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.

[uRNmyway, ASN, RN]

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.

I suggested this to my UD and in the ED, and basically got nothing but eye rolls. Oh well, then keep the dysfunctional system and bad attitudes we have now then, see those customer satisfaction scores start to drop.

[Anna Flaxis, BSN, RN]

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.

The patient may have been good to go, but what else was going on in the ED? Do you know? You waited over two hours from the time you got your SBAR until you called down there to ask when the patient was coming. Did you think to call sooner, or as someone else mentioned offer to come get him yourself? And again, patient perceptions can be unreliable. Was he on central monitoring? Did he perhaps not notice the nurses peeking in on him periodically? Did he not put on his call light to summon a nurse if he was so concerned?

I dunno, maybe the ED in your facility *is* crappy and filled with egotistical, uncaring, dangerous nurses. But then again, maybe there is more to the story. We cannot possibly know. We can only give feedback based on limited information and on our own experience.

While I suppose it's completely possible that the patient was left for four hours without anyone checking on him, it's just not my experience that this sort of thing happens, even in a really busy ED. In my experience, I can understand the types of wrinkles that would result in transport being delayed, but he would be checked on hourly if stable, and a note made in his chart each hour describing his condition.

I'm seriously not trying to cover anyone's behind so much as that it's really easy for me to imagine how this could have happened without it being the result of neglectful nurses. I do agree with MunoRN though, that there should have been better communication.

Did you write an incident report?

[Vanilla101]

First, as others have mentioned, the ED does NOT benefit by keeping patients until change of shift. They get patients continuously until they get SO MANY that the hospital puts the ED on diversion. Second, also as others have mentioned, you could have called the ED earlier and offered to get the patient yourself. That would have helped the situation and fostered teamwork. Third, there is hardly any "glitz and glamour" in the ED when you're witnessing a victim of abuse, a drunk is throwing up on you, or your getting cursed out by a patient. The ED is also the most dangerous place to work in the hospital. I have colleagues who have been bitten, punched, had to take cover if a firearm was taken out, or kicked. My state has made such assaults on RN's a felony, but it took a very serious injury to an RN to make it so. Don't get me wrong, there are rewarding aspects of working the ED as well.

Your comments do not indicate that you were in the ED at all during the wait time. It is, then, a safe assumption that you had no idea what other things were demanding the attention of the team. You don't know for a fact that the patient wasn't being monitored. It may have been bad judgement to send a patient such as yours to the floor rather than the ICU, but that's not a nursing decision. As a Registered professional Nurse on a telemetry unit, you are trained to assess and intervene on patients who are unstable at any point in time, including admission. In such situations, the patient May or may not need ICU level care. If they do need ICU level care, they still require close monitoring on the telemetry unit by an MD/RN until a bed is made available on the receiving unit.

Lastly, ANY patient admitted to the hospital and brought to the unit becomes the receiving units responsibility immediately. It is malpractice to send an inpatient who requires close monitoring and a team with an attending physician back to the ED, especially in the situation described. I've been an Inpatient unit manager for a number of years. If this were to occur in my area, there would be immediate disciplinary action after a review of the event.

Please don't misunderstand. I am responding to comments posted, and cannot judge anyone personally or professionally. I am using this forum to share my opinion only, hoping that someone will learn from this. In medical malpractice cases, nurses are not exempt from being held accountable for their professional judgement. In this situation, had the patient been returned to the ED, and harm had occurred, the RN would have likely been held 100% responsible as it would have been her decision, a decision that showed poor nursing judgement, negligence and not doing what is best for the patient.

[MunoRN, RN]

....Lastly, ANY patient admitted to the hospital and brought to the unit becomes the receiving units responsibility immediately. It is malpractice to send an inpatient who requires close monitoring and a team with an attending physician back to the ED, especially in the situation described. I've been an Inpatient unit manager for a number of years. If this were to occur in my area, there would be immediate disciplinary action after a review of the event.

Please don't misunderstand. I am responding to comments posted, and cannot judge anyone personally or professionally. I am using this forum to share my opinion only, hoping that someone will learn from this. In medical malpractice cases, nurses are not exempt from being held accountable for their professional judgement. In this situation, had the patient been returned to the ED, and harm had occurred, the RN would have likely been held 100% responsible as it would have been her decision, a decision that showed poor nursing judgement, negligence and not doing what is best for the patient.

I think you've over shot that a bit. Patients only become the receiving nurse's responsibility when they've accepted transfer of the patient. The OP's reference was to a transfer during shift change which is not an unusual "no-go" period where the nurses on the receiving units don't accept transfers. It's the handing off nurse's responsibility to ensure that another nurse is assuming care of the patient, if that hasn't happened, due to facility policy of no transfers during shift change, then responsibility for that patient including any harm still falls under the ED nurse since the receiving nurse is not accepting the patient at that time.

It is frustrating as an ED nurse to get turned around once you're on the receiving unit because you're a minute late, it's happened to me, but while it's frustrating it's by no means malpractice on the part of the receiving nurse or unit.

[jadelpn, LPN, EMT-B]

Remember OP, just because you got an SBAR report, does NOT mean orders are written and ready. I have seen a set of orders take forever just because the MD is interrupted with a million little things.

Then the admissions people need to do their thing--just because you have assigned a room, doesn't mean it has been put into the system.

Then I have seen that often the MD waits for any additional orders from the patient's primary, the accepting doc, whomever is taking over from the ED. Oh, and then comes the primary's or the acceptings who want to come and look at the patient themselves first.

This is a process problem best brought up to risk management. Huge Joint Commission issue as well, as it is a look at how long it takes from door to floor.

So you, in fact, may be the person to look at these processes and see what can be streamlined.

Another issue entirely is a patient's perception of not being seen for "hours". Most ER's have central monitoring. Therefore, they may not see a face (which I am not suggesting is good practice, however) but they are being monitored. And not to sound snarky, but an ER patient who is well enough to start complaining about "hours" of not seeing a face is certainly well enough to hit the call bell and ask about the timeline.

ER's have gotten the rep that people ALWAYS wait for hours. So, perhaps if one complains enough the wheels will turn faster. Which can't happen for a number of reasons--most of which ER's are unpredictable in what is coming through the door at any given moment. That anyone going out of the ER has to have some sort of dispo--some taking longer than others. And as a bit of an aside---too many darn doctors in the mix--the ER doc, the admitting doc, the PCP......if it were left up to nurses, give us 20 minutes and all set.......

Make a plan, talk to your manager, and begin a process change. It can only benefit the patient.

As a complete aside, I have seen my share of unit nurses who are more than willing to have patients wait in the ED until they are ready for them--"I just need to give my meds first, assess my patients I have already, don't want to take a new admit right this moment, I will call you when I can take the patient" and next thing you know it is 15 minutes til shift change and the oncoming nurse is going to have a new admit--

[calivianya, BSN, RN]

I think what's even more unsafe than that is getting secondary report from the previous shift nurse who got report from the ED nurse, but then the patient doesn't arrive until after shift change when the nurse who actually got the initial report is gone. It's really inconvenient getting a patient at the tail end of your shift, but that has got to be safer for the patient than the patient having two nurses who have no idea what the heck is going on - the receiving nurse who received report from someone who never laid eyes on the patient and every question she asked was met with ,"Oh, the ED didn't tell me that," and the ED nurse transporting the patient who cannot answer any questions about the patient because she has only been on shift for 15 minutes and has no clue what the patient's condition really is because she has not assessed the patient.

Or how about getting report from someone who has never laid eyes on the patient? Some of the ED nurses who call report to me can't even tell me if the patient has a foley or not. They have to go look. Or I'll ask what the heart rhythm is and get a "Uhhh... hold on..." Really? I work in ICU so we are talking about critical patients, and you can't even tell me what the heart rhythm is? Or whether or not they're on oxygen? Or what kind of IVs they have?

I think the nurse taking care of the patient, at least when we are talking about critically ill patients, should be BOTH the person to call report and the person to transfer the patient to the unit, even if it means they have to stay late. Or, if the nurse who actually took care of the patient cannot stay late, the nurse who is going to transport the patient should have to assess the patient and actually lay hands on them besides just holding onto the bed while he/she pushes it. It's just not safe for a critically ill, potentially unstable patient to be transported by someone who has no idea what's going on. Period.

[Gabby-RN]

First off, I can tell you that boarding an admitted patient in the ED typically does not prevent me from getting another patient, so if I am able to transport the admitted patient to the floor I am happy to do so as soon as possible. Second, there are many reasons I might not be able to bring a patient to the floor after sending SBAR. One of my other patients of is crashing and another nurse is not available to walk with the patient. The admitting team is in the ED assessing the patient or has been down to assess the patient and wants a CT, xray, labs, or something else done before the patient gets to the floor. The patient is not stable when we go to transfer to the floor and the drips need to be titrated first. There is no orderly available because 2 traumas just came in and several other transports are ahead of my patient on the transport board.

Shift change is a non-issue in the ED, we get patients from the moment our shift starts to the moment our shift ends. I would prefer to get admitted patients to the floor as soon as possible because keeping them puts an extra burden on me and takes time away from the ED patients that don't stop coming in. Plus we don't have the resources to board admitted patients long term, the stretchers are uncomfortable, the food is limited, there are no tv's, the bathrooms are far away, and half of the daily meds patients receive are not stocked in our pyxis.

The nurse you called should have given you a better explanation as to what the holdup was because I am sure there was a reason. Maybe next time you can offer to come down and get the patient if they are too busy to bring the patient to you. I am sure then they will tell you why the patient needs to stay longer OR will be super appreciative for your offer to help.

[Gabby-RN]

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.

I introduce myself to every patient on our first encounter and almost daily at least one of my patients asks me to get their nurse or tells me they haven't seen their nurse and I have to remind them that I am the nurse (you know the one that got you those crackers you asked for, helped you with the bedpan, took your vitals every 2 hours, the one that talked to you about what brought you here today before the doctor came in, the person wearing the blue scrubs indicating they are an RN with the name tag that says RN in big bold letters). People are in pain and distracted in the ED they often do not pay attention to who is who. It is also more chaotic in our department and easier to forget who is who. Sometimes patients might not see a nurse for 2 hours and that is usually good. It means they are stable and alive unlike the patient next door that 3 nurses are in with who is being intubated.

Like I said before your patient might not be brought to the floor right away because other patients might be dying. Where I work any monitored patient needs a nurse to go on transport. If I can't safely leave my other patients and neither can another nurse then your patient waits. It could take hours to stabilize someone. Trust me we are not sitting around twiddling our thumbs holding on to your patient until the end of shift.

[Vanilla101]

I am referring to: "if he sends the patient at change of shift, I'm sending him back and writing him (nurse) up." While I would perhaps agree that the patient becomes a unit responsibly when the unit RN accepts the patient, I maintain (please remember that I have, for all intents and purposes worked in an ICU setting) that sending a patient (ICU patients are unstable by default) back to the ED creates a further delay in care and is not acceptable, and causes further delay in treatment. A delay in care can cause harm, thus meeting criteria for malpractice. She had an SBAR report, and at that point would have only needed an update on the patient from an ED RN. And, there are several ways (mentioned in the the previous posts) she could have facilitated the transfer herself. I have never sent back to thE ED from the ICU. I have seen patients die in hallways due to a breech in the acceptable standard of care. So please at least remember that it is not a good idea to traipse around, back and forth, from the unit to the ED. It's just bad practice.

[psu_213, BSN, RN]

We recently had a situation where a pt. was being admitted to the floor. The ED evaluation was complete, report was called to the floor and transport was requested. The pt's neurosurgeon (who makes a lot of money for the hospital, and a true prima donna) came down, blocked transport and refused to have the pt transported to the floor until the pt had a stat MRI. The ED management had had go rounds with the higher ups about the surgeon and the surgeon always won. In other words, it wasn't worth trying to engage this guy in a discussion about why the pt had to go upstairs to the floor. The assumption could have been made, by someone unfamiliar with the situation, that "the ER nurse is just holding on to the patient so she does not have to take another pt." Well, in our ED, if the nurse holds on to a pt for that "reason", he/she will be looking for a new job. I agree that the nurse should re-call report after the MRI before the pt actually does go up, but try in keep in mind that there may have been something else going on beyond the sinister motive that you assume.

[psu_213, BSN, RN]

Shift change is a non-issue in the ED, we get patients from the moment our shift starts to the moment our shift ends.

Your ED must really stink. We just tell paramedics to do high quality CPR for 30 minutes or so until we get done with report and complete shift change.

[IrishErin]

Your ED must really stink. We just tell paramedics to do high quality CPR for 30 minutes or so until we get done with report and complete shift change.

Best comment ever!

On another note, I worked last night and guess what happened?!

When I came on to shift at 1900, one of my six patients showed that they had a bed assigned on an inpatient floor. It had been assigned at 1630, but was not "ready" yet, likely because not clean, or took a while to get previous patient discharged. Whatever, fine with me!

I assess all of my patients quick, answer my call bells, try to chart what I can and finally call the floor at about 2030 and ask if they have an idea when I might be able to bring my patient to them. First I get, "I don't know where that nurse is." When I say I will wait for a minute on the phone, I get "well we are super busy right this second, can we call you back shortly when the bed is ready?" Sure, no problem, I can continue on with my patients.

I start some IVs, change some incontinent patients, discharge one one home and then get a new patient. At 2130, I call to the floor again. "I didn't know we were getting a new patient, you'll have to wait a while." At this point, becoming slightly frustrated as we are busy and could really use the spot. However, start giving out HS medications. At 2240, floor calls down and says "I was wondering when you might possibly be bringing that patient up? I was told you called at 2030 to bring them, and it's been quite a while..." At this point it took every fibre in my being to not freak the ever loving heck out on this nurse!

But I didn't freak out. Not even when noticing upon my arrival to the floor that the nurses were all sitting and having snacks and doing various activities on the computer. Things happen, maybe they WERE super busy and because of that, there was a (major) communication breakdown....

Two sides can play the "I don't want the new patient" game, and the only person it really affects is the patient. We all need to stop trying to screw each other over and work together.