The War with the Floors

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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

Specializes in Day Surgery/Infusion/ED.
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.

Wow, that would work. As has been amply stated in previous posts, there are many factors that can cause delays in pt. transfers. Never have I heard ED staff sitting around saying, "How can we make life miserable for the floor nurses? I know...let's wait to transfer this pt. til shift change just to annoy them."

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Specializes in ICU,ER.

I do understand how frustrated the Floor gets with the shift change admissions. I can only speak for myself and what I have observed with my co-workers.....but I promise..... and I usually don't promise.... that I don't "hold" pts. until shift change. I admit, it works out that way a lot. I have seen the ER docs kind of stall on the admissions...working on the here and now's... and then get the ER "cleaned out" for the oncoming doc. But I can honestly say that I have NEVER purposefully held a pt. until shift change. I mean, really, how in the world would that benefit me?? Trust me, I am ready to pass 'em off as soon as I can most of the time.

Sorry, that holding-til-shift-change accusation just never really made sense to me.

If I am missing some huge benefit of holding a pt longer than I have to, someone please enlighten me.:chuckle

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Do any of you have experince with the use of an Express Admission Unit? At my hospital admissions go from the ED to the EAU for admission and then to the floor.

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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

That's more than enough for this floor nurse!

I am the one who recieved an ER admit while coding another pt.

I am the one who has recieved 3 ER admissions within 5 minutes of each other when I have been one of TWO nurses and the only RN on the floor.

I am the one who has been told to kick a grieving widow out of a room so we can send her husband's body to the morgue to get the room cleaned for the next admit, and this was less than 1/2 hour after his death. I proudly took the write up for refusing to do that.

I am the one who has recieved a "Stable" ER admit that arrived to the floor with O2 sats in the 60's and BP at 210/116 and immediately had to ship him to the ICU. ( Darndest thing, the report said he had a dx of s/p fall).

I am the one who inadvertantly coded a new admission that was brought up without a "no code" armband, and the orders stating he was DNR was never mentioned in report and the paperwork never left the ER.

The only time I refused report was when I knew I was going to have a code, now I have said "I'll call back after I finish x, y, or z" But I do try my darndest to call back in less than 15 minutes.

I really do think that recieving a room in a timely manner (even if the pt doesn't have orders for hours after recieving that room) does color the pt and their family's impression on the hospital and the entire hospitalization. At least on the floor the family can be told, "here's the blanket warmer and here's the coffee pot, the pt is fasting till the MD says otherwise, but help yourselves." It's much easier to keep a family somewhat satisfied, than to start off with them already ticked off and finding fault with everything.

I get along with the majority of the ER nurses who work nights. But if I have to be ready to recieve report with only a 15 minute grace period, be ready to give that report when you call. And yes, I do expect you to tell me the following things:

1.What is the code status, especially if you mention the pt has been on hospice care. I still need to know if the pt has a current DNR order.

2. If you gave nitro and lopressor x3, what's the current BP/pulse.

3. If you gave 2000 ml bolus, what's the current BP.

4. If the pt is in for cardio or respiratory what's the O2 sats, and how much oxygen is the pt on.

5. If the pt weighs over 300#, (and you can usually tell by looking if the weight is close to the 300# mark) let me know so that I can have the bariatric bed ordered and in the room before you send the pt up.

6. If you gave D50 and insulin IV push and then followed that by 2 bottles of kayexalte, how high was that darn potassium level? Or if you gave a bag of 3% saline IV, how low was the sodium?? I don't care about all the labs, or even the ones that are out of parameters, but if it is so critical that you had to take these type of measures, then shouldn't you already know it before giving the insulin/D50 or the 3% saline.

To me you have to give respect to get it in return. If you immediately threaten to go to the supervisor when I ask you to "just give us enough time to finish cleaning this room", or "let me call you back, I have an emergency", I'm going to cut you as much slack as you cut me. However, if you are willing to grant me that time without throwing a fit, I'm more willing to not call and harass you about the admission you said was going to be here hours ago. And at my hospital, we do have the 15 minute rule, but the floor nurses also are allowed to report when there is greater than 1 hour between recieving report and the recieving the pt.

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Specializes in LDRP.

WE have an admissions unit, for what its worth. Not open on weekends or holidays! They only have 10 beds. Not allowed to take pt's on isolation. It is nice when they do go to admissions unit, b/c there they do the database, get orders, start iv's, draw admission labs, etc. So obviously, they can't take all the admissions!

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I do understand how frustrated the Floor gets with the shift change admissions. I can only speak for myself and what I have observed with my co-workers.....but I promise..... and I usually don't promise.... that I don't "hold" pts. until shift change. I admit, it works out that way a lot. I have seen the ER docs kind of stall on the admissions...working on the here and now's... and then get the ER "cleaned out" for the oncoming doc. But I can honestly say that I have NEVER purposefully held a pt. until shift change. I mean, really, how in the world would that benefit me?? Trust me, I am ready to pass 'em off as soon as I can most of the time.

Sorry, that holding-til-shift-change accusation just never really made sense to me.

If I am missing some huge benefit of holding a pt longer than I have to, someone please enlighten me.

__________________

Exactly!!! Holding a patient in the ED is of no benefit what so ever to an ED nurse. I know many floor nurses that hold on to their patients so that they don't have to get a new admission. In my facility some nurses will set on discharges for hours. I honestly cannot think of one time that I thought hmmm I have a bed, but I will wait until shift change so that I have to pack the patient up, take them to the elevators, transport them to the floor where it looks like a ghost town because all the nurses are in report, find the room, move all the furniture in the room so that I can get my gourney in it, position the beds and transfer the patient by myself (again because everyone is in report), again move all the furniture around to where it belongs, orient the patient to where the call bell is and how to work the bed, load up my monitor and equipment back onto the ED gourney, back to the elevators, back to the ED, and then have to report off myself to the next crew, and punch out an hour late. I do all of this just to tick off a floor nurse during shift change. NO! I don't think so.

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Specializes in ER, telemetry.

I have found that as an Ed nurse, some floor nurses are never happy with report or receiving pts. Being on the other end of the phone while trying to call report has been a real eye opener on how rude and obnoxious some (note: I said some) floor nurses can be. I am sorry the iv is in the AC. I am sorry you are taking care of XXX amt of pts, but, trust me, I feel your pain and frustration where I am working as well. I know getting new admits sucks, especially at shift change. Been there, done that. It also sucks to get a CHF'er or STEMI right at shift change by EMS. I am sorry the pt is confused and disoriented. I am sorry that you will have to call the MD for orders. I feel the same when EMS rolls in with pt c/o seizures or active chest pain with no IV site. Disappointed, frustrated, more work for me. In the end, it is all about the pt and the care that they are entitled to.

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We recently had a new policy on this. Call to give report, try again in 20 minutes and then contact the house supervisor to have her contact the floor. Sounded good, except we went for well over an hour before we could give report. We cannot use fax reports, must be verbal with opportunity for questions.

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Specializes in 5 yrs OR, ASU Pre-Op 2 yr. ER.
We cannot use fax reports, must be verbal with opportunity for questions.

As of Sept. 1st, that is what our facility is going to, because of the unanswered questions issue.

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Specializes in Progressive Care.

On our systemit goes like this: Existing pt d/c'd, housekeeping cleans room, housekeeper notes in computer that room clean, bed assignment assigns pt. Charge nurse approves or declines and picks another pt (example: trauma head wound declined b/c we could see there was a bed on post trauma that was empty and we took the pt that bedboard had assigned to them- chest pain. We are internal medicine/ tele) then ER calls report. If the nurse is busy then another nurse who is not busy takes report getting the name of the reporting nurse in case there are questions. No muss no fuss. There are no misconceptions about clean rooms, who will take the pt or otherwise. The only thing that I hate about getting admits is that until our clerk puts in the pt into our floor's system, we cant pre-order IV pumps or kangaroo pumps or bedside commodes ahead of time. That's very inefficient I think.

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Specializes in LDRP.

OK, here's my ER report beef.

We have a "bed board" that is a computer program, so when a pt is assigned to us, we can see it pop up on the bed board. who they are, where they are coming from, why they're coming, etc.

Well, bed board popped up a pt that was coming to us from our partner hospital (the women's adn children's hospital-1 mile down the road) ED. Literally, 4 minutes later, I get told "your patients here!" I'm like, uh, no she's not. I never got report. Well, she was there.

Now, when I've gotten a pt from sister hospitals ED before,t hey call report to me,a nd the hospitals ambulance brings them over.

Turns out, the ED at sister hospital called report to this hospitals ED b/c she didnt have a bed assigned upstairs yet. (she should have stayed there til she had a bed). THey gave report to Nurse X in our ED. THey drive the 1 mile here, go to the ED and Nurse X isn't there. (on break? busy? i dont know) So, they are told, hey she has a bed upstairs, just take her up.

SO they brought her up and never called me report. THe EMT had to tell me about her, and I couldn't ask any questions, b/c he hadn't been the one taking care of her! The disorganization and subverting of the system that already works just teed mee off.

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Specializes in ER, telemetry.

Last night, I had 5 pts, all being admitted for different reasons. I was taking care of unstable GI bleed, stable GI bleed, pneumonia, chest pain and sob. Tried to call report on stable GI bleed pt 2 times at about 1745. The floor refused report, saying they were too busy to take report. I then had a 7 month old in PEA roll in with CPR in progress. Another nurses calls report on my other pt (since I was a little busy), and a tech takes the pt upstairs. The tech gets reamed on the floor and accused of holding the pt until shift change. No one would come to the room to help him transfer the pt to the bed. This is not an isolated case. Er nurses are expected to take care of the worst of the worst, and try to appease the entire nursing staff of the hospital by keeping an eye on the clock. For 1, I could care less what time it is when I transfer a pt. I work 3-11 or 3-3, so the classic 7-7 shift change means absolutely nothing to me. 2nd, I do not get a choice on whether I get to take report or not on my pts. If you don't want a pt at shift change, take report when I call it. Or maybe you would like bedside report? Maybe I should have told the medics last night, sorry, I can't take that not breathing ped pt because I have to make sure that this other non critical pt gets to the floor before shift change so the floor nurses won't be mad at me. Yeah, right! They just arrive and I have to take care of them. Yes, I have gotten very critical pts at MY shift change and I stayed late making sure that pt was stable enough to hand over to the next nurse. That is part of my job.

The night before, a tele charge nurse (on the same floor I used to work on) complained that they got 2 pts at the same time from the ED and accused us of doing it on purpose. Like we have time to conspire with each other to plan this intricate devious plot to piss off the floor nurses. I work in a very busy 42 bed ER and I do not know whats going on in other nurses pods unless it is a trauma or other critically ill pt, much less know when they have called report and are planning to transfer a pt.

Maybe this sounds mean and obnoxious, but I just needed to vent. Used to be a floor nurse, hated getting ER admissions too, until I realized that without those admissions, I wouldn't have a job.

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