Recieving a patient from ER

selulion · Jul 1, 2012

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.
Beautiful!!!

brainkandy87 · Jul 1, 2012

I've worked both ends of the argument. I never understood why floor nurses got bent out of shape when I was a floor nurse and I certainly haven't figured it out as an ER nurse. Maybe it's because I precepted in the ER in nursing school, but I always understood the idea of ER was to stabilize and transfer. So if there were transition orders for an antibiotic or something, I just always told the nurse to send it up with the patient and I'll hang it. It takes me two minutes while I'm settling the patient in and it gets me a happier reporting nurse. *shrug*

Esme12, ASN, BSN, RN · Jul 1, 2012

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.

I mean this in the nicest way........the fact that you could care less and laugh at the nurses who get upset........Maybe....just maybe, therein lies the cause to discention between nurses?

You get what you give........or reap what you sow.

So, maybe you are right, "you can't teach tolerance, acceptance, and trust. Criticism is easier to reach that understanding."

The best predictor of future behavior is the past......perhaps if we all tried to understand each other and walk in the others shoes their would be an improvement in the realtionship between floors/units.

Just saying....we really can all get along.

Crux1024 · Jul 2, 2012

Someone here said it best (I forget who) ER nursing is vastly different from floor nursing, not better or worse...just different.

Ive done both and do all I can in the ER to make the pt as stable and ready as I can before they go upstairs. Sometimes I get everything completed and all the floor has to do is the admission database, sometimes I barely get anything done before the pt is flying upstairs.

Floors sometime get upset, for a few reasons and really they have nothing to do with me personally. In the ER, we DONT call report until the pt is going to a critical floor, so tele and M/S admits just roll upstairs after the floor has been "paged" through the computer system. The ER timeline is accessible through the system and just requires a little bit of research. It kinda sucks, yes, but thats how it is. We used to give them a courtesy call to tell them we were going to be on our way, but that turned into excuse time as to why they couldnt take the pt and so the courtesy calls were put to a stop by the nurse supervisor, as they at least see that the ER is teeming with people with nowhere to put them. Now the floors get upset, we dont have to call, some ER staff will call from the elevator as a 2 minute heads up. Its sucks for both sides. The floor feels like theyre dumped on and the ER is attacked when we arrive with a pt.

Also, we dont ALWAYS have admitting orders for pts before they go upstairs. I think this is stupid and a bit of a liability, but we are not allowed to hold pts in the ER for orders unless the admitting doctor is actively THERE and seeing the pt and writing them out. I cant tell you how many ****** off calls Ive fielded about a lack of orders, this is the way its ALWAYS been. But the process is very simple. Page the doc and theyll either say their on their way in OR theyll give you verbal admit orders. I did it for years on the floor. The ER docs stop prescribing after the admitting doctor is assigned, so calls to the ER for this or that are not happening where I work.

When I was on the floor, I definitely had a "roll with the punches" mentality and would deal with situations as they came up. I never called the ER when I was on the floor to complain about what wasnt done. Now Im in the ER I understand the reason why the heparin wasnt hung or the abx werent started. I can appreciate both sides of the fence.

It sucks that its a Us v. Them kinda deal. Patients need to be cared for 24/7. Im not always able to package them up and throw on a nice bow but when I do I never receive a thank you call.....

VICEDRN, BSN, RN · Jul 2, 2012

This is a good topic... 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.Thoughts?

You do realize that some of the charting is just stale. The patient came in on bipap which was clearly overdoing it by EMS and someone just got sloppy with the chart or planned to change it to nasal cannula shortly thereafter and didn't bother changing it until ready to move to the floor.

As for the sitter, one of my PET PEEVES is being asked about sitters. If I didn't have one and you don't see an order for one, why is that a reason to refuse the patient? Make your own assessment when the patient is yours and upstairs and then you GET AN ORDER FOR THE FREAKIN SITTER. Frankly, the whole thing sounds super super super lazy, like you are looking for an excuse to refuse the patient.

I have seen the same in reverse. I have spent 20 minutes giving report to a floor nurse and answering all of the stupid questions about in patient orders only to receive a call from bed board notifying me that the patient's assignment has been suspended and the patient is being reassigned after the fact. Here is a list of ridiculous reasons: the patient should be assigned to medical floor, not surgical floor (pt here for head bleed following fall after seizure), pt incarcerated (but floor that usually takes these patients is full so...what? we should hold them for you?), inpatient MD now orders isolation (so? you took report. you transfer them to the more appropriate bed, not me).

With the seizure patient, the bed board nurse was actually extremely apologetic and told me that she would understand if I refused to call report again. I told her that I would alert our manager of this preposterous issue and that in the future, report must be refused on the phone, not after the fact 40 minutes later to bed board. If you took report, you accepted the patient. Period. End of Story.

For the record, no one asked me if he was a medical or surgical patient. In the ER, we see it all and do it all. Its kind of silly to object one way or the other in my opinion and silly to expect me to see the difference between your unit and another who also has a million unspoken unwritten rules, don't you think?

Anoetos, BSN, RN · Jul 2, 2012

You do realize that some of the charting is just stale. The patient came in on bipap which was clearly overdoing it by EMS and someone just got sloppy with the chart or planned to change it to nasal cannula shortly thereafter and didn't bother changing it until ready to move to the floor.
As for the sitter, one of my PET PEEVES is being asked about sitters. If I didn't have one and you don't see an order for one, why is that a reason to refuse the patient? Make your own assessment when the patient is yours and upstairs and then you GET AN ORDER FOR THE FREAKIN SITTER. Frankly, the whole thing sounds super super super lazy, like you are looking for an excuse to refuse the patient.
I have seen the same in reverse. I have spent 20 minutes giving report to a floor nurse and answering all of the stupid questions about in patient orders only to receive a call from bed board notifying me that the patient's assignment has been suspended and the patient is being reassigned after the fact. Here is a list of ridiculous reasons: the patient should be assigned to medical floor, not surgical floor (pt here for head bleed following fall after seizure), pt incarcerated (but floor that usually takes these patients is full so...what? we should hold them for you?), inpatient MD now orders isolation (so? you took report. you transfer them to the more appropriate bed, not me).
With the seizure patient, the bed board nurse was actually extremely apologetic and told me that she would understand if I refused to call report again. I told her that I would alert our manager of this preposterous issue and that in the future, report must be refused on the phone, not after the fact 40 minutes later to bed board. If you took report, you accepted the patient. Period. End of Story.
For the record, no one asked me if he was a medical or surgical patient. In the ER, we see it all and do it all. Its kind of silly to object one way or the other in my opinion and silly to expect me to see the difference between your unit and another who also has a million unspoken unwritten rules, don't you think?

You do realize that in the vast, vast majority of cases the first we hear of a patient is on an ill-formed and oddly worded page, the information in which may or may not bear any relation to reality once we get the chance to assess the patient, and that the first interaction we have is when the ED nurse calls report, right? You also realize that in a similar majority of cases where this happens, we actually DO the necessary bed reassignments after ED sends the patient via transport (often prematurely) and they never hear about it?

Frankly, I applaud this floor nurse who asked "all the stupid questions" and who requested a more appropriate assignment for the client. He or she did absolutely the right thing. Far too often we do in fact just suck it up and do what is best for the patient, making more work for ourselves, regardless of the ED's best efforts to simply unload him or her.

And are you really saying you don't know the difference between a medical and a surgical patient?

corky1272RN · Jul 3, 2012

My ER always calls with report, I just find that strange that some don't. I don't know that it is optional at my hospital or considered a courtesy. I believe that as a hospital, all departments should work together to better serve the patients. It shouldn't be us vs them, nor a competition. I just want my patients to get well.

VICEDRN, BSN, RN · Jul 4, 2012

You do realize that in the vast, vast majority of cases the first we hear of a patient is on an ill-formed and oddly worded page, the information in which may or may not bear any relation to reality once we get the chance to assess the patient, and that the first interaction we have is when the ED nurse calls report, right? You also realize that in a similar majority of cases where this happens, we actually DO the necessary bed reassignments after ED sends the patient via transport (often prematurely) and they never hear about it?
Frankly, I applaud this floor nurse who asked "all the stupid questions" and who requested a more appropriate assignment for the client. He or she did absolutely the right thing. Far too often we do in fact just suck it up and do what is best for the patient, making more work for ourselves, regardless of the ED's best efforts to simply unload him or her.
And are you really saying you don't know the difference between a medical and a surgical patient?

You do realize that we often get NO report on the patient at all, right? Personally, I think report is gossipy and overrated.

And if you took report from me, the patient is YOURS. You are not doing me any favors by doing the bed reassignment. Its your patient and now, its your problem. If you refuse to care for the patient after you take report, then you have abandoned the patient.

I don't applaud anyone who takes report and then turns around and calls bed board after having taken the entire report, especially when its obviously an excuse to turf the patient elsewhere.

I am really telling you two things: The seizure patient I mentioned in the scenario is both a medical and a surgical patient. Seizures is a general medicine complaint and head bleed is a trauma surgery service complaint. The patient's assigned bed was medical floor. The floor RN listended to my report and then complained to bed board that trauma admitted the patient and therefore the patient should be reassigned to the general surgery floor. Thus, I think it is less obvious which "unit" the patient belongs on because lots of folks are quite complicated.

The example petty and silly but still a nice example of the kind of nonsense the floors give back.

Esme12, ASN, BSN, RN · Jul 4, 2012

HOw are the facilities that don't give report to the floor fulfilling the hand off requirement by The JC and standards of practice?

Crux1024 · Jul 4, 2012

HOw are the facilities that don't give report to the floor fulfilling the hand off requirement by The JC and standards of practice?

I wasnt aware there was a requirement so I looked it up, b/c thats a really good question. I found this :

What is the requirement for handoff of care ?

Every hospital must implement a standardized approach to “handoff” communications. This includes an institutional

definition of when handoff must occur, what elements must be communicated, that handoff must be “verbal” and include

an opportunity to ask and respond to questions, and that “like” handoffs are performed in a consistent way.

What are “like” handoffs ? Is every handoff the same ? Are we being told how to do handoff ?

The institution is not being proscriptive about how handoff is done. Units or residency programs may decide how they will

do handoff. Handoff may be face-to-face, phoned, taped, or may incorporate information from a computerized data source

as long as it occurs at specific points of care and includes the five standard elements. For instance, some nursing units do

face-to-face change of shift report; others tape record the report. Some residency programs use computer signout; others

do only a face-to-face handoff. Either approach is fine as long as it remains consistent within that unit or program and

includes the five elements."

The facility Im at apparently does "like handoffs" where everything is available online: the ED timeline, pt history, meds etc is all updated and real time in the system. When the pt is assigned itll show up in their upcoming census and thats their opportunity to look up. We call and report to critical floor, but tele and M/S are expected to do their own research. I couldnt find anything more solid, so if Im wrong, I apologize.

If my facility could/would streamline the process, I would have no issue calling everyone. Unfortunately, the bigger emphasis is put on opening up ER beds so everyone is taken upstairs as soon as possible.

Esme12, ASN, BSN, RN · Jul 4, 2012

I wasnt aware there was a requirement so I looked it up, b/c thats a really good question. I found this :
What is the requirement for handoff of care ?
Every hospital must implement a standardized approach to “handoff” communications. This includes an institutional
definition of when handoff must occur, what elements must be communicated, that handoff must be “verbal” and include
an opportunity to ask and respond to questions, and that “like” handoffs are performed in a consistent way.
What are “like” handoffs ? Is every handoff the same ? Are we being told how to do handoff ?
The institution is not being proscriptive about how handoff is done. Units or residency programs may decide how they will
do handoff. Handoff may be face-to-face, phoned, taped, or may incorporate information from a computerized data source
as long as it occurs at specific points of care and includes the five standard elements. For instance, some nursing units do
face-to-face change of shift report; others tape record the report. Some residency programs use computer signout; others
do only a face-to-face handoff. Either approach is fine as long as it remains consistent within that unit or program and
includes the five elements."
The facility Im at apparently does "like handoffs" where everything is available online: the ED timeline, pt history, meds etc is all updated and real time in the system. When the pt is assigned itll show up in their upcoming census and thats their opportunity to look up. We call and report to critical floor, but tele and M/S are expected to do their own research. I couldnt find anything more solid, so if Im wrong, I apologize.
If my facility could/would streamline the process, I would have no issue calling everyone. Unfortunately, the bigger emphasis is put on opening up ER beds so everyone is taken upstairs as soon as possible.

Well done.....have they had a survey under this "electronic" handoff? For I see some documentation and QI holes that they (The JC) may not like. As a long time ER nurse and manager.....I would be uncomfortable with this system but it's their policy.

nuangel1, BSN, RN · Jul 4, 2012

we have a standardized written hand off sheet that we complete for the admit.we then fax this to the assigned unit .per policy we call the floor in 15 min to verify fax was received and to give the accepting nurse opportunity to ask questions.sometimes we need to fax again or wait for the rn to call us back in 15 min.if we don't here from the floor nurse in that 30 min period.we assume no questions and bring pt up.