The War with the Floors

Trauma Columnist · Jul 13, 2006

Aw come on guys. Stop with the personal attacks! This thread has been very busy. However, it is not constructive to do name-calling or generalize as in "the floors always do this" or "the ER are a bunch of...." You get my drift. Please self-police. Other option is to close it for a 24 hour cooling off period but would prefer to leave it open. Thanks for your understanding.

Jennifer, RN · Jul 15, 2006

I have experienced this from both sides. I HATED getting admissions at shift change when I worked on the floor. Actually I hated getting admissions period. They were usually a lot of work and took a lot of time away from my other patients on the floor. Working as charge on the floor was even more frustrating because I would have to not only deal with the cranky nurses on my floor who would try to refuse to take the pt, but also with the ER staff and administration. What a headache.

On the ER side, I truly lose track of time while working. I forget to eat, forget to pee. I usually work 11-11 or 3-3, so 7-7 means nothing to me. I forget it is shift change on most other floors. And other times, I have the charge nurse, the nursing director of the ED, the nurse manager, and the medical director of the ED on my case about moving pt's out NOW to make room for the pt's rolling in the door by ems. Going on divert is the ultimate LAST option. Sometimes, I have no choice but to call report when I call it. And trust me, most of the time, before the bed is even down the hallway, I have another "admission" in my room waiting for my happy, smiling face to put them at ease.

I have found that my attitude defines how beautiful or how crappy my day is going to be, no matter where I work. If I am getting the life sucked out of me by a busy day, I try to laugh it off in order to stay sane and productive. The same goes with getting an attitude from another nurse about bringing a pt up to the floor. I brush it off, because, ultimately, I am going to go home to my beautiful family and the silly, petty things we all argue about at work will not enter my mind or bring me down. Our jobs as nurses are challenging and difficult, even on the best days. We need to try to treat each other with a little respect and have a little dignity in how we communicate with each other. Our attitude at work reflects our attitude with life in general.

**canoehead, BSN, RN** · Jul 15, 2006

Since I started ER we've had a good relationship with the floor. I think part of the reason is that they come promptly when they can, and I hold observation patients when I can so they are discharged from the ER. If I have people stacked up in the hallway and an ambulance coming in, I call them and they are down to take the admission within about 30 seconds. But I also call to tell them when I'm holding an observation patient, just so they know it's not all one sided. If they are busy, and I'm OK, we'll agree to keep one of the admits in the ER for a few extra hours. It really is a two way street, but the trick is to talk to each other and let them know when you are assisting them, and to acknowledge when they go out of their way for you.

mvsnurse2b · Aug 17, 2006

We fax report to the floor-as a courtesy most nurses will send current chart, assessment, labs and physician notes and all current orders will be complete. It depends. Our hospital does not send patients to the floor if there are not enough nurses for safe patient to staff ratio. Our nurses will hold ICU, telemetry and CCU admits-longest I've seen is two days. However, I've also been on the floor and seen how difficult it is to make time for those admits. In the ER you can only survive your paperwork and interventions with constant vigilance-if you sit you take the chance of being slammed! Maybe it would behoove those nurses with open rooms on the floor to have their ducks in a row. You know someone is coming-most likely when you have the least amount of time to deal with it so on those days you are blessed with a lesser amount of patients work fast! If rooms are open, they will come.... Hope this helps. The truth is there isn't enough assistive personnel to help make staff nursing more effective.

JessicRN · Aug 18, 2006

We were having faxed reports and then our patients were to go up "within 30 minutes" One floor decided within means no sooner than 30 minutes. The last three shifts we have been on divert call to the floor where a report was faxed and told we can send the pt up in 30 minutes. Also in the last two weeks I have brought a patiient to the floor to find out a) the bed is not cleaned and B) the patient is male and given a female room and C) no bed in room. (before we are assigned a bed the room is supposed to be washed and ready and the patient is ready to go up). The charge nurse for the floor tells the supervisor when the bed is ready then they tell us. I was expected to stay on the floor until new arrangements were made. We do fax reports up before the shift change but do not send patients until 30 minutes after the shift change. This floor it is also noted that when we bring a pt up we never see the nurse and only see the CNA after the pt is in the bed. The other floors are great we rarely have a problem.

vampireslayer · Aug 18, 2006

I have a question for the floor nurses. Is there something that we ER nurses can do to help out once we get the patients to the floor? My preceptor would basically just use the pt's call system to signal that the patient was here, or tell someone as we walked past the nurses station on the way to the room, then leave the pt. in the room and go back to the ER.

I know that admissions are a lot of work for the floor nurses, and one thing we're supposed to do in the ER is give the patients the admission database to begin filling out on their own, while they're waiting for their room. Some patients however just don't want to do it...they say that they'll look at it later, they can't see without their glasses, they "always do it after they get upstairs" (with the help of the nurses up there) or whatever, and I don't have the time to sit down and ask them all the questions verbally....we've been told in the ER that our only responsibility re. that admission database is to hand it to the patients and ask them to start filling it out. But anyway, I do know that's one thing that I can do to help out the floor nurses on admission, if I can get the patients to start on that.

I also get the patient comfortable in their bed, show them the controls on the bed, hook up their oxygen if they're using it. Before they get in bed, I frequently will start the process of weighing them, if the floor tech has brought in the scale by then...just anything I can think of to ease the pain of getting a new admission.

Anything else I can do before I leave the patient? I just hate the feeling that I've "dumped on" the floor nurses when I bring a patient up...I know it's a lot of work to do admissions, so if there's some other little thing anyone can think of, that would ease the tension when I bring up a new patient?

Thanks!

VS

paccookie · Aug 18, 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.

Thanks, it's nice to know what the nurses really think of the secretaries. We do not dodge the ER or PACU or direct admits because we WANT to. I cannot force a nurse to take report and I cannot force housekeeping to clean a room faster. The nurses may get one or two patients but we get all of them! I work on the post-op/ortho floor and we often turn over at least half of our beds everyday (32 beds and we are forever understaffed!) and with that comes a ton of paperwork. Docs make rounds all day and often into the night. They write pages of orders, sometimes lots of stats. The phones and the call bells never stop ringing, not even in the middle of the night. The tube system is always beeping to announce that pharmacy or the lab or someone has sent us something. Telemetry calls to tell us someone's leads are off. Docs call wanting to speak to the nurse. Family members call wanting info on their loved one. Staff gets personal calls here and there. The house supervisor calls for beds constantly (last night she kept insisting that she needed a certain bed when there was still a patient in it!). Reports have to be printed and filed, labs must be filed, etc. Nurses need help transcribing a doc's bad handwriting or need you to change a diet, order a lab, etc. Charts have to be turned when patients leave. Yet I can say that I am too busy to assign a bed or answer the phone/call bell. If the secretary sounds irritated or unpleasant, it is probably because she has spent most of the shift just trying to catch up and take a breath. Yes, sometimes we do cover for a nurse who is busy, but it's not for the reasons you've mentioned. It may be that this particular nurse IS in the bathroom or on the phone taking orders from a doc or maybe she's already gotten several admissions this shift and is trying to get her patients settled. I try to tell the ER or PACU that the nurse is busy and get a name and number so that they can return the call. If they call a second time, I get the charge nurse. We have a few ER or PACU nurses who refuse to wait for any reason and that is where problems come in. We are not an ICU and we don't get the critical patients that cannot wait. Usually it can wait the 10-15 minutes it takes for the nurse to be able to sit down and take report. I've worked in the ER for overtime and I've seen the attitudes some nurses can get when things don't go exactly as they would like. I've seen nurses call the supervisor to report floor nurses who can't take report right away. I've also seen supervisors who call at 1000 to get a bed and then hold it for hours just to make sure someone else doesn't need it. And then they send that patient up at 1430. One night last week we had five admissions come up between 2215 and 0015. Literally one after another. I think we had another patient that same night that needed to go to ICU so we switched a patient with them. That patient didn't make it back out of ICU. If you think secretaries are such a waste, why don't you work without one for a while and see how you like doing her job in addition to your own?

natsfanrn · Aug 19, 2006

This topic's been pretty much dragged through the coals, but just one thing I'd like to add, as a floor nurse. Please, please, please try to premedicate patients for pain and/or nausea before bringing them up! I try my best to cheerfully accept patients from ER, even when they come up right at the start of my shift (when I'm still getting report about my existing patients). And even when I've put off lunch (that is, one of the few times when I've actually had a free moment to eat) because the patient "will be up in 5 minutes" but in reality doesn't show up for 2 hours (and yes, I understand it's the doc's fault...as is the patient who ends up being discharged an hour after arriving to the floor because he met no criteria for even being in the hospital). But my only real pet peeve is when ER brings up a patient without giving him meds first. Not only does the transport increase the pain/nausea/etc., but then it can be quite a while before we can even access the patient's meds, since we have to wait for them to put into the computer system by the unit sec'y and then by pharmacy...

jkw_83RN, BSN, RN · Aug 19, 2006

Like it has been said several times before, this is one of those never ending battles. The hospital where I worked, we left a recorded report for the floors and then we had to wait 20 minutes after before we could take the patient up, unless it was an ICU patient. Another hospital where I worked we faxed report, and I think that that worked better. Having worked on the floor, and in the ER I see the frustration from both ends. From the ER perspective, people fail to realize that we do not intentionally send people up at change of shift, we do not operate based on what time it is. We do not have scheduled meds, or sheduled I & O's, we operate based on what is going on. Things can change in a matter of seconds, and we never know what the ER or admitting doc is going to order, what type of sick patient will roll through the door, or anything else. From the floor perspective, it is frustrating when you try and plan your whole day around an anticipated admission. :uhoh3: In the ED we don't have much control over what is coming in through the doors, so we cannot hold patients.

nursingisworkRN · Aug 19, 2006

Just for the record, I would like to state that as a floor nurse I would much rather receive an ED admit at 1915 than a direct admit at 1915. Quick reason being I know that the ED has selected at least one iv access, and usually 2 in the ac....meaning when the pt arrives on the floor and I hook them up to the tele monitors, I do not freak out with a HR of 20 or 140...thank god for the ED nurse who took care of that for me. Saves me trying to get access AND figure out what doctor to call for orders (they are really great at telling you who the md is too, even before orders are written). They are also really great in the ED at my hospital at identifying those patients who may be "difficult." :uhoh3: Of course, it is never mentioned like that, but I can always read between the lines. It is so nice to get a heads up, rather than find out in the middle of taking the history and physical when you still need to start an iv and review transfer orders and put the admission into the computer that the pt wants to leave AMA.:trout:

I think any admit after 1830 will be tough on a 0700-1930 shift, but at least with the ED they will have started an iv and placed a foley/ng if needed. LOVE you guys for that alone! By the way, it always has helped me to ask what meds have been given, where the iv site is, and what tests have been done. The ED nurse has always taken care of everything, she may just have forgotten to mention it! I know that we've all been there/done that! Gotta look out for one another, because nobody else will!

Oh yeah...I forgot to mention that staffing will call our charge or uc to get census and inform us of an admit or transfer. That pt is then assigned to a nurse. The nurse is notified of the pending admit, and then it is our responsibility to get report. However, if we are too busy to take it, we have the ability to call back within 15 minutes or have the charge nurse take report. I have honestly NEVER seen anybody try to dodge report...it is just so much easier when you have heard directly about the pt. I have been told to wait to transfer a pt to another floor from ours because of the shift change and how it is not fair to assign the pt to a nurse for 1 hour. This is largely frowned upon as "dumping." But if we have to take a cardiac pt from ICU/CCU/ED and we are full, then the broken shoulder is going off to the ortho floor to empty a cardiac bed. I suppose that is should be, but it isn't fair. And it happens the other way too. Everything evens out in the end. I try to be as understanding as possible, as you never know when you might need a favor :)

Jen2 · Aug 19, 2006

We tape record report where I work at and it is not working. It may work well between floors from shift to shift, but from an ED standpoint it does not work. After we record we call up and tell the nurse that report is in. More times than not the, recieving nurse gets offensive. Me: "Hello so and so I was just calling to let you know that report is recorded on Mr. so and so going to bed whatever." Floor nurse: "Well, I just cannot listen right now I'm still passing meds (fill in the blank with doing sterile dressing change, blood transfusion, having lunch, hanging an atibiotic, or whatever). It is policy in my hospital that the patient goes to the floor within 15 minutes of taping the report. I find that unrealistic. If I can I will usually give about 45 minutes and then call back. I will call back to find out if report has been listened to yet and will often get a "I just haven't had time yet." This is when I get on the offensive. I have had to get harsh at times and tell the nurse that I will tell the helicoptor to circle around the hosital a few more times until she is ready. I have also had to say that I will give a bedside when I get there.

I do not know what shift change means in the ED. I am the first to admit that. We do not operate on time schedules. Our HS gives us a bed. I don't know nor do I care what time it is. All I care about is making room for the full cardiac arrest that has a 5 minute ETA. I can also tell you that we may have to keep a patient in the ED if they need medical intervention from plastics or ortho. It has been many times that we get a trauma patient that has been scalped and even though I am told I have a bed and call report I cannot take them upstairs with a bleeding headwound. We have to wait until plastics, trauma, ortho, or whoever sews up, reduces, or repairs what ever needs done before we can take them up, at which point I will tell that nurse that I will bring them up as soon as they are not bleeding any longer.

I have also had drunks in the the trauma bay M*$her F#*cking everybody and a four year old child in the next bed. When I get a bed (which I have no control over what time that is nor do I care), I want that child to be away from that person no matter what time it is.

Yesterday we had 40 trauma patients from 3p-7p. We only have 40 beds. I had chest pains laying in the hallway without monitors, because we didn't have any left. I have a hard time when a floor nurse complains about getting 3-4 admissions on their shift when we had 40 patients, all traumas needing two large bore IV's, x-rays, labs, scans, and fluids in a 4 hour time frame. How many nurses did we have in the ED yesterday 6 including the charge nurse and triage nurse. The waiting room was standing room only. Being a level 1 trauma center we cannot divert traumas. Did we go on diversion? No! Would it have helped? No! Because we would have still had those 40 traumas and the waiting room packed.

I don't know what the answer is. It is a problem everywhere. Emergency departments are closing down all around the country. The patients we are taking care of are older and sicker than ever. I may be assigned 5 beds at the beginning of my shift, and end up with eight patinets all very very sick by noon on most days because my hall way is able to hold 3 beds. Does anyone care that I have 8 patients, ( 1 on Dopamine, 2 vented, 3 on NTG GTTs, 1 ectopic pregnancy, and 1 kid having a severe asthma attack)? No! I try to give them the best care that I can and get them to the floor/unit where I know that they will recieve much better care than I am able to give. So am I a bad nurse because I am pushing for my patient to get where they need to be?

I think the problem is beyond us vs them. It is more of a political and administrative problem. People are living longer and are therefore sicker. ED's are overcrowded and understaffed. People use the ED as their PCP. We see over 300 patients a day a few will get admitted. Yes people still wreck, have MI's, strokes, and try to commit suicide all hours of the day. It would be nice if the hospital could close down for shift change but that won't happen any time soon.

I believe most problems are internal within the hospital. I believe that we as nurse from the time we start nursing school are taught to plan our care. Hence the care plan. When we graduate nursing school we start working the floors and have timed meds and MAR's and Kardex's to tell us what time we need to do this and that. We are told what time our patient is going to the OR and everything is scheduled and planned our whole day even our bathroom breaks if we get to take one. If one thing goes wrong or happens out of the norm we start getting antsy. This wasn't in my plan type of a thing and oh my now I am slammed what am I going to do? I think nursing schools should start gearing their programs more toward real world nursing. I think that the whole healthcare system is crumbling down around us. No one knows what to do for the older sicker population that we have now. ED's don't know what to do especially the level 1 trauma centers because they have had two community ED's close in the last month and the remaining two are on diversion. It is not a floor ED problem. It is a crisis that healthcare is in and no one knows how to fix it. Until then nurses will either keep doing their best or the good ones will end up leaving the profession because the can't take it no more.

vamedic4, EMT-P · Aug 19, 2006

At my facility the ER faxes report, but "report" consists of NOTHING more than a copy of the admit orders..how stupid is that?? Anyway, I digress.

If you do have questions, you seldom get to talk to the nurse who took care of the patient..God forbid you want to know what this kid looks/sounds like prior to them hitting the floor. This has been quite a patient safety issue in the past...but as usual, they do nothing.

As for the ER, they're famous for sending patients up right at shift change...literally right at 0655, 0700. Now there's absolutely NO reason for this...they've been there 6/8/12 hours..whatever...another 30 minutes isn't gonna kill them. They usually dump on us at 0300 and 0700, when the shifts end, even though the patients could have come at any time PRIOR since, in most cases we've been waiting awhile.

It would almost be better if we went and got our patients FROM the ER, just to be able to do it when it was convenient for US, and get them settled and their treatments begun.

Oh, well.