Problems with ER

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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

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.

When I worked cardiac tele, we were the only floor outside of ICU that did certain types of gtts- and then, we had limits on them. I remember one night I had a pt on a nitro gtt for BP control- totally NOT within our scope- we could run nitro, but not for BP, but there were no ICU beds. We were the only place that pt. could go that was capable of managing that gtt (yes, the ED sent the pt up hypertensive!). We ended up having to take an ICU pt in exchange (the ICU pt was ready for step down) so that the ICU could manage this one. I wasn't happy, because I was enjoying managing the pt, and my others were all stable. The one we got in exchange was a train wreck on enteric contact precautions, post rectal tube removal, not nearly as much fun.

Today I had an unresponsive pt that I really enjoyed caring for, and I thought about how I really like the unresponsive ones, and it made me wonder about working ICU. I just don't think I would do well with all the T crossing and i dotting. I'm a little rebellious, and I like having a little wiggle room and not having to know what brand of toilet paper the patient prefers, or what the name of their first dog was. I'm comfortable looking in the urinary catheter drainage bag and saying "Oh yeah, she's putting out plenty- it looks awful, but there's plenty of it" instead of calculating how many mLs per kg per hr it is.

Specializes in ICU / PCU / Telemetry / Oncology.
When I worked cardiac tele, we were the only floor outside of ICU that did certain types of gtts- and then, we had limits on them. I remember one night I had a pt on a nitro gtt for BP control- totally NOT within our scope- we could run nitro, but not for BP, but there were no ICU beds. We were the only place that pt. could go that was capable of managing that gtt (yes, the ED sent the pt up hypertensive!). We ended up having to take an ICU pt in exchange (the ICU pt was ready for step down) so that the ICU could manage this one. I wasn't happy, because I was enjoying managing the pt, and my others were all stable. The one we got in exchange was a train wreck on enteric contact precautions, post rectal tube removal, not nearly as much fun.

Today I had an unresponsive pt that I really enjoyed caring for, and I thought about how I really like the unresponsive ones, and it made me wonder about working ICU. I just don't think I would do well with all the T crossing and i dotting. I'm a little rebellious, and I like having a little wiggle room and not having to know what brand of toilet paper the patient prefers, or what the name of their first dog was. I'm comfortable looking in the urinary catheter drainage bag and saying "Oh yeah, she's putting out plenty- it looks awful, but there's plenty of it" instead of calculating how many mLs per kg per hr it is.

You understand my pain very well :)

I also work cardiac tele, and get your frustration with the patient you mentioned. I once had a patient who on tele showed textbook sustained VT ... we ran to his room (of course, the farthest one on the unit from the nurses station LOL) and found him semi-Fowler comfortably reading a book, in no distress. Bedside tele monitor showed continued VT. Long story short, he was placed on amio gtt, Mg x1 and transferred to CCU. While awaiting transfer he did convert to NSR but went back to VT 10 min later. Totally asymptomatic.

But I was mad that I had to give report to CCU and had to physically transfer the patient on a monitor with the resident and pass the patient off to another nurse's care -- feeling as if saying "Here ... they say you're better than me to take care of him." I hate to admit it, but the whole thing was like a walk of shame, shame that I don't have the skills to care for a patient with this condition when I had such a desire to do so. BTW, this is not the first time I've transferred patients to an ICU, but this particular instance is when all this hit me hard.

That doesn't seem to be the mentality however from ED. It's about starting the work and sending to floor to continue the care, not necessarily because you are not skilled enough, but because the ED itself is the gateway. I'm also pretty good at keeping details which is why I'm attracted to working in the CCU as well. I just haven't really figured out which direction to go yet. I just know I've outgrown acute care and I'm ready for more complex specialties. I'm currently a traveler, so my stronger desire to travel right now is what's keeping me in tele. But once I'm done with traveling I'm returning to staff as an ED or CCU nurse and certifying after a year or so.

Traveling as a tele nurse is bearable only in the sense that I can move on from different units every 3 months. If it sucks, I know there is an ending date and I can go on to the next exciting destination. However, once I exhaust my bucket list of destinations, I'll be settling down in one place eventually but not in tele.

Specializes in Critical Care; Cardiac; Professional Development.
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.

Then there is a broken system in place, because the vast majority of the time the hospitalist is HOURS before they see the patient. It truly has nothing to do with "my individual liking" and I can assure you, I do not avoid getting patients. I do question getting the ones I am not empowered to care for. The ETOH withdrawal sent up without orders. The DKA without insulin of any kind ordered. When patients come up without any orders to cope with BP or blood sugar or other things that show up (NOT meal trays. Trust me, I know how to find food like nobody's business) and those are the reason the patient came to the ER and the reason they are being admitted, it is actually backed by management for those patients to be refused until they have SOMETHING in place to let us care for them. It does nobody any good to have a patient we aren't capable of treating leaving the place where they ARE capable of being treated to come to the floor. I don't want to have a war here. I love the ER nurses and have indeed contemplated jumping the fence to that side of it. But it only takes one crashing to realize the system is broken. Rather than fighting one another over who works harder, we need to get the administration to address the real issue, which apparently is more along the lines of a huge gap in transition from ER physician to hospitalist.

And yeah, you sound pretty harsh and hostile. Trust me, I don't refuse patients because they are inconvenient. I refuse when I am held responsible for their care but not actually empowered to provide it. It has zero to do with any desire to avoid the patient or to make the ER nurse frustrated, though that seems to be the only reason we floor nurses could ever possibly question an admission by the sound of ER nurse opinion. We aren't all lazy. In fact, quite the opposite. This conversation would be much less polarizing without the generalizations and the "us vs them isms" flying around.

I don't want to make your job hard and I don't want to be in a pickle with a crashing patient, no orders and trouble reaching a physician to get any. All that get solved with a few appropriate orders in place for when the patient actually reaches the floor. I just don't understand why that would even be questioned as appropriate and how wanting that makes me guilty of poor patient care. I do have the right to refuse patients. Every nurse does. The hospital has the right to fire me for doing so and so far they never have. In fact, they have not even blinked. When the ER nurses get crazy eyed about it, the managers talk and the patient comes up with orders in place instead of just comes up. Everyone gets what they need and the day continues on in its crazy fashion for us both.

Then there is a broken system in place, because the vast majority of the time the hospitalist is HOURS before they see the patient. It truly has nothing to do with "my individual liking" and I can assure you, I do not avoid getting patients. I do question getting the ones I am not empowered to care for. The ETOH withdrawal sent up without orders. The DKA without insulin of any kind ordered. When patients come up without any orders to cope with BP or blood sugar or other things that show up (NOT meal trays. Trust me, I know how to find food like nobody's business) and those are the reason the patient came to the ER and the reason they are being admitted, it is actually backed by management for those patients to be refused until they have SOMETHING in place to let us care for them. It does nobody any good to have a patient we aren't capable of treating leaving the place where they ARE capable of being treated to come to the floor. I don't want to have a war here. I love the ER nurses and have indeed contemplated jumping the fence to that side of it. But it only takes one crashing to realize the system is broken. Rather than fighting one another over who works harder, we need to get the administration to address the real issue, which apparently is more along the lines of a huge gap in transition from ER physician to hospitalist.

I don't advocate sending patients to the floor without orders. They will at least have rapid admit/holding orders from the ER physician, who consults with the hospitalist and will enter any orders the hospitalist recommends to have in place until they can get there. I work in a small hospital, so often the hospitalist beats the patient to the inpatient unit. But believe me, the patient will always have orders of some sort. Sounds like that's not the case where you work, and I think that's an important problem to address.

I was mainly trying to explain why a patient might be hypertensive or hyperglycemic upon transfer to the floor- we don't rapidly drop those numbers. We get the process started and the inpatient team takes over. That was my main point.

And I agree, you should have those orders or at least know that the hospitalist will see the patient promptly. That's another issue worth addressing as well.

Could it be that your hospitalists are stretched too thin d/t efforts to cut costs on the part of the facility?

Specializes in ICU.

The orders vs. no orders thing is a pretty important distinction, I'm glad someone brought it up. On my unit, a patient may have no orders if they went to another facility's ED, the facility determined they didn't have the ability to care for the patient, and they bypassed our ED and sent the patient straight to our ICU. Those patients frequently come up without any orders whatsoever because no physician who is working in that hospital has seen the patient yet.

But, the physician is usually about 30 seconds behind the patient rolling in, getting orders written as soon as we need them and giving us orders for the things we grabbed to stabilize the patient before the physician showed up. Patients showing up without orders of any kind really isn't a problem if there are intensivists laying in wait to write orders. The problem happens when there is no physician ready to meet the patient at the door and start writing orders, which is what it sounds like some of you are running into, which is stupid. Your hospitals either need to hire more hospitalists, or start lighting a fire under your current hospitalist's butts to drop whatever they are doing when a new admit with no orders rolls in.

Hospitalists are treated like dirt at a lot of places, routinely overworked, having their practice dictated by patient satisfaction and reimbursement, and a lot of the same issues faced by nurses.

If this is the case at your facility, your problem isn't with the ER- it's with the hospital that is allowing this to happen. Dig deeper.

By keeping us at each others' throats, TPTB can keep us bickering amongst one another while they go about business as usual- and it sounds like they're being pretty successful at that at your hospital.

Specializes in Neuro ICU and Med Surg.

You get report? At my facility they stopped giving report. The bed is assigned and we are supposed to have 30 minutes to look the pt up in EPIC, but in all honesty we don't get that amount of time. Bed is assigned and within 5 minutes they call saying they are bringing the pt up.

Specializes in Neuro ICU and Med Surg.

I do have a question for all you ER nurses. There are patients that are on telemetry and brought up by a tech not on telemetry. These are the patients that go to the step down and medical surgical tele units.

Do you bring up any patient on tele or only ones on drips or receiving blood? I am just curious.

In one facility I worked at a patient on telemetry would be brought up by a nurse and at this facility if on telemetry they can go up to the unit no telemetry and with a tech.

I just wonder what most ER's do that is all. I do spend some time as rapid response in the ER with stroke alerts, and traumas, but my time there is limited and not too frequent.

Specializes in Critical Care, Emergency Medicine, C-NPT, FP-C.
I do have a question for all you ER nurses. There are patients that are on telemetry and brought up by a tech not on telemetry. These are the patients that go to the step down and medical surgical tele units.

Do you bring up any patient on tele or only ones on drips or receiving blood? I am just curious.

In one facility I worked at a patient on telemetry would be brought up by a nurse and at this facility if on telemetry they can go up to the unit no telemetry and with a tech.

I just wonder what most ER's do that is all. I do spend some time as rapid response in the ER with stroke alerts, and traumas, but my time there is limited and not too frequent.

The two facilities I have worked in allowed the ER medics to transport any patient up to the floor, including drips and monitors. Vented patients were the only ones we didn't go alone to, usually those had an RN and RRT along with the medic.

Specializes in Neuro ICU and Med Surg.

At my current facility the monitored patients are coming up with ER techs not medics and no monitor. Patients with drips (amio, Cardizem, etc) are brought up by an RN.

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

Because no one cares if there is no proper transfer. As long as you open a bed up fro more to come in ED. Mass production.

My pt's are usually brought up by a tech, who has no idea what the pt is there for. I imagine they are told to bring them up asap before anything happens.

No report is called. We are just given a name and a dx. the rest is your problem.

Oh, and since charge has a full assignment, they cant usually help either.

Specializes in PCCN.
Hospitalists are treated like dirt at a lot of places, routinely overworked, having their practice dictated by patient satisfaction and reimbursement, and a lot of the same issues faced by nurses.

If this is the case at your facility, your problem isn't with the ER- it's with the hospital that is allowing this to happen. Dig deeper.

By keeping us at each others' throats, TPTB can keep us bickering amongst one another while they go about business as usual- and it sounds like they're being pretty successful at that at your hospital.

Bingo.

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