The War with the Floors

Cheyenne RN,BSHS · Jun 28, 2006

i am writing a paper for school on the all out war that goes on between the er and the floors. i have worked at several hospitals for the last 27 yrs-it's always the same. they do everything in their power not to take report. is this a problem for you? please tell me how you handle this at your hospital. does your administration pamper the floors? do you utilize fax reports? do you have a time limit for patients to be sent to the floor? what is working in your hospital? appreciate your input! pam

our facility is about 150-200 beds. the house supervisor coordinates our admissions and/or transfers. the hs will obtain the room number from the unit's charge nurse and find out when the bed will be ready and who the nurse will be accepting that patient. the hs then gives the information to the er nurse. one person has the responsibility of coordinating the actual admission/transfer process smoothly and can deal with any individual issues that exist or see patterns in problem areas.

the charge nurse, at the same time, will have been in touch with the staff enough to know the patient acuities and who is up for an admission next. she will tell the nurse that she/he is getting a patient, where they are coming from, and a name and general diagnosis.

the er nurse calls to the floor accepting nurse to give verbal report. if the nurse is unable to take report right then, such as they are in a patient's room or doing a procedure, they are to call them back for report as soon as they are finished. to the best of my knowledge, the floor nurses do always call back promptly and the er nurses are great at waiting a few minutes while a task is completed because no one abuses the other's time.

imho, it is all a matter of repecting one another when giving or receiving a patient. everyone has either needed or used the er at some time or other in their life and should remember that.

Uptoherern, RN · Jun 29, 2006

our process is ridiculous. the ER doc needs to know what insurance the patient has before he can call the hospitalist. This is because different groups cover different insurance plans. There is one group assigned each day to patients who have no insurance. Bed board doesn't even want a "heads up" on admissions until there is an accepting physician. Registration is told they cannot register the patient until they have a copy of the admitting orders. Then we wait, and wait for bed placement to call us back. Patients ask, how long till I go upstairs? I tell them, wellllllllllllllllllllllllllllll.... The ER doc has to get a Dr. to admit you, then he has to write the orders, then we have to call bed placement and wait for them to call us back, then registration has to see you to get paperwork signed, the floors won't let us bring you up until we have the paperwork for admission, then we have to fax report to the floor, then we have to wait 30 minutes for them to "get ready", then we have to call to make sure it's ok to bring you up. The "system" can break down at any of these steps. This doesn't work well under the best circumstances. Add to the fact that administration closes floors (moves patients, charts, etc ) to another floor when the census is "low". Thus filling the other floor leaving no where for admissions to go! Then the ER becomes it's own med/surg/tele/icu hold. Upon where patients and their families get mad at US because they are stuck in the ER for 24 hours or more, just so the hospital can "save money" by closing a floor. We've had a 20 bed ER reduced to just 3-4 beds because all other ER beds contained patients that were waiting for a bed upstairs! Of course that has it's own reverberations. The people in the waiting room get mad at the wait for an ER bed, the paramedics get tired of waiting for an ER bed, everybody is cranky...... No win, no win. We pray to god we don't get a code, or critical patient because administration won't let us go on bypass to ambulance traffic. no matter what. :madface:

In the "old days" the floors prepared to accept unanticipated admissions. The nurses were assigned "first admission, second admission" etc. As an ER nurse, I would just call the floor and say "I've got John Doe, an 86 yo male with chest pain r/o MI, admitting Dr. is Dr. Highhorse" and the charge nurse would say, "ok, you can have room 525, the nurse is sally, I'll let her know and have her call you for report" Sally would call, report would be given and the patient would go upstairs. No Muss No Fuss.

Now it's hours to get them out. and yes, sometimes it IS the ER doc's fault. They work 7-7 like most of us, and don't want to leave "work" for the next ER doc, so they leave the admissions till last and tell the oncoming doc "don't worry about bed 8, I've written admitting orders and Dr Highhorse is accepting" THAT is why admissions always seem to occur around change of shift!!!!!!!!!!!!!

My 2 cents

sjt9721, BSN, RN · Jun 29, 2006

I work on the floor and we are never busy. We just sit around the nursing station and wait for the ER to call and then we delay delay delay until w are finished with our card game and beer. We are only there to fill water pitchers and tell the people we cant help them with anything. We also know that the ER is the only place in the hospital that actually works hard so try not to be too ticked off with us floor nurses because we are busy doing "other" things and we try to work in a little nursing during commercials, or right after our naps...................................

Yes, funny...but let's turn it around...

I work in the ED and we are never busy. We just sit around the nursing station talking with docs or hang out in the ambulance bay flirting with the firemen. We do get a lot of patients, but we don't cover them, clean them, water them, or feed them. Hell, we barely speak to them. When a patient is ready to be admitted, we watch the clock and wait until we know the receiving nurse is at lunch, out smoking, or still in report. We are so bored in our department that we have time to keep track of the individual flooor nurses' schedules. We also know that the inpatient units are the only places in the hospital that actually work hard so try not to get too upset with us.

The shoe can fit on either foot. Can't we all just get along? :balloons:

tramalady45 · Jul 1, 2006

I am writing a paper for school on the all out war that goes on between the ER and the floors. I have worked at several hospitals for the last 27 yrs-it's always the same. They do everything in their power NOT to take report. Is this a problem for you? Please tell me how you handle this at your hospital. Does your administration pamper the floors? Do you utilize fax reports? Do you have a time limit for patients to be sent to the floor? What is working in your hospital? Appreciate your input! Pam

Okay, I know that this sounds pretty harsh but I say it one way when they refuse, " you will take report on this patient or I will be up to give you bed side report in 15 minutes, you choose which way you would like this". I work in a level 1 trauma center in one of the busiest counties in the nation and we are always and forever on sat. It is extremely frustrating to us ER nurses to have to babysit a patient-especially an abusive loud really nasty one-all day long. We pray that this is the one patient that gets a bed and we have no luck in that area. Then wham! Like magic 30 minutes before shift change we suddenly get beds for some of our patients and we are required to call report within 30 minutes. One day I got beds for all of my patients 20 minutes before shift change! What a nightmare! I don't know about anyone else but I just want the patients to get out of the ER. I've had the same patient for as many as 3 days before they finally got upstairs to a room! One time I called report to ICU an hour before shift change. The nurse actually refused report saying it was the middle of shift change ( which wasn't taking place for another hour yet and she only had 1 patient that she was sitting on) then proceeded to tell me that she was too busy and I am like pulling my hair out as we had literally 11 ambulances waiting inside the bay to be able to drop off their patients and all 40 of our ER beds were taken. I wanted to die! Needless to say she got bedside report via the charge nurse. Too crazy. Sometimes I wish that I were in administration :lol2:

perfectbluebuildings, BSN, RN · Jul 1, 2006

At our hospital, it seems to work pretty well most of the time, and when we get admits right around shift change it IS very frustrating but it's not the ER nurse fault... it isn't they who decide who and when needs to be admitted to what floor anyway- it's the nursing supervisor, there is one supervisor we joke that every time she walks through our unit, you know in 5 minutes Admitting will be calling up another admission to us, it's pretty accurate. If we are busy in a room and can't get report, sometimes the ER nurse will hang up and call back or sometimes another nurse will get report for us and then report on to us. Usually how it works is we get a faxed copy of the orders and then a few minutes later report is called, and they are usually willing to give us 15 minutes if needed to set up the room if it's not yet, we try to be understanding if they are getting slammed too of course. It's a small hospital and we know a lot of the nurses in the ER and they know us, which kind of helps probably. Sure there are jerks on both ends but that's not most of us. Just common courtesy and respect for each other's time and hard work, like someone else said, is one of the keys I think.

The craziest times have been about a week ago when I think we got four or five admissions in the first 2 hours of the shift; and then another night during Rotavirus season when we got somewhere in the teens I believe of admissions and the NM had to come in and help us out.

PANurseRN1 · Jul 1, 2006

This happened all the time when I worked in the ED. The nurse was never available ("She's still in report...now she's with a pt....oh, she went to lunch...") What often happened was during all of those delays we would get an ambulance or several triages, so then of course that pushed back our getting the pt. upstairs. Then we'd get yelled at..."You called two hours ago! Why did you wait until now!" :angryfire FWIW, we were not allowed to transfer pts. during the hours of 0630-0730, 1430-1530, 2230-2330. I think that was more than accommodating.

I understand the difficulty of getting admits from the ED. I worked M/S, too. At that time, though, we just were not allowed to refuse report, period.

I work in Day Surgery now. The other week, one of our pts. became unstable and needed to be admitted. I called the floor. "Oh, his nurse is doing a dressing change. She'll call you back." Twenty minutes later, no call back. I called again. "Oh, I think she went to lunch." I called the supervisor to intervene. That was ridiculous. I'd probably still be sitting there with that pt., waiting for a call back if I hadn't gotten the sup. involved.

teeituptom, BSN, RN · Jul 1, 2006

so much easier in the old days

I called the floor asked for a bed got it, gave report and sent them up.

now its turned into a process

seems to me process is really a 4 lettered word in its meaning

bethin · Jul 7, 2006

I may be an aide, but I see the wars that go on. On numerous occassions I see a cart going down the hall with and ER nurse pushing it. I ask stunned "are we getting a patient?" Technically yes, but do they come with ANY orders? Nope. Did they call for a bed? Nope. Pisses me off because I have to scramble to get the room ready and then the pt has to pee and you wonder if they need a U/A or you wonder what their diagnosis even is. :devil:

I think my fav is when they call for a bed at 1000 and the pt doesn't show up until 1700. Yes, this has happened and the pt is later discharged at 1900. A waist of our time and the patients time.

Thank God the ER nurses on the weekends are excellent. If we're busy and they know it they will set up the IV's, get the pt settled, etc.

RedcarRN · Jul 7, 2006

I think that this probalem is never going to go away.

We fax report to the floor and then take the patient up 20 mins later.. okay, we actually take them up as soon as we can... lets be real.

I work in the ER and I have a really hard time, when the nurse is too busy on the floor to take my patient, but I have all my ooms full and we can't stop the ambulances coming in and I have a guy on a nitro drip in the hallway! I have a hard time believing that she is busier than me Ha!

I also know that I really don't know what's going on up there.. it's hard to care about more than what's going on with me at that point.

They've started doing a quick rotation in the ER for new nurses who are going to work on the floor so they will have some understaning... and some of the floor nurses have actually come to work full-time in the ER and have come to understand some of the things that we do (AC IV lines) that they always used to complain about.

I can only thank God that we don't have to work on the floor because I couldn't stomach it.

For the most part, I think that we are really all in this together and we each have out own problems.. it's just hard to see the other side of things when things are going crazy where you are.

Nurses have a very difficult job at times and that goes for wherever you work.

I would like to complain about the OR nurses though, they expect that your patient will have all the copies and be ready for OR whenever THEY are ready.. really.. what's with that! Ha! Don't they know I have a chest pain that's just come in????

Nurses are amazing and we all think that what we do is the most important thing, because we give a ****!

JessicRN · Jul 8, 2006

At our hospital, it seems to work pretty well most of the time, and when we get admits right around shift change it IS very frustrating but it's not the ER nurse fault... it isn't they who decide who and when needs to be admitted to what floor anyway- it's the nursing supervisor, there is one supervisor we joke that every time she walks through our unit, you know in 5 minutes Admitting will be calling up another admission to us, it's pretty accurate. If we are busy in a room and can't get report, sometimes the ER nurse will hang up and call back or sometimes another nurse will get report for us and then report on to us. Usually how it works is we get a faxed copy of the orders and then a few minutes later report is called, and they are usually willing to give us 15 minutes if needed to set up the room if it's not yet, we try to be understanding if they are getting slammed too of course. It's a small hospital and we know a lot of the nurses in the ER and they know us, which kind of helps probably. Sure there are jerks on both ends but that's not most of us. Just common courtesy and respect for each other's time and hard work, like someone else said, is one of the keys I think.
The craziest times have been about a week ago when I think we got four or five admissions in the first 2 hours of the shift; and then another night during Rotavirus season when we got somewhere in the teens I believe of admissions and the NM had to come in and help us out.

I agree we send alot of pt's at change of shift from the ED. Not because we plan it but because the supervisor assigns us beds and says there is no nurse now so we have to wait for the next shift. Sometimes we have 4 patients to go up at change of shift.

auzzieneuronurse · Jul 8, 2006

This is one of the most interesting debates I've read to date. Great thoughts and comments.

I work in a major trauma hospital on a busy neuro ward and the battle between us and ED is never ending (almost as bad as our war with ICU!). How about a bit of understanding and patience!!! We are all nurses working in a frantic environment and trying to do the best for our patients under very stressful circumstances? Why do we insist on eating each other??

There is the old walk a mile in someone elses shoes!! I did a week placement in ED as part of a post grad diploma which was an eye opener. I came to appreciate their stresses and hardwork, I don't think they were any busier than I am on a day to day basis but it can go from quiet to out of control in seconds. Hence, I never stall getting patients from ED but when I say I can't take them now I have good reason so cut me some slack!!!!!

We don't do faxed handovers but a heads-up for all ED nurses if you stop calling me every five minutes to see if I'm ready for the patient I might get a chance to discharge or transfer my patient to free up the bed.

How about all remembering we are on the same team, cut the other departments some slack there are very few lazy nurses!!!!!

cherex74369 · Jul 8, 2006

:angryfire Don't get mad...Get EVEN!!!!

It's always a dirty little game of secretaries/clerks running flack for the floor nurses here. Another good forum query ,ya' think!? Who runs your hospital...administration, RN's or the ever-unpleasant ward clerks!?!?Hm-m-m.

Here's some of the replies we get when attempting report:

"Oh, that nurse is in the bathroom, I'll have her call you back". (Translation: She' standing right beside me giving me the "NoWay,NotToday" hand signals.)

"Oh, that bed is still being cleaned, we'll let you know". (T: She's at the nurse's desk on the phone screaming at the top of her lungs to her soon-to-be-ex about his recent sexual transgressions.)

"I can't locate that nurse now, (despite our wunnerful 'Big Brother' tracking devices we have to wear!!) I'll have to find them and call you back". (T: Don't go looking in the report room!!) Ever hear of "If the house is a-rockin' don't come a-knockin"!? That's probably where your Doc is that you've been feverishly paging for the last 45 minutes, also!

Hours later....Nuthin'! No acknowledgement, no request for report.

Well, two can play that game...I just get the name of that RN who I will be reporting to, and then a few moments later- using an outside line, of course- I call them back and ask for them by name (remembering to use poor phone etiquette and not ID myself). They think they're getting a personal call and JUMP right on that one!!!! Man, I slay 'em everytime. Problem is, they never remember. Fish in a bucket?

Sounds WAY harsh, I know, but desperate times call for desperate measures. We all have a common goal...getting the heck out of there at the end of the day with some resemblance of our sanity intact.