Safe to take new admit at shift change

Emergent, RN · Dec 5, 2015

Yes, it's safe.

Is it convenient, pleasant, optimal? Probably not. But, don't get into the common habit of saying situations are unsafe when they are really just annoying.

In the ER, the patients keep pouring in no matter what. Think, if you are a patient, would you rather be in a busy ER on an uncomfortable gurney, or a comfy bed all tucked in?

sjalv · Dec 5, 2015

What is up with some hospitals and the ER not calling report? Is it a time issue? I work in an ICU and if we are getting a patient from the ER, they always call report before they send the patient up. We know if they have a catheter, why they came to the ER and what the ER has done for them, what IV access they have, what their most recent vitals were, if they have family, what allergies they have, etc. It isn't always the nurse who admitted the patient, nor is it always the nurse you got report from who brings the patient up, but at least you have an idea of what is going on.

emmy27 · Dec 5, 2015

My experience as a floor nurse was that the report I got was rarely useful (all things that were all documented on the kardex, and often given by a nurse who had not seen the patient and was just reading off the chart- something of which I'm perfectly capable) and my experience as an ED nurse is that inability to get someone to give and take report at the same time is the primary cause of admission delays- sometimes for hours. I also get a little irritated about receiving nurses who require that every line on the SBAR sheet be read to them, so they can copy it on to their own, when I am SENDING THE SBAR UP WITH THE PATIENT and they are welcome to use it, and meanwhile the department is falling down around my ears.

While there are absolutely patients who need a verbal report called, there are many who don't. Places I've worked that tried faxed report have not seen a sudden spike in adverse events and have seen a big increase in speed of admissions.

We transport our own ICU patients and do verbal report at the bedside.

ColoradoRocky · Dec 5, 2015

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.

This is exactly how we do it too (plus best practice screens for EtOH etc). I do wonder that the ED nurse isnt required to give report. That seems legally shaky - and questionable from a nursing practice point of view; I should be getting demographic data, the admit diagnosis and the reason for visit, last set of vitals & trends, pertinent s/s, and meds given especially what the drips are and what rate. I cannot conceive of a patient coming up without that - then again, im in a specialty Tele-PCU, not general med surg, so we typically get cardizem or heparin running, or neuro, etc.

anjalidevit · Dec 5, 2015

I too feel that giving ER admit within half hour befor and after change of shift and that too with out any report is totally unsafe and I am an RN for 13 yrs .... And people who talk about time management ... Please .... Patients are not like computers or paper work .... Things change rapidly ... A need for a bed pan can take up to 40 minutes of your time on a bed rest patient and that can happen almost 80% of the time .... Now instead of taking report on the already existing patients .... U have aggravated the previous RN who have just done a 12 long hour shift .... And please don't say that the supportive staff like PCAs or charge nurses could help ... Trying to find them during change of shift will be another 15 minute job .... Sorry if I sounded rude....

emmy27 · Dec 5, 2015

This is exactly how we do it too (plus best practice screens for EtOH etc). I do wonder that the ED nurse isnt required to give report. That seems legally shaky - and questionable from a nursing practice point of view; I should be getting demographic data, the admit diagnosis and the reason for visit, last set of vitals & trends, pertinent s/s, and meds given especially what the drips are and what rate. I cannot conceive of a patient coming up without that - then again, im in a specialty Tele-PCU, not general med surg, so we typically get cardizem or heparin running, or neuro, etc.

z

In EMR systems, all that information should be accessible to the receiving nurse as soon as they're informed they're getting a patient. In fact, the ICU nurses generally wave us off if we attempt to give a full report, because they've usually already looked up the patient long before we rolled them up, and there is no magic in me repeating their admission diagnosis to someone who has already read the chart.

I have no objection to calling to clarify confusing information or add things that might not be obvious from the chart if there is such information, such as family dynamics, conveying special requests from a consult who already saw them in the ED, etc. But for basic demographic info and orders, there is no reason that two busy nurses have to align themselves for a voice report, the same way the triage nurse doesn't track me down to give me report on my ED patients in person and the admitting hospitalist doesn't call me to read me their orders. If it's safe for me to carry out those orders having received them electronically from the EMR, there's no reason it isn't for a floor nurse, as well.

I really do get why it's frustrating to get an admit when you're just coming on. But holding that patient in the ED means both that patient and the patient coming behind them are much less comfortable and safe. An admitted patient rolling on to the floor during shift change, while not ideal, is still in MUCH better hands than a patient being forced to wait another hour on a chair in the lobby or EMS holding the wall with granny on a stretcher while the floor takes a leisurely report on their existing patients and their new admit waits two hours in the ED for it to be "safe" to send them.

VANurse2010 · Dec 5, 2015

As long as your other patients are stable then I feel that you can can take an admit at shift change. Is it ideal? Nope, nor does it feel good, but when they gotta come they gotta come, as long as it's within your safe ratio and the admit is stable. Now if there's something going on with my other patients when my admit comes I'll ask for the charge to settle my admit or at least to arrange for someone to settle my admit. We do have resource nurses that we can page but they don't come up right away.

I agree with this, but there are a lot of "ifs" there that extremely often aren't present in the real world. ED seems to be ruled by the next squad coming in, but many of those squad patients are a hell of a lot more stable than people already in the hospital.

VANurse2010 · Dec 5, 2015

z
In EMR systems, all that information should be accessible to the receiving nurse as soon as they're informed they're getting a patient. In fact, the ICU nurses generally wave us off if we attempt to give a full report, because they've usually already looked up the patient long before we rolled them up, and there is no magic in me repeating their admission diagnosis to someone who has already read the chart.
I have no objection to calling to clarify confusing information or add things that might not be obvious from the chart if there is such information, such as family dynamics, conveying special requests from a consult who already saw them in the ED, etc. But for basic demographic info and orders, there is no reason that two busy nurses have to align themselves for a voice report, the same way the triage nurse doesn't track me down to give me report on my ED patients in person and the admitting hospitalist doesn't call me to read me their orders. If it's safe for me to carry out those orders having received them electronically from the EMR, there's no reason it isn't for a floor nurse, as well.
I really do get why it's frustrating to get an admit when you're just coming on. But holding that patient in the ED means both that patient and the patient coming behind them are much less comfortable and safe. An admitted patient rolling on to the floor during shift change, while not ideal, is still in MUCH better hands than a patient being forced to wait another hour on a chair in the lobby or EMS holding the wall with granny on a stretcher while the floor takes a leisurely report on their existing patients and their new admit waits two hours in the ED for it to be "safe" to send them.

there is actually very good reason that "two busy nurses" should align themselves for a verbal report - one being that the information in the EMR is often not completely up to date and access to information from the floors to ED is not entirely consistent between hospitals and EMR systems. I think you're projecting your hospital's experience (which I still don't agree with) on everyone. I left a job partially over that unsafe BS system of not getting report from the ED (although the ICUs still got verbal report). I assure you the information from the EMR was not informative and often the picture painted by it and the reality of the obtunded patient arriving to the tele floor needing immediate intubation often clashed. Eliminating verbal report is about the throughput convenience of the ED, not about patient safety.

~PedsRN~, BSN, RN · Dec 5, 2015

I really feel like shift change anything is unsafe. Transfers, admissions, discharges... truly, we should have an hour and a half block where all of that ceases. But you know, want in one hand....

emmy27 · Dec 5, 2015

If they're admitting obtunded patients in imminent need of intubation to the floors, there are institutional issues that go way beyond how report happens to be addressed.

"Throughput convenience of the ED" IS a patient safety issue- at most facilities I've worked, one of the largest safety issues. The patients at the entry point who can't be throughput because floors are resisting admits are getting NO care. If they become visibly unstable, they may be put on a hall bed- or placed in a room or bay while the existing patient is pulled in to the hall- but new ER nurses and beds don't spring up to acommodate the patients who come in during the four hours a day that some people in this thread have been advocating for no transfers to the floor.

Yes, it's not ideal, but if that admit isn't putting the receiving nurse over a safe ratio, moving a patient to the floor at shift change and getting a patient out of triage in to start their workup is almost always a safer choice than leaving someone in the waiting area or overloading the ER with more patients than there are staff and facilities to treat.

It would be great if facilities placed a greater emphasis on completing discharges and room turnovers in a timely manner to avoid the coincidence of admissions and shift change, but until that happens, getting patients out of the ED is the best of imperfect solutions.

Incidentally, the first facility where I saw a time frame and faxed report instituted for ER to floor transfers, I was a floor nurse, not an ER nurse. It took an adjustment of unit culture, but it wasn't long before we realized that our patients and their families were MUCH happier and easier to care for when they weren't left sitting on an ER stretcher for hours, and our door-to-provider times for the facility dropped dramatically as ER beds started to open up. I'm an ER nurse now, and I've worked in places that tightly structure the admission process and places that tolerate hours of delay. The former have all been places I'd rather be a patient myself, no doubt.

VANurse2010 · Dec 5, 2015

If they're admitting obtunded patients in imminent need of intubation to the floors, there are institutional issues that go way beyond how report happens to be addressed.
"Throughput convenience of the ED" IS a patient safety issue- at most facilities I've worked, one of the largest safety issues. The patients at the entry point who can't be throughput because floors are resisting admits are getting NO care. If they become visibly unstable, they may be put on a hall bed- or placed in a room or bay while the existing patient is pulled in to the hall- but new ER nurses and beds don't spring up to acommodate the patients who come in during the four hours a day that some people in this thread have been advocating for no transfers to the floor.
Yes, it's not ideal, but if that admit isn't putting the receiving nurse over a safe ratio, moving a patient to the floor at shift change and getting a patient out of triage in to start their workup is almost always a safer choice than leaving someone in the waiting area or overloading the ER with more patients than there are staff and facilities to treat.
It would be great if facilities placed a greater emphasis on completing discharges and room turnovers in a timely manner to avoid the coincidence of admissions and shift change, but until that happens, getting patients out of the ED is the best of imperfect solutions.
Incidentally, the first facility where I saw a time frame and faxed report instituted for ER to floor transfers, I was a floor nurse, not an ER nurse. It took an adjustment of unit culture, but it wasn't long before we realized that our patients and their families were MUCH happier and easier to care for when they weren't left sitting on an ER stretcher for hours, and our door-to-provider times for the facility dropped dramatically as ER beds started to open up. I'm an ER nurse now, and I've worked in places that tightly structure the admission process and places that tolerate hours of delay. The former have all been places I'd rather be a patient myself, no doubt.

Sure there were institutional issues - caused by a lack of communication facilitated by a system that eliminates nurse-to-nurse report. With respect to the throughput of the ED being a patient safety issue - guess what - the patients in the ED aren't the only sick ones in the hospital. Prioritizing movement out of the ED at all costs compromises the safety of the people already on the floors.

emmy27 · Dec 5, 2015

Of course the patients in the ER aren't the only ones in the hospital, but the ones in the lobby are the only ones who don't have a bed, a monitor, and an assigned caregiver (unless you count the triage nurse, who in many a busy ER at 1900 is theoretically responsible for "reassessing" dozens of triaged patients who at that point may have been waiting for hours), and moving them past triage to begin an actual workup is a much larger net gain to patient safety than ensuring that patients who are already monitored, assessed, medicated, and assigned to a caregiver don't have to share their nurses's attention with an admit at an inconvenient time.