The War with the Floors

aberrn · Oct 2, 2006

Where I work presently we have one hour to get the pt up to the room once we know the room #.If we call and cannot give report,the nurse has 10 mins to call back,if she/he doesn't, we fax report and send the pt up.

Since this policy was activated the floors have been better at taking report,no more of the long string of excuses of why they can't take it.

We did have one of the ICU nurses work a shift with us,and at 6am I asked him if he would be back.His response "No.And I won't expect everything to be done from you guys in the future..I had no idea what it was like down here..

The floors are better,but we still have to fight with ICU.Whats that about?

CrazyPremed, MSN, RN, NP · Nov 21, 2006

Not a nurse yet, but have worked as a CNA, PCT, HUC and monitor tech on the floors and in the ER.

The truth is, everyone thinks that they have it bad and others have it easy. Until there is more staffing all around, it won't be fixed.

Secondly, the mentalities of the two areas are different. Throwing a pt in the hallway to open up a room is common practice in the ER, while floor nurses need a clean room and an available nurse to focus 15-45 minutes on a new admit. Assessing and stabilizing a chief complaint is normal in the ER, while floor nurses must be thorough, hitting every major system and helping to create and complete a plan of care. Finally, many people who work in the ER like the fast pace, treat and street (or admeet (admit)) philosophy, while floor nurses love the opportunity to spend quality time with the patient and his/her family (sometimes). Until a system is created that forces nurses to walk in each other shoes (a med/surg-ER rotation system) each group will not agree with each other.

Even Jack Sprat and his wife never ate the same thing.

Oh, well.

CrazyPremed

PS: I just hate when I bring a pt up from the ER and - as I pass the nurse's station - everyone just sits and stares. Get off your butt and give me a hand, people!

UM Review RN, ASN, RN · Nov 21, 2006

Not a nurse yet, but have worked as a CNA, PCT, HUC and monitor tech on the floors and in the ER.
The truth is, everyone thinks that they have it bad and others have it easy. Until there is more staffing all around, it won't be fixed.
Secondly, the mentalities of the two areas are different. Throwing a pt in the hallway to open up a room is common practice in the ER, while floor nurses need a clean room and an available nurse to focus 15-45 minutes on a new admit. Assessing and stabilizing a chief complaint is normal in the ER, while floor nurses must be thorough, hitting every major system and helping to create and complete a plan of care. Finally, many people who work in the ER like the fast pace, treat and street (or admeet (admit)) philosophy, while floor nurses love the opportunity to spend quality time with the patient and his/her family (sometimes). Until a system is created that forces nurses to walk in each other shoes (a med/surg-ER rotation system) each group will not agree with each other.
Even Jack Sprat and his wife never ate the same thing.
Oh, well.
CrazyPremed
PS: I just hate when I bring a pt up from the ER and - as I pass the nurse's station - everyone just sits and stares. Get off your butt and give me a hand, people!

Well said, CP.

About your PS--the "stare" is an expression that we floor nurses get on our faces as we think, "My gosh is that MY patient? I have to ____ before I can take a patient! Do they need help? Do I have time to help? What's their dx? What are the labs? Is the room clean? Why'd the ER send them up so soon!What time is it? Can I please go pee/eat/go home sometime in the next millennia?????"

TrudyRN · Nov 21, 2006

I think we can all see that the answer is to try to keep the patient's needs first and to try to be nice to each other. Using common sense and common courtesy goes a very long way to resolving problems like this.

We have to be flexible and we have to not think that the newly arriving patient is a disruption. We also don't have to do everything for him or her STAT. A quick eyeballing of the patient for status of major systems, such as cardiorespiratory and neuro, correctness of IV and O2 parameters, no kinks in the Foley, chest tube working, and a quick set of VS, just real basics, and a quick perusal of the orders can suffice unitl you can get around to doing your full physical assessment. Hopefully, there is someone who can start the processing of the orders. If not, well, you just can't be everywhere at once.

But being civil and courteous will always help.

aileenve, ASN, RN · Nov 21, 2006

I know the problem from the floor side. There has been too many occasions to count when we have been expecting a patient from the ER and they don't arrive for hours. The Doctor (Hospitalist) is asking where the patient is because they wrote the order to admit 3 hours ago!! And amazingly, 5 to 10 minutes before shift change here is the ER wanting to give report. At that time they get to wait until the new shift is on the floor to take report. If you are have trouble getting the floors to give report, is it happening all the time or worse during certain times such as shift change. Just a thought.

Sounds like you and I work at the same place!! As a floor nurse I have a problem when nurses from MICU, SICU, ER, send a pt. to our unit 1-2hrs after giving report and it happens to be at shift change!! This makes it difficult for staff and MOST especially the pt.!

PANurseRN1 · Nov 21, 2006

Well said, CP.
About your PS--the "stare" is an expression that we floor nurses get on our faces as we think, "My gosh is that MY patient? I have to ____ before I can take a patient! Do they need help? Do I have time to help? What's their dx? What are the labs? Is the room clean? Why'd the ER send them up so soon!What time is it? Can I please go pee/eat/go home sometime in the next millennia?????"

And this is what drives ED nurses crazy. We're either getting yelled at for bringing the pt. too soon or taking too long to bring the pt. I mean, we're sorry that you have to take another pt., but we have to make room for our pts., too. And on our end, it does get a little old getting the run around ("Oh, we can't take the pt., it's almost time for report...We can't take the pt., we just got out of report and have to assess our pts...We can't take report, we're giving meds/doing drsg. changes, etc...We can't take report, we taking lunches/dinners...We can't take report now, it's almost time for change of shift..."). The other night it took 4 hours for us to get a pt. admitted. Short of simultaneous codes going on on that floor, there was simply no excuse for them to keep dodging us that long. It took getting the supervisor involved to finally get the floor to stop yanking us around.

Marie_LPN, RN, LPN, RN · Nov 22, 2006

Well said, CP.
About your PS--the "stare" is an expression that we floor nurses get on our faces as we think, "My gosh is that MY patient? I have to ____ before I can take a patient! Do they need help? Do I have time to help? What's their dx? What are the labs? Is the room clean? Why'd the ER send them up so soon!What time is it? Can I please go pee/eat/go home sometime in the next millennia?????"

Our stare was usually "Um, i guess we're getting an admission. No one told us, so here we are, not prepared. Great."

EmerNurse, BSN, RN · Nov 28, 2006

I have to say for the most part, our floor nurses are pretty good. There's one or two where I think "oh great, I get to give report to XYZ" . The ones who have that tone of voice and attitude that makes you KNOW you're just pissing them off by existing . But it's only a couple, thank God!

In our ER, admit orders are taken by the ER nurse, and once the patient is admitted (orders on the chart), THEN they get a bed and we can call report etc. For my part, I try to:

1. write those orders very neatly

2. give prn pain med if needed before patient goes up to floor

3. draw any labs (tropo, whatever) that's due real close to when the pt is going up.

4. note ON the admit order sheet which meds ordered have been given in the ER, which labs have been drawn and sent and what time the next tropo is due

5. have very recent VS documented

6. address any instabilities before they go up (they'll have a reasonable BP)

7. do an accucheck, especially if the admit is going up near shift change.

8. give them a heads' up for very heavy patients, patients that'll probably need fall or asp precautions, and what I've already told the family that simply will not get off our backs.

9. empty the foley and document the output before they go up

In short, I TRY to not leave the floor nurse with 15 things to do the moment the patient hits the floor. On their side, they understand that I simply didn't have time to do a full skin assessment on that patient, that maybe I have 5 fire rescues in the hallway waiting on a bed, and I NEED to send the pt up now even though it's not convenient for them. We try to take care of each other, when we can.

Of course, I worked med-surg before I worked ER, so I have the view from both sides of the river.

kimmicoobug · Nov 28, 2006

Usually when our ac's let us know about an admit, we usually have report called from the ER within the hour. However, I have come across the day shift charge on my unit refusing admits for this, that, or whatever reason. So, night shift gets stuck with the admit at shift change. Or, we have the day shift ERnurse who wants to give report at 1915 while I am in the process of getting report on my five or six other patients. You would not believe how many times I have gotten chewed by some of the ER nurses...(or maybe you would). I love it when I hear, "This patient has been sitting here in the ER for seven hours...they need a bed...and I will be on overtime if I don't give report right now" Then when looking at the admit orders, the orders were written 4 hours earlier. I just tell the ER nurse that getting report on my five or six other patients is just as important as getting report on that one. I guess maybe we just need a better system.

JessicRN · Dec 13, 2006

The other day we had a pt who was in the ED almost 12 hours. I faxed report at 0300 and the nurse from the floor asked if we could hold the pt until 0400 retake his Cardiac Enzymes because the IV Nurse called out. We were busy but not slammed so I agreed to do it at 0400 I took the blood then called and said I was sending the pt as it was getting very busy now and we needed the bed. I was told they did not recieve the faxed report so I will have to resend it and then wait another 30 minutes before I sent the pt which is the policy for faxed reports. I was stunned I said to the nurse how could you not have gotten the report at 0300 YOU CALLED ME. I reported this to the supervisor and all he did was shrug.

Last time I do that nurse a favor....:angryfire :angryfire

mvsnurse2b · Dec 13, 2006

I keep seeing the floor saying that the ED holds patients-I would love to move my patients along, have no holds, and have all those lovely admitting orders entered by the unit clerk on the admitting floor-instead of having to deal with them myself. HOWEVER, we cannot move patients to the floor without first getting a bed assignment- GUESS WHO DOES THAT IN OUR HOSPITAL? The charge nurse on the floor receiving the patient. If all hospitals work this way, then I would guess that floor nurses should and could blame their own charge for holding their admissions and backing them up. The longer an ER nurse in a teaching hospital holds a patient-the more orders go on that chart from consults, students and residents. I am more than happy to move my patients asap so that my waiting room time is reduced. I want my patient's to be happy and safe. Unfortunately, ICU and CCU (2 pt load) do what they want and in their own time. I just don't understand how this area can only handle 2 pts, when I must handle 5(2 of which are usually icu holds) how is this safe or fair? I always try to complete admit tasks, however the floor nurses must remember-98 % of patient tasks are initiated in er-these things take time. Patients are fluffed and buffed and awaiting maintenance by floor time.

The contributors to the problems:

Private physicians who do not direct admit-they blame the floors.

ER attendings afraid of being sued-millions of tests-and BS admit orders.

Patients who come for everything under the sun-and fake CP and such to be admitted.

Exhaused caregivers of patients with deficits-who I swear contribute to their love ones conditions so they are admitted and can have a break.

AND FINALLY-rules that make it difficult for us to get along and do what's necessary to make our lives and the lives of our patients easier. I always try to be friendly to the floor nurses and send labs, physician notes, and anything extra that will help them with their patient. I also encourage them to call me if they have additional questions. Be open minded-there are always some who want to stick it to you-you must rise above it.

craigrn4er · Dec 14, 2006

Few things really irritate me as much as feeling like the floor is dodging a patient. This seems to happen all of the time. We are actually working on changing the process in our hospital. We are working on a form that will be used for any patient being transferred anywhere in the hospital (i.e: ER to floor, ICU to tele, tele to ICU, etc). We are supposed to fill out a detailed report form and fax it to the floor. If they do not call with ???s within 30 minutes, the pt goes to the new bed.