I've only worked in two ED's, but have noticed that both have the same tension between the ED staff and the floor nurses. When we're calling report on an admit, they seem to be really snarky and nasty to us. They'll grill us about why the doctor hasn't addressed this lab result, or why the doctor hasn't ordered a foley and why we didn't ask for said order, and get really nasty if we don't stop our report, go address whatever they think needs done before we transport, and then call them back to give report again. Or get nasty because we're transporting without waiting for that gabapentin to be sent up from pharmacy so we can administer it instead of them.
I tend to think it's because if they haven't worked ED, they have no idea the kinds of pressures we're under - not just with the patient we're transferring, but the other 3 patients who are at various levels of stability and needs. If we've made the doctor aware of an out-of-range lab value, and the doctor didn't think it needed addressed in the ED, I don't have time or the inclination to second-guess him. If the admitting doctor didn't order a foley, I don't have time to track him down wherever he is in the hospital to get the order so that I have to place it and not the floor nurse.
I know that floor nursing has its own challenges, and I try to be sensitive to that. I don't repeatedly call back every 2 minutes to try and give report when the receiving nurse is in a room or in report, I try to get all the information they need and the patient tasks as caught up as possible. I do everything in my power to make sure my patient is as well packaged as I can before I send him up - patent IV, antibiotics started, BP in a decent range, etc. Sometimes we just can't have the patient perfectly packaged, and all the meds given before we send them up. Sometimes things like how mobile they are or a complete skin assessment wasn't translated in report from the previous shift, and I just don't know the answer. It's not necessary to beat me up over it or imply that I'm a lousy nurse, yanno?
Anyway, I am not trying to go off on a rant... I'm honestly interested in if this is common, and if anyone's hospital has had success in putting a stop to this and how. It's not feasible to have every nurse in the facility shadow and ER nurse for a shift, though I'd love to see it. (And vice versa... I know sometimes ER nurses get high and mighty with the "lowly" floor nurses -- I don't see it that way, we have different focuses is all.) After all, the goal should be providing the best care for the patient, not proving that we're better than the other guy.
Thanks for all the feedback. We are required to call and give a verbal SBAR, and our medics/PCT's do the transport except to ICU. I'm fine if you say "hey, I've already read the chart, is there anything else I need to know?" I'm fine if you question something like a low potassium that hasn't been addressed. What I get upset about is not dropping it when I give you an answer you don't like. If we have a bed assigned, we are not delaying transport so I can track down a doc and ask him why he didn't order potassium. And am CERTAINLY not going to take the 45 min it takes to track down the admitting when you're going to have to call him for orders anyway.
I try to give 30 min either side of shift change, and 15 min after the bed has been assigned by bed control because I know the floor is looking up the chart and making assignments. I try to get as much done as I can for the pt before they head up, but sometimes I know it's not a lot. I just wish we could treat each other with a little compassion. I know floor nursing is hard, and I'm not trying to make it harder. I need the floor nurses to understand we have constraints and demands on us that they just don't know about, and quit being snarky with me.
I wish there was a solution that would help everyone just be nicer to each other. I know, Pollyanna-ish of me, but I just don't see what's to be gained by being nasty to each other.
Typically, when a bed is assigned, we HAVE to get the patient up due to the hospital tracking our time from bed assignment to the time the patient goes to the floor. If I give report to the floor on a patient I have barely seen, that report is going to be complete sh*t. I don't know a thing about the patient and I don't retain a ton of info from the nurse giving report, since we typically do our own assessment on patients we keep. As the nurse going off shift, I try to call report to help out the nurse who is coming on shift. If you won't take report and the patient clearly has to get upstairs as we have 50 people in our waiting room, it'd be nice if you'd just take it and relay that message so you don't get a terrible report. It takes less than 5 minutes to give report on a patient coming from the ER. If you want a good report, taking 5 minutes out of your hour long report would be much appreciated. I get patients ALL THE TIME in the ER. I can have a patient going downhill and get another patient in the room. I've had patients in my room for an hour before laying eyes on them. I mean, sorry you get patients during an inconvenient hour, but I get patients that are inconveniently timed ALL DAY LONG. Thankfully, at my home job, we don't give report other than on ICU/PCU so this has remedied this a lot. I will only call to give a heads up on something necessary (something regarding meds or patient status if I am unable to take care of something in the ER that needs to be addressed). But really... There is ZERO REASON to have attitude if an ER nurse calls to give report when it's inconvenient for you. I have never ever eeeever been rude to a floor nurse no matter how many times I want to ("the doctor is in the ER, can't you address it down there?" THE HOSPITALIST DOES NOT LIVE IN THE ER and our ER physicians DO NOT give orders on admitted patients! AHHHH!- and do you REALLY need to know your IV access? won't you assess the patient as soon as they get there???), so it'd be appreciated that when a nurse calls during shift change because we get so much slack from our supervisor if we don't (and it's not like we aren't trying to get things together at shift change in the ER), that we don't get attitude.
For the most part our ER nurses are happy to rectify these situations but MANY times I call to get report (we have 15 from the time the bed is assigned) and there are no PRNs for BP, pain, nausea, etc. when the diagnosis or vitals indicate they're needed. I work nights and unless the admitting MD so happens to randomly be there, we sometimes wait hours and hours for any orders at all. (We don't have hospitalists or interns so no orders til the doc gets to it)
Then we have a patient screaming at us or getting put in a dangerous situation that could've been avoided if someone had paid attention to admitting dx and presentation.
We are all busy in our own way. I just wish our administrations would work with us so we can focus on our actual patients.
I rarely have problems with ER, but I do have some thoughts and opinions on the subject.
Shift change admissions aren't just inconvenient, they are a safety risk. I have been on the floor when a patient was brought up and the wrong people were notified, because of the shift change overlap. For whatever reason, the patient was left alone in the room and became unstable.
Sometimes the ER staff are in too much of a hurry. I have had patients whose flu results were ignored and were transported through the hospital without precautions, requiring each employee who came into contact with the patient to wear a mask for five days and be tested. (More than once.)
Please communicate with me. I don't mind calling a doc if labs aren't addressed, but I need to know if you haven't addressed them. Also, if the patient has a stat type and screen and two units ordered 8 hours ago, I expect the T&S to be done and the blood at least started before they come up to the floor, unless you tell me what happened to keep you from doing it. (I hate writing delay of care incident reports.)
Please tell me which ordered abx have been given since my MAR doesn't communicate with your MAR.
Also, please give me your real call back number. I hate calling the ER charge and getting you in trouble. (This has happened more than once, too. Felt like singles night at the club.)
Don't take it personally. Floor nurses feel the same way about any new pt. It doesn't matter if they are from emergency, OR, ICU, a scheduled admit, direct admit, etc. One more pt means more work to do and no one likes extra work. The OR, cath lab, and ICU feel/act that way when you try to send a pt, too. And I know we all groan when 4 more pts and their family members all sign in to be seen all at once... Even worse, the repeat offender for the third (4th, 5th...) night in a row.
I rarely have problems with ER, but I do have some thoughts and opinions on the subject.
Shift change admissions aren't just inconvenient, they are a safety risk. I have been on the floor when a patient was brought up and the wrong people were notified, because of the shift change overlap. For whatever reason, the patient was left alone in the room and became unstable.
I'm sorry, but I'm having difficulty understanding how an inability for basic communication between coworkers on a receiving unit is a problem that should force the ED to delay the patients care (as in, delaying getting the patient to the receiving unit). It sounds to me like a RN on the receiving unit took report, and then didn't hand off care of that patient to the oncoming RN. I'm really glad this isn't an issue at my facility, as I would be livid if one of my patients care was delayed due to such a simple and easily resolved issue.
Although the ED tries to schedule it's workload and admissions evenly throughout the day, people just seem to think that they can come in whenever they want to! And just like restaurants have lunch time rushes, we seem to get those same rushes throughout the day.
I have noticed that at my facility the providers (who change shifts at the same times as the RNs do) tend to have a rush of admits during the last hour of their shift. I'm not sure why all of those patients magically get sufficient results for admission just prior to their shift change, but they do. By the time the house supervisor get's room assignments, it tends to be close to shift change.
When there are multiple admits, I know the ED RNs at my facility will try to stagger them going to the floor so that no one gets slammed (at shift change or otherwise), but that goes out the window when the house is packed and the hallways have chest pains in them, which is not all that unusual at the evening shift change as for some reason that seems to be a peek flow time.
Sometimes the ER staff are in too much of a hurry. I have had patients whose flu results were ignored and were transported through the hospital without precautions, requiring each employee who came into contact with the patient to wear a mask for five days and be tested. (More than once.)
I agree completely that if the patient has been identified as infectious, then the proper precautions should be taken. However, there is no reason to hold the patient in the ED until all test results come back just to figure out if the patient needs some sort of precautions.
The ED is in a hurry, it's the job of the ED to get the patient to the floor as quickly as possible. Almost every study indicates that outcomes are better the quicker the patient is admitted and gets to the floor.
Please communicate with me. I don't mind calling a doc if labs aren't addressed, but I need to know if you haven't addressed them. Also, if the patient has a stat type and screen and two units ordered 8 hours ago, I expect the T&S to be done and the blood at least started before they come up to the floor, unless you tell me what happened to keep you from doing it. (I hate writing delay of care incident reports.)
I think labs addressed is different for each role. The ED provider and RN are not going to "address" many labs that the hospitalist and the floor RN are going to address. Again when looking at outcomes, the evidence shows that many things like hypertension for example addressed in the ED does not improve outcomes. The ED focuses on stabilizing the patient sufficiently for the receiving unit to take over care.
Now, if the hospitalist (or whomever writes the admitting orders in your facility) decides to write an order for that, and it is a now order, the ED RN should give that med as per that order. However, it's not the ED staffs responsibility to determine that the hospitalist should have ordered something for..... unless the patient is patently too unstable to transport and hand over care.
On the other hand if the patient had a stat T&S ordered 8 hr ago, as well as was suppose to have blood hung and none of that got done, well, that should be written up. If there are stat orders, they need to be done, well, stat! And I hope when you wrote that up, it got looked into. Yes, we all can find situations where the nurse was overwhelmed and there were truly more critical issues for that entire 8 hr, but really there if they are that busy someone should have been called in to help.
Please tell me which ordered abx have been given since my MAR doesn't communicate with your MAR.
Also, please give me your real call back number. I hate calling the ER charge and getting you in trouble. (This has happened more than once, too. Felt like singles night at the club.)
The fact that the MAR in the ED does not communicate with the MAR on the floors is a huge deal, one that should be raised as a big red flag in my opinion. I would bet if I came and audited your patient records I would find more undocumented med errors because of this than the documented med errors you have already. That in and of itself should force your facility to change this practice. Unfortunately, since meaningful use does not address this, the likelihood of it getting fixed for you is probably remote at best.
My facility does not have this issue, but when a patient is transferred from our ED to another facility, a printed copy of the MAR is sent with the patient. I know that is valuable to them because there have been several occasions where the receiving facility has called back for clarifications.
We don't have a charge in our ED, so feel free to call the house supervisor to get anyone in trouble who deserves it. The only callback number we have is the main ED number, the ward clerk will find whomever you need to address your question assuming your issue is more important than the patient we are currently working on.
I've been married so long that I don't have a clue what you mean by "feels like singles night at the club", but hopefully your facility will hook you up with someone soon jk
This is common in my hospital. I am a floor nurse telemetry to be specific and one thing that gets to me is the fact that an ER nurse calls for report but I could be in the middle of a task in a patient room and they expect me to drop what I'm doing for report n then the ER nurse will keep calling every 5 minutes and say we refuse to take report when they can't wait a few minutes for me or another nurse to finish that task and also calling around 6-630pm one after another trying to give report when we are getting ready to change shifts...n I will say this while I have never worked in the ER I wouldn't mind shadowing to see what u guys do...I also have to ask questions n get a little difficult because our ER tries to send us medical patients without tele orders n try to lie to us n it's happened a lot..most of the time patient comes with no orders, if k is low not replaced, I've had patients who were diabetics sent up wit a crazy sugar because the ER didn't feed them all day or several times the ER sends patients up with elevated BP's and no meds were given. Quite frankly the ER at my hospital never really gives meds at all n that's a little frustrating when u send me an unstable patient or send a patient on a drip n didn't mention that In report..both sides have challenging tasks but ED nurses need to also maybe shadow us and see why we give you a hard time as well it is vice versa..from what you tell me u sound like u do your part but not all ER's are the same...my urban ER always has job openings like crazy because no one stays...
And to add like another poster mentioned stat orders...I had orders to transfuse a new admission the other day and was told type and screen was done etc then I call blood bank of blood is ready and nothing was initiated...Its things like this that I don't stand for you delay patient care don't lie about it Cuz a lot of Ed nurses say yes this was replaced or it was done and it wasn't n that's not right...I could only see so much through my computer as our Ed has its own system than the floor
I'm sorry, but I'm having difficulty understanding how an inability for basic communication between coworkers on a receiving unit is a problem that should force the ED to delay the patients care (as in, delaying getting the patient to the receiving unit). It sounds to me like a RN on the receiving unit took report, and then didn't hand off care of that patient to the oncoming RN. I'm really glad this isn't an issue at my facility, as I would be livid if one of my patients care was delayed due to such a simple and easily resolved issue.
Although the ED tries to schedule it's workload and admissions evenly throughout the day, people just seem to think that they can come in whenever they want to! And just like restaurants have lunch time rushes, we seem to get those same rushes throughout the day.
I have noticed that at my facility the providers (who change shifts at the same times as the RNs do) tend to have a rush of admits during the last hour of their shift. I'm not sure why all of those patients magically get sufficient results for admission just prior to their shift change, but they do. By the time the house supervisor get's room assignments, it tends to be close to shift change.
When there are multiple admits, I know the ED RNs at my facility will try to stagger them going to the floor so that no one gets slammed (at shift change or otherwise), but that goes out the window when the house is packed and the hallways have chest pains in them, which is not all that unusual at the evening shift change as for some reason that seems to be a peek flow time.
I agree completely that if the patient has been identified as infectious, then the proper precautions should be taken. However, there is no reason to hold the patient in the ED until all test results come back just to figure out if the patient needs some sort of precautions.
The ED is in a hurry, it's the job of the ED to get the patient to the floor as quickly as possible. Almost every study indicates that outcomes are better the quicker the patient is admitted and gets to the floor.
I think labs addressed is different for each role. The ED provider and RN are not going to "address" many labs that the hospitalist and the floor RN are going to address. Again when looking at outcomes, the evidence shows that many things like hypertension for example addressed in the ED does not improve outcomes. The ED focuses on stabilizing the patient sufficiently for the receiving unit to take over care.
Now, if the hospitalist (or whomever writes the admitting orders in your facility) decides to write an order for that, and it is a now order, the ED RN should give that med as per that order. However, it's not the ED staffs responsibility to determine that the hospitalist should have ordered something for..... unless the patient is patently too unstable to transport and hand over care.
On the other hand if the patient had a stat T&S ordered 8 hr ago, as well as was suppose to have blood hung and none of that got done, well, that should be written up. If there are stat orders, they need to be done, well, stat! And I hope when you wrote that up, it got looked into. Yes, we all can find situations where the nurse was overwhelmed and there were truly more critical issues for that entire 8 hr, but really there if they are that busy someone should have been called in to help.
The fact that the MAR in the ED does not communicate with the MAR on the floors is a huge deal, one that should be raised as a big red flag in my opinion. I would bet if I came and audited your patient records I would find more undocumented med errors because of this than the documented med errors you have already. That in and of itself should force your facility to change this practice. Unfortunately, since meaningful use does not address this, the likelihood of it getting fixed for you is probably remote at best.
My facility does not have this issue, but when a patient is transferred from our ED to another facility, a printed copy of the MAR is sent with the patient. I know that is valuable to them because there have been several occasions where the receiving facility has called back for clarifications.
We don't have a charge in our ED, so feel free to call the house supervisor to get anyone in trouble who deserves it. The only callback number we have is the main ED number, the ward clerk will find whomever you need to address your question assuming your issue is more important than the patient we are currently working on.
I've been married so long that I don't have a clue what you mean by "feels like singles night at the club", but hopefully your facility will hook you up with someone soon jk
LOL! Thanks for your reply. "Singles night at the club" is an old reference to girls/guys giving out fake phone numbers when they like a person but not enough to have sex with them or pursue a relationship.
These situations I wrote about are all recent and all happened at a facility that I am currently a Per Diem for. There is not enough time in the world to go over all the ER problems I have had in my career.
This particular issue with shift change is that the ER transporter flagged a nurse passing by and didn't follow protocol and alert the charge nurse and take the chart to the desk. The chart was left at the bedside, the nurse assumed the ER transporter followed protocol and went home. A lot of the time the ER nurse will call report when she has a minute, not necessarily when the bed is available, and the patient won't come up for an hour or two. We had no idea the patient was there until half an hour later when the CNA discovered them and we had to call a rapid d/t VS issues. There have been other, similar situations. My biggest pet peeve, though, is when it's a slow day in the ER and they hold patients all afternoon and then dump them on us at the end of the day. It doesn't happen often, but it's usually with the same set of RNs. The facility has had a few complaints about this, and hopefully it will stop soon.
Usually we will catch a drop and run much faster if it happens when it is not so chaotic.
As far as the precautions go, we had a bad run of flu and the ER was screening the patients. I don't know the whole situation, but they were sending up patients' that had a positive Influenza A screen that had been resulted for more than an hour without any precautions.
I agree with you on the labs. I don't want you to ignore a cardiac patient to fix a magnesium, unless it is critical. I do, however, want you to tell me if you have addressed the labs so I don't re-order a bunch of stuff the patient has already gotten.
The last bunch of hospitals I have worked in have different computer charting in the ER than they do on the floor, so the MARs literally do not communicate. Some of the hospitals have a paper in the chart that tells me what's been given, some don't and I have to rely on verbal report. Same with the OR.
I agree with you that this practice is stupid, but I don't stick around long enough to affect change.
The only thing that really gets me is when an emergent CT/MRI isn't done before the patient comes up. Our ED has ITS OWN RADIOLOGY DEPARTMENT. That's right, ED has dedicated CT machines and dedicated MRI that are located in the very middle of the ED, whereas CT/MRI are all the way on the other side of the hospital and on a different floor from where I'm located. And then I'm taking a brand new admit that I don't know anything about down, the patient is probably unstable, and it's just a hot mess. Anything else at all I can deal with just fine.
We started a new protocol where the floor nurse has to come down and do a bedside assessment with the ER nurse giving report.
Yes, that's right. The floor nurses have to go to the emergency department and assess their incoming patient before they are transported to the floor.
This is what kills me. The floor nurses come down like it's some kind of holiday. I have 3 new ambulances putting new chest pain patients and altered mental status patients into rooms where we have strict "under 10 minutes of arrival" protocols of care. The floor nurse asks me if I can do a quick assessment with them and then spends 20 minutes talking to the patient, telling them how pretty their shoes are and how they think they will like it on their floor because the nurses are nice, whether or not phones are pay-to-use in the room, etc...
While I'm stuck in this room for our new mandatory 2 nurse assessment, the clock is ticking for possible TPA administration or MI. I was calmly asking the floor nurse if she felt that I was still needed and she gave me a death glare and reminded me that a 2 nurse assessment was now mandatory. I wanted to tear my hair out in frustration!
I ended up calling my charge nurse for back up and she sent another nurse over to help with the (now confirmed) stroke patient while another had seen the issue and had already helped get things going for the 2 chest pain patients.
We started a new protocol where the floor nurse has to come down and do a bedside assessment with the ER nurse giving report.
Yes, that's right. The floor nurses have to go to the emergency department and assess their incoming patient before they are transported to the floor.
This is what kills me. The floor nurses come down like it's some kind of holiday. I have 3 new ambulances putting new chest pain patients and altered mental status patients into rooms where we have strict "under 10 minutes of arrival" protocols of care. The floor nurse asks me if I can do a quick assessment with them and then spends 20 minutes talking to the patient, telling them how pretty their shoes are and how they think they will like it on their floor because the nurses are nice, whether or not phones are pay-to-use in the room, etc...
While I'm stuck in this room for our new mandatory 2 nurse assessment, the clock is ticking for possible TPA administration or MI. I was calmly asking the floor nurse if she felt that I was still needed and she gave me a death glare and reminded me that a 2 nurse assessment was now mandatory. I wanted to tear my hair out in frustration!
I ended up calling my charge nurse for back up and she sent another nurse over to help with the (now confirmed) stroke patient while another had seen the issue and had already helped get things going for the 2 chest pain patients.
jk
theantichick
320 Posts
Thanks for all the feedback. We are required to call and give a verbal SBAR, and our medics/PCT's do the transport except to ICU. I'm fine if you say "hey, I've already read the chart, is there anything else I need to know?" I'm fine if you question something like a low potassium that hasn't been addressed. What I get upset about is not dropping it when I give you an answer you don't like. If we have a bed assigned, we are not delaying transport so I can track down a doc and ask him why he didn't order potassium. And am CERTAINLY not going to take the 45 min it takes to track down the admitting when you're going to have to call him for orders anyway.
I try to give 30 min either side of shift change, and 15 min after the bed has been assigned by bed control because I know the floor is looking up the chart and making assignments. I try to get as much done as I can for the pt before they head up, but sometimes I know it's not a lot. I just wish we could treat each other with a little compassion. I know floor nursing is hard, and I'm not trying to make it harder. I need the floor nurses to understand we have constraints and demands on us that they just don't know about, and quit being snarky with me.
I wish there was a solution that would help everyone just be nicer to each other. I know, Pollyanna-ish of me, but I just don't see what's to be gained by being nasty to each other.