Problems with ER

eroc · Mar 19, 2015

Policy at my hospital has been unless they are going to the ICU they don't have to call report. And a ER nurse only escorts a patient up if they are on a cardiac drip.

It has worked well and I see no problem with it. They are going from critical care to acute care. If they are A&O just ask the patient, and look at the chart. I have never had one issue when working on an acute floor.

trinitymaster · Mar 19, 2015

I am so glad to now be working in a facility without an ER. ER is horrible. The Managers want them to have a one-hour turn around which is nearly impossible. There are core measures. The charting systems neither communicate nor reconcile with each other. Too many brand new nurses. Focused assessments where the 103 temp is attributed to bad food and not to the osteomyelitis that the patient did not mention.

The floor is dangerously understaffed and no one wants to take report, especially from an ER tech who has never seen the patient and is only reading off of a report sheet.

Both sides are completely stressed to the limit and sometimes it puts them at each others throats.

Neither side is to blame, they just learn to cope in their own unique way.

trinitymaster · Mar 19, 2015

Never have I sent an unstable patient to the floor, and usually most of my inpatient orders have been started (can't speak for other nurses on this one).

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NewYorkerGirl · Mar 19, 2015

I would just settle for my ER sending me stable patients. They recently sent me a patient at shift change: 207/100 BP. We are not a cardiac floor, and have to call intervention to deal with crazy cardiac -ish like this. Thanks ER.

PacoUSA, BSN, RN · Mar 19, 2015

We get patients from the ER without report all the time, it's actually the standard practice at the hospital I work at right now (one of the top 10 hospitals in the country per US News & World Reports). I haven't had a problem so far, patients are always relatively stable when they arrive. I suppose the ER makes sure to not send them until they are. I've worked at another hospital (not nationally ranked) where the ER called the floor for report and I always found it a hassle. The ER nurses there always reiterated to me the same details I could read on the EMR from upstairs, so for me it was a waste of time, and they rarely offered info not in the chart, such as neurotic family member at bedside coming up with patient. They also often tried to send patients up that clearly belonged in higher care. I like it better where I am now. Shame tho, as I am a traveler and moving on to another hospital in about a month, hopefully they also have no-report transfers from ER.

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Anna Flaxis, BSN, RN · Mar 19, 2015

We've been having issues with the ER in our hospital. I work on a busy telemetry floor and when the ER calls up to give a report on a new admission, if the nurse taking the patient is unable to take the call right away, our ER sends the patient up without giving report. I've spoken with the nursing supervisor regarding this and he said that's just what they do, but quite honestly, this doesn't seem safe or legal. Any insights would be appreciated

Reading between the lines, it sounds like your hospital is trying to reduce ER throughput times, and that delays in giving nurse to nurse report have been identified as a factor. I agree that no handoff report is a patient safety issue- have you spoken with your manager? Could the charge nurse take report if the primary nurse is unavailable?

What others have said is true. Throughput times are a huge focus at my facility right now. The moment they have a bed and a nurse, they are supposed to roll. The receiving nurse is expected to look the patient up in the EMR, and the telephone report is just a quick conversation to cover anything not in the EMR (like the neurotic family member). If the receiving nurse cannot take report, then the charge nurse does.

Sometimes I feel badly, especially when there are several admits, like we're just cramming patients down their throats up on the floor, but it is the directive we have received, and is supported by administration, the house supervisor, our manager, and the manager and charge nurses on the floor. Getting them rolling with minimal delay is what we are supposed to do.

Could it be that's the case at your facility and nobody has bothered to inform the floor nurses of this?

EmergencyRN22 · Mar 19, 2015

Sorry for mistakes, I'm posting from my phone.

At my hospital, we give bedside report the magority of the time. The rare occasion we don't, report is given by phone/vocera to receiving RN or their charge RN.

The floor RNs come to the ER to retrieve their patients. We hold each other accountable in the ER and there are no "surprises" to the floor nurs. If there are issues, hopefully it can be resolved easily.

With ICU patients, most of the time the ER nurse will travel up the unit with the ICU rn to assist - at times in the company of support staff.

I like this system. Yes it takes more time and sometimes the floor RN will harass the er rn about orders but I feel it's best for the patient.

OhioCCRN, MSN, NP · Mar 19, 2015

not acceptable plain and simple. How can there be proper transfer of care when you do not give/receive report?

ReggieN · Mar 19, 2015

Thank you for your input. It does help to see the other point of view. Unfortunately, the hospital I'm currently working at, our ER isn't the most reliable. We have had multiple issues with them not making sure that the patient is stable. We have gotten reports of patients with extremely elevated BP (SBP of 200+ DBP over 110), in which our ER has not even begin treatment for, and when questioned they respond with "oh yeah." Same with very low hgb (another example). I do not expect our Er to "fix" the patient before they hand them off, but I would like to see that if there is a critical lab/vital/etc. that its at least addressed and at least orders placed. This has been my main concern with the whole sending a patient up without giving a report.

I do like the idea of bedside reporting. We do it on the floor now, but that may be a way to solve some of the issues we are having between the units.

eukaryote · Mar 19, 2015

Does the ER have an admissions RN? We had a similar issue to this at our ER, and they hired an admissions RN which has been immensly helpful.

The problem I have with quick throughput times and not getting report on ER patients, is that often patients come to our floor and the attending will see them upstairs/when they are ready. This could mean we have patient on the floor for an hour or sometimes more with no orders (we cannot implement or view the ER orders). If we receive an unstable patient, or a patient with no report, this is a huge patient safety issue. I recently got an ER patient - in report they told me she was stable, BG was 73. On a hunch I checked the BG when she came up to the floor - it was 23!! I had to page the attending 3x and had to override the system to push d50 - THREE times because it took the attending 45 minutes to get back to me (which we are allowed to do with d50 on my unit). I was about to call a rapid. This is an extreme example, but a good reason floor nurses need a good report. If that patient had just been sent up to the floor without a report, in the middle of something crazy or at shift change and had just been left sitting in the room, there could have been a very poor outcome for that person.

EmergencyRN22 · Mar 19, 2015

Honestly, many times we don't even get a chance to address hypertensive pt and the blood isn't ready for those low h&h you're talking about. Most ER docs won't address chronic hypertensive pts unless they are a dissection or a bleed. They allow the admitting doc or specialist decide plan of care of the htn.

Moving patients to the most acceptable floor ASAP is vital for a good, functional ER.

If I have an anemic pt whose only been in the er for 2 hours and they receive a bed. I'm not going to keep them dowN here and taking up (much needed) space until the blood is ready for transfusion. If the patient warrants emergency transfusion we will obtain 0- from blood bank and Initiate it in the ER and move the pt to the ICU asap.

Unfortunately, the ERs goal is to acutely stabilize the pt and then move them to the icu for further stabilizing. We don't keep critical pt in the dept for hours of "stabilizing" unless we have no available beds.

eukaryote · Mar 19, 2015

It's really important for floor nurses to understand the way the ER functions. It's literally crazy down there. I've had to float there a few times, and yeah, I can understand the need to get ppl outta there! When they call report, we usually do a short SBAR, I view the appropriate info in the computer that I need, labs, radiology, ect and just need the absolute skinny. Also, I make sure they know I just need the basics - anything critical pls address since it could be awhile before I have orders. ABX, blood, whatever - just send it with the pt. and I will complete it. That stuff doesn't need to be completed in the ER.