Recieving a patient from ER

[jkr2020788]

I know this topic will differ greatly from hospital to hospital.

I am a nurse that has been working in ER/ICU for almost 3 years and have never worked on a general nursing floor. The way my ER sends patients up is fairly straightforward. ER doc calls admitting doc, ER doc and admitting doc write orders together, room is requested, report is given, and patient is brought up.

I often have problems with floor nurses complaining that nothing on the admission orders were done.

First off let me say that our ER uses computer MD ordering and to have any orders that are written out completed by ER requires me to ask to busy ER doc to put in for a lisinopril because the BP is high even though it is on the admission orders and not meant for ER.

I don't mind doing this kind of stuff to help out if I'm not extremely busy, but it kills me when a nurse says "can u give the lisinopril for that 160/90 BP" when I have 5 brand new sick patients every hour.

I don't know if it's floor nurses thinking we are trying to dump patients on them, but I think a lot of them don't realize that I am getting new patients constantly, having to collect urines/ekgs/blood, start ivs, titrate and monitor drips, and appease pain med seekers, all while trying to separate sick ppl from ppl that need to go home.

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.

[beeker]

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.

THIS. x100!!!!!

[Anoetos, BSN, RN]

Fair enough, I beg your pardon...if your experience has been different and my perception of the comments made by ER nurses in this thread was inaccurate, I apologize.

I think what set it off was the nurse who said floor nurses want you to "do everything for them"... And that they cant understand unless they've been there (in the ER). So, you might want to look elsewhere when you lay the first charge for an "us and them" interchange.

That said, I should not have taken the bait.

[Altra, BSN, RN]

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

I can only explain why it happens at my hospital - I can't speak for yours.

Because that's when beds get assigned. Like magic, every freaking day around 5:30 - 6pm, the ER tracking board lights up with bed numbers assigned by bed control for admitted patients who have been waiting 2 - 12 hours for a bed. I can only assume that it's related to the fact that by mid-afternoon, most discharged patients have gone home, the rooms have been cleaned by housekeeping ... and the music starts again.

[JBudd, MSN]

Because that's when beds get assigned. Like magic, every freaking day around 5:30 - 6pm, the ER tracking board lights up with bed numbers assigned by bed control for admitted patients who have been waiting 2 - 12 hours for a bed. I can only assume that it's related to the fact that by mid-afternoon, most discharged patients have gone home, the rooms have been cleaned by housekeeping ... and the music starts again.

Why at shift change? It isn't always, those are just the ones that stick out as annoying. "Don't call 30 secs after bed assigned"? I get told frequently, send the written report as soon as room is up (have it written ahead of time), follow with a phone call in 5 minutes, and send within 30-45. They track our times, and come back at us. Don't like it? Get your manager to negotiate with mine and change it; but 'till then I have to answer to mine.

Why do I get the rooms just before shift change? Because the staffing pattern changes. Nurse are expected to take more patients the later in the day it gets, which opens beds that were previously not available: if you had 4 before the change, now you can have 6, so I get two beds for people that may have been waiting for several hours. And I have a time limit on getting them to you, as above.

As for which orders I can do, I don't have all the meds available that the floor pyxis has. Unless it is a now or stat, I am not responsible for it as that would delay my getting the ER bed available for the multiple people still in the waiting room.

I've worked both ends, lotta years. It is all about different priorities, and pressures that we don't necessarily see going on, on the other end at any given time. So, I will try to polite as possible about rotten situations, and would really appreciate getting some courtesy in return. Face it, both of us are being put in increasingly difficult situations; let's put the blame where it belongs (and you know it isn't each other).

[anotherone, BSN, RN]

What gets to me is when stat orders are not carried out and the pt is brought up at CHANGE OF SHIFT and then it is delayed even further because I have 5 other patients. also.

[nuangel1, BSN, RN]

in my ed we are only responsible for stat orders or timed labs like cpk/troponin.

[VICEDRN, BSN, RN]

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.

You realize that our ERs are uniformly pushing us to move patients. Its not our fault that bed board also work 12 hour shifts that end at 7, doctors dispo at the end of their stretch in the ER (around 3) which means lots of admits that start to wait on beds between 4-5 in the afternoon or worse 7 am if its overnight and finally, that patients discharged from floors leave behind empy beds that need to be cleaned and turned over.

We have 30 minutes to move patients upstairs. The charge crawls all over us after 10 minutes: has report been called? what else needs to be done to move patient?

As for what I will and won't do, I will do all ER MD orders unless it is obvious that admitting doc just wants to circumvent the process, then he or she can talk to floor nurse. I am not drawing a routine TSH because hospitalist wants to wait. He or she can wait for phleb on the floor. I don't care how much whining is involved and I swear to you, that I don't hold patients for shift change. Even if I wanted to (I don't), I couldn't.

[shoegalRN, RN]

In my ED, we are only responsible for STAT labs.

We fax report up to the floors (with the expection of ICU/OB), we wait 15 minutes after confirmation that fax was received and we take the patient up.

I will even give a more detailed bedside report to the floor nurse once I get the patient up there, but I'm not required to.

I will even help get the patient settled in, if I'm not assigned to trauma. If you are not in the room once the patient gets up there, I will hook your patient up to the monitor, zero out your bed, and change their gown. But again, I'm not required to. And I only do this is I'm not assigned to trauma.

I am NOT required to draw AM labs nor routine labs. I am required to complete out all my ER orders and any STAT orders the inpatient doctor will order. Anything else after that needs to be completed once the patient gets to the floor.

[FlyingScot, RN]

I can only explain why it happens at my hospital - I can't speak for yours.

Because that's when beds get assigned. Like magic, every freaking day around 5:30 - 6pm, the ER tracking board lights up with bed numbers assigned by bed control for admitted patients who have been waiting 2 - 12 hours for a bed. I can only assume that it's related to the fact that by mid-afternoon, most discharged patients have gone home, the rooms have been cleaned by housekeeping ... and the music starts again.

I would give a million "likes" to this if the system would let me.

[Esme12, ASN, BSN, RN]

I can only explain why it happens at my hospital - I can't speak for yours.

Because that's when beds get assigned. Like magic, every freaking day around 5:30 - 6pm, the ER tracking board lights up with bed numbers assigned by bed control for admitted patients who have been waiting 2 - 12 hours for a bed. I can only assume that it's related to the fact that by mid-afternoon, most discharged patients have gone home, the rooms have been cleaned by housekeeping ... and the music starts again.

Agreed Altra......a little understanding and empathy for each other can go a long way. ER nursing is vastly different form floor nursing. Not better, not worse just...... different.

Those beds light up at 5:30-6pm because any of the surgical days that may have been admitted, have gone home.......discharges have, finally, left the building because their rides have gotten off work. The ED docs HAVE to dispo as many as they can so the oncoming MD doesn't mug them in the back room for leaving a mess.

The ED wait times and room times is a huge focus for quality care and The JC. Most facilities want 30 min bed assign to room times. Giving the patients regular meds while important to the floor is not a focus of the ED. For the ED 160/90.....lying on a stretcher, in the hallway listening to the drunk cuss out the staff, monitors alarming incessantly and the radio going off every 4 min would raise the blood pressure of Job. (you know the one from the bible) But it is not a priority to treat.

The ED goal is immediate stabilization and transfer (even the floor) to where extended treatment and cure can occur. while the nurses on the floor have valid points the nurses on the floor need to understand they are being hounded to move the patient ASAP.....and there is always someone ready to fill that bed before the patient is ready top leave. ED nurse can have 5 beds and have 5 new patients almost every hour when you account for the patients that get rotated in and out of rooms with the hall.

Every ED is responsible for different things according to policy.

How to get everyone on the same page? Have a meeting with them or set up a committee to evaluate a system so everyone is on the same page.

The up side? this has been an on going dispute since when I graduated school and we have survived up til now.

Patience and understanding is key

[corky1272RN]

This is a good topic. I have worked Med-surg at my hospital for 3years. There is a lot of grief between the floor nurses and the ER staff. The floor nurses (my co-workers) don't always say it to the ER staff but will talk amongst themselves. There is sometimes a thought amongst us that our ER "lies" just to get the pt transferred. I know that would sound weird to some but there have been quite a few instances that have confirmed our suspicions. For example, It is charted in the vitals that a venti-mask has been used by a pt for the last 4 hours, but when the ER nurse is told that our floor won't accept a pt on venti-mask, suddenly it is charted in the vitals that the pt is now on a nasal cannula. It is all charted in the computer so we are able to see it. Another example, a pt is assigned to a room, the floor nurse planning on getting the pt initially reviews the pt's ER chart, when report is called, the floor nurse asks if the pt needs a sitter (whatever the nurse saw in the chart makes her wonder about this), the ER nurse says no, but 10 mins after the floor nurse notices that there is a new order of Geodon IM stat. I do think that some of my co-workers want a total assessment given in report, that is a little silly, but sometimes there a things that I think should have been taken care of or just reported. If I don't know what the pt's baseline was in the ER, how would I even know if there has been a change in condition? Thoughts?

[nurse2033, MSN, RN]

I laugh at nurses who get "upset" that we haven't implemented admission orders. They are for patients once they reach the floor, not the ER. If they don't get it, I couldn't care less. I have enough to worry about meeting my protocols and patient needs. You can't teach tolerance, acceptance, and trust. Criticism is easier to reach for than understanding.