Unsafe ED

silverbat · May 2, 2014

I once received a pt to a med surg unit an hour before shift change, obtunded, Full Code, Sa02 86% on 5L non re-breather, skin yellow, smelling of Ammonia, VS tanking. When I contacted her Primary Dr, with VS, etc., he had me send her to ICU, where she remained for days. ER MD had not checked an Ammonia level(known dx of hep. encephalopathy), it was wayyyy off the charts, she had pneumonia, was in renal and liver failure and nearly died. I was written up for "questioning the ER nurses decision to send her to an med surg floor instead of ICU/PCU".

The ER nurse told me, "Sometimes you just have to let the pt code on med surg first"!!! I know its the ER dr who decides to admit, but in that ER, the ER doc generally did as told by the ER nurses.

My response to this was that any time I recieved a pt in the condition I received that one, I would do as I did--call the primary care Dr and give my SBAR/assessment, etc., and let the pt go or stay as determined by the Primary Dr.

Generally my experience as a floor nurse with the ER staff has been positive. At least in the 2 hospitals I was a floor nurse at. This was the worst situation I experieinced with an admit. We occ had the change of shift admits, but for the most prt...all was good.

I respect the heck out of ER staff, having floated there, been on Code teams and pulled to triage a bunch of times.

Esme12, ASN, BSN, RN · May 2, 2014

OK everyone BREATHE!

I can sense your frustration and anger over this situation. That will not improve the situation for the patients.

Flow in the emergency department is an ongoing challenge. I KNOW. I ahve attempted to change and improve processes for at least 25 years. It takes full cooperation of the staff both in the ED and on the floors. It requires involvement of the administration to set policy and the mangers to assure compliance. It is a real team effort and requires open, non aggressive communication and problem solving.

It has much more to do with the ED MD and getting them to dispo the patients. Even after admitting orders are done....I have seen the ED MD keep the patient (who have 2 speeds stop and reverse) so they can "dictate on the patient". So MD's do drag their feet on the dispo until shift change to keep the bed full because it does keep non emergent patients out of the ED. NOTHING keeps emergent/EMS patients from coming to the doors except diversion. But this is everything to do with the ED MD and NOT the nurses.

Esme12, ASN, BSN, RN · May 2, 2014

OP....use this energy. Approach your management. Find a solution to better your patients experience. I can give you many tools to accomplish this and improve relations between the departments. Everyone needs to stop pointing fingers. IN my career. I have seen floor nurses hide beds....not clear them in the computer to make it appear they have no availability. Stonewall report by not being available....so the road runs both ways. The objective here is to open the line of communication between departments.

You are right....patients need to have vitals taken. They need to be reassessed before leaving the department. There should be ED guidelines on assessment re-assessment within the department and discharge criteria that the patient needs to fulfill before leaving the department....IF it is a well run department. NEVER vent your frustration with the department in front of the patient. That is an ABSOLUTE NO NO!

Continuing on the path of anger and accusations will only lead to a deterioration of patient care. Focus on improvement.

I am NOT covering anyone's behind and sticking up for one or the other. I am asking you to look at both sides of the coin. Both departments have their challenges. Once.... as a manager I hosted and exchange program between the floors/ICU and the ED. It was AMAZING how the lines of cooperation and communication changed.

HeartRN13 · May 2, 2014

I agree. I come across very strong because I do care about my patients and look out for their best interest. It absolutely does run both ways. This time my intuition does tell me it originated in the hands of the nurse, but I will remember moving forward that it's not always the case.

TriciaJ, RN · May 2, 2014

I have seen shirkers fight about work load - well, they're lazy and don't want to do much. But I have also seen hard workers argue about work load - and that tells me there is too damn much work and too few people trying to get it done. The logic goes: "If I am working flat out and I'm still buried, someone must be slacking." The reality is the staffing envelope being pushed. Again.

I think it's a wonderful idea to approach management about dialogue between two departments, with the rule that everyone keeps a problem-solving attitude. If everyone can refrain from finger-pointing and defensiveness, maybe something can get done. Keeping my fingers crossed for you.

Esme12, ASN, BSN, RN · May 2, 2014

I once received a pt to a med surg unit an hour before shift change, obtunded, Full Code, Sa02 86% on 5L non re-breather, skin yellow, smelling of Ammonia, VS tanking. When I contacted her Primary Dr, with VS, etc., he had me send her to ICU, where she remained for days. ER MD had not checked an Ammonia level(known dx of hep. encephalopathy), it was wayyyy off the charts, she had pneumonia, was in renal and liver failure and nearly died. I was written up for "questioning the ER nurses decision to send her to an med surg floor instead of ICU/PCU".
The ER nurse told me, "Sometimes you just have to let the pt code on med surg first"!!! I know its the ER dr who decides to admit, but in that ER, the ER doc generally did as told by the ER nurses.
My response to this was that any time I recieved a pt in the condition I received that one, I would do as I did--call the primary care Dr and give my SBAR/assessment, etc., and let the pt go or stay as determined by the Primary Dr.
Generally my experience as a floor nurse with the ER staff has been positive. At least in the 2 hospitals I was a floor nurse at. This was the worst situation I experieinced with an admit. We occ had the change of shift admits, but for the most prt...all was good.
I respect the heck out of ER staff, having floated there, been on Code teams and pulled to triage a bunch of times.

You should not have been written up.....maybe the delivery of your comment wasn't in the best "format" possible....which is understandable however it does inflame the situation at times.

I have gone toe to toe with many ED MD's and admitting MD's about a patients admission placement. It has NEVER made me popular in administration, and I was the administrative supervisor in house. That is the sad truth. Administration doesn't want conflict and certainly not when it involves the MD's in some hospital cultures.

Decisions to admin to one unit or another have requirements for the patient to be seen. ICU is usually within an hour. MANY MANY admitting MD's will force a patient to a lessor acuity to avoid this....when the patient is admitted to the lessor acuity and then transfers to the ICU the patient falls on the hospitalist/in house covering MD and if the patient is "stable" the have an additional 4 hours for the patient to be seen and the "intensivist" who is now a consultant instead of admitting MD (giving the attending the higher billable amount) now sees the patient. THERE IS SO MUCH MORE INVOLVED than meets the eye.

The ED nurses comment of

"Sometimes you just have to let the pt code on med surg first"

tells me that they were as frustrated as you and couldn't get the MD to do the right thing. Now we are back at making the MD's behave. I am NOT ashamed to say that in order to get the attention a patient has needed called a code or rapid response to set the proper wheels in motion. There is always more than one way to skin a cat. I once worked a place where the hospitalist actually covered from another facility!!!! when he always said he had just left for coffee....or food....or the bank...you get the picture.

Out of the whole scenario my biggest question...why is a patient with a non re-breather only on 5Lpm?

Esme12, ASN, BSN, RN · May 2, 2014

I agree. I come across very strong because I do care about my patients and look out for their best interest. It absolutely does run both ways. This time my intuition does tell me it originated in the hands of the nurse, but I will remember moving forward that it's not always the case.

The nurse just might be as frustrated and angry as you....if they are working in unsafe conditions without support from their manager in a culture that supports the MD no matter what....it's tough.

IrishErin · May 2, 2014

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.

The same could be said for when us "ED nurses" try and get a patient to the floor because we are bursting at the seams and we get "oh, that nurse is on their break", "the bed isn't clean yet"(four hours later), and so on. The floors can play just as many games as the ED, and we all complain.

Stop trying to make it seem like an us vs them, we all need to work together.

MunoRN, RN · May 2, 2014

First of all nurses should be required to work both ER and inpatient, the us vs them thing doesn't work in anyone's favor. Inpatient nurses often don't understand how things work in the ER, and too often ER nurses can't or refuse to recognize when there's criticism that is actually completely valid and instead respond with undeserved vitriol.

As for the original questions; yes, a delay of 3-4 hours after report was given should require a quick update of what, if anything, has gone on between report and the actual transfer.

BrnEyedGirl, BSN, MSN, RN, APRN · May 3, 2014

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.

Perhaps you should have offered to go get the patient?

0.adamantite · May 3, 2014

The logic goes: "If I am working flat out and I'm still buried, someone must be slacking." The reality is the staffing envelope being pushed. Again.

I really like this quote because it brings us together as nurses. It's a broken system and we are pushed to our limits. We shouldn't be turning on each other but turning to management.

I work on the floor and also get frustrated with change of shift admissions. We have had some dangerous situations with these as well.

ChristineN, BSN, RN · May 3, 2014

I am sorry the OP had to deal with this. No one knows the full story as far as what all was really going on in the ER, or if there were other factors.

At my hospital we have a policy that once a room is ready we have 30 min to give report and then put in transport for pt to floor. This helps avoid the situation you describe because the floor and the ER both know the expectations once the room is ready.

Not saying there can't sometimes be issues, but it is the exception and not the norm