Problems with ER

taj09 · Mar 24, 2015

It seems to me that your facility has the problem. Joint Commission states that facilities must implement a standardized approach to HAND-OFF communications. It is a National Patient Safety Goal. Ineffective hand off communication is recognized as a safety problem in healthcare. Dropping off a patient without report and a accepting nurse puts the patient at risk as well as both nurses. I would approach the issue with this is mind. Some hospitals are more concerned about passing a JCAHO inspection than "patient safety". I just today had to fill out a survey at my hospital on our environment of safety and I think it might have been the 4th time in the preceding years that I have done the same survey, but would you care to know what has changed over the years? Absolutely nothing, sad to say. Regardless, every year I fill up the comment section, the only thing in my control.

MunoRN, RN · Mar 24, 2015

^^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.

Unless something has changed recently that you could direct me to, there is no set requirement for ED throughput times. In order to receive full incentive payment for participating in meaningful use stage 1, facilities must track and report their overall throughput times, there is no change to reimbursement based on what those times are. In order to receive stage 2 reimbursement it needs to be stratified by diagnosis. The extra reimbursement is just for having EMR's and other data systems that can capture this data, not for what that data is.

seconddegreebsn · Mar 27, 2015

Our ER no longer gives report. I was informed that an ISBAR generated by the computer was sufficient and I should just read the doctor's notes. The one time I did get a report they gave me the patient's age, chart number, diagnosis and shirt color. Thanks?

I also got an ICU downgrade yesterday and the nurse told me the ICU will no longer be giving reports for transfers, once again: ISBAR. I didn't let her leave until she gave me report because I think this is ridiculous and this patient was clearly fragile and in distress at the time of transfer. Transferred without warning as well so I didn't have any time to read up on her history, etc...At least with an ER patient I'm only looking through a few hours worth of treatment history in their MAR. For ICU patients, sometimes record keeping goes back months - trying to comb through that can take a lot of time.

Cafelattee · Mar 27, 2015

from someone that was a floor nurse 23 years ago and now working ER its dangerous and wrong period. I worked on a med-surg floor night shift back then we routinely had 11-13 night shift can't remember the day shift.. WE were always understaff. The ER brought up a patients put them in the room on heparin drip not sure how long the patient was in the room this was back before all drips were not on pumps. I had a habit taught to me by the older nurse to check all rooms for IV poles and hide them LOL. WE were always short. I open a room looking for the pole and found a patient that was not on any of our assignments. There were some changes made and I was not involved in whatever internal or external investigation stuff that happen. I started code on the patient they intubated him and that's the last I ever heard he was sent to the unit but I learned some valuable lessons. I check all empty rooms no matter where I'm at which I still do in my current position in the ER. I make sure no one is missed even with electronic everything. I also always chart who I report off on the floor/unit. I do the transport if its a unit patient but other staff transports floor patients.

allnurses Guide · Mar 31, 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.

We have been having this problem as well, with the ER getting pushed so hard to transfer patients out that they get ugly with us when we refuse a patient who has not been stabilized and for whom there are no appropriate orders entered. I feel for the ER, but after a few "hit and runs" where we call a code or RR on an patient who has not been in the room for 15 minutes yet after transfer and was obviously unstable, it gets frustrating. It is inappropriate and dangerous. I once had an ER nurse try to tell me to call the MD for orders myself. Um. No. Not my patient yet. Take care of your patient, at least attempt to stabilize them before bringing them up and make sure appropriate orders have been written so the patient will get good care from the moment they arrive on the floor. BP 220/110? Nope. I won't accept the patient until it is under 200. Blood sugar of 620? Um...hello? I am truly baffled why these things aren't addressed prior to transferring the patient. It is blatantly not good care. Maybe the ER nurses here can shed some light, because it is infuriating to get a patient with values like this or worse and they crash almost from the second they arrive, usually before we have even had time to review the patient's chart thoroughly.

bebbercorn · Apr 1, 2015

We send an SBAR and the RN upstairs is given a reasonable amount of time to call with concerns/questions before the pt comes up. ICU gets a call, or if a pt is complicated we will call report. I generally try to give a courtesy call on all pts, and definitely do if there is pertinent info (pt is claustrophobic, pt comforts/dislikes, family concerns, etc). Coming from another place that called report, I prefer this method. The questions I get are relevant to care and not challenging or attempts to delay admission. Incident reports should be filled for what you perceive to be an unsafe transfer.

EmergencyRN22 · Apr 6, 2015

Please refer to the 22nd post to this thread ... Think page 2 for my opinion/response.

thanks.

We have been having this problem as well, with the ER getting pushed so hard to transfer patients out that they get ugly with us when we refuse a patient who has not been stabilized and for whom there are no appropriate orders entered. I feel for the ER, but after a few "hit and runs" where we call a code or RR on an patient who has not been in the room for 15 minutes yet after transfer and was obviously unstable, it gets frustrating. It is inappropriate and dangerous. I once had an ER nurse try to tell me to call the MD for orders myself. Um. No. Not my patient yet. Take care of your patient, at least attempt to stabilize them before bringing them up and make sure appropriate orders have been written so the patient will get good care from the moment they arrive on the floor. BP 220/110? Nope. I won't accept the patient until it is under 200. Blood sugar of 620? Um...hello? I am truly baffled why these things aren't addressed prior to transferring the patient. It is blatantly not good care. Maybe the ER nurses here can shed some light, because it is infuriating to get a patient with values like this or worse and they crash almost from the second they arrive, usually before we have even had time to review the patient's chart thoroughly.

Anna Flaxis, BSN, RN · Apr 6, 2015

BP 220/110? Nope. I won't accept the patient until it is under 200. Blood sugar of 620? Um...hello? I am truly baffled why these things aren't addressed prior to transferring the patient. It is blatantly not good care. Maybe the ER nurses here can shed some light, because it is infuriating to get a patient with values like this or worse and they crash almost from the second they arrive, usually before we have even had time to review the patient's chart thoroughly.

I'll try to shed some light for you.

In the case of the hypertensive patient, if the patient is having no focal neurologic deficits, we don't aggressively treat high BP ( we treat the patient, not the numbers). Even if the patient is having focal neurologic deficits, it is not best practice to lower BP rapidly. What typically happens is that the ED physician will leave this to the hospitalist to address- the ED RNs have no orders for antihypertensives, because the hospitalist will be writing those admission orders for the inpatient nurse to carry out. In order to move the patient to the inpatient unit efficiently, which is best for patient safety, the ED physician will often write holding orders so that we can move the patient, and then the hospitalist will evaluate the patient once they are on the floor, and write appropriate orders for further management. For you to refuse a patient simply because the SBP is >200 is wholly and completely inappropriate and not your call to make.

Same goes for a CBG of 620- we can start treatment in the ED, but rapid decrease of CBG is not good patient care, and we cannot keep the patient in our department until the CBG is within your acceptable parameters- that could take hours, which we do not have. It is up to the ED to get things started, and the hospitalist and inpatient unit to continue treatment.

Again, to refuse a patient because their numbers don't fit your individual liking is terrible patient care and totally unacceptable.

The one caveat I will make is that sometimes, the person(s) responsible for deciding where the patient will go, whether "Bed Placement" or a House Supervisor, or whoever makes that call, makes a bad call. It happens. If the patient's particular situation falls outside of the scope of your unit (for instance, the patient needs to be on a Cardizem drip and you don't have telemetry), then the issue is not with me, the ED nurse, it is with the bed placement decision- which I do not make. I have no idea what you can and cannot do, what your staffing is like, what drips you're allowed and not allowed to do, etc. All I know is I've been told I have a bed and a nurse, and I'd better get the patient rolling, because we have a full lobby and the ambulances won't stop. We don't get to say "Oh, I'm sorry, your blood pressure is too high" or "I'm in the middle of report". We take what comes as it comes and do what is necessary to preserve life and limb.

Anna Flaxis, BSN, RN · Apr 6, 2015

Sorry if I sound hostile. I generally like your posts and agree with you on many things. I just find it tiring sometimes to be criticized when folks have no idea what a war zone the ED can be. And I've worked inpatient too, so I'm not talking out my behind. I invite you to come and play sometime!

EmergencyRN22 · Apr 6, 2015

Few years back, I was giving report on a cp pt that's now asymptomatic to a floor nurse. The pt original Bp was like 220/140 then an hour after nitro paste - down to 185/100. The floor nurse flipped out and was yelling enough that our ER doc over heard her. The Doc ended up standing up and fired back at her before I could even spit out any words.

Since that episode, that nurse HAS never said anything but praise to me. Lol

there will *always* be those nurses who will attempt to find any reason not to receive a new pt

Anna Flaxis, BSN, RN · Apr 6, 2015

Yeah, I don't mean to sound so aggressive. I just get protective sometimes. I think if the focus is truly on safe patient care, then some of the stuff we get criticized for is really stupid.

I remember one time, I took the patient to the ICU on a dopamine gtt. The ICU nurse was dumbfounded that we had started dopamine in the ED. She just kept repeating "Really? You guys can run dopamine down there?" and other such things. My mind was so boggled that she had such a limited understanding of what we do, that I really didn't have a response- all I could think of was sarcasm, like "Uh, yeah, we are the Emergency Department, we do everything....".

I remember when I worked inpatient and I would receive patients at inconvenient times, or less than pretty with no neat little bows, or demanding a meal tray upon darkening the doorway to their room, and think the ED was slacking and pushing off a bunch of work onto the floor- now I know better.

One time, I had just received a patient and was getting her all settled in, when she coded with a PE. The ED didn't even know she had a PE- she was being admitted for something completely different, so how would it have been their fault that the patient coded within minutes of reaching the floor? It was such a rapid deterioration- here one minute, A&O in no distress, and gone the next. It happens.

But yes, as to the original post, a handoff report of some sort needs to happen.

PacoUSA, BSN, RN · Apr 6, 2015

"Uh, yeah, we are the Emergency Department, we do everything....".

This is one of the reasons I want to work in an ED. As a floor nurse, I absolutely hate transferring patients away from me simply because we don't do certain things. Makes me feel less skilled than other nurses, so now I want to be like them ... I don't want limits on my practice.