Shift change department transfer errors

BrnEyedGirl, BSN, MSN, RN, APRN · Nov 16, 2008

How is it any safer for the pt to be in the ER during shift change, than it is to be in the CCU Stepdown during shift change?

al7139, ASN, RN · Nov 16, 2008

Hi,

I feel your pain. Transfers or admissions right at change of shift are the bane of my existence! I HATE getting to the floor at start of shift to be told that I am getting an admission, or a transfer, or that one of my patients just got to the floor, but "I have not had time to assess them yet" by the off going nurse.

Most times (thank God!) the patient is stable, but is my first priority after getting report, since they have been put to the back burner (so to speak), is to visit them and assess them and see to their needs. Unfortunately, lots of times, the ED and the other units have a goal of getting the patient out of their dept before they change shift so the nect nurse doesnt have to deal with it.

Consequently, has anyone noticed how many codes or MRT (Medical Response Teams, for the patient who still has a pulse and resps, but is not stable) are called at change of shift? I swear I can picture them racing the patient to their new room because they don't want to deal with it!

On my unit, if we get an admission or transfer, we are told about it, and given the opportunity to look up that patient prior to recieving them. I have often gone to my ClinII and refused the admission because they are not stable for transfer, or if it is an admission, because they need to go to ICU/PCU. In a perfect world, this would happen all the time, unfortunately it doesn't. I would LOVE to have a policy in place at my hospital that prohibits transfers at change of shift. Please let me know if your hospital changes their policy! Then I can propose it to ours!

Amy

morte, LPN, LVN · Nov 16, 2008

i think this speaks to having the different depts on different scheules......years ago, when i worked as a clerk in ED, the ED nurses were 8-4,4-12, and 12-8....were the floor was 7-3 etc......with 12' shifts, it would seem a similar 1' offset may help with this issue.....on the other hand perhaps the floors should have one nursing position that is offset by 1', if a systemic change is not possible....

BrnEyedGirl, BSN, MSN, RN, APRN · Nov 16, 2008

Has anyone read the new articles about hall beds on the floor? I spent 8 yrs on cardiac unit before transferring to ER so trust me, I understand the frustration of getting a new admit at shift change. The articles on hall beds are quoting research that states it is actually safer for the pt to be in a bed in the hall on the floor than it is to be in a hall bed in the ER. I'll try to find a link.

Alternating shift times might help a bit,.although when you really look at this from a pt safety issue, it is usually safer to move the pt to the floor, which means one less pt in the ER waiting room or in a hall bed in the ER. That is one of the more frustrating parts of ER,.we can never say we are full, give us an hour to catch up. It doesn't matter that we have all beds full, 25 hall beds full and are placing people in chairs and treating in the waiting room, people keep coming, ambulances keep showing up and someone has to care for these people! This is why floor staff gets so angry about things that aren't done in ER. When you're trying to take care of someone in a chair in the waiting room and also have two pts that need to get to cath lab, three waiting for OR and 6 on vents that are constantly needing IV push meds,.we have to prioritize and do only what must be done NOW.

Our hospital is actually timing how long it takes from when ER requests a bed, and when the pt is actually moved to the bed. When there are delays someone gets a "nasty gram". Not transferring pts at shift change is not an option,.although if we aren't full many of our nurses will hold on to a pt if we can at least call report and have everything ready for the on coming nurse to just transfer. I'm not sure that helps much, as you still get a new admit at the very beginning of shift.

I think we all need to remember that a hospital is a 24/7 job. Pts don't make appointments to have illness or trauma happen to them and we must be ready to take care of them when they need it, be it shift change, lunch time, Christmas etc.

Tweety, BSN, RN · Nov 16, 2008

I don't think we need to get into the old ER nurse vs. floor nurse battle about shift change transfers. Do a search and you can find a few heated discussions.

To answer the OP's question. At my facility all policies were dropped and the ER can transfer patients any time they feel necessary. If it's crazy at shift change, I'll simplly ask them to wait and most of the time they can. When they can't, I have to respect that. Most of the time I don't obstruct the transfer and allow the patient to arrive, that way when I do ask they usually will since I don't make a habit of it.

In my 17 years, I haven't ever seen any dangerous outcome in shift change transfers. Although I'm sure someone somewhere will come up with examples. I think they should be avoided however because of the inconvience to the patient, staff, as well as safety concerns. But the safety concern is a bit weak if you ask me.

Tweety, BSN, RN · Nov 16, 2008

Our hospital is actually timing how long it takes from when ER requests a bed, and when the pt is actually moved to the bed. When there are delays someone gets a "nasty gram". Not transferring pts at shift change is not an option,.although if we aren't full many of our nurses will hold on to a pt if we can at least call report and have everything ready for the on coming nurse to just transfer. I'm not sure that helps much, as you still get a new admit at the very beginning of shift.
I think we all need to remember that a hospital is a 24/7 job. Pts don't make appointments to have illness or trauma happen to them and we must be ready to take care of them when they need it, be it shift change, lunch time, Christmas etc.

We are also timed from the time they get the admission orders to the time they arrive to the floor, but no nastygrams if we don't meet the goal and the goal is 90 minutes, because sometimes they might have to carry out some orders, and it takes a few to get a bed assignment. Trends and causes are analyzed and ways to improve the system are discussed when a large percentage of patients aren't meeting the goal. Sometimes there's a gridlock that can't be helped.

I think the nastygram approach only serves to create further ill will between floor nurses and ER nurses.

Yes it is a 24/7 job. I hear the "there's a trauma coming in....." at least a dozen times a day. Floor patients don't make appointments with incoming addmissions when they are confused on and fall on the floor, or decide to go bad, or need blood transfusions, pain medicine, be incontinent, bleed out or have a COPD attack, etc. (Sorry couldn't resist.)

BrnEyedGirl, BSN, MSN, RN, APRN · Nov 16, 2008

Yes it is a 24/7 job. I hear the "there's a trauma coming in....." at least a dozen times a day. Floor patients don't make appointments with incoming addmissions when they are confused on and fall on the floor, or decide to go bad, or need blood transfusions, pain medicine, be incontinent, bleed out or have a COPD attack, etc. (Sorry couldn't resist.)

:coollook: :eek: :kiss

:bugeyes:

touche,...one more reason I try to remind my coworkers to NEVER assume that the ER is busier, more short staffed, more over worked etc than any other staff member in the hospital. First off it's just rude, and secondly it just isn't accurate! We're all in this together folks,.I'll scratch your back if you'll scratch mine! :yeah:

mpccrn, BSN, RN · Nov 16, 2008

we have a study going at our hospital...door to floor......where the icu actively calls for report the minute they are notified of the admission. it is quite impowering to be the active party rather than the one waiting at the whim of another department. it is safer for the patient to be in the icu than the er. it's showing that the door the floor time actually decreased dramatically when the power was shifted. of course, it goes without saying that the patient must be stablized in the ed. if the receiving nurse is busy when the patient arrives, we hook them up, get a set of signs, do a quickie assessment based on diagnosis. it takes all of a few minutes. shift change admission or transfers are a reality, it's just the way you look at them that can change.

Tweety, BSN, RN · Nov 16, 2008

:kiss
:bugeyes:
touche,...one more reason I try to remind my coworkers to NEVER assume that the ER is busier, more short staffed, more over worked etc than any other staff member in the hospital. First off it's just rude, and secondly it just isn't accurate! We're all in this together folks,.I'll scratch your back if you'll scratch mine!

Exactly.

We get beeped and an overhead announcement when the ER is on "pre-divert" and I do what I can to facilitate admissions no questions asked, bring them on up.

Also, I have to give props to the ER for giving me the benefit of the doubt when I say "we're so swamped right now, my nurses are 7:1 can you give us a break" and they do indeed give us a break. I'm sure if I had a rep of being uncooperative and crying wolf they wouldn't give me the time of day, much less wait when I ask them to.

BrnEyedGirl, BSN, MSN, RN, APRN · Nov 16, 2008

Exactly.
Also, I have to give props to the ER for giving me the benefit of the doubt when I say "we're so swamped right now, my nurses are 7:1 can you give us a break" and they do indeed give us a break. I'm sure if I had a rep of being uncooperative and crying wolf they wouldn't give me the time of day, much less wait when I ask them to.

You are soooo right,....we know which floors really mean it when they say they are swamped and need a few minutes and which floors are just trying to get their smoke breaks in. I'm all for everyone getting their breaks but it is very frustrating to be running your butt off, trying to hold on to a pt so the floor nurse can play catch up, then see that very same nurse walk out the ER doors to smoke! (I work nights, the only way in/out of the building is through ER to the sidewalk where everyone smokes). Please don't tell me you have a pt crashing and need to get them to the ICU then walk out the ER doors to smoke! :madface: :angryfire

mama_d, BSN, RN · Nov 16, 2008

I don't care much for end of shift admits either. Beginning of the shift, well, I'd rather have them then than at the end.

It doesn't matter to me though what time the patient comes, I do an assessment on them, make sure that they get vitals, and make sure that their monitor is on and a strip run. The only time I don't is if the day nurse getting the patient is already there and we go in together to get the patient settled in and she/he does the assessment at that point instead. As far as I see, there is no excuse for a patient to go for an extended period of time without an assessment and care regardless of when they hit the floor (barring a code situation). But I am lucky enough to work on a unit where if I'm dealing with a situation with another patient when my new admit rolls up, another nurse will willingly take over so that I can tend to my new admit. I guess if this wasn't the case I might have a different point of view.