Recieving a patient from ER

ByTheLake · Sep 6, 2012

... when that EMS radio goes off and you take report on another thousand year old nursing home patient presenting with chronic vagueness and maybe a fever sometime last year.

**snicker** Going to have to steal this line. As to ER nurses "lying" to get a patient up, I'm not saying it doesn't happen, but I don't think it's a fair characteristic of ER nurses, and I don't think it is *exclusive* to ER nurses. For instance, we have floors that tend to "ride the dirty beds" to shift change. It may not happen in your facility, but it does in ours, as confirmed by ex-floor nurses in ED or ED nurses who float to floors. That sort of practice is unfair to the oncoming shift, unfair to the ED nurses who will inevitably be despised for something like not giving synthroid before breakfast/transport or because the latest finger stick is an hour too old, (never mind they had 3 helicopters and 8 ambulances in the last 2 hours), and it is really unfair to the patient who had to sit in the ED. It's not an appropriate level of care for them. It is too likely they will get neglected in favor of people whose problems are more immediately life-threatening. But you know who it endangers the most? The *completely untreated* patients sitting in the lobby. Sometimes with critical labs that can't be sufficiently addressed in the lobby. Sometimes with scary scary presentations. Even ED nurses too easily forget the lobby patients.

I've never worked the floor, but I do try very hard to be understanding of the floor nurses. They do what I know I could never do. I respect them, and I try to make the transition efficient for us all. I know there are some meds we have in our pyxis that they don't have in theirs, so I try to get those *at least* pulled to send up, hung if possible. But if they have it stocked and I don't, it can wait. I try to offer pain meds if they're due. I try to be honest--if the patient is a jerk-face with a "I'm a CNA and I'm going to judge your nursing care all day" aunt at bedside, if they're suffering from incopresis and a monkey-like urge to finger paint with their own feces, if they are winey button-jockeys, I'll tell you because I sure wish I'd had a heads-up. So if I say they're nice, they're nice. If I say they haven't tried to climb out of bed all shift, they haven't. I try to stagger patients to same floors. But sometimes, I have had no beds all day, and it's been a cluster fest downstairs. Sometimes, *trying* to medicate for pain, pull special fluids from pyxis to send up would mean not getting tpa started on time for someone else, or delaying an ED room for the kind of walk-in whose across-the-room assessment makes your stomach do flips.

When I call report and apologize that I haven't given insulin but fingerstick is done and tray is riding up on the strecher, please be nice.

When I call report and tell you that the solusets are on the patient's lap and they just got some more dilaudid and all the stat/now orders are done/drawn, please say thank you.

When I totally ***** something that I know better, and it's all my fault and there's no excuse, please let me know, nicely, and trust that it's rare, and that mostly we are doing our damndest.

You know how you have those mornings when it seems like ALL your patients are on sliding scales and breakfast shows up early, right before shift change, and ED is on the phone to give report, and Ms. Jones in 308 just grabbed your arm, and when you looked down, poop oozed between her fingers? Again? And remember how you felt 30 minutes when the day shift rolled their eyes about something you dropped the ball on? Yeah, we feel that way too sometimes. I think we have more in common than we realize, including an innate tendency to blame the prior shift, blame the senders (EMS or ED or NH), and think more about our own rotten luck than what drove those other people to leave you such a mess. I'm totally guilty of it at times, too.

jweidern · Sep 6, 2012

In response to those whose comments seem to imply that we secretly plot to crap on your day by sending everyone up at shift change : please be aware that this has more to do with a provider who can't go home without disposition of all their patients than a nurse trying to make your life hard. Also please consider that as we send on our patients to you...we are filling our said empty rooms up right at shift change and are charged with settling kn the patient and starting protocols on those patients. Believe me I hate doing that too but when my patient has been laying on a terrible gurney for 5 hours already...the best thing I can do is move patients as soon as the Md places a dispose order. Not to mention that at peak times in my Dept we have up to 30 people waiting for that bed and possibly an ambulance or two waiting in the hall.

sapphire18 · Sep 6, 2012

...the best thing I can do is move patients as soon as the Md places a dispose order...

A "dispose" order..hahaha..love it

357maggie · Sep 11, 2012

That actually IS the case where I work. The EC has a totally different assessment form, hand off form, computer status board, and many other differences from the floors. I didn't know this until I was floated down to the EC.

jenfromjersey · Sep 20, 2012

I have been a nurse for 15 years, the last 10 of which I have spent in my current hospital. I worked on a med/surg floor, then telemetry, then a holding unit prior to moving to the ED about 5-6 years ago. Having seen both sides of the issue, I can understand both viewpoints.

The OP asked what can be done to make the receiving nurses more accepting and here are some suggestions based solely upon my experiences in my current hospital:

1) Our ED, as others mentioned, uses a different charting software than the main hospital. We use IBEX and the main hospital uses SCM. They do not speak to one another. We also use physician order entry making it difficult for the ED nurses to see the admission orders placed. Our secretaries are expected to go into SCM and print out the admission orders and place them on our chart. This way, we can see what has been ordered. If anything is stat, we can get to it AND we can give a better report because we know what diagnostic testing has been ordered for the future (which may affect NPO status or the administration of certain medications).

2) If a patient is allowed to eat, I try to feed my patients before they go to the floor. I work 11am to 11pm. Our main cafeteria closes at 7pm. Patients holding in the ED for hours may be starving when they go up to the floor and the floor has nothing to offer them. Despite the turkey sandwiches in our fridge, realize that graham crackers and juice may be all the floor has to offer them. If possible, get a patient a meal tray if you know they are going to be staying overnight. It takes me 15 seconds to call dietary and they deliver it to the room. Not a big time waster and much appreciated by the floor nurses not to have a starving patient on their hands.

3) If a patient has maintenance IVFs ordered on admission, I hang them on a pump and on pump tubing at the prescribed rate. We have a room that is stocked with a small supply of pumps that we can easily obtain. The ease by which we can obtain a pump is sometimes taken for granted in the ED. On the floor in our hospital, you must a call a department, provide the patient account number and then wait for a pump to be delivered to the room by the equipment department. When I tell the receiving nurse that I have initiated the IVFs ordered on admission and that it is already on a pump, they appreciate it. Most of the ED nurses hang fluids on primary tubing as a large majority of our fluids are hung wide open or at fast volumes.

4) If I suspect that a patient is going to be admitted from the onset, I try to obtain IV access in a forearm or hand. (There are limitations to this if patient is a trauma, getting studies requiring an AC site, etc. But a patient with an obvious leg cellulitis who failed oral antibiotics as an outpatient who is not septic and clearly needing admission can benefit from an IV not in a joint to prevent constant alarming on the pump when they get to the floor. ED nurses tend to run things off pump and do not get to experience the sound of an alarming pump all night as often as floor nurses. It is a pain in the butt.

5) If a patient hasn't taken ANY of their routine meds today ("because they were coming to the hospital") and it is 5pm, look to see if there are any important ones that you can give BEFORE a problem arises. I recognize that 160/90 may not be significant in the ED perspective, but 2 hours from now, once it climbs to 190/100 it may be an issue. Bring proactive rather than reactive is a good mindset to have. I work in the ED full time and I know that it can't always be addressed when the place is falling apart. However, I do try to get their meds in them. If getting the med from the pharmacy is problematic and it is not stocked in the Pyxis, think about what you do stock that can help manage the BP for tonight. I may not stock PO vasotec, but I have it in IV form. We stock clonidine 0.1 and 0.2. We have PO and IV Lopressor. If the patient takes an ACE inhibitor po at home, giving 1 dose of an ACE inhibitor IV in the ER may not be that big of a deal to ask the ER doc for. Do I care about their MVI, Calcium, Vitamin C, Colace? Their weekly Fosamax? Not really. But you better believe I am calling pharmacy for that PO dose of Risperdal grandma takes routinely at 9pm because her smiling face right now is gonna change RAPIDLY without out and I'm not waiting for a showdown.

6) Question the docs when you think a patient is going to the wrong level of care. We are comfortable handling pretty sick patients, but when you are sending a patient to a med/surg floor where the nurse has an assignment of 8 patients, it may not be as easy for them to manage. I think about the amount of care that patient is going to need and whether or not that patient may decompensate. Does the patient merit maybe a higher level of care for 24 hours until they're a little more stable. I have fought with many docs over who they deem appropriate for med/surg and who I know needs a tad bit more monitoring. There is nothing worse than sending a patient to the floor who gets rapidly responded later in the shift. If I fluid resuscitated someone and they now have a BP of 105/70, I may be happy, but I have to remember that they came in a few hours ago with a BP of 85/52. They look good now, but maybe we're not out of the woods just yet. When a patient is being admitted with a diagnosis related to cancer, I question why they are not going to the oncology floor. Maybe there are no beds, but sometimes admissions drops the ball. I know we are busy and they are on our butts to move the patient as quick as possible because the waiting room is full and there is a medic at the door. I know. But that patient is depending on us to make sure that they get better and have the best outcome. We spend a hell of a lot more time in the room with the patient than the docs do and we know the patient a lot better than they do. I advocate for what I feel is best for the patient.

All I can say is that I typically don't have a problem giving report. The nurses know me and they know that although the patient isn't going to be tied up with a bow, I will do whatever I can to make their life a bit easier. Can I do it all? Absolutely not. That is why nursing is a 24 hour job. Do I know when their last pneumovax was? Probably not. But I can tell you what brought them here, what they looked like then as opposed to now and what I did for them in between. Ask me what you need from me to make your job easier. I am not a mind reader. But if it's something relatively simple, I can do it. I hear more often than not, "I love getting report from you" rather than hostility. I think it's because I consider both sides, don't have an attitude and genuinely care. As stressed as we are day to day, we need to help each other out because the shifts are getting rougher and the staffing shorter.

Just my 2 cents.

sapphire18 · Sep 20, 2012

Jenfromjersey...I would love to work with you!! Sound like an awesome coworker in taking the next nurse's situation into consideration...which ultimately benefits the patient!

tami101481rn · Sep 20, 2012

We have a system that works well. While yes, we do have two seperate charting systems, we in the ER are responsible for checking admitting orders and are responsible for carrying out stat ornow orders. With that being said though, I am not going to delay admission of a patient based on a ridiculous stat order ( there is no reason a cholesterol drug needs to be given right this minute) bc in the ER a lot of times we have yo wait on meds like that from pharmacy. We also have a policy in place that we have 30 minutes after a bed assignmet to get a patient out of the ER, unless there are pressing reasons we cannot ( unstable patient, sudden influx of critical patients etc) That means the floor nurse has that amount of time to take report. I really support observation floating. Come work the ER on a busy night, when you have multiple traumas rolling through the door, or code after code, and you will see why we want admitted patients out ASAP, we have a high patient turnover, and sometimes really do need beds open that fast.

Guest219794 · Sep 24, 2012

This thread confirms my own observations. When either or both nurses have experience in both environments, the handoff goes smoothly.

During orientation to a floor, the nurse should spend some time in the ER, and Visa Versa.

I am trying to make this happen where I work.

DC Collins, ASN · Nov 20, 2012

We are not going to electronic med ordering until next year. It is still on paper. Add to that, in emergencies, sometimes verbal med orders are necessary. To accommodate those issues, our Pyxis gives complete access to all meds in them to all ED nurses.

So technically, we ED nurses can give those meds, if we have time.

I personally haven't run across a problem like that with floor nurses, though I have been doing this for only 2 years. I don't know if its because we have great relationships with them (which in most cases is true), or because they just instead grumble behind our backs (most certain to happen sometimes, we are all human).

But considering that I believe we do have great relationships, in most circumstance, I, at least, will give pain meds that are due straight off the admit (non-ED orders) because I know that if I don't it may be some time before the floor nurse *can* give those. Maybe because the floor nurses know I am looking out for the pt and also taking care of the more urgent med need so they don't have to, they don't complain when I haven't had time to give something non-urgent, like lisinopril?

DC :-)