Just a question from a clueless med/surg nurse, not trying to blame or make assumptions!
Why is it that all my admissions from the ER get sent to me at change of shift? I understand that it may be due to that the ER nurse did not get a chance to earlier and wants to call report so he/she can leave. However, it then results in that the nurse I am relieving cannot give me report because suddenly the admission is rolling through the doors and needs pain medicine, the family wants to know what's going on, etc. This seems to happen all the time and the result is the previous shift has to stay over.
I know it is not due to anyone being thoughtless, just wanted to hear from some ER nurses what is going on from their side of the trenches :typing
Keep in mind, I work in an 8 bed ER. Approx 40 bed facility. But this is a question we have pondered in our ER on several occasions. My shift is 11a-11p so I am there for shift change at 7p and we DO send more patients to the floor at shift change. We ER nurses are NOT happy about it because we know what the floor nurses are thinking about us. But until we can figure out why it is happening...we can't fix it.
We have one doctor working in the ER at any given time. I have seen it happen time and time again...all labs are back; xrays complete; patient getting frustrated. Doctor just sitting on the charts. Calling home, going to supper break, treating and streeting the clinic stuff. We're nagging and nagging the doctor (we only have about 5 MD's and only 6 nurses in the department, so we're all family) to get a move on with the admissions. They basically ignore us. I've seen my doctors wait 3 or 4 hours before writing admission orders after ALL results were in. They tend to want to work up the quick patients before settling in to write orders.
We nurses tend to get a little louder and more insistent with our nagging the closer it gets to 7pm. Especially the RN, because she is leaving at 7 and doesn't want the next RN to walk in with 3 patients waiting to go to the floor. So when the doctor has finally procrastinated as long as possible, they will sit down and write admission orders at 6pm for all 3 patients that have been hanging out in the ER for the last 3 hours. Drives me completely insane! I have been known to sit down next to the doctor and write his admission orders for him in order to keep this from happening. The funny thing is the floor nurses love it when I do this because they can read my writing! Doc looks over them and signs.
I can't prove it. And I have no data to back up my theory. But I believe it is just sheer procrastination on the part of the doctors. In our facility, the ER doc writes most admission orders. And this means committing to just one pt/task for 20 minutes, something that good ER folk don't get to do often. We are all very good at flitting from one thing to another. Anyway, that's my theory and I'm sticking to it until someone can prove me otherwise!
Thanks. That was my Baby. He died several years ago but I had him for 14 years. Is that a pic of your husky? He's cute!!
Completely off topic (sorry op!!)
Miami-
Yeap, thats my baby! We've had him since the end of October, and hes 2 years. I never would have gotten a husky in Texas, but he was a rescue and needed a good home. We picked a sick rescue (not by choice) but i think hes finally all better!
Hes a PITA sometimes - when its time to get up, you will get the covers ripped off the bed if you dont immediately get up..hes so cute though...
Was yours trained? I find its impossible to train, unless I have treats..
We are at the mercy of the floor charge nurse to give us a bed and we wonder why beds seem to be more available around shift change time. Are they "dumping" on the next shift?
Specializes in Peds Critical Care, Dialysis, General.
We find PACU more the offender than ED. ED admits are always priority for us. Sometimes, we've delayed patients coming to us, mainly because the room wasn't ready (no bed, called x4 to get one).
On an upnote, the PACU nurses are now using the critical care flowsheets if the patient is coming to us. It's a small thing that makes a huge difference to us, especially for that 1845 admit.
Specializes in CNA, Surgical, Pediatrics, SDS, ER.
We are a 7 bed ED w/ 1 doc on for 24 hrs only. Depends on how critical other pts are that are in the ED. Priority pt first then in the mean time while waiting for labs,xray,EKG ect. for the critical then he see's the minor pt's which still may need a bed so then you have to wait for all the critical pts stuff to be done first before the other depts can tend to the other pts. The doc also has to contact the pt PCP which you have to wait on them to c/b sometimes it takes 2-3 pages to get a response. Then he sits down to write orders. Usually if it's not off the hook busy we will try to take care of all the labs/meds, w/ the exception of home meds floors responsiblity, that doc ordered in the ED before taking them to the floor. We try to get the IV started foley put in and anything else we can do to help the floor out so we don't have to take time away from their other pts. Also sometimes we have to xfer critical pts out to another facility and that eats up a lot of our docs time. You just can't pinpoint when you will be taking an admit up. It sucks to have to go at shift change because then we get the run around also. We are not out to make anyone's life miserable but it just depends on the flow of the ED at that particular time. 1 doctor can only do so much contending w/ 7 pts.
Example-
CP being flown out to another facility
Another pt w/ a laceration-
A pt w/ a severe black eye head injury-
pt w/ minor burns to their arm from grease at work-
a pt who got a splash of grease in his ear and now he just knows he has an ear infection now-
a pt w/ gout-
a pt w/ severe abd pain.
One pt got flown out and 3 others got admitted to the floor. Imagine being that doc in that mess. He can only do so much and all we can do is wait for him to catch his breath and get orders written.
We seem to get a bunch of ready beds at 1730, then report gets faxed to the floor, then we have to call, get the nurse who is in an isolation room to confirm that the fax was received. Usually, the nurse is in the middle of a procedure and has to call back. Then I call again - now its about 1800 because I had two discharges and two patients pulled back from the waiting room - or a sick ambulance patient in need of stabilization or just a line, labs and meds. At 1815, the nurse on the floor and I touch base and any additional information is traded since the chart faxed is now almost an hour old and I probably gave more pain meds or sent another set of cardiac enzymes. Then I get the patient hooked up to the portable monitor, grab a tech and get going. So there's the 1835 admit. Sometimes I've got two coming up, and I can't leave two patients with bed assignments for night shift to beg the floor to accept while they are "in report". (Until 1945 some nights.) Don't get me wrong, we are all acutely aware that we are bringing a patient up at 1835. Don't forget that I will already have a new patient in that area waiting for me (foot tapping, angry as all get-out family member included) when I get downstairs.
Honestly, I think that this is a medical issue & case management issue that has become nursing's problem. The attendings need to plan for discharge earlier in the day and actually come to the floor and sign the paperwork in the morning. Patients need to have transportation arranged, LTCs need to be notified the night before a potential discharge so that their am report can include the admission or readmission. If we are supposed to treat our patients like they are in hotels, then we should have a check out time as well! :)
Our ER is 55+ beds, and when patients receive a bed they go! The only exception is if I have someone coding, or I am slammed with new patients who are very sick. Obviously, moving a patient up becomes secondary to an MI or stroke. They wait, as does everything else.
What no one seems to understand is that beds are assigned by some mythical creature in the hospitals. Obviously the magic is stronger around shift change-all of a sudden after holding 15-40 people for 24 hours, WE HAVE BEDS! Unfortunately, the call report fairy does not come to our location to complete the job. I must do it.
Seriously, our problem is due to not having a formal discharge time, and poor coordination with housekeeping. Holds have been forcing people to adjust and we have been placing stable patients in the hallways. Something floor nurses don't like, but we deal with constantly.
Personally, I think the whole system is bogus. We all know it is due to staffing, and the lack of planning by administration and management. We shouldn't be blaming each other....instead, we should be rallying to fix this cruddy situation.
What some floor nurses do not realise (I know I am generalising) is that our pts do not present to us at convenient times either.
We do not plan for them to come up before shift time but if I am going off as a pp stated you do not want to leave 3 or 4 pts to be sent up to the floor so I will try and get 1 or 2 up before I go home.
We are open 24 7 and so is the rest of the hospital. When I work ICU it is the same thing.
I always try and start the initial orders if there are meds to give such as antibx or ivf etc and the pt is there for a while but otherwise it is beyond my control as an ER nurse. My CN is on my butt trying to get pts up to
the floor because, amazingly, there are more pts in the waiting room. They do not care if it is shift time or not. (the pts I mean, not the CN)
As a med surg nurse may be you can tell me why ALL the nurses disapear when I roll in with an admit!!
I've worked E.R off and on at my hospital and you are right at least some of the time. A doc will write admit orders on a patient but other treatments,labs,meds, on the other patients take priority as we are still trying to get a handle on them. The admits are "stabilized" and we usualy have a clue whats wrong with them. It gets to change of shift you don't want to give report on a patient that "isn't the E.R. docs' problem anymore" it's more time effective to rush the patient up to the floor than give report to the next E.R. nurse. We used to have a rule- no transfers 30min before or 60min after COS but that went away when they started tracking our E.R. length of stay in hours.
Another problem we run into, is the supervisor saying that this floor is getting several admissions, please wait half an hour between each one. So, the third one has to wait and extra hour and half in a noisy ER on a hard cart, and I can't get all those folks out of the waiting room because my beds are tied up. And if that wait pushes me to close to change of shift, I'm sure not going to make them wait yet another hour + because of the time of day.
I like the policy of just settle them in with some vitals if we're that close to change over. I'm sure not going to send a patient that is unstable to the floor!
OK, I have already posted on this thread, but it is 0445 and I am just getting home from my 3-3 shift. It was horrible. We have 50 actual rooms for patients with 12 official hall beds. I was in triage tonight. When I left at 0345, we had 19 patients.....19 patients who were ready for floor beds, but there were none. Some were direct admits, when they knew we had no beds, but most were our home grown patients.
We did get a few beds come available earlier in the shift but they were slow and few, the rest of the patients had to wait, and wait, and wait. Some of the floors had beds but did not have enough nurses. So what about the patients? They are stranded in a hall bed on a portable monitor where a nurse whizzes by every 30 min or so to say hello. We had so many patients on portable monitors, we did not have any left to transport pts to the floor with.
We had one nurse stuck in special procedures for 4 hours with a ventilated patient. We had another stuck in with the hand surgeon for 3 hours who wanted his hand held every step of the way. Then you throw in several acute MI's who went to the cath lab, a 9 yr old with a ruptured appy who went to surgery, a man who wanted detox from crack, last used 30 min prior to coming to the ER, kids smashing their heads into furniture needed sutures, pregnant vag bleeders who were all in hall beds or stayed in triage and were treated here and there. There were still 6 patients in the waiting room when I left, one had been there 5 hours for a large abscess on his buttocks, another was a 2 yr old with a lac to the back of her head who had been there 3 hours, a 2 year old with fever, a pregnant belly pain with low BP tachycardia, a vomiting 8 year old, and little old lady with post op wound infection.
ALL of our available beds were taken by those boarding, who should have been out of the ER hours before, causing a backlash that goes straight out the front door of the ER. Something had GOT to be done about the boarding issue. It is burning out ER nurses at amazing rates, the patients hate it, with good reason. We are giving substandard care because we are stretched to the limit.
So when we do try to get a patient to the floor, please be kind and understand that we have them backed up and streaming through the front door at all times.
The problem is not staffing, we have enough nurses, we have plenty of doctors, we just don't have room to put all of our admissions. There are some short term fixes like sending holding patients to PACU, Outpatient, any place with an empty bed, but you still have to have nurses to staff those areas.
Anybody have any good suggestions as to what might be working at your hospital? Obviously everyone has to be on board for it to work. I can see another mass exodus of nurses if something isn't done to improve the situation.
I kind of thought that, this being a topic that has come up over the past who knows how many years, people would just accept this and stop complaining or questioning why the ED sends patients up to the floor during or around shift change. Not directed at the OP, just at floor nurses in general and not meant to be offensive, just... when the same thing inadvertently happens for 20 years, you would think you would (a) get used to it and (b) no longer act like it's an act of God when it happens.
I really don't LIKE to send patients up at shift change being I originally started on a Med/Surg/Peds unit, but it happens. And believe it or not, we ED nurses have much more important things to do than sit around thinking of ways we can annoy the floors. :) It happens. Nothing we can do about it -- 90% of the reason is on our docs that put in the admit orders, and 10% is on bed control, when they post the bed, we want to (a) get report called ASAP and (b) get that patient out of the ED so we can use that bed for someone else.
As I'm sure the ED has been telling you and other floor nurses for years and years and years... it's nothing personal, just sometimes how the cookie crumbles.
I wonder if floor nurses have ever thought about rearranging their routine and adjust or be flexible to allow for a possible admission at shift change. Or adapting their process of admitting a patient to be efficient so that their "first 2 hours" of their shift is spent admitting 1 patient.
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HopeItWorksDNP
83 Posts
Keep in mind, I work in an 8 bed ER. Approx 40 bed facility. But this is a question we have pondered in our ER on several occasions. My shift is 11a-11p so I am there for shift change at 7p and we DO send more patients to the floor at shift change. We ER nurses are NOT happy about it because we know what the floor nurses are thinking about us. But until we can figure out why it is happening...we can't fix it.
We have one doctor working in the ER at any given time. I have seen it happen time and time again...all labs are back; xrays complete; patient getting frustrated. Doctor just sitting on the charts. Calling home, going to supper break, treating and streeting the clinic stuff. We're nagging and nagging the doctor (we only have about 5 MD's and only 6 nurses in the department, so we're all family) to get a move on with the admissions. They basically ignore us. I've seen my doctors wait 3 or 4 hours before writing admission orders after ALL results were in. They tend to want to work up the quick patients before settling in to write orders.
We nurses tend to get a little louder and more insistent with our nagging the closer it gets to 7pm. Especially the RN, because she is leaving at 7 and doesn't want the next RN to walk in with 3 patients waiting to go to the floor. So when the doctor has finally procrastinated as long as possible, they will sit down and write admission orders at 6pm for all 3 patients that have been hanging out in the ER for the last 3 hours. Drives me completely insane! I have been known to sit down next to the doctor and write his admission orders for him in order to keep this from happening. The funny thing is the floor nurses love it when I do this because they can read my writing! Doc looks over them and signs.
I can't prove it. And I have no data to back up my theory. But I believe it is just sheer procrastination on the part of the doctors. In our facility, the ER doc writes most admission orders. And this means committing to just one pt/task for 20 minutes, something that good ER folk don't get to do often. We are all very good at flitting from one thing to another. Anyway, that's my theory and I'm sticking to it until someone can prove me otherwise!