER just sends them on up - i have had them change a bed in the computer from dirty to clean - so they can transfer the pt to our unit. they come up and find they cant go in the room, we make the aide stand with the pt in the hall until the room is ready. I was told by the ER Charge that i was not marking my rooms as clean to keep the pt in the ER? that was apparently not true!

Our Pacu is very good at communicating with our unit, it makes for a good working relationship - and for good scores on pt satisfaction . . . pay for performance is gonna be key the profitability of units in the near future.

amarilla, RN · Nov 8, 2010

I work on a med-surg floor in a 475 bed level 1 trauma hospital. Our PACU will hold off (if asked) between 7 - 7:30 pm while nurses are walking through report, (we do bedside.) It really is problematic to have two, three or four nurses to report off to for six to eight patients and be interrupted by an admission rolling down the hallway. That means I can't give report to the nurse on her remaining patients while she tends the admission, keeping me on the clock and unable to leave, also.

I will say that I don't appreciate when patients are sent without report being called up; at my facility, we have 20 minutes to return the call and accept report or we can be written up. If a patient arrives to me without report being given, I will call down to find out what happened, then quantros the incident and write up the sending nurse. It's dangerous and more than once has turned into a big mess - patients arriving who are inappropriate for our floor, patients arriving despite their orders being for specialty or critical floors, patients actively bleeding or having evolving chest pain!

I agree with the first reply that the ideal policy will give a half hour (or more) either way - before shift change and after - to allow nurses to settle their patients and round. I also understand that patients need to be moved out on a timely basis. One thing I've noticed with our PACU is that I'll wait on a 4:30 arrival postop who has been in recovery since 1 pm...and they don't call to give report until 6pm. :uhoh3: Timely works both ways, and I wish the more stable folks could come to the floor more quickly instead of eating and watching television downstairs.

I sometimes wonder why the schedule isn't staggered; that PACU nurses go off/come on an hour or more earlier or later than the floors. It might be easier to stagger admissions and clean house at 5:00 or 8:00 than right at 7:00, when the whole hospital is changing over.

JME, and a few thoughts.

Up2nogood RN, RN · Nov 11, 2010

We are not a trauma center and have approximately 450 beds. I work on a 24 bed GI surg unit and PACU sends them as soon as they're ready with no regard to shift change. It's very difficult to receive a fresh post op at like 1900-1930 when trying to get report on our other pts. Same thing with ICU transfers. I know there are rationales for this but it sure does hinder my other pts care.

I've also had to take pts that still required ongoing 1:1 monitoring either because they needed the bed in PACU or they wanted to go home. Seriously? If a pt needs a sternal rub to be aroused that does not meet protocol for transfer in my book. After settling the pt in bed the PACU nurse then informs me to call him if I have any questions, he'll be on the clock for another hour. Really ?!?!?

carluvscats · Nov 12, 2010

Oh. My. Gosh. ~ TittytatRN. (2nd paragraph) That is just horrible.

Ellekat · Nov 20, 2010

Admits from OR or ED are assumed to be stable; the aide takes vitals and the nurse sees them as soon as possible. It does keep us from seeing patients. Getting an admit at shift change can put a nurse behind by several hours throughout the day. What I've seen is that when the time to staff based on number of patients is over, the floor is suddenly overrun with admits that the ED and PACU have held in order to keep their staffing levels up-to a floor whose staff is lowered because we don't have the patients yet. This leads to serious understaffing and poor patient care, especially since our floor also receives direct admits from physcians' offices and outpatients who need blood, wound care or IV antibiotics. (Outpatients aren't considered in our staffing policy.)

Penelope_Pitstop, BSN, RN · Nov 20, 2010

I used to work in a PACU myself, and the patients were often held until the end of the PACU RN's shift as a courtesy to HER (only female nurses in this PACU), NOT the floor. And report was faxed, not called.

I think it's a little different in my hospital now because it's much bigger, with more ORs, and a much wider variety of surgeries (old hospital was mostly ENT, ortho and plastics with a smattering of belly surgeries). But I work on a medical floor here so we usually don't get post-ops.

All4Seasons · Nov 20, 2010

Ellecat said:

"What I've seen is that when the time to staff based on number of patients is over, the floor is suddenly overrun with admits that the ED and PACU have held in order to keep their staffing levels up-to a floor whose staff is lowered because we don't have the patients yet."

Ellekat,

I've never heard of anything like this before,do you have a minute to elaborate?

Does this mean that nurses are pulled off floors to staff others on an ongoing basis - a constant shifting of nurses in the hospital throughout the day?

Thanks!

LouisVRN, RN · Nov 22, 2010

Ellecat said:
"What I've seen is that when the time to staff based on number of patients is over, the floor is suddenly overrun with admits that the ED and PACU have held in order to keep their staffing levels up-to a floor whose staff is lowered because we don't have the patients yet."
Ellekat,
I've never heard of anything like this before,do you have a minute to elaborate?
Does this mean that nurses are pulled off floors to staff others on an ongoing basis - a constant shifting of nurses in the hospital throughout the day?
Thanks!

I think what she is saying is a phenomenon we've noticed as well. If PACU or ED would have to flex-down (send a staff member home) by releasing a couple of their patients to the floor they tend to hold on to those patients and maybe accept additional patients to keep their unit fully staffed. Meanwhile as the floor is not receiving those patients and often times do not know about those patients being available to come to their unit, they flex down due to a low census. Then near end of shift, after the cutoff to send people home for low census, PACU and ED will try to batch all of their patients to the floor at once because they now can keep all their staff members, meanwhile the floor no longer has the staff to care for these patients and this often results in pulling people from all over to try to care for these post-op and admission patients while desperately trying to call in additional staff members that may have been canceled from the oncoming shift because of low census.

ETA I work on a 28 bed med/surg unit, we are not a trauma center. I can honestly say I despise getting PSA during shift change. I do not think it is safe. Often times the offgoing nurse has been the one to receive report from the PACU nurse, but has then told PACU to hold off bringing the patient until shift change. I find these reports to be sub-par as the receiving nurse knows she will not be caring for the patient. I also feel like I do not get any time to ask questions, because the PACU nurse has already given report and is not interested in answering additional questions at the end of the day and the offgoing nurse did not think or was not interested enough to ask. This tends to be the time when unstable patients come to the floor. I have had several post-ops complaining of chest pain, difficulty breathing with horrendous O2 sats, uncontrollable bleeding come to the floor which I would have never accepted.

BonnieSc · Nov 23, 2010

Does this mean that nurses are pulled off floors to staff others on an ongoing basis - a constant shifting of nurses in the hospital throughout the day?
Thanks!

Yes, in my hospital. We are staffed in four-hour increments. If we have "too many" staff for our unit's census at 10 AM, one of our staff members can be ordered to float to another unit. Doesn't matter if we get more patients at 11 AM.

Music in My Heart · Nov 23, 2010

We close the floor to new admits beginning 45 minutes before shift change and 30 minutes after.