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When will everyone understand things are different in the ER

Emergency   (10,407 Views | 62 Replies)
by ClayH ClayH Member

ClayH has 6 years experience .

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Mandychelle79 has 2 years experience as a ASN, RN and specializes in Psych.

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I only care when the LBM is if they are being admitted for something like lower abdominal pain, illeus, etc. most of the time I'm asking people not to read me the computer screen. Give me he basics because this is most likely not my only admit of the night.

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I find that it's the less experienced floor nurses who ask questions like pt's LBM. Give them a break and just politely say "I don't know". Because I work night shift where the pt may not see an MD until the morning, I do ask that the pts come to the floor with basic orders like pain meds, telemetry, diet, sliding scale insulin. Also, please try not to send me a pt who's been on NRB for 30 min and O2 sat is 90%. This person is not stable enough for a telemetry unit.

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Because I work night shift where the pt may not see an MD until the morning, I do ask that the pts come to the floor with basic orders like pain meds, telemetry, diet, sliding scale insulin.

That is perfectly reasonable, but realize that such orders should rightfully come from the inpatient side (in a legal sense, not a "workload" sense). How would you like to be the provider on the hook for ordering all these things on a patient whose care you will no longer be participating in, when you have no planned future interactions with the course of care? Given the regulations we all are working under, it is no longer acceptable for the ED to provide any sort of long-term inpatient orders. Any thing more than brief (4 hours or less?) holding orders is not acceptable. I'm not saying it isn't fairly common, but it is not acceptable. The patient's status has been changed to inpatient and for various legal reasons they should be receiving care in line with that fact, not having a set of generic orders placed by an outpatient physician so that no one else has to see the patient for the next 12 hours. Whether its 0200 or 1400 shouldn't change that.

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bgxyrnf has 10 years experience as a MSN, RN and specializes in Med-Tele; ED; ICU.

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Because I work night shift where the pt may not see an MD until the morning, I do ask that the pts come to the floor with basic orders like pain meds, telemetry, diet, sliding scale insulin.

Unless the patient is boarding in the ED, I do not review the patient's admit orders beyond the level of care. If the floor nurse sees deficiencies in the floor orders, it's on them to contact the hospitalist to resolve those issues. In the ED, I am responsible for the ED orders and working with the ED physician as needed for clarification or modification.

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~Mi Vida Loca~RN has 6 years experience as a ASN, RN and specializes in Emergency Dept. Trauma. Pediatrics.

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Scrolling though this it reminded me of a common misconception to some non ED Folks. ED Docs don't admit patients. Inpatient docs do. So the orders you need, the questions you have concerning continuing patient care and so on has to come from the inpatient side and addressed to the inpatient docs. I have had many nurses before confused on this and they assumed the ED docs admit the patient and then the inpatient doc will make their way. No, the ED docs consults and advises an admission and if the inpatient doc refuses they have to keep "shopping" until they find a service willing to admit.

Some ED docs with dual specialties (EM/IM or EM/) for example, or off service docs rotating in the ER might have some pull and can start the process on behalf of the inpatient team. But ultimately these things need to come from the inpatient nurse contacting the admitting physician.

Various hospitals have various protocols on what basic orders the admitting docs need to have in to send the patient to the floor, however; in the ER we answer to our charges, and house supervisors (whatever your hospital calls them) and when we are told we have a room number and someone to give report to, we are expected to do that and the the patient our within so many minutes. So if we are going to get upset, lets get upset at the proper people for these things.

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12 Followers; 3,832 Posts; 28,928 Profile Views

Scrolling though this it reminded me of a common misconception to some non ED Folks. ED Docs don't admit patients. Inpatient docs do. So the orders you need, the questions you have concerning continuing patient care and so on has to come from the inpatient side and addressed to the inpatient docs. I have had many nurses before confused on this and they assumed the ED docs admit the patient and then the inpatient doc will make their way. No, the ED docs consults and advises an admission and if the inpatient doc refuses they have to keep "shopping" until they find a service willing to admit.

Good synopsis and I agree it is widely misunderstood. I don't think people really think about it at all. The only reason ED docs were EVER writing "admission" orders to begin with was as a courtesy to private practice physicians, based on a basic phone call between the two and usually the primary's preferences. The days of it being acceptable from a legal standpoint are long gone.

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~Mi Vida Loca~RN has 6 years experience as a ASN, RN and specializes in Emergency Dept. Trauma. Pediatrics.

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Good synopsis and I agree it is widely misunderstood. I don't think people really think about it at all. The only reason ED docs were EVER writing "admission" orders to begin with was as a courtesy to private practice physicians, based on a basic phone call between the two and usually the primary's preferences. The days of it being acceptable from a legal standpoint are long gone.

Yea I never knew this was a misconception until one of the nurses in report asked me one time why I couldn't just ask the doc since they were right here. Then it clicked and she told me she thought the ER docs admit the patients and put in basic orders and then a service will come by. But I explained to her for liability reasons that's not the case because once the patient leaves the ER the doc has no more to do with the patient. Now my best friend is EM/IM and ICU and so he can have a little more pull in the way he handles his admissions, especially if he plans on continuing the care, and I know many EM/IM docs that can get some pull from their other service. But all of these are such rare occurrences.

I have tried to explain in report too that I barely know the inpatient docs, now if I know it will be a while to get a bed and stuff I absolutely will go to my ER docs and try to get an order for something to get them by or go ahead and redraw a lactic of something I feel is important and I don't want to get missed. My best friend ingrained in me to think both EM/IM since that's what he did. However, they inpatient nurses are well more knowledgeable on the paging system and getting a hold of their docs than I am. If I want my doc I simply overhead them or go find them in the ER.

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ED orders expire in 24 hours anyways in my facility. If pts come from ED with simple orders like tylenol, telemetry, cardiac/DM diet, it makes life easier on everyone and the floor nurses will really appreciate you for it. If a pt is being admitted under a hospitalist service, I don't expect orders from ED. There are always those crabby attendings who hate being paged at 3am to be asked if it's OK for a pt to have a sandwich. I'm just saying...jeez.

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ED orders expire in 24 hours anyways in my facility. If pts come from ED with simple orders like tylenol, telemetry, cardiac/DM diet, it makes life easier on everyone and the floor nurses will really appreciate you for it. If a pt is being admitted under a hospitalist service, I don't expect orders from ED. There are always those crabby attendings who hate being paged at 3am to be asked if it's OK for a pt to have a sandwich. I'm just saying...jeez.

I truly do hear where you're coming from, but it's not okay. I feel for the inpatient nurses because hospital policy and medical staff bylaws are the avenues through which this should be addressed. Think about the larger view: Your place's ED doc writes orders that are good for 24 hours. Is this doc kept in the loop about what's going on with the patient and whether or not his/her orders might still be appropriate? No. It is a huge liability for them to be active on this chart when they have no further input into the patient's care. This should stop. I know it's not your (plural) fault AT ALL. But it's not a good practice. Not to mention from a patient's point of view. Someone is paying for an inpatient level of care for that patient (whether their own insurance, gov't, etc.). It is not okay to say that the attending service has a long period of leeway for getting actively involved. I know it's very hard to make change, but there is no excuse for the on-call attending provider to not be able to enter computer orders. Rightfully they should have a practice of seeing the patient in person without regard to day/night shift. This is a 24-hr operation and the patient is getting charged.

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~Mi Vida Loca~RN has 6 years experience as a ASN, RN and specializes in Emergency Dept. Trauma. Pediatrics.

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ED orders expire in 24 hours anyways in my facility. If pts come from ED with simple orders like tylenol, telemetry, cardiac/DM diet, it makes life easier on everyone and the floor nurses will really appreciate you for it. If a pt is being admitted under a hospitalist service, I don't expect orders from ED. There are always those crabby attendings who hate being paged at 3am to be asked if it's OK for a pt to have a sandwich. I'm just saying...jeez.

Every facility I have worked at (6 different ones total in various states) the ED has never put in admission orders as the ED doc. There isn't expiring orders or anything like that. There isn't even the option. I don't feel bad for the doc paged at 0300. They are on call, that's what being on call is for and they are compensated for it.

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I've worked in numerous small, community ERs. My current ER? The ER pages the admitting MD, the admitting MD talks with the ER Doc, and the nurse hand writes orders because the admitting MD doesn't want to use the computer. Which means the ER nurse has to think like a floor nurse and an ER nurse, and well, it's exhausting. Generally it's basic orders like Dx, consults, etc. Basic meds. But because you talk to the admitting MD, the floor RN expects you to think of everything they would think of--break through pain medication if the main pain medication isn't enough; PRN for every conceivable thing; labs tha tshould be ordered; various other consults (psych, ot/pt/st, etc).

About 5% of the time you're the one that is telling the doctor that the pt. isn't suitable for the level of care they are suggesting. No, I'm not going to admit someone who's BP is 230/120 after 5 doses of IV BP medications to tele for observation. Sorry, the floor would freak out and not accept the patient.

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I've worked in numerous small, community ERs. My current ER? The ER pages the admitting MD, the admitting MD talks with the ER Doc, and the nurse hand writes orders because the admitting MD doesn't want to use the computer. Which means the ER nurse has to think like a floor nurse and an ER nurse, and well, it's exhausting. Generally it's basic orders like Dx, consults, etc. Basic meds. But because you talk to the admitting MD, the floor RN expects you to think of everything they would think of--break through pain medication if the main pain medication isn't enough; PRN for every conceivable thing; labs tha tshould be ordered; various other consults (psych, ot/pt/st, etc).

About 5% of the time you're the one that is telling the doctor that the pt. isn't suitable for the level of care they are suggesting. No, I'm not going to admit someone who's BP is 230/120 after 5 doses of IV BP medications to tele for observation. Sorry, the floor would freak out and not accept the patient.

That sounds like a horrible place to work. I worked in a very small community hospital before where the MDs hated putting their orders in so the nurses did everything. I lasted there for less than a year. I feel for ya.

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