Thoughts On Eliminating Nurse Report

[Lovethenurse2b25]

Yet another workplace rant. As of yesterday my supervisor dropped the bomb on us stating nurses caring for patients admitted from the ED are no longer required to give report. Instead the patients will be sent up with a form. I have no idea what the form will have on it, im guess sort of like a ipass sheet or sbar. If any information is missing the nurse will have to look for it in the chart. Not to mention having a hard time reading other people hand writing. 

In certain situation such as CIWA & sepsis report is required but the criteria for it is not yet known. 

However my concern is that patients transferred to the unit unstable resulting in unnecessary RRT’s. (I cant tell you how many times the ED attempted to send up pts with a bp over 200 or bs less than 60 without an intervention or even without meds listed in the mar). Also we many not have enough time too look up the patients chart especially if its a busy day. Or the form will be either lost in transport or sent up uncompleted. Also the ED nurses don’t always chart important patient information. 

I know that as I nurse I have to read my patients chart regardless. 

How would you handle this? What are your thoughts? 

I think their goal is to get the patients to the units much faster by eliminating time used to give report. Prior to this they weren’t allow to send patient without calling first. 

Whats is your companies policy on receiving and giving report?

[Yep, Me]

In the real world, there is verbal info that needs to be passed on, that one would not necessarily want to put in writing, for liability sake.
if floor is avoiding ER transfers, that is an issue that Risk Management needs to address.

Back in the days when we had time to give our pts HS back ribs, I was given verbal report on my floor pts: one in particular “ate a good lunch and is sleeping now”. When I did my immediate “eyes on” rounds, I found the pt with their lunch tray cold and untouched on the over bed table, as well as a cold and stiff pt. I ran back to the floor in time to catch the off-reporting nurse and said we needed walking rounds on this pt. She was resistant to that but came along anyway. When we entered the room, she said “well, you will need to call the doctor  to report this pt died.” I responded :”no you will. I don’t take report on dead patients.”

Verbal report is necessary. 

 

 

[Wuzzie]

36 minutes ago, Yep, Me said:

In the real world, there is verbal info that needs to be passed on, that one would not necessarily want to put in writing, for liability sake.

And when that was the case I would pick up the phone and make the call as any prudent nurse would do. 

[Lovethenurse2b25, ASN, BSN, CNA, LPN, RN]

20 hours ago, floydnightingale said:

Yeah, we went to the no report thing except for ICU transfers and if a patient is unstable they should be going to an ICU or at least travel with a nurse.

Fact was, too many units avoided report which delayed care and backed up the ER. I worked at one stand alone ER and the hospital we transferred most of our patients to never took report. One could spend an entire 12 hour shift trying to get a nurse on the phone. It was a game they played and continued to play even after they began laying their overstaffed a$$es off. One legit problem was that patients would arrive too rapidly in sequence, but they made their beds and now can metaphorically lie in them. ER doesn't have the luxury of delaying admissions.

 

I work in a small hospital I ER is rarely packed. I work nights and most of the time that they were calling to gave report was exactly at 7pm change of shift. Anytime after that was fine. We also have a weight limit on my floor that admissions do not pay attention to so it helps to get report. We are actually over staffed due to have low census in the hospital so a lot of times it just two nurses on my unit with no pca. 

[Tweety, BSN, RN]

If it's a very thorough report, with history, head to toe, test results, labs and vital signs, the plan of care,  it's probably going to take the ER nurse just as much time to write it all down on the form as it is to give report on the phone.  But it should be okay.  

What I wouldn't like is the opportunity to ask questions, to dig a little deeper and put two heads together. 

Also I'm not always doing nothing, in fact rarely am I sitting around waiting for the patient to arrive and having to look at their chart electronically for information might delay me knowing something important when I could have asked. 

I understand the idea the ER isn't allowed to stop ambulances from coming to them and the floors stalling on taking report is a problem.  We are not allowed to stall to take report.  Someone has to take report, even if the nurse taking the patient isn't available, is at lunch, busy or its shift change.  

 

[gere7404, BSN, RN]

We’ve got an admission handoff flow sheet we do in epic but I’m pretty sure the floor nurses can’t even see it.

we only have to call report to critical care, which they hate, because we never know the answers to questions like when the last time they took a dump was.

[LovingLife123]

Honestly, half the time I just say bring the patient up.  The reports I get from the ED are awful anymore.  The one taking care of the patient never calls.  The info is never correct.  I don’t ask about small things but I do need to know why they are coming, neurological status, vitals, and respiratory status.  I can’t even get that anymore.  I’m in critical care, I need to know who I need to have at bedside when the pt comes.

I’m a person that likes my admissions sooner rather than later.  So the minute my pt has a bed on the floor, I’m calling report so I can turn the room over and get the next one in.  I hate 1700 admissions.

I get all kinds of pushback from the floor about report anymore.  Then the ED gets crappy with me that my room isn’t ready and thinks I’m sitting on a transfer when I’m not.

But I think it comes down to everyone is overwhelmed from the floor to critical care to the ED.  It’s rare for me to have a steady, even day anymore.

[SunDazed, BSN, RN]

On 7/2/2021 at 10:48 AM, Wuzzie said:

I think their goal is to get the patients to the units much faster by eliminating the time used to avoid taking report. 

The reasons for avoiding report, for the most part, are valid. Too many patients, too busy, not enough staff for the patient load. None of which are the fault of the in-patient nurse, the ED nurse or the patient. Most ED nurses understand this but it's the invalid reasons that stick in their craws. The nurse is at lunch, the room isn't cleaned (when it actually is), it's almost shift change (see below). 

On the flip side the ED has to keep turning over their rooms for the sake of the patients in the waiting rooms (arguably the riskiest patients in the hospital given that they have not received a medical evaluation) and are bound by administrative time constraints once a room has been assigned. Nothing like getting a verbal because nobody would take report.  They are also at the mercy of the physicians who write the admit orders. Despite popular opinion they don't get to decide to which unit a patient gets admitted or when that happens. The idea that they hold patients until shift change is a fallacy. Most ED nurses try to send patients up buffed and polished but unfortunately there are some that don't and it gives them all a bad name. 

Moral of the story... quit painting your nursing colleagues with the same broad brush. 

Disclaimer: I was an ED nurse that did faxed report. It worked well and there was no measurable increase  in RRTs. The floor nurses hated it at first but their attitudes changed about this once they got floated down to take care of boarded patients.  It was also good to have a chance for us to get to know each other. 

Our ED has been trying new ways of speeding up admissions and the reporting process is part of that. They did the faxed handwritten for a while. It was very hard to read, it contained very limited info, and was basically pointless as it was not well executed. And our wireless fax system meant the faxes might never show up. 

With Tele Tracking nurses from different units could communicate easily when beds were ready and what nurse to call to give report. Mind you there were still delays sometimes. Hard to know who is dragging their feet where. Sometimes I would call down to ED if the bed had been assigned for a long time and I had not heard from anyone yet. I would be asked to wait as that ED nurse did not have time to give report. They would call back. Fine.

Then we switched to Epic. About the same time we were being crushed by the Delta variant. Tele tracking went away. Many workflows and processes were being relearned and recreated in the Epic world. One of them was the ED approach to report. I have been on two different inpatient units in the same week where an ED 'runner' nurse brought a patient up without the assigned nurse or charge nurse taking report, AND without calling to see if the room was really ready. 

Some how the ED has decided that if Epic says an assigned bed is ready, it is so. All it actually means is that the room has been cleaned. It doesn't mean that there is a bed or the appropriate monitoring equipment in the room. It doesn't mean the nurse has been able to transfer their other patient out, so they will be out of ratio if this new patient comes up before that.

So in both instances the ER 'runner' nurse, who knew nothing about the patient, stands in the hall with the patient for 20 minutes or more, waiting for a clean bed and equipment to be brought to the room. They are not even calling the charge to just check that things are really good to go?

Meanwhile the inpatient charge nurses are under the impression that the runner nurse will give a bedside report on delivering the patient if no previous report was able to be given. But the runner doesn't have a report to give? 

Someone mentioned that the doctor decides where the patient goes? Um, no. Our doctor's often don't know what units can do what as far as different gtts or acuity ratios. They have their preferred units, but doesn't mean the patient ends up there. And with bed numbers so tight in different units, like ICU and the step-down units, there is sometimes a sort of triage happening if someone can't be transferred out. And proper isolation status can be an issue too. Can't put a c. diff in a shared room with a non-C. diff. It is the inpatient nurse not the ED nurse that catches those things. 

The house supervisor at our hospital tries to quickly review the orders and confirm the bed placement. The nurses on the units still have to verify the patient is appropriate for their unit's level of care. Most of the time that is the charge nurse. Sometimes new orders are added after the initial bed assignment and the house supervisor is unaware until contacted by the intended units charge nurse. 

For instance, a patient with an arterial line was brought up to a unit that was not the ICU. In our hospital, patients with arterial lines can only be inpatient in the ICU. The ED nurses, admitting doctors, and whoever else didn't know or care and just sent the patient up. It was a couple of hours before we could get the patient to ICU to receive proper care. 

Here's a funny bit. I work on a unit that was closed this week due to staffing shortages in the hospital. I was floated out to work on other units. I was sitting in my unit for my lunch break the third night we were closed because the other unit's break room smells funny. Suddenly the phone rings and it is an ED RN phone. I answer and it is an ED nurse calling to give report on a patient assigned a Ready bed in Epic. Sorry, bud. The unit is closed. 

What? It is assigned in Epic. Yep, well, call the house supervisor because they might have a plan, but there is no nurse here tonight. If no one had answered, would they have done the two tries in 10 minutes then bring the patient up? That would have looked pretty dumb. Clearly communication at the hospital is not great, when most staff don't know a unit is closed, even if it is a pretty small unit. 

 

[SunDazed, BSN, RN]

On 7/3/2021 at 8:51 AM, Tweety said:

 

Also I'm not always doing nothing, in fact rarely am I sitting around waiting for the patient to arrive and having to look at their chart electronically for information might delay me knowing something important when I could have asked. 

I understand the idea the ER isn't allowed to stop ambulances from coming to them and the floors stalling on taking report is a problem.  We are not allowed to stall to take report.  Someone has to take report, even if the nurse taking the patient isn't available, is at lunch, busy or its shift change.  

 

I agree 100%. 

Lately we have been getting some very frail, fall risk patients. How do I stay an arms length or less away from them while toileting them and still be available at any moment the phone rings to take report on another patient? There are only 2 nurses on my unit. That night the other nurse had a direct admit that needed everything done before surgery. 

There is so much unnecessary aggression.

I am sorry the ED nurses are feeling so much pressure, that they are willing to take it out on the patients. 

 

On 7/3/2021 at 12:11 PM, LovingLife123 said:

Honestly, half the time I just say bring the patient up.  The reports I get from the ED are awful anymore.  The one taking care of the patient never calls.  The info is never correct.  I don’t ask about small things but I do need to know why they are coming, neurological status, vitals, and respiratory status.  I can’t even get that anymore.  I’m in critical care, I need to know who I need to have at bedside when the pt comes.

I’m a person that likes my admissions sooner rather than later.  So the minute my pt has a bed on the floor, I’m calling report so I can turn the room over and get the next one in.  I hate 1700 admissions.

I get all kinds of pushback from the floor about report anymore.  Then the ED gets crappy with me that my room isn’t ready and thinks I’m sitting on a transfer when I’m not.

But I think it comes down to everyone is overwhelmed from the floor to critical care to the ED.  It’s rare for me to have a steady, even day anymore.

Yes!

[EDNURSE20, BSN]

As a different perspective, I work in ED and this is what we do.

We do it on the computer and it’s saved on their file, so can’t be lost or hard to read. We still do a phone handover for ICU/HDU/Children though. 

personally I think it works well. All the important info is on the sheet and is easy to find. I think units receive better handover, because its much quicker to type up. Whereas a verbal handover is normally rushed. 

Plus Pt move through ED much faster, we found most of the times no one would pick up the phone, and when they did half the time the tried to decline handover. Before they knew anything about the pt, they would start going on that they couldn’t take the pt for at least another hour. 

nurses need to learn to work together within the whole hospital, not just there units. There are times where holding a pt in ED is needed because the floor is busy, and there are times ED have no choice. When there’s 70 plus pt in the waiting room, we can’t keep a pt for another hour. 

Also , Things are missed in ED, because there aren’t are our priority. They should be things that aren’t urgent and can wait. it’s a fault of the health system, not the individual nurse. Over run EDs and poor staffing, means care is prioritise for emergency’s only. 

as someone whose worked in both med/surg and ED I understand your complaint. but there is always another perspective to consider before you start blaming another nurse. We are all doing our best with what we have. 

[SunDazed, BSN, RN]

4 hours ago, EDNURSE20 said:

Plus Pt move through ED much faster, we found most of the times no one would pick up the phone, and when they did half the time the tried to decline handover. 

nurses need to learn to work together within the whole hospital, not just there units. There are times where holding a pt in ED is needed because the floor is busy, and there are times ED have no choice. When there’s 70 plus pt in the waiting room, we can’t keep a pt for another hour. 

 

We are all doing our best with what we have. 

I agree nurses need to work better between units. 
 

sometimes the phone isn’t answered because all our NAs have been pulled to be sitters on pts in the ED- so the nurses have to toilet all the patients themselves and there is a freak thing where sometimes everyone needs to toilet at the same time

Once pts are inpatient we aren’t allowed to put them in a diaper and not change it for 6 hours 

[Wuzzie]

1 hour ago, SunDazed said:

Once pts are inpatient we aren’t allowED to put them in a diaper and not change it for 6 hours 

This kind of passive-aggressive snark is why we can’t have a polite discussion about this and maybe come up with a workable solution. If you truly think nurses in different units need to work together better, comments such as this need to stop. 

[SunDazed, BSN, RN]

1 minute ago, Wuzzie said:

This kind of passive-aggressive snark is why we can’t have a polite discussion about this and maybe come up with a workable solution. If you truly think nurses in different units need to work together better, comments such as this need to stop. 

How may times has a CHF exacerbation patient gotten IV lasix and the ED nurse can't even say if the patient voided? Any follow up on treatment? Breathing better so it must have worked. No idea if they voided or if they did... where is it? So often. 

Conversations need to happen. It is partly the administration putting pressure on the ED staff and the unit staff to create the conflicted situation. Both the ED staff and the Unit staff think they have logical, ethical reasons for doing what they do. Sometimes it comes down to not enough staff to perform the magic tricks the bosses want in the time frame they are pushing for.

The poster I was responding to did not take into account why the unit nurses could not drop everything to serve the ED needs for patients in the waiting room. The quote from the other post: we found most of the times no one would pick up the phone...

Seems to me this is not very empathetic to unit nurses? Any one in the ED think, "wow, they might be having a hard night too." 

Doubt it. Any hope the ED nurses will understand there are times where we literally can not pick up a phone because we are with a fall risk patient who doesn't want to use the bed as a toilet anymore, but can't be left alone. And are very slow moving.

We have had so many behavioral patients in the ED during the pandemic plus confused patients hospital wide. Some nights all the NAs from 3 units can be sitting on 5150s or other holds, both ED and hospital wide. If we aren't staffed to grid on the unit (because we don't have NAs on the floor to help), there are times where the phone doesn't get answered.

Do you think we are watching it ring? Also we are told to never be distracted during a medication pull or pass. Always be within an arms reach of a fall risk patient who is toileting. Oh and the new rule last week... everyone is a fall risk patient. There are so many rules on how we do things on units that are not taken in to account by ED. If the charge nurse has an assignment too? Definitely another reason the phone is not be answered, the bed board not being watched. 

Also, please keep in mind as ED staff, you are not the only people who give us patients on inpatient units. One night there were 22 transfers around the hospital to create more critical care beds - do you have any idea how long that takes or how much coordination with housekeeping and nurses giving report to each other between 4 units? 22 patients moved in the middle of the night in a hospital that is full when it has around 160 patients. That does not even count the ED patients coming up to take newly created spots.

And don't forget we on the units also do not get to hold up post-op transfers. If short stay or recovery is bringing a patient, they don't always show up on our bed board first. Maybe the house sup approved it by telephone, but no one told anyone on the unit. Then suddenly there is a couple of nurses asking where we should put the patient they have with them. We have to serve them immediately too.