Safe to take new admit at shift change

dudette10, MSN, RN · Dec 4, 2015

No, and one thing I've noticed is they like to give the most difficult, time consuming patients to us new grads. They don't take the nurse's experience or ability into consideration when they make assignments.

Is it possible that you are perceiving that the new grads get the "most difficult, time-consuming patients" because you are still working on prioritization and time management?

dudette10, MSN, RN · Dec 4, 2015

No. Unsafe. At my facility, the DON set things up so that we couldn't accept a new pt within a hour of shift change. That's not safe for pt care.
Sometimes, this meant forcefully not accepting a pt who had arrived. Transport had to stay with the pt. transport didn't like it. But this policy was beneficial.

This isn't right. Transporters should not be responsible for a patient any longer than it takes for the person to actually transport.

emmy27 · Dec 4, 2015

An admit patient who isn't transported to the floor is in an ED bed. In the best case scenario, they're in a less-comfortable setting where many of the meds and amenities of admission are not readily available, and receiving an additional care transfer (from the offgoing ED nurse to the oncoming nurse, who will, in your preferred scenario, then call report to you in an hour). In the worst case scenario, they're occupying that bed while someone equally or more unstable waits for it to open up- or that same ED nurse cares for your admit AND the EMS/lobby patient, with one of them in a hall bed, again for the hour you want them to wait.

I know it sucks to get admits at shift change, I was a floor nurse once too, but they don't stop coming in the ED door at shift change, and the fact that you don't personally witness the ER situation doesn't mean that by refusing report until you're feeling good about your other patients you've somehow increased overall patient safety.

If your admissions are putting you over a safe ratio or your admission protocols are so onerous it's impossible to safely care for other patients while you have a fresh admit, those are problems that the facility needs to address. But just holding patients in the ED longer is rarely a net gain to patient safety.

Cola89 · Dec 4, 2015

No, and one thing I've noticed is they like to give the most difficult, time consuming patients to us new grads. They don't take the nurse's experience or ability into consideration when they make assignments.

That's not right. They did that at the hospital I just left, too. It seemed like the nurses established to the floor thought they were getting away with something by giving the new nurse the worst assignments while they kicked back and face booked at the nurses' station. Really it just pushed me out the door that much faster and I hope they're all running their azzes off now.

russianbear · Dec 4, 2015

Is it possible that you are perceiving that the new grads get the "most difficult, time-consuming patients" because you are still working on prioritization and time management?

Must possible, however we have a computer system that shows which patients are being admitted and to which units. I've heard the charge nurses discussing the future admits and who to give them to, so it's not always who's next for an admission, but who gets which specific admission. 70 year old in heparin drip for PE who is incontinent, may have the diff, and is confused and likes to leave his room naked. I'll get that one. 33 year old with chest pain and negative troponin up ad lib. We'll give that to the experienced nurse with fewer patients.

RescueNinjaKy · Dec 4, 2015

Must possible, however we have a computer system that shows which patients are being admitted and to which units. I've heard the charge nurses discussing the future admits and who to give them to, so it's not always who's next for an admission, but who gets which specific admission. 70 year old in heparin drip for PE who is incontinent, may have the diff, and is confused and likes to leave his room naked. I'll get that one. 33 year old with chest pain and negative troponin up ad lib. We'll give that to the experienced nurse with fewer patients.

Then document this and bring it up to the charge nurse and nurse educator. You have to have solid evidence of this. If someone had 2 patients and I have 3 and they give me the next admit, you can be sure I'll be talking to the charge nurse about it. This is not being confrontational or trouble starting. It's advocating for yourself and your patients. Giving a harder patient to a new nurse is okay in my opinion if the rest of the patient load and acuity is doable. This way they get to learn more as the experienced nurse probably already had that experience. Now if you have way too many patients or your other patients were unstable then it would not be a good teaching moment to get a complex patient.

vintagemother, BSN, CNA, LVN, RN · Dec 5, 2015

This isn't right. Transporters should not be responsible for a patient any longer than it takes for the person to actually transport.

Quoting: "It must be nice to work in a hospital with an ER where it is slow enough to have that rule. We usually have multiple admits and we give them 45 minutes to cover shift change. We have patients in the waiting room that need to be seen. We still get patients during shift change in the ER. If more hospitals instituted this policy, then that would be unsafe for the ER."

I worked in an acute psychiatric care hospital. The Referring facility was aware of the policy not to send pts during this one hour window, but sometimes, didn't follow the policy. The transporters were staff of the referring facility; therefore, I don't see how it's wrong for them to have to wait.

So, it might be a different situation than one in which pts come from the ED to a different floor in the same facility.

The rationale behind the policy was related to the fact that admissions take time. If an admit arrived within an hour of shift ending, that would only give the nurse 30 mins to complete the admission assessments and document them. The last 30 mins of the shift were designated for report.

Now I'm curious though. How do nurses in other facilities handle admits that arrive close to shift change? Do you stay overtime? Is it paid? Or can you pass off the remaining admission requirements to the next shift? This was frowned upon by the noc nurses. I never did it. Or are you able to handle completing sometimes 2 admissions within 30 mins?

Most of the admission requirements could be completed before the pt arrived. But there was still a head to toe assessment, full body check, and a few other assessments that had to be completed before the pt reached the floor. I'm curious now....

Graduatenurse14 · Dec 5, 2015

The main problem I have with your scenario is that the ED nurse isn't required to give report. One of the things we are always told about abandonment is that you cannot leave your patient until you have reported off to a nurse who has accepted the assignment.
I wonder how that practice would hold up in a lawsuit.

In my unionized hospital we get pts on the floor at shift change and the ED faxes up "report" and there are 2-3 different versions that are used. One is pretty good and the other one that I've seen has the patient's name, DOB, and latest set of vitals and that's literally about it. Why not just one report sheet? Who knows and it probably won't change.

Meriwhen, ASN, BSN, MSN, RN · Dec 5, 2015

Now I'm curious though. How do nurses in other facilities handle admits that arrive close to shift change? Do you stay overtime? Is it paid? Or can you pass off the remaining admission requirements to the next shift?

If the admit arrives within an hour of shift change, all we are required to do are vital signs, skin check and if needed, emergency medications. The rest is left to the next shift. If it's a slow night and the patient is cooperative, we may go ahead and complete some more or even all of it, but usually we're getting ready for shift change. Finishing an admission is not considered a good enough reason for getting paid OT, and we can be fired if we work off the clock. So we have to pass it off to the next shift.

akulahawkRN, ADN, RN, EMT-P · Dec 5, 2015

The ED doesn't have the same luxury of refusing admits at shift change...

Nonyvole, BSN, RN · Dec 5, 2015

So, from the ED prospective. That courtesy time ends up being pushed back longer and longer, until all of a sudden we've had this admitted patient, with orders, sitting in an ED bed for seven hours and for no reason beyond that the floor simply didn't want more patients and they could be managed just as well in the ED. (Which yes, is glaringly false for many reasons, but just as the ED nurses didn't know what it was like on the floor, the floor nurses didn't know what it was like in the ED.) It's one of those issues that is becoming as old as time and as highly argued as politics no matter where you go.

I've had patients go up and been refused. Welp, that patient had a phone in their room, no? I call the house supervisor. Then I go to my unit manager.

Now, as for your situation, OP, I can only chime in with the others. There's taking a good look at ratios, admits, and levels of acuity for your unit, and going to the charge nurse, unit manager, and unit educator.

dudette10, MSN, RN · Dec 5, 2015

To vintagemother:

if if they come up within 30 minutes of shift change, we do a skin and mobility check, get them settled, oriented to routine, vitals. If I'm working tele, I put the monitor on and check rhythm. If all is stable and I'm all caught up, I do as much of the admission as possible. Otherwise, that patient becomes the admission for the night nurse.

If it's an hour to 90 minutes before shift change, same deal, but I do all admission documentation, which really doesn't take too long for most patients. I prioritize admission orders, and I can usually get them all done. If not, the lower priority orders get handed off. It's a 24/7 job; the next shift can ***** all they want, but I'm not staying late to wait for the TED hose to be delivered from central supply.