Starting the admission orders

mpccrn, BSN, RN · Oct 8, 2008

if you are referring to my post earlier, you might have missed the fact that the time referenced was several hours without a bed available on the unit. i don't expect admission orders to be started in the ED, nor do i think it is appropriate or in your job description. however, i am upset when a patient has to sit in the ED for HOURS because i don't have a bed to give them with fluids ordered and they aren't started. as long as i'm ranting a bit, UA's should be sent in the ED as well. often patients spend hours down there. if admitted, a UA is a standing order. the faster the samples get to the lab, the faster the patient can be treated.......just makes sense to me.

JessicaSN · Oct 8, 2008

patients have to sometimes wait for hours in my er, too, waiting on a bed, but that does not mean the orders are written or given to the er nurse yet.

if it is going on another way in your er (and you have some type of proof that it is) you should speak to your charge nurse or a higher up at your hospital. i definitely don't think the patient should be in limbo for hours being "ignored" by the er nurse.

fuffie · Oct 8, 2008

If you are getting your patients to the floor within 15- 30 mins after getting orders, I want to come work there!! Seriously though, if the patient is getting to an inpatient bed that quickly then there is no reason to start adm orders. If a patient is in the ED as a hold for several hours we need to do all we can do to keep the patient comfortable, if that means hydrating them, treating their pain, nausea and feeding them thaen thats wha we need to do. The bottom line is patient care. :twocents:

hospitalstaph · Oct 8, 2008

I definately start the admission orders IF the pt is a hold in the ER or even if it is just a delay in getting them to their inpatient bed (room not clean, etc)

I have NEVER had one of the accepting nurses be upset that admission orders were not started. That being said I often do start the fluids and give the first dose of pain med before leaving the ER, unless I am absolutely swamped. In return the receiving nurses have always been good to me. I have even had them offer to come down and get a pt when we are busy. In the end we all just need to learn to work together better in the interest of the pt. When it turns into a floor vs ER battle, it is ultimately the pt that loses.

ThrowEdNurse, BSN, RN · Oct 8, 2008

I think some floor nurses don't understand that ER pts are in the ED for half the day sometimes before admit orders are written. I've had to explain that multiple times when I get "so the pt has been there since noon and you didn't do that?" Also I can't imagine a pt being admitted without a UA done. That's almost always an ER order. Antibiotics I will always start immediately and any now or stat order. If the pt is going right up I won't always start IVF either if the pt is stable and can wait to get them on the floor. It saves my tech from fighting with the extra equipment. Often floor nurses don't understand that the admitted pt with an IV and labs done who has seen multiple MDs is officially my least sick pt and their orders will get ignored because of this. Of course if the pt boards in the ED for a long time, I will get orders going. Which makes me wonder why I still get attitude when calling report. Everything's done, sorry to ruin your day by forcing you to take this pt. It's not as if I am driving arond town and bringing them to the hospital just to ruin your day. I also wish the residents wouldn't write the time they step on the unit as the time the orders are written. I've sat on a pt for 2 hours with a bed as the resident played around writing orders then it looked as though I just didn't do anything. ARGH! I wanted to ask if I could write the orders for her and she could look them all up later!!! :banghead:

futurecnm · Oct 8, 2008

if you are referring to my post earlier, you might have missed the fact that the time referenced was several hours without a bed available on the unit. i don't expect admission orders to be started in the ED, nor do i think it is appropriate or in your job description. however, i am upset when a patient has to sit in the ED for HOURS because i don't have a bed to give them with fluids ordered and they aren't started. as long as i'm ranting a bit, UA's should be sent in the ED as well. often patients spend hours down there. if admitted, a UA is a standing order. the faster the samples get to the lab, the faster the patient can be treated.......just makes sense to me.

I think it depends how long the orders have been in the system. unfortunately, it often takes the admitting MD a long time to get down to see the pt, and even longer to put the orders in. Many times, the orders are in there just before calling report, even if the pt has been in the ED for hours. so, that part is out of our control.

I am a pretty new ED RN and was surprised to see the conflict between the ED and the floors (med/surg, tele, icu). I know I do the most I can with the resources and time I am given. It is almost as though other floors think we are just sitting around not doing anything for our pt.

Another point, if we release a specific order (fluids, antibiotics etc), it is then not on the orders when they go upstairs (that is my understanding) and then it is sometimes difficult to get the order on again and the MD must be called etc.

hospitalstaph · Oct 8, 2008

I think it depends how long the orders have been in the system. unfortunately, it often takes the admitting MD a long time to get down to see the pt, and even longer to put the orders in. Many times, the orders are in there just before calling report, even if the pt has been in the ED for hours. so, that part is out of our control.
I am a pretty new ED RN and was surprised to see the conflict between the ED and the floors (med/surg, tele, icu). I know I do the most I can with the resources and time I am given. It is almost as though other floors think we are just sitting around not doing anything for our pt.
Another point, if we release a specific order (fluids, antibiotics etc), it is then not on the orders when they go upstairs (that is my understanding) and then it is sometimes difficult to get the order on again and the MD must be called etc.

Happens to me all the time! The doc puts in the computer that the pt was up for disposition at say 0100, but didn't actually write orders for another hour, then those orders get handed off to the unit secretary so she can request a bed and I don't get the orders back until a bed is assigned. Throw in a code or two and it may be 0300 or later before I even see the orders or the room number. But if you look in the computer, it appears that I have just been sitting on this pt for hours.

mpccrn, BSN, RN · Oct 8, 2008

i understand how busy an ED can get.....been there.

i understand how busy an ICU can get.....am there.

i agree that patients should be our prime concern and it shouldn't matter who does what. it's not a my turf your turf situation. what is upsetting is when an ED nurse reads me admitting orders instead of giving me a body system report and i am referring to what is customary in MY hospital. it's not at all unusual to get a patient admitted with a diagnosis of pulmonary edema and in report get the meds they received in the ED, the lab results, (sometimes actual numbers, sometimes 'the cbc was ok'), the admitting orders read to me rather than what i consider important......like breath sounds, O2 requirements, resp rate/effort, and current O2 sats. sometimes i ask only to get "oh, he's junky" or worse yet "i don't know, i didn't listen". yes, it is frustrating and does a real disservice to the patient.....so much so that we have now screamed loud enough to have a hospital committee look into it. we all have a difficult job but the patients need us all to do what's right.

hospitalstaph · Oct 8, 2008

i understand how busy an ED can get.....been there.
i understand how busy an ICU can get.....am there.
i agree that patients should be our prime concern and it shouldn't matter who does what. it's not a my turf your turf situation. what is upsetting is when an ED nurse reads me admitting orders instead of giving me a body system report and i am referring to what is customary in MY hospital. it's not at all unusual to get a patient admitted with a diagnosis of pulmonary edema and in report get the meds they received in the ED, the lab results, (sometimes actual numbers, sometimes 'the cbc was ok'), the admitting orders read to me rather than what i consider important......like breath sounds, O2 requirements, resp rate/effort, and current O2 sats. sometimes i ask only to get "oh, he's junky" or worse yet "i don't know, i didn't listen". yes, it is frustrating and does a real disservice to the patient.....so much so that we have now screamed loud enough to have a hospital committee look into it. we all have a difficult job but the patients need us all to do what's right.

To care for a pt with pulmonary edema and not know the answers to those basic questions is certainly not ok.

ThrowEdNurse, BSN, RN · Oct 8, 2008

I didn't see where anyone posted anything regarding turfy business, but I too am so tired of it always coming down to that. I sometimes really think floor nurses think I do things just to make them mad. Maybe I didn't realize whatever you were asking was so important to you, maybe in this instance there's a valid reason for something not being done, maybe I TOLD YOU BUT YOU OBVIOUSLY WEREN'T LISTENING AS EVIDENCED BY YOU ASKING ME A QUESTION THAT I ALREADY ANSWERED. I have a horrible time giving report. I have given up trying to tell the pt's story in report because I have been interrupted so many times with questions like, "Does he have a foley? When was the last BM? Where is his IV?" These questions are the ones that make me think that ED report and floor report are way different and we want 2 different things from report. So I give up, tell them what I assume they want to hear which usually comes down to what was done and what needs to be done. It's always task mastering items and nothing to do with pt assessment. I would like to give the receiving nurse a feel for the pt but I have given report to nurses who are openly hostile, rude, interrupt me, sigh loudly into the phone. It's demeaning, insulting, and unnecessary. Obviously, this is not true of all receiving nurses but when only 1 nurse out of 5 behaves this way, it makes me feel like they "always" do this and makes me dread giving report. We also have crazy guidelines about when we can send a pt up and have a very hard time getting nurses to take report. This can lead to a nurse having a pt for all of 15 min before giving report, of course you're going to get a poor report because all I know is what I am reading. I think this is always going to be an issue. I know when I take report from another ED nurse if she doesn't know much about someone or is behind I don't freak. Why? It's always for a good reason. There's always that one pt who can ruin the last hour of your shift and mess everything up. All I ask is that the pt has a pulse. I can figure the rest out. Sometimes, it's just that crazy for me. I want to say, "Look, I am very sorry. All hell is breaking loose down here and do to a series of events out of my control all I can say is the pt is alive. I know because once every hour I glance in her room as I run past and I keep seeing respirations." Sorry, know this sucks, but I am an ED nurse. I provide ED care on an emergent basis. It is extremely difficult to do what floor nurses do in the ED while managing the care of ED pts. I would rather have all boarder pt who are admits or all ED pts. It's just impossible to manage time for both though because it's so different and can just destroy your flow. That's why boarding admits in the ED is a bad idea. They will get an ED assessment by an ED nurse which is problem focused, very quickly, tasks will be done and once they are "all caught up" chances are good I spend very little time with the pt afterwards due to them not being as sick and just not needing me as much as my other pts. I do what I can, but I would never criticize how a tele nurse handles an emergent situation because they are not ED nurses. They have the luxury of not being forced to care for ED pts straight off the street and then being criticized for the ED care they provide by experts in the field (the ED.) I think it's fair to not do the same to the ED nurses when care isn't provided to the level of the experts who work daily on the unit that pt is supposed to be on as they occupy the ED stretcher waiting for their bed upstairs. :argue:

That said, can't we all just get along?

hospitalstaph · Oct 8, 2008

I didn't see where anyone posted anything regarding turfy business, but I too am so tired of it always coming down to that. I sometimes really think floor nurses think I do things just to make them mad. Maybe I didn't realize whatever you were asking was so important to you, maybe in this instance there's a valid reason for something not being done, maybe I TOLD YOU BUT YOU OBVIOUSLY WEREN'T LISTENING AS EVIDENCED BY YOU ASKING ME A QUESTION THAT I ALREADY ANSWERED. I have a horrible time giving report. I have given up trying to tell the pt's story in report because I have been interrupted so many times with questions like, "Does he have a foley? When was the last BM? Where is his IV?" These questions are the ones that make me think that ED report and floor report are way different and we want 2 different things from report. So I give up, tell them what I assume they want to hear which usually comes down to what was done and what needs to be done. It's always task mastering items and nothing to do with pt assessment. I would like to give the receiving nurse a feel for the pt but I have given report to nurses who are openly hostile, rude, interrupt me, sigh loudly into the phone. It's demeaning, insulting, and unnecessary. Obviously, this is not true of all receiving nurses but when only 1 nurse out of 5 behaves this way, it makes me feel like they "always" do this and makes me dread giving report. We also have crazy guidelines about when we can send a pt up and have a very hard time getting nurses to take report. This can lead to a nurse having a pt for all of 15 min before giving report, of course you're going to get a poor report because all I know is what I am reading. I think this is always going to be an issue. I know when I take report from another ED nurse if she doesn't know much about someone or is behind I don't freak. Why? It's always for a good reason. There's always that one pt who can ruin the last hour of your shift and mess everything up. All I ask is that the pt has a pulse. I can figure the rest out. Sometimes, it's just that crazy for me. I want to say, "Look, I am very sorry. All hell is breaking loose down here and do to a series of events out of my control all I can say is the pt is alive. I know because once every hour I glance in her room as I run past and I keep seeing respirations." Sorry, know this sucks, but I am an ED nurse. I provide ED care on an emergent basis. It is extremely difficult to do what floor nurses do in the ED while managing the care of ED pts. I would rather have all boarder pt who are admits or all ED pts. It's just impossible to manage time for both though because it's so different and can just destroy your flow. That's why boarding admits in the ED is a bad idea. They will get an ED assessment by an ED nurse which is problem focused, very quickly, tasks will be done and once they are "all caught up" chances are good I spend very little time with the pt afterwards due to them not being as sick and just not needing me as much as my other pts. I do what I can, but I would never criticize how a tele nurse handles an emergent situation because they are not ED nurses. They have the luxury of not being forced to care for ED pts straight off the street and then being criticized for the ED care they provide by experts in the field (the ED.) I think it's fair to not do the same to the ED nurses when care isn't provided to the level of the experts who work daily on the unit that pt is supposed to be on as they occupy the ED stretcher waiting for their bed upstairs. :argue:
That said, can't we all just get along?

I hear you on sooooo many of your points. I am getting tired of the ER holds. Why? Because I am not a tele, med/surg, ICU, etc nurse! I am sure that many of the nurses on the floor wonder why this matters? Well, I am not familiar with your charting system, I don't know your doctors and what is important to them, I am not always familiar with the medications that you routinely administer, etc. The pt will get much better care on your floor. I cannot plan scheduled medications around multiple ambulances and codes, but I will happily "hold" a pt for a bit if things are crazy on the floor, because I understand craziness! LOL

Just last week we had 11 ER holds! Usually we are on our own, but this time they sent us a med/surg nurse and a med/surg tech. What a god send this was! They truly turned the "night from hell" into a managable situation. When the nurse first got there she asked my why we don't do a more complete assessment, after a few hours she asked how we managed to get an assessment done at all. LOL

We have a pretty good relationship between floors at our facility and I am grateful for that. But PLEASE administration, don't ask me to be a floor nurse, because I **** at that:)