Recieving a patient from ER

Altra, BSN, RN · Jun 27, 2012

In my experience, no, you cannot "make" the receiving nurse more accepting. People either understand that different environments function differently, or they don't. People either "get" that nursing care is continuous, or they have the mindset that there can be this magical moment in time when the patient is perfectly packaged, everything else can stop, and the patient can arrive.

Hang in there. Rise above the eye-rolling you "hear" on the telephone. :smokin:

BluegrassRN · Jun 27, 2012

Do floor nurses ever float down to the ED when you're short staffed? The occasional floating experience sure helped me understand how things worked down there. I wish our ED nurses had to float up to us, too, rather than it being a one way street. I think that'd help with many a misperception of how things work.

The only things I expect the ED to do are things that are rather emergent. I don't mind waiting to start the blood; unless the hgb is in the 3s or less (I'm nights on a medical floor in a small, community hospital). Anything that needs to happen within 30 minutes of arriving to the floor probably needs to happen in the ED, as it takes 20-30 minutes for admissions to get them in the computer and then for pharmacy to verify all meds. This is a physician issue rather than a nurse issue, though, and I have no problem calling the ED docs and asking them to order something to be given/started prior to leaving the ED if it's reasonable.

I also prefer that any stat radiology occur before they leave the ED, and I've learned to request that before the pt leaves the ED. Our radiology dept is in the ED, so this makes sense, particularly since the floors have no transporters on night shift. Also, I've had several instances where the outcomes of the stat imaging dictate a change in status. It's just a cluster to get someone up on the floor, assess them and get their history, then send them back down to the ED for radiology, then receive them again, only to have the on call doc call and give me a string of stat orders, and tell me we're transferring to surgery or ICU. Now I've spent an hour on an admission that I could have spent on my other pts, the family and pt aren't happy about all the moving around, I have a crap ton of orders to do before transfer, the one aide on the floor has been tied up with transport instead of helping on the unit, and i've got a dirty room that I can't use until housekeeping comes in at 0500.

Frankly, if it's in the admission orders but not in the ED orders, our ED nurses wouldn't have access to those meds to begin with. It seems a little presumptuous to think that it's somehow easier for the ED nurses to get that order and give it than it is for the floor nurses. I agree, you're just going to have to say no to the less reasonable requests.

ckh23, BSN, RN · Jun 28, 2012

You can't unless you do everything for them. Unless they have worked in the ER it is hard for them to understand. When I was in the ER, the only orders we carried out where things on the admission orders that were written "stat" and timed labs like cardiac enzymes. In those cases the admission doc would let the ER doc know so they can put the orders into the computer (where I worked the ER had electronic documentation and orders, but the floor didn't). I think a big thing for them to grasp is that it's the ER's job to stabilize them and get them upstairs, not carry out and get them the daily meds they missed while in the ER for 10 hours.

The only time I ever had an issue with an ER nurse is when I was getting report that a patient was being admitted for a hypertensive crisis and his BP was still over 200 systolic and nothing had been done, but he had stat BP meds on his admission orders. The thing that really set me off was when she said that "it is something you will have to address with the doctor". Let me tell you the choice words I had for her. However, 99% of the interactions with admissions have been positive. I sometimes think it was to do with the nurse.

hiddencatRN, BSN, RN · Jun 28, 2012

My question is if there is anything in particular that I can do as an ER nurse to make the receiving nurses more accepting without me having to get a med that I have to stop the MD for for something of relatively low importance.

Probably not. As long as you are following your facility's protocol for completing orders, not much you can do about the receiving nurse who expects everything done on the patient. If your facility doesn't have any guidelines on what needs to get done in the ER versus what can wait, maybe you need to develop some.

We have separate order sets, so if there's something that the floor team REALLY needs done on the patient stat prior to their transfer upstairs, the floor team has to contact our ER docs and ask them to order it in our system. I frequently don't see the floor orders until I'm handing them to whoever is taking the patient upstairs. Although we still get some huffing and puffing it's very helpful to have a clear distinction between what is a floor order versus what is an ER order.

BrnEyedGirl, BSN, MSN, RN, APRN · Jun 28, 2012

I agree with the others, we all need to stop and realize that we have different priorities, different working environments, different protocols etc, but we all still work together ! The ER I work in uses a completely software program than the rest of the hospital. Often I don't even see the inpatient orders! Depending on what is going on in the department, taking the time to log into a different system, copy orders to the ER system, then wait for meds may mean someone sits in the waiting room for another hour or longer! I have never seen a time when there wasn't someone waiting to be seen. It just isn't best patient care to take the additional time to try to do things on inpatient orders. If it is really an emergency the ER doc will address it,...if not we need the bed for someone in the waiting room.

allnurses Guide · Jun 28, 2012

If the call for report and movement of the patient would not come right at shift change, I would be the most freaking flexible floor nurse ever. True story.

Anoetos, BSN, RN · Jun 28, 2012

If the call for report and movement of the patient would not come right at shift change, I would be the most freaking flexible floor nurse ever. True story.

Excellent. Just excellent. And so true. How does this happen EVERY DAY?

But to make sure I am hearing the ER RNs correctly: your job is so different and hectic that floor nurses should just suck it up and deal with the fact that you don't have time to do a complete job of charting and reporting?

Now, if there is a completely different ordering, charting, reporting process in the ER than in the units your patients go to such that you're doing it but they cant see it, then the problem goes much deeper than just misunderstanding. It's systemic and needs to be fixed.

Aurora77 · Jun 28, 2012

For the most part, it seems like the relationship between the ER and our floor is good. My only complaints: if I'm in a room with a patient and can't take report--don't keep calling or, even worse, just bring up the patient. I will call back, I promise. Also, please don't call to give report 30 seconds after the patient gets a bed assigned. Give us a few minutes to get organized.

Other than that, our patient hand off works well. I've never worked ER (and with only a year experience, the idea scares me!), but I know my floor can be hectic and crazy stressful, so I assume ER is the same way.

linnaete, ASN, BSN, MSN · Jun 28, 2012

We also have two different systems between ER and floor. When our pts get admitted, the ER docs write up an order sheet (on paper) for the floor, and usually consult a hospitalist or specialist. Many times I don't even get the chart to see the orders before either the unit clerk is putting the order in or one of the consulted docs picks up the chart and holds it hostage.

Often by the time I have the chart in hand and all the orders to review, I've got registration telling me I have a ready bed and I need to call report ASAP or risk getting chewed out for holding on to the pt too long.

That being said, when I do get a chance to see the order sheets I'll run and make copies so I can have one with me to write up a report sheet and do whatever I can while I wait for a room assignment. Sometimes it just doesn't work out that perfectly.

FlyingScot, RN · Jun 28, 2012

Um...where in this thread did you "hear" an ER RN saying she was too busy to chart or give report correctly? I also don't remember seeing the phrase "suck it up". The OP asked, in a very nice way I might add, what she might do to make the transition easier. Don't turn this into yet another us vs. them ******* match.

BrnEyedGirl, BSN, MSN, RN, APRN · Jun 28, 2012

Excellent. Just excellent. And so true. How does this happen EVERY DAY?
But to make sure I am hearing the ER RNs correctly: your job is so different and hectic that floor nurses should just suck it up and deal with the fact that you don't have time to do a complete job of charting and reporting?
Now, if there is a completely different ordering, charting, reporting process in the ER than in the units your patients go to such that you're doing it but they cant see it, then the problem goes much deeper than just misunderstanding. It's systemic and needs to be fixed.

I spent 9 years in a cardiac unit prior to the last 6 in the ER. I understand the frustration of getting report from the ER during report to the next shift. I know that in my hospital anyway, the admit database must be completed within 2 hours of the pt hitting the floor. Major pain in the butt! I get that, really I do!

I would never, never make the assumption that I somehow work harder or have more work than any other nurse in the hospital! I've been there, done that, and to be honest I can't see myself ever working on a floor again. At least in the ER I have access to 20 other nurses and 6-7 doctors to help me! The big difference is our priorities. We don't get report for our patients, unless the come in via EMS. Then our report consists of 73 yr F, c/o SOB and a set of vitals. No hx, no allergies, no medications etc. In the first 10 minutes I am supposed to get a complete history, start a line, draw labs, do the EKG, place the pt on the monitor, BP, SPO2 etc. We don't have the option of refusing a patient because we just intubated the guy in the next room and the guy next door needs to get to the cath lab asap! We have to prioritize and do those things that keep someone alive first! I don't listen to breath sounds unless it appears necessary, or ask about last bowel movement. It isn't that I think those things aren't important, just not now!

We do send a hard copy of the chart up with the patient. I agree two different software programs that don't communicate with each other is just stupid,...but I didn't make that choice! There was talk about sending a fax report to the floor instead of calling report,..glad that didn't fly!

The frustration of calling report during shift change has always been around. When I transferred to ER it was a huge pain, as we are changing shifts at the same time the rest of the hospital is and that is part of my shift change! If I don't get report called, even if the pt doesn't go up, then a nurse that hasn't seen the pt has to call report! Not good patient hand off!

The name of the game in the ER is to keep people alive long enough to get upstairs and get the specialty care they need. We need to do that quickly to keep the flow moving. The longer a patient is in the ER, the longer a patient is in the waiting room with almost no care!