ER nurse with a serious question. The question only applies to nurse who have access to the ER's computerized chart.
Why don't you just read the chart?
It has all the details you ask me about. In fact, I haven't memorized all those details, I just peruse the chart as you ask me.
I don't mean read the whole chart, I mean scan it for the details you want. I have no idea why you need to know ahead of time what size IV and where it is, but it's charted.
As far as a history? H & P, last visit, etc, is all at your finger tips. As far as what time each med was given- when you ask I open the MAR, and read you the times. I even say "I don't know, but it's been charted, I will open the MAR an look". When I say that, I am hoping you will get the hint that it would be faster for you to have already done that. Somehow, you always miss the irony.
Please don't say that you don't have time. That doesn't make sense. Think about the difference between reading something, and having it read to you. I can scan a chart for 2 minutes, and know just about everything. Add to this the fact that I really don't know all the details you want- I just kind of guess. As an ER nurse I may have received that same PT with a 1 minute report. It's all I need.
There is no question that it is faster and more accurate to scan the chart.
Turnabout is fair play, I have some questions for ER nurses. Why do you almost always put IV's in the antecubital which as you know ends up being a positional nightmare if you need to actually use it for IV fluids/meds? Why not the forearm for instance? We spend the night chasing the IV pump as it endlessly beeps, asking the patient to keep their arm straight yet again or asking for an armboard only to be told there are none and in the end have to put in a new IV. This is my biggest pet peeve and can ruin a night as we are subjected to so many endless alarms we don't need another alarm that wouldn't be a problem if the IV wasn't put in the antecubital! I've even read being subjected to alarms can raise your BP and I already have HTN. I don't need the aggravation as there is enough stress already at work without one more alarm blaring all night! Does anybody else get upset about this?
Another issue I have is the ER nurse's response to why BP isn't better controlled or K level corrected because the Dr didn't order it. On the floor we are proactive and speak to the Dr and get orders for meds in these situations, but it seems like the culture of ER is nurses only do what they are told and no more and don't advocate for their patients. Is this just an isolated problem where I work or is this a system wide issue. People please speak up, ER nurses and floor nurses, thanks!
Another issue sometimes the person giving report wasn't actually the nurse assigned to the patient and consequently didn't know much. I don't understand that practice either.
But of all the issues, if ER nurses wouldn't put the IV in the antecubital that would make my life and so many other floor nurses so much easier. Can we have a vote on this? I can't tell you how many times patients have complained about it even when they didn't have running IV's because it was uncomfortable and hurt when they bent their arm and then wanted a new IV. Putting in a new IV wastes time and can be difficult as many patients are hard sticks and we are not all pro's. I have to rely on my fellow nurses who have the knack for getting difficult IVs, but I hate to have to beg others. Unfortunately, I don't have the knack and am mediocre and dread trying to put IV's in, I sure miss the IV team we used to have back in the day!
I don't claim to speak for anybody else, but happy to take a swing.
Turnabout is fair play, I have some questions for ER nurses. Why do you almost always put IV's in the antecubital which as you know ends up being a positional nightmare if you need to actually use it for IV fluids/meds? Why not the forearm for instance? We spend the night chasing the IV pump as it endlessly beeps, asking the patient to keep their arm straight yet again or asking for an armboard only to be told there are none and in the end have to put in a new IV. This is my biggest pet peeve and can ruin a night as we are subjected to so many endless alarms we don't need another alarm that wouldn't be a problem if the IV wasn't put in the antecubital! I've even read being subjected to alarms can raise your BP and I already have HTN. I don't need the aggravation as there is enough stress already at work without one more alarm blaring all night! Does anybody else get upset about this?
I often us AC's because I can get an 18 in. Then I can easily draw blood, usually without a tourniquet, so less chance of hemolysis. And, I am usually comfortable doing subsequent draws, reducing chance of infection from multiple sticks. Aslo- I don't know the patient, and have no idea if they will have a bad reaction to something I give them. There are many emergency drugs best pushed through a big vein, and fluid resuscitation is much faster. And then of course, there is the old CT Angio, If there is any chance of that, gotta have the right access.
If I am confident they are likely to remain stable, and are likely to be admitted, I look for the most comfortable place for the pt, which is generally the forearm- and causes fewer pump issues.
Another issue I have is the ER nurse's response to why BP isn't better controlled or K level corrected because the Dr didn't order it. On the floor we are proactive and speak to the Dr and get orders for meds in these situations, but it seems like the culture of ER is nurses only do what they are told and no more and don't advocate for their patients. Is this just an isolated problem where I work or is this a system wide issue. People please speak up, ER nurses and floor nurses, thanks!
Simply not the case where I work. Most ER nurses I know will advocate for the pt and work as a team with the docs. Just because it hasn't been treated, does not mean the ER nurse din't point it out to the doc.
Admitting docs are a different story- they often see the pt, then sneak off to write the orders. I often don't get a chance to speak with them. When possible, I try to talk to the hospitalist and make sure I understand the plan of care. I also check if an of there orders are critical enough to do in the ER.
Another issue sometimes the person giving report wasn't actually the nurse assigned to the patient and consequently didn't know much. I don't understand that practice either.
Where I work, this generally happens when we have to wait too long to get the patient to the floor. And an ER handoff often focuses only on what the ER nurse NEEDS to know to safely care for the patient for a short time. I really don't need to know all that much, as we have a half decent EHR. My brain has limited storage, and I don't use it to store information easily accessed elsewhere. It's right in the EHR, accessible by me or any other nurse involve with the care of the pt. I realize this way of thinking about patient care is unusual in most specialties, but common in the ER. It's not a question of slacking, it how to best utilize your time.
But of all the issues, if ER nurses wouldn't put the IV in the antecubital that would make my life and so many other floor nurses so much easier. Can we have a vote on this? I can't tell you how many times patients have complained about it even when they didn't have running IV's because it was uncomfortable and hurt when they bent their arm and then wanted a new IV. Putting in a new IV wastes time and can be difficult as many patients are hard sticks and we are not all pro's. I have to rely on my fellow nurses who have the knack for getting difficult IVs, but I hate to have to beg others. Unfortunately, I don't have the knack and am mediocre and dread trying to put IV's in, I sure miss the IV team we used to have back in the day!
Well, you can vote on it, but I am still going for an 18 in the AC. Ever give somebody a drug that tanks SBP to 70? I have. Ever have a benign looking abd pain in that goes into V-fib arrest? I have. Sure did dig having good access. But- If I have the time, and know it will interfere with their comfort, I'll try to start a second line.
Good questions, and a great argument for all staff to cross train a bit in other departments. You would know why I am comfortable caring for a pt with a 30 second handoff from another ER nurse, and I would know why you don't like AC iv's. (FWIW, with 2 years of ICU, I do understand which IVs work well with pumps. I just have different priorities.)
Turnabout is fair play, I have some questions for ER nurses. Why do you almost always put IV's in the antecubital which as you know ends up being a positional nightmare if you need to actually use it for IV fluids/meds? Why not the forearm for instance? We spend the night chasing the IV pump as it endlessly beeps, asking the patient to keep their arm straight yet again or asking for an armboard only to be told there are none and in the end have to put in a new IV. This is my biggest pet peeve and can ruin a night as we are subjected to so many endless alarms we don't need another alarm that wouldn't be a problem if the IV wasn't put in the antecubital! I've even read being subjected to alarms can raise your BP and I already have HTN. I don't need the aggravation as there is enough stress already at work without one more alarm blaring all night! Does anybody else get upset about this?
Another issue I have is the ER nurse's response to why BP isn't better controlled or K level corrected because the Dr didn't order it. On the floor we are proactive and speak to the Dr and get orders for meds in these situations, but it seems like the culture of ER is nurses only do what they are told and no more and don't advocate for their patients. Is this just an isolated problem where I work or is this a system wide issue. People please speak up, ER nurses and floor nurses, thanks!
Another issue sometimes the person giving report wasn't actually the nurse assigned to the patient and consequently didn't know much. I don't understand that practice either.
But of all the issues, if ER nurses wouldn't put the IV in the antecubital that would make my life and so many other floor nurses so much easier. Can we have a vote on this? I can't tell you how many times patients have complained about it even when they didn't have running IV's because it was uncomfortable and hurt when they bent their arm and then wanted a new IV. Putting in a new IV wastes time and can be difficult as many patients are hard sticks and we are not all pro's. I have to rely on my fellow nurses who have the knack for getting difficult IVs, but I hate to have to beg others. Unfortunately, I don't have the knack and am mediocre and dread trying to put IV's in, I sure miss the IV team we used to have back in the day!
I can answer those questions for you.
1. We use the AC because we don't always know if the patient will need fluids, potassium replacement, CT scan or chest compressions. Also many times the patients are dehydrated when they get to us and the AC is the only thing we can find. By the time you get them they are usually re-hydrated and other options start popping up. Furthermore, we constantly have patients rolling in and we don't have time to fart around looking for another site just in case of admission. Or it was a field start and is a perfectly good IV and the patient is already miserable and it doesn't make sense to restart it at that time.
2. Untreated BP and whatnot. We can ask for orders but if the doc says the admitting doc will have to deal with it there isn't much we can do. I'm not going to throw a hissy fit for a K of 3.2. I save those for when a patient needs intubated and the doc is dragging his feet. If it's a life threatening situation you can bet I'll throw a doozy of a temper tantrum though.
3. Lots of reasons for this. The floor refused report long enough that my shift was over and my replacement who barely knows the patient has to give report ( fixed that with faxed report). And before anyone starts howling I worked 9a-9p so my going home did not coincide with the floor nurses shift change. Interestingly someone complained earlier about a nurse that tried to call report before the bed was ready so the floor could talk to the person who had actually cared for the patient. Apparently that is unacceptable too. Or I was too busy with the critical patient who rolled in while I was waiting for you to call back "in 5 minutes" which actually turned into 45 but rather than put you off I asked a peer to give you the courtesy of report as best they could so as not to waste anymore of your time.
I promise all of you floor nurses. The ED isn't staffed with a bunch of nasty people. We have our reasons for doing things the way we do and the last thing on our minds is making life difficult for you.
Fr the folks who have chimed in regarding systems that work well without relying on a verbal report: Thank you.
Many of the responses here demonstrate a belief that verbal report is a critical part of patient care. I have worked in systems without it, but only on the sending end, not the receiving end. I know it is done, and it's interesting to hear from people who work with, and like, a system that uses some more modern technology.
I think any change is difficult. It's a bit like bedside report. Most nurses hate it, nut once you get used to it, ou realize that it is good for pt care, and actually pretty easy.
We do almost nothing on paper in my hospital...the transfer log and maybe a printed ECG report and my brain is the only paper I touch on an entire shift. As for what information I get at handoff, I only really want the info I need to be able to care for the patient straight off the stretcher. I need to know how many modules to have attached to my pump brain (for example: if there is blood and antibiotics). I need to know how big of a priority the patient will be when they hit my floor...can I make them comfortable, say hi, give them a drink or food (so DIET is important), and then pass the rest of my meds before I do the long part of their admission...OR will this patient be screaming in pain or actively vomiting from the minute they arrive and I need to call my charge nurse to help me pass my other meds so I can focus on stablizing this new patient? I need to if they are oriented and if they speak English. I need to know if they are stable to walk to the bathroom or if I better make sure that my tech or I am available since they may not understand that they aren't safe to walk alone. I need to know if I need to be hunting down orders for pain medications since the standard "tylenol" might not be adequate and waking up the attending and getting a response might take some time (often the ER pain orders are one time doses or expire before the patient hits our floor). Nausea meds might take a couple calls to the pharmacy to beg for STAT tubed doses of phenergan so the poor patient doesn't lay their vomiting for the first half hour on our floor.
Basically, I need to know the information to take care of THIS patient. Feel free to tell me to look up something that is a stupid question (like the state of their coccyx if this isn't the admitting diagnosis). I would still love to have had a handoff for the patient with the admitting diagnosis of "Fever of unknown origin" who never had a fever from admission to now 4 days post admission. I was EXPECTING a very sick patient to hit the floor...not a patient who was going to talk my ear off and show up with a suitcase of her personal belongings. Two days prior, I received a patient hooked up to her first unit of blood with no pump (required on our floor for all blood transfusion) and this patient arrive just as I was starting to pass my 2100 meds and do my patient assessments. It was further complicated when my tech called to report another patient (who I had not assessed yet) was running a rapidly rising fever for the first time since admission. Since I had no time to look the new patient up yet, a basic handoff would have helped reassure me that she was basically stable and very familiar to getting transfusions so after 15 minutes, I could have made my fever patient my priority and still had the basics on my transfusion patient. Oh, and the patient arrived without a blood transfusion consent form, so I had to do that prior to ordering her second unit.
Even a short handoff of like "patient is a 48 year old female who throwing a fit in the emergency room and doctor admitted her for further testing, patient's vital signs are stable, we gave her .5mg dilaudid 30 minutes ago, IVs in her left AC with 0.9 @ 75ml, note: patient is a walkie talkie and hasn't had a fever since arriving in the ER. She ate a sandwich in the ER. We have already collected blood cultures and a urine specimen. We have done an abdominal ultrasound but they may be sending her for an MRI yet tonight" or "pt is 30 year old who was told to come to the ER because her doctor discovered low hemoglobin at a regular appointment. Her Hmg is 4.3. Her vital signs are stable and she isn't in any pain. Her blood transfusion consent is in her folder. She is calm and accompanied by her husband. She has an 18 gauge IV in her right AC for blood and a 20 gauge IV in her left arm for possible hydration which is currently saline locked. She is currently NPO while they are deciding if they need to perform surgery in the morning to look for the source of the bleeding. " Both give me a quick peek of what to expect when they hit the floor. The rest of the information, I can look up because it isn't crucial to their care.
however I am no longer allowed to ask if I can call you back when I have a free second as my hospital now says we must take report from the ED and PACU when they call, no exceptions, to help with patient "flow"
So in other words if you are in the middle of:
Preparing a med
hanging a med
a sterile central line dressing change
a complex wound dressing change
giving a bath
doing complex discharge teaching
and many others
You are supposed to stop right then and there and take report? If you are not allowed to call the ED back when you have completed the task in progress, then how long is it acceptable to leave the reporting nurse on hold? The people who run your hospital sound like clueless out of touch morons.
But of all the issues, if ER nurses wouldn't put the IV in the antecubital that would make my life and so many other floor nurses so much easier. Putting in a new IV wastes time and can be difficult as many patients are hard sticks and we are not all pro's. I have to rely on my fellow nurses who have the knack for getting difficult IVs, but I hate to have to beg others. Unfortunately, I don't have the knack and am mediocre and dread trying to put IV's in, I sure miss the IV team we used to have back in the day!
I think it makes sense that the ED usually places in the AC. It is annoying when they get to the floor and constantly bend their arm, but I understand and can appreciate why the ED uses it as their go to site.
Our hospital requires a 20g in the AC or above for CT contrast and several other medications/fluids. Since the ED RN is probably anticipating the patient getting contrast, fluid bolus's, or vesicant meds then the AC seems like a good proactive choice. Also, many patients are admitted dehydrated and the AC is easier than fishing around for dehydrated and sunken forearm veins.
I used to work at a place as a tech where emergency department nurses were no longer required to give any sort of report, bedside or via telephone. I was shocked.
Not surprisingly, the patient satisfaction scores for the ED was atrocious and the hospital has a reputation for being subpar for good reasons.
I don't ask much from an ED nurse report-wise. I understand the ED is busy. But I work on a med-surg floor with five to seven patients. I don't always have the time to shift through a chart.
And I won't even touch the "guessing" comment. Yikes.
And what if the doc still has the H&P in hand? Where do you think I'm going to get my information if not from you?
I don't feel like I ask a lot of questions. It is obvious as soon as the nurse opens her mouth whether I'm going to get good report or bad report. Either you know this person or you don't. It doesn't do much good to ask a whole bunch of questions when the nurse doesn't know anything anyway.
All I want is for the meds that were ordered 3 hours ago to be given before they come up. Or have a good reason for not giving them and send them up with the patient. I'm flexible.
RainMom
1,117 Posts
I think the faxed report works well & don't understand why more places don't do it.