I work as an acute care Med-Surg float nurse and my hospital has implemented a new process where patients are being transferred to units from other units, ie. the ED to the floor, ICU to the floor, and from affiliate hospitals to our hospital without having to call and give a verbal report. I find this practice outrageous and an accident waiting to happen.
The reason behind this new policy is to expedite patient transfers and open beds faster. All I ever learned is how important patient the hand-off is, and now we are actually no longer required to give report to the next nurse who will be taking care of the patient.
Apparently now that we have the EPIC system to do our patient charting, the decision-making people feel that verbal reports are no longer needed. However, I have had several instances where EPIC contained very little patient information and virtually no history, so I literally had to ask the female patient, who was busy vomiting, why she was even admitted to the hospital. The fact that she was a stage 4 CKD patient with only one remaining kidney was nowhere to be found on EPIC. She needed pain meds, but her current medication reconciliation had not been completed, delaying her receiving any medications.
And I must also stress the last Magnet hospital I worked at did the same thing by getting rid of verbal report for patient transfers. Has anyone else been experiencing this practice, and if so, how do you deal with the huge safety risk? What happened to placing patient safety first?
Seems to me the whole purpose of this change is the result of a disciplinary issue. Nurses refusing to take report is a disciplinary issue, and compromising patient care for a disciplinary issue is appalling to me! Maybe some nurses argue for no reason but it is our job to advocate for our patients and what if an assignment is unsafe? You call to the floor and a nurse is say changing several dressings and can't come to the phone and you send a patient when the assignment is unsafe? Sure this rarely happens, but it could.
I probably feel more appalled to this because I work at a smaller hospital and our system is horrid, there is no chance looking in the computer or chart would get you the same information as report. We don't delay receiving report at my hospital. You get a call you answer it, finish up what you are immediately doing to take report, ask your questions and go back to what you were doing until your patient arrives. If you don't take report within a few minutes management/charge is going to be tracking you down. We have more problems with people holding on to patients so that they won't get a new admit. That too is a disciplinary problem, but I wouldn't say we need to skip discharge instructions to solve it...
The purpose of no-verbal report varies by who you ask. We tried it out because of a consultant the administration had brought in who referred to it as a part of "revenue optimization". A good sized chunk of hospital revenue comes from daily room charges; this covers nursing care costs, food, clerical, housekeeping, etc.
The standard way of figuring the room charge is based on where the patient is at midnight. If a patient is admitted to a floor at 2355, then the hospital gets a full day room charge of revenue for that 5 minutes. If the patient is admitted to floor at 0005 then the hospital doesn't get paid for that patient until the next midnight. So at least from a revenue standpoint, the purpose is to take those patients who might have otherwise been admitted at 0005 and make sure they're on the floor at 2355, which gets the hospital an extra few thousand in income.
In theory no verbal report speeds things up because it allows the patient to be moved to an inpatient unit even if the receiving nurse is too busy at the time to receive report, the obvious problem with that is this would also mean the nurse hasn't had a chance to read the written report or look the patient report, which means they are getting a patient they haven't gotten report on which is problematic and potentially not legal.
If cutting out verbal report is as good as or better than report that contains a verbal component, why do we have a verbal shift -to-shift report? What's less important about an ED to floor transfer?
Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.
So what's the bad thing that happened? And the truth is, this isn't an issue of verbal report, this is an issue of patient flow.Why is that? How was the ED a better place to hold the patient than the floor?
Verbal report is important because sometimes things happen on the floor and the nurse is not equipped at that very moment to handle the new patient. At least if a call is made, the ER nurse can be made aware that the floor is in the middle of a code or the receiving nurse is urgently held up for the immediate moment. Administration/Bed Placement can then be notified that a transfer cannot occur in 15 minutes or have the Charge take on the patient until said emergency is over. It's all about communication and if the ER is made aware of an unusual issue going on upstairs, most ER nurses are very understanding as long as this is not abused.
A hard, fast rule of 'move 'em on out' within x amount of minutes is NOT safe. On the floor, if I'm in a room giving Chemotherapy, especially a chemo IV push over an extended time, I cannot take on a new admit at that moment. I can't check the fax, I can't take a call, and I can't review the chart for quite awhile. Same if a nurse is in a room doing CPAD, or some other long process where the patient can't be left. But so what according to TPTB, there's an open bed. Just have transport bring the new patient up and basically leave them there in a bed until I have a moment to check on them. The ER nurse is done with them, but I haven't even laid eyes on any information about them; therefore basically they have NO nurse for awhile. At least in the ER, some nurse knows something about them.
I don't know the complete solution to this issue and I respect that the ER nurse has patients coming in constantly that need her attention, but putting patients on the floor after some esoteric time line set in place by administration and bed placement isn't the answer.
And I have seem harm come from this practice. Not all patient's sent from the ER are totally 'stable' and remember the assigned floor nurse may not see them for a bit. I've seen patient transfers left in beds with quickly dropping sats, chest pain or bleeding that began in the elevator, etc.
Maybe transport needs to get a signature from the Charge, assigned nurse, or an available RN before just leaving the patient in a bed. Maybe that's the best idea so at least a nurse has eyeballed the patient upon arrival.
Nurses are busier than ever. A 5-minute verbal report can give valuable overview on pt status that would take a much longer time searching through charts. Besides that, I have received pt that have deteriorated on the way to the floor. Not getting a verbal report before or at least the same time as receiving the pt would seem to be a safety issue in many cases.
I still like to give a verbal report. If a family is "dynamic" (difficult to interact with), or has unreasonable expectations, if the patient is constantly on the call bell for unnecessary things, or needs "encouragement" to complete own ADL's or other tasks they are perfectly capable of completing but is not driven to do so, I am not sure I want to write exactly that. However, since I have worked in a hospital where the ER faxed report, I have learned how to get around it. "Patient requires much encouragement to complete own ADL's", or "Family is very devoted to patient" are code to the receiving floors of the previous statements, and I made sure the floors were aware, and asked they pass along that tidbit to their coworkers. I hate faxing report, and would hate to receive it that way.
This thread has become about things it should not have become. I have seen some very indignant ED nurses making this about them vs. the rest of the hospital and it should not at all be about that. It should be about patient safety.
My clinical in ICU Friday was a perfect illustration of why verbal report is needed. I'm not going into specifics but we received a gentlemen from med/surg who was going downhill fast on our unit. We did not have any time to look at a computer. By the way, who still faxes?? Lol. We had no time to leave the patient.
The nurses from his floor had the appropriate info we needed and verbally gave the pertinent info to us. Info we needed for this gentleman's care.
This is should not be about well, I don't have time to do this, or I need to open up a bed. This is about patient safety and care. This is about the patient only. Some of these comments have confounded me. Every nurse in your hospital is busy. Every nurse has charting, meds to give, new admits, discharges. Every, single, one. No floor is better than any other, no dept is exponentially busier than another.
Stop making this about you. It's about the patient. What I liked about where I was at Friday, it was stressful, but every person worked together. Every one. I feel like anymore the best interest of the patient has gone by the wayside for paperwork and an "assembly line" which I think was quoted earlier.
A crashing patient being emergently transferred to the ICU is a much different situation then a patient bring brought from the ED to the floor with advance notice.
If cutting out verbal report is as good as or better than report that contains a verbal component, why do we have a verbal shift -to-shift report? What's less important about an ED to floor transfer?
My answer to this would be the same as it was a few pages back.
In theory no verbal report speeds things up because it allows the patient to be moved to an inpatient unit even if the receiving nurse is too busy at the time to receive report, the obvious problem with that is this would also mean the nurse hasn't had a chance to read the written report or look the patient report, which means they are getting a patient they haven't gotten report on which is problematic and potentially not legal.
As many here have attested to, it's not theory, it is happening. If the process is put in place correctly, patient movement from the ED can happen efficiently and safely without a verbal report.
My place does it for ED to floor transfers and has for quite sometime. It works very well. TJC and CMS have not disapproved of it, and I would bet my hard earned money that our hospital is among the safest there is.
You are correct, if all pertinent information is given to the nurse who will be caring for this new patient. However, as the writer stated, not all needed, and pertinent information was given to the nurse who received the patient for whom she was now responsible. "Short and sweet," must, also, be "complete."
Regrettably, I have rarely found this the case - in 26 yrs, and too many hospitals, ED departments neglect to give the floor nurse the appropriate data or even a head's up about the pt they are receiving. Part of the issue is a lack of understanding of what that specialty requires. I have seen several cases where I was told that the pt had some oozing near where blood was drawn, only to walk into the room with blood pouring out of an arm where a passport was punctured by a an ER blood draw with a regular (coring needle). Or extremely critical ( for hem/onc pts) lab results that were not marked but totally benign labs reported and stressed. Or being told that we are receiving a 400 lb pt that takes six people to even move or turn safely, knowing full well there are only two nurses that staff the unit, notifying no one when you bring them up and leave them in the hall, trying to sneak off without helping us transfer the patient. Or doesn't notify us regarding the weight/lift requirements, when we could easily get the appropriate bed or room with the ceiling lift, making everyone's job much easier. Each specialty is different and a one size fits all basic form is not always going to tell us what we need. And often MDs do not put in data for hours.
I have also received patients on Nitro or Diprivan drips that never mentioned on those lovely sheets nor was it mentioned why they were on the drips. On nonmonitored floors. There are perpetual problems in that the MD may admit a pt under one diagnosis but be giving other care that is more complex and require a higher level care/different unit than the admitting diagnosis. Often medical patients are assigned beds on units that are inappropriate, and that can much better be cared for before sending them to a unit where they cannot receive the care that they absolutely require.
But the most annoying maneuver. Joint Commission REQUIRES that the receiving nurse be able to ask questions of the sending nurse. This is a common sense requirement. If ED wants to send a fax and someone notifies us of the admit, fine. That's totally fine, but invariably if we have questions and call, fat chance that the floor nurse will be able to speak to the nurse that actually saw and and laid hands on the pt. S/he just went on break/is too busy/will call back (and they never do)/left off shift. And there is the problem. One can try to speak to the charge but they don't know anything beyond what was written on that paper.
Management is happy because they developed this system, but doesn't care if it doesn't work in real life. The floor finds a way to try and prevent too many problems from the issues that arise and ED is happier. And of course they skate on the joint commission visits. Does JC ACTUALLY follow the process on a day when there is not enough staff, and where the ED MDs delay admissions, dumping many just before change of shift so they can "clear the board". Of course not, they don't so they don't see the poor communication. I have worked for two hospitals that had no HIPAA proper way to dispose of paperwork. Every unit had paper shredders but most of the shredders had not worked in years and were virtually never repaired. Papers were just put in the garbage and everyone knew it. Joint Commission comes around, and if they ask one of the managers, they point to the shredders and the JC checks it off their list.
Both ED nurses and floor nurses have some valid complaints and issues in this matter. But we need to be working together to be doing what is best for the pt. As a Hem/Onc nurse, I have often gone to access ports in the ED if needed or given MTX for their pt if needed.
The people who see no issue with not giving verbal report are, of course, mainly the nurses who are sending the pts, not receiving them. (And of course the administrators- many of whom have never been nurses- that are all about keeping everything moving, moving, moving, $, $, $!) Whether or not you have worked the floor/ICU or where ever and "understand both sides," is irrelevant. One will care most about whats easier for their most frequently worked position. Pt safety should come first, but our hospitals are way beyond that at this point.
I believe best practice has gone to bedside reporting; Therefore, ED should just bring the patient up if the bed's ready and give a bedside handoff.
90% of the time it's not the primary RN transferring the patient. They aren't able to leave their assignment of 3 or more other patients, some of whom are in the process of getting stabilized to transport their stable patient to the floor. this bedside report isn't happening. It's usually a lunch relief or float RN acting as a transport nurse. The one exception is ICU patients.
i also worked in an ICU where we went and got the patients from the ER. It was one of the busiest ERs in so cal, so their solution for flow was to have us go down instead and get report. Kept the ER nurses down there and we were able to get report and take the
patient up. An ER tech went with us and brought the gurney back down. It was really different but it worked very well.
When I worked in another ICU, my charge nurse would tell me the patients name and I was getting. I'd look in the chart and review diagnosis, history, abnormal labs, lines. What treatment they had got and what they were going to need. By the time report was called I already knew most everything so there were few questions with minimal additional information needed. We can blame each other, but there are a lot of different ways we can make report work to and from the floor, a simple verbal report is one of my least favorite methods because I'm going to forget something. I like having the ability to put info in a formal outline that is pertinent to the nurse who is receiving the patient,and I like when I call that I can fill in whatever questions they have to add additional info.
MunoRN, RN
8,058 Posts
The purpose of no-verbal report varies by who you ask. We tried it out because of a consultant the administration had brought in who referred to it as a part of "revenue optimization". A good sized chunk of hospital revenue comes from daily room charges; this covers nursing care costs, food, clerical, housekeeping, etc.
The standard way of figuring the room charge is based on where the patient is at midnight. If a patient is admitted to a floor at 2355, then the hospital gets a full day room charge of revenue for that 5 minutes. If the patient is admitted to floor at 0005 then the hospital doesn't get paid for that patient until the next midnight. So at least from a revenue standpoint, the purpose is to take those patients who might have otherwise been admitted at 0005 and make sure they're on the floor at 2355, which gets the hospital an extra few thousand in income.
In theory no verbal report speeds things up because it allows the patient to be moved to an inpatient unit even if the receiving nurse is too busy at the time to receive report, the obvious problem with that is this would also mean the nurse hasn't had a chance to read the written report or look the patient report, which means they are getting a patient they haven't gotten report on which is problematic and potentially not legal.