Problems with ER

NurseSpeedy, ADN, LPN, RN · Mar 19, 2015

Where I worked primarily, the chart nurse would take the report for the nurse if she was tied up. It would usually be about 10 minutes before ER shift change and the patient had orders to transfer to the floor a few hours earlier but they held on to the patient and asked for a bed last minute and then were in a hot hurry to unload several patients out to the floors so they could go home. It was like a flood gate would burst at shift change on a daily basis and no one would make them call for a bed and give report when they had obtained the order. Our complaints fell on deaf ears. Other facilities that I have worked for sent a faxed report (didn't we check our machine?) and some have sent a nurse escort as they came rolling down the hallway "I have a new patient for you where do you want them?". However, I have always received some form of report, however sketchy the situation may have been. I'm not saying it was an accurate report, but I was told some details that I would either verify or disprove with my own assessment upon arrival to my unit.

EmergencyRN22 · Mar 19, 2015

Many times the ER docs batch admissions -many times th e same admitting doc as well. It's unfortunate it's goes in batches but sometimes its how the request for admission goes.

Many of those times we receive bed assignments in groups too. That's also unfortunate as well because I understand floor nurses may receive multiple new admissions within a short time.

I'm sorry it happens but it's just the nature of the beast.

There are also times Ive received two brand new cp/sob/aloc ems squads at once because I'm the only one with rooms. It's not fair most of the time but that's life in the ER.

Thas not even considering the full arrest/OD/stabbing/shooting victims that get "dropped" off in our bay or front lobby.

FlyingScot, RN · Mar 20, 2015

Where I worked primarily, the chart nurse would take the report for the nurse if she was tied up. It would usually be about 10 minutes before ER shift change and the patient had orders to transfer to the floor a few hours earlier but they held on to the patient and asked for a bed last minute and then were in a hot hurry to unload several patients out to the floors so they could go home.

You do realize that the ED nurse has no control over when the physician decides to finally admit the patient or when a bed is ready? Not only that I can pretty confidently say that no ED nurse anywhere in this day and age holds onto patients just so we can go home. We are expected to move the patient within a prescribed time frame and have to explain ourselves if we don't. In addition, because of the nature of the ED sometimes things happen (you know little things like full arrests, babies born in cars, MIs, strokes and such) that cause delays in moving the patient. So our choice is having a nurse who knows next to nothing call report and transfer the patient which floor nurses complain about or waiting until we are done with whatever crisis we are dealing with and doing it ourselves, sometimes hours later, which the floor nurses complain about. It's insulting for nurses who do not do what we do to make such disparaging remarks. I'm pretty sure you wouldn't like it much if an ED nurse would say all floor nurses run away and hide every time the ED tries to call report just to avoid taking the admission.

NurseSpeedy, ADN, LPN, RN · Mar 20, 2015

You do realize that the ED nurse has no control over when the physician decides to finally admit the patient or when a bed is ready? Not only that I can pretty confidently say that no ED nurse anywhere in this day and age holds onto patients just so we can go home. We are expected to move the patient within a prescribed time frame and have to explain ourselves if we don't. In addition, because of the nature of the ED sometimes things happen (you know little things like full arrests, babies born in cars, MIs, strokes and such) that cause delays in moving the patient. So our choice is having a nurse who knows next to nothing call report and transfer the patient which floor nurses complain about or waiting until we are done with whatever crisis we are dealing with and doing it ourselves, sometimes hours later, which the floor nurses complain about. It's insulting for nurses who do not do what we do to make such disparaging remarks. I'm pretty sure you wouldn't like it much if an ED nurse would say all floor nurses run away and hide every time the ED tries to call report just to avoid taking the admission.

I'm speaking from my experience at the hospital that I worked. The orders are also timed so we know when they were written. I worked Poole so I saw first hand what was going on in the ER because I worked shifts there. It was a small community hospital that was not part of a big organization and rarely received complex cases because we just did not have the means to treat these patients but two larger hospitals within a 5-10 minute drive did. I'm not saying that the ER nurse was trying to unload a person so that they could "go home". I'm saying that they held on to the patient so that they would not have to take the next ER patient and then when it was the end of their shift it was suddenly, "Hurry up, I need to give report so I can go home. I'm supposed to leave at 3"....this was a common statement, not an assumption. We wouldn't get a single ER admit for almost 12 hours and all the sudden we have many, at a specific time each day for 8 years (probably more, this was just my time there) All I did was state what my experience was at the hospital that I worked and had the opportunity to experience anything from med surg to ICU to Pysch to ER. There was just one thing that routinely happened at 3am and 3pm which was ER shift change...and, like I said, I was told to hurry up and take report because it was time for them to go home. The only problem was, the pm shift on the floors let out at the same time. So we would take report, give it to the oncoming shift, they would ask us a question that we could not answer because the patient hadn't arrived yet, and then they would call down and no one in the ER knew what they were talking about because they were gone too. I'm not saying that all hospital ERs work this way. It's just the way that this one did (it doesn't happen at the exact same time of day for that long now).

psu_213, BSN, RN · Mar 20, 2015

The orders are also timed so we know when they were written.

I'm not sure how it works at your hospital, but this is how it works at ours: The ED doctor writes an admit order. That order is written as soon as the doc determines that the patient needs to stay in the hospital (the docs are timed their door to admission order times, so the docs do this as soon as possible). this order is timed on the EMR. This does not mean the patient can go up to the floor right then--the pt's ED workup still needs to be completed, get lab results back, get rad. reports back, etc. After everything is back and the doc determines that the pt. is stable to leave the ED, he/she puts an icon up on the board that the pt. is now able to go up to the floor.

So, the timed admit order may be in for 1630. The doctor may not approve the patient to go up to the floor until 1855. (The "OK to send to the floor" time is not listed in the EMR.) Now, unfortunately the floor has to get a patient around shift change time--and it has nothing to do with the ED nurses waiting until shift change to get the patient upstairs.

Also, if one of our nurses were to continually "sit" on patients--and not get them upstairs promptly--they will no longer work in our ED. I know how much it stinks to get a patient from the ED at shift change, but blame the process, not the nurses.

NurseSpeedy, ADN, LPN, RN · Mar 20, 2015

I'm not sure how it works at your hospital, but this is how it works at ours: The ED doctor writes an admit order. That order is written as soon as the doc determines that the patient needs to stay in the hospital (the docs are timed their door to admission order times, so the docs do this as soon as possible). this order is timed on the EMR. This does not mean the patient can go up to the floor right then--the pt's ED workup still needs to be completed, get lab results back, get rad. reports back, etc. After everything is back and the doc determines that the pt. is stable to leave the ED, he/she puts an icon up on the board that the pt. is now able to go up to the floor.
So, the timed admit order may be in for 1630. The doctor may not approve the patient to go up to the floor until 1855. (The "OK to send to the floor" time is not listed in the EMR.) Now, unfortunately the floor has to get a patient around shift change time--and it has nothing to do with the ED nurses waiting until shift change to get the patient upstairs.
Also, if one of our nurses were to continually "sit" on patients--and not get them upstairs promptly--they will no longer work in our ED. I know how much it stinks to get a patient from the ED at shift change, but blame the process, not the nurses.

Like you said, you don't know how it worked at my hospital, so please get off my back...and not that it means anything, but we saw the okay to transfer orders-everything was still paper. I gave the quote that we almost always got from the ER. We were a small 300 bed facility and I never saw numbers near that number. A lot of things were allowed there that would not fly at other facilities. I found that out when I worked agency and saw nurses freaking out about things that I saw routinely in the past and since I didn't know these things didn't normally happen I didn't know what they were freaking out about. Every hospital is different. All I did was share my experience. Like I said in an earlier post, I did not state that all ERs were this way.

nursej22, MSN, RN · Mar 20, 2015

I hate to see this nurse against nurse battle, when it is a system problem: ED is mandated to through-put patients, but the floors are not staffed or otherwise able to take the patients.

Add to this, more and more inexperienced nurses who don't recognize how sick their patients may be (I am talking about the impending respiratory failure patient or the active MI) who are sending these patients along, because their ED time is up. Just wait until someone codes in the elevator and see who's head is on the chopping block.

EmergencyRN22 · Mar 21, 2015

Wouldn't it be nice if everyone was understanding and supportive of nurses on differentr floors?

No snide remarks, no disgruntled eye rolls, and no passive aggressive...

Sounds amazing to me ...or I'm loopy because I haven't ate a meal today.

Cheers! :)

Anna Flaxis, BSN, RN · Mar 21, 2015

Wouldn't it be nice if everyone was understanding and supportive of nurses on differentr floors?
No snide remarks, no disgruntled eye rolls, and no passive aggressive...
Sounds amazing to me ...or I'm loopy because I haven't ate a meal today.
Cheers! :)

Actually, that happened to me today!

I dropped off a patient smack dab in the middle of shift change report on the Med/Surg floor, and you know what kind of response I got when I tried to explain myself?

"It's alright, stuff happens!" with a smile. A real, genuine smile. Not snarky, not passive aggressive, but a real, genuine, understanding attitude.

psu_213, BSN, RN · Mar 21, 2015

I hate to see this nurse against nurse battle, when it is a system problem: ED is mandated to through-put patients, but the floors are not staffed or otherwise able to take the patients.

Just consider that the ED may be short staffed also.

Nonyvole, BSN, RN · Mar 21, 2015

Just consider that the ED may be short staffed also.

Or considered fully staffed, but even then, we may have some crazy patient ratios going on. There have been times that I've had two ICU patients waiting on beds and admit orders, plus up to three other non-ICU patients that still needed things - very rare, but it happens. Or I may be picking up the entire unit because the other nurse is in with a 1:1. With no way to delegate because everybody else has been just as slammed. Not everybody is lucky enough to work in facilities where there are ways to enforce sane ratios. (Two codes at once is a particular nightmare of mine, might I add.)

Really, I do like how my facility has decided on it's policy. We have two attempts in 30 minutes to give report, and if the floor refuses to take report the second time, we fax a SBAR, bring the patient up, and give a bedside report. If we're left hanging upstairs, well...that's when we have to start filing incident rreports. I'll give my report while helping to get the patient settled, and I'm willing to give my report to anybody with RN on their badge. Exceptions are made if there are things like a code blue or a rapid response happening.

Christy1019, ASN, RN · Mar 21, 2015

I'm not sure how it works at your hospital, but this is how it works at ours: The ED doctor writes an admit order. That order is written as soon as the doc determines that the patient needs to stay in the hospital (the docs are timed their door to admission order times, so the docs do this as soon as possible). this order is timed on the EMR. This does not mean the patient can go up to the floor right then--the pt's ED workup still needs to be completed, get lab results back, get rad. reports back, etc. After everything is back and the doc determines that the pt. is stable to leave the ED, he/she puts an icon up on the board that the pt. is now able to go up to the floor.
So, the timed admit order may be in for 1630. The doctor may not approve the patient to go up to the floor until 1855. (The "OK to send to the floor" time is not listed in the EMR.) Now, unfortunately the floor has to get a patient around shift change time--and it has nothing to do with the ED nurses waiting until shift change to get the patient upstairs.
Also, if one of our nurses were to continually "sit" on patients--and not get them upstairs promptly--they will no longer work in our ED. I know how much it stinks to get a patient from the ED at shift change, but blame the process, not the nurses.

^^THIS! Not to mention the new CMS regulations that we have to get ED patients upstairs within 272 minutes or not get full reimbursement. If it was up to us nurses, things would be done differently and every patient would come up perfectly packaged and wrapped in a bow. However, CMS, management and hospital administrators have created this culture of "move faster", which unfortunately means we can't control if pts come at shift change, or whether floor orders were started.