Unsafe ED

[HeartRN13]

Lately I've noticed more and more that I happen to get my admissions right at 1040, 1045, change of shift you get the drift. Today I was told at 5 I was getting an admission. The SBAR got faxed at 7, in my hand at 710. 930pm I'm wondering where my patient is. I called down and asked the nurse when they planned to send him and his response was "ehhh I'll send him up in a bit." I told him that if he sends the patient at change of shift I'm sending him back to the ED and writing it up. To me it's unjustifiable to send a patient 3-4 hours after sending the SBAR. They hold these patients until change of shift so they don't get new patients. Now I know why my patients are coding on me when they get to my floor, or coming to me in rapid afib. The patient told me that he never met a male nurse, in fact he didn't see a nurse for 3 hours before he came up. This infuriates me. If I'm sure of one thing, it's that I'm a good nurse and always will act for my patient. I would never ever do things like that. Does this go on in all ERs? I understand they deal with a lot of BS, but these people are ones that require attention, I work on a tele floor. These patients typically need the attention and they aren't getting it.

[Esme12, ASN, BSN, RN]

Getting patients out of the ED is a complicated issue. Before assuming the nurse does this on purpose find out from management why this process is delayed. Depending on what is going on in the ED there may not have been anyone to transport the patient. Not everything that takes up time in the ED gets admitted to the floor.

Shift change is a problem and actually has more to do with the ED MD than the nurses. The ED doc might want the patient stay until a test result is back. They might want them to stay until they dictate......they ALL beat feet at shift change so the oncoming ED MD isn't mad and have to do another assessment.

You can't assume that the nurse isn't a good nurse....that nurse might have had a conscious sedation to reduce a shoulder. Another nurse might had had a conscious sedation to suture a child. Another nurse might have been triaging treating the chest pain that walked in the door that got shipped out and others are fighting with an ETOH brought in by police custody. All the while the rest of their patients usually 4-5 or so (depending on the ED) are in a holding pattern waiting for x-ray, labs, give a urine, see if the Maalox worked....etc.

Keeping a patient in a bed in the ED does NOT stop the incoming flow of patients. They show up whether you have a bed or not....the EMS does NOT hold them in the ambulance bay in the rig until a bed is available. Unlike the floors/ICU/units...if a patient is in the bed....the ED holds them until a bed is available and clean.

Ask your manager if you can develop an action plan to better facilitate positive change.

[FlyingScot, RN]

Where is the pocorn emoticon when you need it!

[morte, LPN, LVN]

eh, Scot, just shameless, ye be! lol

Where is the pocorn emoticon when you need it!

[Anna Flaxis, BSN, RN]

You never know what is going on in the ED. We definitely do NOT hold onto admitted patients on purpose. Once the decision to admit has been made, we want to move the patient along as efficiently as possible. For one thing, patients do not stop coming just because we're full, and even if our beds are all full, we're still responsible for those waiting in the lobby. We really do not want an admitted patient taking up a bed when we have potentially unstable patients in the waiting room and ambulances are coming in.

Patient perceptions can be very unreliable. Often they are completely unaware of what else is going on in the department, such as procedural sedations, intubations, critically ill patients, etc., and they make assumptions about the personnel they interact with- for example, assuming that man in scrubs who came in and checked their vitals is a doctor and not a nurse, or assuming the unit secretary who came in to get their signature is a nurse because she's female and wearing scrubs- or they could think they haven't seen a nurse for three hours, and yet they've been on central monitoring the entire time, and the nurses were frequently doing visual checks the entire time.

If there was a delay in transporting the patient, it could have been for any number of reasons, such as not having anyone available to transport or everyone being tied up with critically ill patients, or maybe the hospitalist came and saw them in the ED and took forever to do their evaluation, and wrote a bunch of NOW orders that had to get done before the patient could go to the floor. Don't make assumptions!

I never ever plan my floor admits to be transported right at shift change. That benefits nobody. It's just as inconvenient for me as it is for you. But sometimes, right at shift change is when all the stars are aligned and everything comes together and the patient needs to go. In my opinion, the inpatient units need to have a process in place to allow for this on their end.

Please, do not show displeasure with the ED in front of the patient. This undermines their confidence in us, and displays really poor teamwork. Try to understand what else might have been going on that could bog down processes and cause hiccups in the smooth flow of things. Remember we are on the same team, and need to work together.

[imintrouble, BSN, RN]

I don't work ED (I like ER better, but I'll bow to the experts).

I just know how it works downstairs. Just because you don't have a bed, doesn't mean you don't have patients.

If it's really busy, they just park the patients in the hall with a screen around them. I know:nono:really old school.

[HouTx, BSN, MSN, EdD]

Dunno about your facilities, but in ours - hanging on to a patient in the ED will not prevent the nurse from getting another patient assignment. Once the Docs order transfer/discharge, that patient is pretty much 'off the books' in terms of ED census... moved into a holding area if transport is somewhat delayed. ED can't control patient influx, they must respond as indicated by Triage status. So it is their best interest to move patients out as quickly as possible.

[HeartRN13]

In this case the doctor wrote the transfer orders at 6pm and the patient was good to go. And my patient also told me he hadn't seen a nurse for nearly 4 hours. Both are unacceptable and I mentioned it in the initial post.

[HeartRN13]

I get that all of you ED nurses try to cover each other's "you know what" but faxing an SBAR and not sending the patient until hours after isn't acceptable. They want to replace the verbal report with the SBAR but it's not right to send a patient hours later. You are going to tell me that you didn't do anything for the 4 hours since it was sent? You all can make every excuse in the book for each other, and while I do believe that in your EDs this may not be the case, in the one I'm speaking of it is. It has been an ongoing issue, it's unsafe practice, and it's not right.

[That Guy, BSN, RN, EMT-B]

Just try to send the pt back down. I freaking dare you.

[HeartRN13]

Not arguing with anyone over it. You want to be on the same team? Then don't send me a patient that you didn't bother to assess for hours who came in with a pulse ox in the 80s to begin with. You want all the glitz and glamour and credit for being an ER nurse then do your job and don't neglect patients. Take 3 minutes to check a pulse ox, ask your patient how they're doing to do a quick mental status, see if there are any changes. You all are so defensive yet you're the ones who are supposed to be helping these people in the front lines, yet somehow the ones in my ED send them to us worse. Have some accountability. That's part of being a nurse. Good luck with our career if you lack that. It's ridiculous the egocentrism I see with ED nurses sometimes. Not all of them, but some of them. Worst attitudes.

[HeartRN13]

Just try to send the pt back down. I freaking dare you.

The post above was in response to you.