transferring pts. from ED to floor

jojotoo, RN · Jul 11, 2007

I have seen this work the opposite way too. As a floor nurse I knew who was working ER by the way the patients were being transferred! Some ER staff would hold onto a patient in order not to get another assignment, then dump them all at once. Had three come to the floor in the same elevator one time. This was on a unit with only 2 RN's and one CNA working! So it goes both ways. We give report to the charge nurse and get the patients in the room ASAP. Someone besides the primary nurse can get them in the bed & get vital signs.

I can't even imagine what this means. If an ER nurse has 4 patients, and more come rolling in via EMS or through the front door, then she'll have 6, then 8, it just continues. There is no magic number where it stops. If we run out of beds, we line people up in chairs. If there is no bed or chair and EMS arrives, we see patients on the EMS gurney. Doctors will go into the waiting room to see patients, and yes, write orders for those patients. Even if the ER is on diversion, that only stops SOME paramedic transports to us. BLS rigs still come. Codes still come. Walk-ins still come. Trauma from homeboy drop-off still comes. Don't ever think that ratios stop any of this.

So there is no upside to the ER nurse "holding" a patient in the ER because it's not going to stop them from getting another patient.

JessicRN · Jul 12, 2007

We have a system in place that seems to be working. We are only assigned the bed when everyone is ready. The report is faxed and they have ten minutes to either call the supervisor and tell them they are too busy to accept the pt or the patient is sent to the floor. ICU is the only one we do not fax report they are still sometimes a problem but if 15 minutes go by without a return call from the nurse the supervisor gets involved. With supervisor involvement there are no percieved game playing on either side. It is working well so far. No ED nurse will send a pt if the nurse is truthfully busy and no floor nurse will refuse a pt when the ED is truthfully crazy. Our ED is completely no divert so when things go crazy we go on pre divert and all the charge nurses make assessments of their floor and see who can be moved or discharged pt's are seen quicker by the floor team doctors and patients are sent to the floor earlier sometimes without admission orders. It can get a little crazy but we all work as a team

AngBthatsme · Aug 20, 2007

i have worked at many hospitals as a traveler in the er, and i have to say, this seems to be a universal problem. the following are my pet peeves about transferring pt's from the er to the floor/icu:

1. it is very irritating to be told a nurse from the floor or icu can't take report because the bed is dirty, he/she's on break, in the bathroom, busy, etc.... there are other nurses on the floor, someone must be able to spare 2 minutes to take report.

i dont think the bed being dirty is a good excuse and neither is that the nurse is on break, someone is covering her/him. it is reasonable that we may not be able to stop what we are doing to come and take report for many reason. i'm starting an iv, im doing a dressing change, im with an unstable patient, the list goes on and there are many valid reasons. however i think the person that is supposed to be getting report should call back within 10-15 minutes and if that is not an option for a valid reason then my charge nurse should take report.

2. being asked to wait 30 minutes to bring someone up because "we just got another admission." um, yeah, let me sit on this patient for another 30 minutes while my hallways & waiting room fill up so that you and your co-workers can check in one patient that has been nicely pre-packaged for you by the er (iv started, foley in, ng in, etc.....). i wish we could tell ems- "please drive around the block a few more times, we just got another ambulance in....."

i dont understand this one either.......what would be the purpose in waiting. the patient will rest better on a bed in a room rather than in a stetcher in the ed. however the pre-packaged comment, out of line we have lots of paper work to do when the patient hits the floor so your iv stick (which by the way is always in the ac and beeps all night), labwork and foley is only a minute beginning to the admission process.

3. being asked things that do not pertain to the patient's condition. example: being asked about bowel sounds in someone being admitted with pneumonia, etc.... you know what? if my patient is in the er for respiratory issues, i don't listen to their bowels! does that mean i'm a bad nurse? no- it means i'm an effecient er nurse- we do focused assessments in the er, don't ask me about my patient's ingrown toenails when they are here for pancreatitis.

flip side of that is the ed nurse who wants to tell me about the ingrown toenail on my chest pain patient, but when i ask what the second troponin was ......"oh ill try to get that before i send him up", thanks since the first one from 6 hours ago was elevated.

4. getting phone calls from the floor 2 hours later wondering why i didn't do this or that from the admission orders. they are admission orders- if it doesn't say "stat" or "now," it is to be done on the floor, not in the er.

i agree.

5. nurses refusing to take report at shift change. you know how badly you want to give report to the next shift so you can go home? well guess what? so do i! i have no control over admissions waiting until 10 minutes before shift change to give me a bed, but now that i have it, just let me call report so i can go home. my report will only take 2-3 minutes, so it would be common courtesy to not make me stay 30-45 minutes late just to give it.

so this one just burns me. i come on shift and i have to get report on five patients and ed is on the phone ten minutes into my report wanting to give report. i tell them, im getting report i will call you back in 15 minutes. oh ed nurse if you were standing beside me and i was talking to someone getting report, would you interrupt me and cut off the other nurse so that you could give your report to get out sooner than the other nurse you just interrupted????? if you did that would be very rude, just like it is rude to call up to the floor and insist that we take report so you can go home. give report to your oncoming staff and she can call it later.

6. floor/icu nurses who have a problem with the admission orders, and give me grief about them. know what??? i didn't write them! if you have a problem with the orders, call the doctor.

most of the orders that i have seen have been taken by the nurse and written for the doctor, those can sometimes be cleared up by the nurse that took the verbal order, otherwise yes the nurse needs to call the doctor.

7. nurses refusing to take a patient because "they need to go to icu, ccu, telemetry, another hospital......". the physician specified what type of bed he/she wanted. if you have a problem with this, take it up with the doctor- it is not up to me what type of bed the patient goes to, it is decided by the doctor & by what's available in the hospital.

just the other night i took report on a patient and told the nurse that i wasnt so sure that the patient needed to come to our floor. i took the reporting nurses name and extension. normally i work on a cardiac floor, but i had picked up a shift on the observation unit. they called me a 50 year old female that was transported via ems with a heart rate 180s, adenosine 6,12,12 was given by ems. in the ed she got 6 more of adenosine and then a cardizem bolus. the carotid massage brought her down to 110. first troponin was 0.046after receiving this report i was not so sure that the woman did not need to be on a cardiac floor. im a cardiac nurse i could have cared for her........but the placement was not appropriate. house super sent her to a cardiac floor.

thanks for the chance to vent..... admitted a lot of patients last night, had to deal with a lot of the above........ :uhoh3:

glad you vented, i appreciate your perils in the ed. we know that you are busy down there. personally i try to be courteous to the ed nurses. my best friend up home is an ed nurse. she's funny she tries to appreciate the floor nurses too. whenever she can, because i crab about it:idea:, she tries to not start ivs in the ac haha. happy nursing everyone!!

DutchgirlRN, ASN, RN · Aug 20, 2007

1. it is very irritating to be told a nurse from the floor or icu can't take report because the bed is dirty, he/she's on break, in the bathroom, busy, etc.... there are other nurses on the floor, someone must be able to spare 2 minutes to take report.
i dont think the bed being dirty is a good excuse and neither is that the nurse is on break, someone is covering her/him. it is reasonable that we may not be able to stop what we are doing to come and take report for many reason. i'm starting an iv, im doing a dressing change, im with an unstable patient, the list goes on and there are many valid reasons. however i think the person that is supposed to be getting report should call back within 10-15 minutes and if that is not an option for a valid reason then my charge nurse should take report.
2. being asked to wait 30 minutes to bring someone up because "we just got another admission." um, yeah, let me sit on this patient for another 30 minutes while my hallways & waiting room fill up so that you and your co-workers can check in one patient that has been nicely pre-packaged for you by the er (iv started, foley in, ng in, etc.....). i wish we could tell ems- "please drive around the block a few more times, we just got another ambulance in....."
i dont understand this one either.......what would be the purpose in waiting. the patient will rest better on a bed in a room rather than in a stetcher in the ed. however the pre-packaged comment, out of line we have lots of paper work to do when the patient hits the floor so your iv stick (which by the way is always in the ac and beeps all night), labwork and foley is only a minute beginning to the admission process.
3. being asked things that do not pertain to the patient's condition. example: being asked about bowel sounds in someone being admitted with pneumonia, etc.... you know what? if my patient is in the er for respiratory issues, i don't listen to their bowels! does that mean i'm a bad nurse? no- it means i'm an effecient er nurse- we do focused assessments in the er, don't ask me about my patient's ingrown toenails when they are here for pancreatitis.
flip side of that is the ed nurse who wants to tell me about the ingrown toenail on my chest pain patient, but when i ask what the second troponin was ......"oh ill try to get that before i send him up", thanks since the first one from 6 hours ago was elevated.
4. getting phone calls from the floor 2 hours later wondering why i didn't do this or that from the admission orders. they are admission orders- if it doesn't say "stat" or "now," it is to be done on the floor, not in the er.
i agree.
5. nurses refusing to take report at shift change. you know how badly you want to give report to the next shift so you can go home? well guess what? so do i! i have no control over admissions waiting until 10 minutes before shift change to give me a bed, but now that i have it, just let me call report so i can go home. my report will only take 2-3 minutes, so it would be common courtesy to not make me stay 30-45 minutes late just to give it.
so this one just burns me. i come on shift and i have to get report on five patients and ed is on the phone ten minutes into my report wanting to give report. i tell them, im getting report i will call you back in 15 minutes. oh ed nurse if you were standing beside me and i was talking to someone getting report, would you interrupt me and cut off the other nurse so that you could give your report to get out sooner than the other nurse you just interrupted????? if you did that would be very rude, just like it is rude to call up to the floor and insist that we take report so you can go home. give report to your oncoming staff and she can call it later.
6. floor/icu nurses who have a problem with the admission orders, and give me grief about them. know what??? i didn't write them! if you have a problem with the orders, call the doctor.
most of the orders that i have seen have been taken by the nurse and written for the doctor, those can sometimes be cleared up by the nurse that took the verbal order, otherwise yes the nurse needs to call the doctor.
7. nurses refusing to take a patient because "they need to go to icu, ccu, telemetry, another hospital......". the physician specified what type of bed he/she wanted. if you have a problem with this, take it up with the doctor- it is not up to me what type of bed the patient goes to, it is decided by the doctor & by what's available in the hospital.
just the other night i took report on a patient and told the nurse that i wasnt so sure that the patient needed to come to our floor. i took the reporting nurses name and extension. normally i work on a cardiac floor, but i had picked up a shift on the observation unit. they called me a 50 year old female that was transported via ems with a heart rate 180s, adenosine 6,12,12 was given by ems. in the ed she got 6 more of adenosine and then a cardizem bolus. the carotid massage brought her down to 110. first troponin was 0.046after receiving this report i was not so sure that the woman did not need to be on a cardiac floor. im a cardiac nurse i could have cared for her........but the placement was not appropriate. house super sent her to a cardiac floor.
thanks for the chance to vent..... admitted a lot of patients last night, had to deal with a lot of the above........
glad you vented, i appreciate your perils in the ed. we know that you are busy down there. personally i try to be courteous to the ed nurses. my best friend up home is an ed nurse. she's funny she tries to appreciate the floor nurses too. whenever she can, because i crab about it:idea:, she tries to not start ivs in the ac haha. happy nursing everyone!!

it sounds like you need to try working on the other end of the phone call. we have had an ed nurse or two get pulled to med/surg and were absolutely losing their sanity the entire shift. after their experience they quit complaining about med/surg nurses.

perhaps med/surg nurses should also try working ed. our shifts end at completely different time from the ed shifts and that is done purposely.

TinyNurse, RN · Aug 20, 2007

As an ED nurse I've seen this done a number of ways. The most effective was when the entire hospital was "on board" with an understanding of ED holds, and overcrowding. The floor nurse had no choice but to take report. At a rare time when the primary nurse could not take report the floor charge nurse took report.

Faxed report was also very effective. However I felt as though my report wasn't very complete because it was a "fill in the blank" fax report sheet. Then a MR on the floor would verify that the report was received on the floor fax machine.

If I had a dollar for every time i've heard "the nurse is busy", "the nurse can't take report", "the charge nurse is busy", "the nurse is at lunch, "we have a patient seizing", I'd be rich.

When one nurse is busy in the ER, chances are the entire ER is busy, but we still make time for the incoming ambulances, the seizing patient, and time for the nurse to urinate.

I will never understand why the ER is the only department that is expected to burst at the seams to accomodate patients. Teamwork between ER and floor nurses will go a long way to do the best thing for our patients.

hollysunshine · Aug 25, 2007

Amen!!!

PedsER-RN, BSN, RN · Aug 25, 2007

hello everyone! i've been an er nurse for almost a year now. i was just wondering what the policy is for your hospital for transferring a patient from the er to a floor/icu? it seems like every time i attempt to give report i'm told "the nurse is busy. can she call you back?" or "that nurse is at lunch and the nurse covering her has 10 patients already and can't possibly take another." it is very frustrating to hear this. i completely understand people get busy, but there's a point where enough is enough.

we fax. we call the floor, let them know we're faxing report and orders, then wait 15 minutes, and take the pt up. seems like a good plan until they call down, "can you give us more time/did you start my fluids/etc." or like the other night "there's no bed". i agreed to wait, waited nearly 30 min., called again, was told, still no bed, housekeeper had to go to main hospital, we'll call you. lo and behold housekeeping was down in the er, so i questioned her, and yes, she had already taken the bed up. so when i called to tell them, hey we're coming up now, i was told "oh, sorry, we must not have seen it". what?!? are you blind?!?! how can you not see a bed?!!?! do they really think we're that dumb? anyway, i let my boss know about it, so hopefully something will happen.

i should mention that this incident involved a nurse who is notorious for being lazy and postponing everything possible (although i actually was foolish enough to buy into her story of the missing bed); there are some nurses that are great and actually say "ok, thanks" when we send them report. in those instances the faxing works fine.

gentle_ben_RN, ASN · Aug 26, 2007

My favorite from ICU is "that patient isn't stable enough to come to us." I've never understood that. I think people say that, thinking we've got the ER doc to write orders for the pt. Well, that ER doc has already turned over care to the admitting doc. So he/she won't even begin to write orders.... "That's not my patient anymore. Call the attending." We then end up doing all the phone calls to get that blood pressure from the high 80s to the low 90s. I also think the unit feels like we're trying to dump a crashing pt. so we won't have to deal with a death.
I'm aware that ultimately this is probably best for the patient... i.e. no delay in care. However, as somebody mentioned when you've got a full waiting room, and ambulances coming at you it's hard not to get frustrated. Plus, the time spent with that one critical takes me away from helping others in our ER right now. So a somewhat catch-22 situation.
Another pet peeve is how our ER process works (which appears to be common). We wind up transfering admits right at shift change. The floor nurses think we're out to slight them. I have no desire to go into detail, but I will just say we aren't looking to dump our patients at shift change! It's just the way our system works (or fails to work).
I have a question in relation to this. My perception is that our department is the most despised in the facility. No one wants more work, and everytime we call our report the floor staff has a bad attitude because our call represents more for them to do. Do others get this vibe?

Maybe as equally despised as the PACU....

JessicRN · Aug 27, 2007

For those floor nurses who complain that we stick IV in patients in the AC. At least in my case there is a reason. If the pt comes in with abd pain he will most likely have a ct scan ergo IV in AC if they come in with chest pain again chest CT (IV in AC) Dilantin for seizures ( if we put an IV in the hand we would then have a big problem) Cardiac chest pain or OD or any criticle pt you need a large vein for the vasopressors. IV boluses need to be given fast that means large IV in large vein. fINALLY IN THE ed THE md'S order lab and IV. We usually draw lab from the IV and Labs drawn from the hand usually hemolyse, When you get them you usually give fluid at 125cc/hr or you put in a central line in the critical care floors.Believe you I prefer to put it in the hand if I had the option but a patient c/o if you have to stick them twice.

Toquay · Aug 29, 2007

Well the reason it seems like the ER is dumping at shift change is not because of the nurse it's the ER MD. The Night ER MD comes on at 11pm and leaves at 7am, so the MD going off tries to clear out all his patients for the new MD coming on. They usually start wrapping things up about an hour before they are due to go home. Therefore, all the admit orders start coming in... the house supervisor is slammed for room assignments, which gets further delayed since it's an hour before shift change. The floor night nurse gets mad when we try and call report or tell us they are too busy, floor day nurse is upset as she is still getting settled or finishing report from floor, ER day nurse upset the floor would not take report and they have to take it. Nights is particularly different as we do not have the resources days shift has... volunteers, case managers, social workers, transport, techs days shift has 6 to our 1 or 2 (if lucky). The sad thing is nurses get mad at each other (dept against dept) instead of the powers that be.... its a grand plan to keep us all pissed at each other and blame each other so we don't pull together. Hospitals would be afraid if nurses actually stood united and supported each other.

Toq