The War with the Floors

debbyed · Jul 8, 2006

We have developed a working relationship with all the units in the hospital. Because we have become so busy and the acuity so high, We as a group of nurses had to come up with a plan. Admitted patients with "not ready rooms" may now go upstairs to a "hallway bed" just like we used to do in the ER. There are of course criteria for what is acceptable. If you wouldn't feel safe placing your patient in the ER hallway than don't put them on a floor hallway.

By working closely with admininistration thru staff based committees we are succeeding in opening the "Back door of the ER" so that we can increase our thru-put. Over-crowding in the ER has now become a housewide responsibility rather than just an ER problem.

On of the things that has helped is that we have "bed board"meetings at 0800, 1600 and 2400 every day. All the chargenurses attend with accurate numbers of fullbeds, clean empty, dirty empty, possible discharges and transfers. We meet for about 15 - 20 minutes together with the directors or in my case at night with the Adm. Nursing Coord. so that everyone in the hospital is aware of the current situation.

Overland1, RN · Jul 8, 2006

The 3x/day Bed Meetings at 0830, 1400, and 2200 seem to work well at my hospital, as long as the person representing each unit is adequately prepared, and it does not need to be the charge nurse; it can be a designee who is up to speed on what is going on with the respective unit. When we first started the meetings, some of the ER charge nurses would come in and say that almost every patient in the ER needed a bed somewhere. We (House Sooperz) learned in a hurry to not book a bed until there were orders in hand or the case was so obvious (i.e., S/P Resuscitaion from Full Arrest going to ICU) that it was a definite keeper. Too many times, when a patient was "pre-booked" (yes, some admissions were based on EMS reports before the patient even arrived in the ER, a room/bed was tied up because nobody communicated that the patient went home. Now, the charge nurses carry VoIP phones, so there is better/faster communication between them. The Supervisors carry a text-capable pager, so staff can easily reach us from a phone or PC within any of our facilities.... we may change to the VoIP phones later on, although the pagers have some advantages, too - maybe we will carry both.

Yes, communication is the key to success here, and the charge nurses of the various units have a say as to where a patient will be placed. It is a collaborative effort between the ER and receiving unit charge nurses and the Supervisor on the evening shift (14-0000). During the day, the Admissions clerks contact the floor for a room assignment; there are usually few admissions during the day..... most happen between 2 PM and 10 PM. At night (even fewer admissions), the ER charge nurse calls the appropriate floor for a room assignment.

As for surly ward clerks trying to keep those eeeeeevil revenue-bearing admissions away, they need to be treated to a conversation with the unit's manager or director ASAP. Such behavior will not carry the water where I work; we all work as a team, and it works quite well.

During the times when a House Supervisor is on duty, that person often assists with transporting patients to the floors, along with other clinical support and related tasks. On the night shifts, we often have a Clinical Leader available to provide clinical and educational support to the staff, as well as "hot-spotting" (short-term) assistance when things get really crazy.

Trece · Jul 8, 2006

Do any of you have a "bed control officer" or "bed control coordinator" or "nursing supervisor" who handles all admissions? At our hospital all admissions, whether through ED or direct from clinics, must first go through bed control. This person is an RN with supervisory and care managment experience. The bed control coordinator takes the admission information and places the patient in an appropriate bed and notifies the ED or clinic with a bed number when the floor is ready. This person also acts as an "intermediary" between the ED and the floors when things get tight and sometimes must push the floors to take the admit or push back on ED to hold the patient so the floors don't get slammed. This certainly isn't a perfect process and we still have many of the same issues with ED trying to push 6 patients to one floor in an hour (usually our telemetry floor), docs waiting to write admit orders on all his/her patients at the same time, and those "shift change" issues. One process we put in place after an RCA on an adverse patient outcome was no admissions at shift changes (we work 8 hour shifts, so this would be from 0700-0730, 1500-1530, and 2300-2330). This gives the floor nurses time to give/take verbal report on their patients and be available to admit the patient when he/she arrives from the ED. We're still struggling getting ED to comply with this and they push it, but the floors push the time too (say they're still getting report at 0740 and refuse to let ED bring the patient up). We're also forming a mini task force of ED nurses, floor nurses, an ED doc, and a PCP doc to try and open dialogue and increase understanding between everyone involved and problem solve some of these issues to at least try and create a better atmosphere of cooperation. After all, safe patient care is really the issue here and safe handoff is a huge part of this equation.

Sodie, BSN, RN · Jul 8, 2006

Our administration pampers the ER. We are not allowed to refuse report, in fact we get a faxed report. They call to see if we've received the fax and bring the patient up in a manner of minutes. Control is taken out of the floors hands and given to the ER.
I've seen both sides. I've seen the floor nurse play games with the ER and refuse to take report until they are good and ready00 I also recently did an observation in the ER a few weeks ago and sure enough before the 11pm charge nurse arrived they were scrambling to get patients up the unit, and I saw four admissions get transferred to the floors at 10:45.
Good luck with your paper. It's an age old problem. This thread will probably go no where, with floor nurses flaming the ER and the ER flaming the floor nurse. :)

I have seen both sides as well. I have also worked in the cath lab. One day I was called in at 2 AM to do an emergency heart cath. I called the unit to give report at 6:30 (we had just finished the procedure) and was told that we need to wait to shift change. Fisrt of all, we can't just sit around with a patient we are on call becasue we never know when the next one is coming. We have offered to bring the patient up and stay in the room with them a little longer to help the nurse get situated. At least this way, we can give report and move on if we get paged.

I have been around in the ER alot as well and many times the patient really isn't ready to go up ntil closer to shift change. I have seen doctors hold the patient in the ER until a MD comes in to see them as a consult or the patients GP comes in and decides to admit the patient. If the MD waits until the office closes to come and see the patient in the ER (during the week), the admission time is going to fall closer to shift change in my hospital because most nursing units do 12 hour shifts.

I have seen games played on both sides though. I worked on a nursing unit for 9 years before the ER and cath lab. There is a policy that the ER uses now. If they call two times and the nurse will not take report, they take the patient to the room and give report when they get there.

I have called the ER as a staff nurse before and asked them to give report on a patient that had been assigned to the room 2 hours before. They thought I was crazy. The ER nurse could not believe that I was asking for another patient. I told the ER nurse that it was a great time for me to do an admission becasue the other patients were eating and I had caught up on the paperwork. They gave me report and brought the patient up right then.

UM Review RN, ASN, RN · 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.

I give respect and I expect it in return. Head games are unacceptable and unprofessional.

'Fraid I would not stay at that job very long. Why put up with that when there are actually good places that don't have those problems?

wooh, BSN, RN · Jul 8, 2006

Now, there will always be that "who cares what their problems are" ER nurse or the "if I don't call back, it'll go away" floor nurse, but mostly its just hard-working, good nurses with too many patients and not enough hands. Flaming doesn't help. This is where we need to take a deep breath, figure out the problem and if there's a way to solve it.

This is so true. It's so easy to get caught up in your side of things. If I say I can't take a patient, it's not because I want to finish waxing my legs. ER nurses are able to put off anything that isn't critical, floor nurses can't. So while a med pass or dressing change seems unimportant, I can't just skip it to take another patient. Admissions take time, a lot of paperwork, a lot of settling in. And all the while, a full load of other patients is expecting that their needs and wants are being met. But I know ER is busy too. If I'm hanging in there, I'm more than happy to have your patient sent to me as soon as your ready. But if I'm slammed, it just may be a little bit before I can safely handle another patient.

mysticalwaters1 · Jul 9, 2006

I've been in med surg for 3 years. Now I am on the other end working in ER still on orientation and it has been wonderful but I really had a misconception when passing pt's from ER to floors. I expected more done. I know idealy stats should be started. I also felt critical lab values should be addressed before comming to the floor just that the md knew, ex K 2.5 even 3 should have been told to the admitting doctor. It stinks b/c the mds do have everything but sometimes they miss it. That I think is reasonable to do and plan to strive for that time permitting. And honestly...I am SERIOUS!!!!!! I know floor nurses, well face it all sides certain people play games and other times you are busy on both ends. But I used to get so upset b/c I'd take report from ER and the bed would not be cleaned! Some I know would lie but myself and several others when I worked along side them we do not have enough house keepers and if it was very busy, lots of admissions and discharges, would not clean the bed for 1 sometimes 2-3 hours. I'd call house keeping AND supervisor b/c that's ridiculous. Our cleaning supplies including tissues are locked up and I was eveneings! And I'm sorry even if I had a mop I wasn't going to scrub everything with it.

Anyway talking about cleaning beds that just reminded me of my experience with it. I'm so serious. Anyway, if I was in the middle of something on med surg I'd just tell the secretary I'll call them back and in 15min get back. Some of my coworkers would prolong way longer. Now I'm in ther ER and wow....I talked to a pt did extra chit chat and next thing I know 4 new patients needing full workups were there! That's the catch. I think the floors feel b/c you don't do all the med surg typical routine you have more time, but it's different it's still busy. When I moved to ER one of my coworkes told me if I call report on 3p-11 shift and it's the begining don't expect for him to take report until after 1630! There has to be a line! And it stunk b/c OR had it mandated in policy we on med surg could not prolong report. It's so hard b/c there has to be some flexibilty but at the same time report is priority. So now our ER has a policy if floors can't take report they have 30min and then if they don't again the head of our patient services is contacted.

One coworker been nurse 10 years says time management is not being taught or people are just not getting correctly. That has been a HUGE issue with me!!!! I totally agreed with her. I don't know how to fix it. I think it's a personality trait with me. I get discombobulated. But I've streamlined it way better. But get that mixed with poor staff numbers and lots of patients and you're screwed!

My problem now working in the ER is feeling guilty giving report to floors. It's silly but I do feel strange, like I'm dumping even though I'm not! I want to start stats and I do but sometimes pharmacy doesn't have the medicine, or a type and screen didn't result back until the pt was just sent to the floor so I couldn't start a blood transfusion. I feel guilty b/c I want to initiate stuff but if it's not there or ready I can't. So to me when I tell report I almost feel as if I'm giving excuses. I can hear it in their voices too and partly b/c it is a lot to do! I'm really pathetic b/c I'm doing what I'm suppose to do but anybody feel like that? And how did you overcome it? 9/10 times I've called report well it's one specific floor especially they have to call me back sometimes I have to call again after 30min 2x. That's a very fast paced cardiac floor I think that's wh. We are all busy and important. But it really feels strange being on both sides. But ER is totally different which is EXACTLY what I needed.

Marie_LPN, RN, LPN, RN · Jul 9, 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.

Game????!! Good grief :trout: .

Marie_LPN, RN, LPN, RN · Jul 9, 2006

Head games are unacceptable and unprofessional.

Agreed. Not to mention it only makes the 'war' worse, by creating a crappy work environment.

beautifulbooks · Jul 9, 2006

AAAARRRRRRGGGGHHHH.... I can't even stand to read through all the posts. Some of you are so sucked into them vs us mentality. Can't we all just realize that it can really be awful in each department and cut each other some slack? Of course there are those that are jerks and cause delays for selfish reasons -- I think most don't, however.

Thankfully I worked on all the units as a float nurse before settling into the ER. On the floors I experienced much more delay about moving a pt from one floor unit to another because the current nurse did not want to open up one of her own beds so close to end of shift..... or hadn't had time to change that darned PICC dressing on the transfer pt which was way past it's schedule change time and you don't want to leave that for the new nurse. For all the usual reasons. I also understand the feeling of being understaffed on the floor. It sucks --- which is why I stopped working there. Too stressful...... and this coming from an ER nurse in an understaffed ER :trout:

Now, in the ER, I know that most nurses here NEVER delay transport to floor for that reason -- It is almost always because they are just so slammed with patient care, ambulances coming in, getting deceased pts the priest/minister their family wants while balancing the need to get the person bagged for the morgue, and "dammit-how-can-I-empty-this-bed-for-the-cardiac-pt medics-are-waiting-with-on-the-other-side-of-the-curtain" running through my head. No transporter available or I have to go with the pt. because of need for cardiac monitoring. Sometimes I have an admitted pt, with an assigned bed and I am so busy with other pts I simply don't have time to update paperwork and make photocopies of the chart so the pt. can go -- sometimes it is only because your relief has shown up at change of shift and assumed care on the rest of your pts that now allows you to wrap up everything for the admitted pt. and I can take them up to the floor.

And yes, I have felt that way on the floors --- just not nearly as often. There the delay was usually because of the ridiculous amount of paperwork associated with getting a new admission - therefore there is a tendancy to want to "not have an empty bed".

Anyhow, please, please, please let's try to give each other a break and believe that most nurses are working their asses off to get the job done and don't take stuff so personally or as "1 dept against another".

Another thing I have found is that if I have the opportunity to have a face to face conversation with the receiving nurse, the whole thing goes much better -- wanting to explore video phone useage for report --

Mahalo,

Kristin in Hawaii

mysticalwaters1 · Jul 9, 2006

.....I also understand the feeling of being understaffed on the floor. It sucks ---

That's why I left med surg. Then on top of that I had issues with coworkes with no team work and 2 managers within my 3 years there just not working out. It was turning more into a geriatric floor as well and not enough help mixed with severe coworker problems. Not to mention my learning was not advancing just stagnating there. I left. Now I'm in the ER and I like the type of work better and it's busy but a different kind of busy, still crazy but I like it better. I say that now! At least med surg helped me with were I am now. I have that to be grateful for.

felixfelix · Jul 11, 2006

oh, man....this thread should be in the student nurse forum so we can all quit while we're behind!!!