Unsafe ED

Anna Flaxis, BSN, RN · May 3, 2014

We get the runaround from the floor All. The. Time.

If they tell me they're really busy and could I just hold onto the patient for another 30 minutes, I try to respect that if I can. Sometimes the answer is no, like the other day when the hospitalist was on the floor waiting for the patient to arrive, or when our lobby is full and we're expecting ambulances and we're about to go down by 1/3 of our staff at shift change.

I am willing to work with the inpatient nurses when I can- I used to work on an inpatient unit, so I get it- and I really appreciate it when I feel like the inpatient nurse is working with me.

Altra, BSN, RN · May 3, 2014

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It is my experience that inpatient nurses tend to have No. Freaking. Clue. how bed control at their own facility works.

It is also my experience that inpatient nurses have no idea how the ER works, AND that ER nurses have no idea how an inpatient unit works. But I'm far less concerned about that -- you chose inpatient nursing, and I chose the ER, ... for a reason, and that should be respected. But bed control: this is something that we can and should all join together to wrap our heads around and jointly deal with for the sake of improving patient care.

Depending on where you work, the bed control/patient flow function can take any one of several forms.

At large hospitals, it is likely that this function has people dedicated to it full time - one or more people are continuously coordinating the flow of patients to and from:

1. OR ---> PACU ---> appropriate inpatient unit

2. ED ---> appropriate unit

3. outlying hospital ---> to ED

4. outlying hospital ---> directly admitted to appropriate unit

5. current inpatient unit ---> higher or lower level of care depending on patient condition

6. patients discharged to home

7. patients discharged to other facilities

In smaller hospitals, this function may be performed by a house nursing supervisor or in very small settings just coordinated among individual unit charge nurses. In all cases, this function is very interdependent with nurse staffing and with housekeeping. These folks deal with all the complexities of getting the right patients to the right places within the very real constraints of limited resources and the unpredictable nature of human beings. There does tend to be a larger amount of movement of patients at shift changes which affect staffing. For example: if the nurse-patient ratio on Unit A is 1:5 on day shift but switches to 1:7 at 7pm ... this likely means that a number of beds which were "unstaffed" and therefore unavailable at 2pm are magically available for assignment later in the day. I've said this before here at AN: our bed board lights up like a freaking Christmas tree every day at 6pm.

There are as many ways to manipulate this system as there are variations of the system. Who decides and how it is decided which patients go where is depends on 1001 hospital-specific and physician-specific preferences and policies. But I can say this universally:

IT IS NEVER THE ED NURSE'S PEROGATIVE WHERE/WHEN A PATIENT IS MOVED.

The statement that an ED nurse "holds onto" a patient with an assigned/available inpatient bed to avoid getting a new patient has no basis in reality. New patients will continue to arrive ... regardless of whether or not an individual nurse's patients are quick or slow to get dispositioned.

Let's focus on learning where the breakdowns are in the systems in our hospitals and exert pressure for change.

MunoRN, RN · May 3, 2014

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.

I here ya, but the reason why they don't accept admits at shift change is to avoid a delay in treatment, you could argue that refusing the patient during that time might cause the same effect and I have heard people argue that but they've always lost that argument, but feel free to try and change the system of blocked transfers during shift change, until then though that's how it works in many facilities. If you're correct and that is an obvious patient safety issue, there should be some sort of reference where a department of health frowned on that practice. The problem is that the reason why we've lost the argument that patients should be able to transfer at any time is that the suggestion of blocking transfers at shift change actually comes from our DOH surveyors.

psu_213, BSN, RN · May 3, 2014

It is my experience that inpatient nurses tend to have No. Freaking. Clue. how bed control at their own facility works.
IT IS NEVER THE ED NURSE'S PEROGATIVE WHERE/WHEN A PATIENT IS MOVED.

As for your first statement...do we work in the same facility? Reading posts on here by floor nurses about the ED, I'm suspecting that not knowing about patient flow is practically universal. I worked on a floor before the ED--night shift. A bed was assigned by the nursing supervisor at approx. 0400. The patient was then brought up to the floor, by ED nurses, at approx. 0715--i.e. smack dab in the middle of shift change. Several people, including myself, said...How dare they!!! Sit on the patent for 3 hours and then bring them up at shift change! Once I started in the ER, I realized I had no idea what the process of "bedding" patient was like at this hospital. I had no idea that just because they are being admitted and had a bed assigned, they may not be ready to leave the ER and come to the floor. At the time, it was easy to blame the ER nurse, but, hey, for all I know, 3 arrests came in during those three hours.

As for the second statement, I don't think any other statement could more succinctly sum up the issue.

MomRN0913 · May 4, 2014

Honestly....... It goes all sorts of ways. Yes, I've experienced the ER nurses holding their patients they were supposed to bring up hours before until 15 min before the end of the shift as to avoid getting another one. And it's not an assumption. Especially when it's the same repeat offender.

i worked in the ICU who also held onto to tele transfers so they didn't get an admission to fill their bed.

actually, I will be flat out honest. I've been guilty of it myself. But of course I still fully care for that pt I'm holding onto. ( this was not a regular occurrence . Just on particularly bad nights where I'm already swamped)

there re is never an excuse for not assessing a patient. Can't tell you how many we would get up for the ER dead already. Or the pt we got I. Rapid afib who had on his admitting orders SIX hours before I received the pt to start a cardizem drip and lo and behold the reason it wasn't started was because " well, they are the admitting orders, he wasn't considered ER when they were written ". What?!?!?!? I made the MD aware but I didn't write them up( should have, really)

the he truth is it is done all around, holding the pt. But it should be addressed by management

k-flo · May 4, 2014

I once had a floor nurse report me to my charge nurse in the ED because I sent a patient up who's colostomy bag was full and an ordered foley was not done. Granted I did not know the bag was full and I communicated in report that the pt needed the foley. I felt terrible, but what that nurse did not know is that I got a pt next door by EMS who was a stroke alert who had an attitude that made it difficult for us to assess him. Shortly after, I get another EMS pt in respiratory distress. We had 3 nurses and 1 tech for 12 pts, that day we were busy with nothing but truly sick pts one after the other, they just kept on coming. In my neck of the woods diversion is only a courtesy, EMS can always choose to override our request and bring the pt anyway, which sure does happen a lot.

I'm sorry you got inconvenienced at shift change, but for us in the ER, the pts keep coming whether it's shift change or not, getting a combative pt that needs to be restrained at 1859 does happen, we can't tell them to wait till we're done with shift change. Same with chest painers, traumatic arrests, etc...

ausrnurse · May 4, 2014

This is definitely a two-sided issue. We have huge problems transferring patients out of ICU - we will get delayed for literally HOURS waiting for a bed to get cleaned, then the nurse will complain about the time the patients arrives (which is usually close to shift change because we have been waiting ALL DAY for one reason or another), and will usually wear a comment about how we don't understand because we only have one or two patients. But the nurses on the ward don't seem to realise that the second I get back, I have to take a new patient. For patients who need a safety aide, we normally inform the wards one or two days in advance of that so they can organise appropriate staff for that patient, but every single time, they don't. Some wards are better than others to transfer patients too, and I'd say the majority of it has nothing to do with the nurses on the floor and everything to do with the management.

That Guy, BSN, RN, EMT-B · May 4, 2014

The main thing that bothers me about this is the lack of communication on both ends. Why didn't the floor nurse at an hour call down and ask whats up? At 2 hours, 3 hours, 4 hours? Why isn't the floor nurse worried about where their pt is? The ER nurse should have also called up and updated on the delay too.

When I worked the floor, anything over 30 minutes warranted a call down to the ER asking whats up. But I had a very good working relationship with my ER nurses *shock and awe*. We were on the same team and we would offer to go get our pts all the time or send a tech to get them. We knew when they were getting killed. They would come and help us out when we needed it too.

Personally, I like getting rid of my pts as fast as I can. Gives me a new one with lots of stuff to do as opposed to an old pt that everything is done on.

MunoRN, RN · May 4, 2014

The main thing that bothers me about this is the lack of communication on both ends. Why didn't the floor nurse at an hour call down and ask whats up? At 2 hours, 3 hours, 4 hours? Why isn't the floor nurse worried about where their pt is? The ER nurse should have also called up and updated on the delay too.
When I worked the floor, anything over 30 minutes warranted a call down to the ER asking whats up. But I had a very good working relationship with my ER nurses *shock and awe*. We were on the same team and we would offer to go get our pts all the time or send a tech to get them. We knew when they were getting killed. They would come and help us out when we needed it too.
Personally, I like getting rid of my pts as fast as I can. Gives me a new one with lots of stuff to do as opposed to an old pt that everything is done on.

While I don't mind getting calls asking for an update on when to expect a patient, and while you might take these calls politely, I've seen plenty of ED nurses whose responses to these calls are best described as hostile, so I can understand why floor nurses would hesitate to routinely call about why their patient isn't there yet.

That Guy, BSN, RN, EMT-B · May 4, 2014

While I don't mind getting calls asking for an update on when to expect a patient, and while you might take these calls politely, I've seen plenty of ED nurses whose responses to these calls are best described as hostile, so I can understand why floor nurses would hesitate to routinely call about why their patient isn't there yet.

So complain because it took 4 hours or a nurse was mean to you on the phone and you at least know? See the problem here?

MunoRN, RN · May 4, 2014

So complain because it took 4 hours or a nurse was mean to you on the phone and you at least know? See the problem here?

At least know what? When I've overheard ED co-workers get snippy in these situations the floor nurse doesn't actually end up with any more info than they had prior to calling. So the problem seems to be that a floor nurse is hesitant to call if they're just going to get attitude and no actual information.

HeartRN13 · May 6, 2014

Well here I am days later after posting this and definitely cooled down a lot since. It is unfortunate that there is a huge and obvious disconnect between the floors and the ED nurses. Unfortunately it seems as though a big factor in it all is attitude. To be quite honest, i can put any personal grievance aside if it means my patient is taken care of. To me, sending up a patient who is in rapid a.fib and nothing was done about it at all is not acceptable. Sending up a pneumonia patient who has a pulse ox in the 80s and now needs bipap is not acceptable. Both of which have happened in the last couple weeks, including a patient who was also a pneumonia, coded, and died. 3 patient scenarios all within a couple of weeks coming from the ED, something here is a little fishy. This may not be the case in all EDs but unfortunately I do suspect it is the case in mine. I'd do anything to help my patients and lately it feels like the ED doesn't. Could it be they are stretched too thin? Absolutely. But people are left in critical condition and nothing is being done until they get to our floors. I just wish there were a different answer than what has been happening.