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.
Your last sentence really should be qualified with "based on the setting." I give and get report from a variety of settings--ICU, ER, PACU, GI lab, cath lab, IR, SNF, rehab, medical, surgical., telemetry. Every one of those nurses gives report differently and expects report differently. Maybe I'm the odd one who tries to give report based on the setting the patient is going to. I also ask questions of reporting nurses that are a priority to start my care of the patient, wherever I may be. If I'm working SNF that day getting a patient from acute floors, I will ask about bowel movements, any pain management problems, and if there are wound care orders. I will not ask that of ER nurses, however, when I'm working acute floors.
The settings we work in dictate what we need and want to know and what's important.
I agree, as have worked all levels of care also. And working in the ED I know what each one needs to know, versus what they want to know. Wanting and needing are to different things. Wanting to know what gauge the IV is…is not important unless it directly related to the plan of care.
Report yesterday from ED solidified why verbal report is important. It was a very screwed up medical and nursing plan of care due to the family. The ED nurse and I didn't talk about IV site, interventions, etc. We just spoke about plan of care--or lack of it. Different docs with different ideas on how to handle it, family dynamics, decision-making (or lack of). It was VERY important for me to know these things.
In this situation, it helped me prioritize the conversations I wanted to facilitate on the floor. I (or, more importantly, the patient and family) NEEDED to have the attending/PCP talk directly to the family to figure out how to proceed. When the resident came in to accept the patient, I insisted that he get the attending in the room before he did anything else. Frankly, he seemed relieved by this, and the conversation did happen, and the plan of care was clarified and acted upon.
This is the stuff I would like the verbal part of the transfer to focus on.
If, as where I work, the objective information is easily accessible in the EHR, I think verbal report should be limited to subjective info, impressions, etc.
In a perfect world:
Med surg, icu, ortho would decide what information they feel they need before receiving a pt. The computer would generate the report. If the pt is transferred by the ER nurse, a short bedside report would be done. Like all bedside reports, there would be the option of that out-of-the-room-private-report that we know is often helpful.
This would stop m from looking up things that are equally accessible to the next nurse. Maybe if it was printed, nurses who carry a brain sheet could just carry it.
Really though.....why so serious? Getting so angry over a tongue in cheek comment.
And no, I don't work in the ED. And I'd be willing to bet you don't work in my facility. So you don't know what gets said to us on the phone for report or how things get handled.
Calm down buddy, it's the Internet.
Who said I was angry? I asked you some simple questions which you have not answered. It gets extremely tiresome for ED nurses to constantly get accused of holding onto patients when it simply isn't true. I highly doubt anybody is actually telling you that so basically you are perpetuating that myth. And how can you be sure I don't work in your facility?
Also, for the record I'm not your buddy, I'm not a dude and I don't need to calm down. I'm actually quite relaxed.
Who said I was angry? I asked you some simple questions which you have not answered. It gets extremely tiresome for ED nurses to constantly get accused of holding onto patients when it simply isn't true. I highly doubt anybody is actually telling you that so basically you are perpetuating that myth. And how can you be sure I don't work in your facility?
Also, for the record I'm not your buddy, I'm not a dude and I don't need to calm down. I'm actually quite relaxed.
That myth is actually pretty amusing, A co-worker who was at a meeting heard a reference to us "holding on to patients" and was completely shocked that anybody would think that. I also had no idea anybody in my facility could actually believe that given the great lengths we go to to try to get the patient to the floor. We chase hospitalists, floor nurses, etc.. I even have a couple of tricks up my sleeve to get nurses to actually take report.
But it is enlightening to learn that anybody could actually believe that. On the other hand some people believe in alien abductions, so I guess this isn't that far fetched.
I am quite sure it must happen somewhere, but I have yet to see it.
I actually do read the chart when I can. I usually get a better report that way. Nurse or tech bringing the pt up usually hardly even knows the pt's name , much less any pertinent info.
Trouble is, sometimes the bed is booked and pt is already on their way up. There is NO TIME for me to scan the chart. I have literally gotten of the phone with bed assignment, and the pt is arriving on floor. Not exaggerating.
If I have time, I do read the chart. sometimes my hands are tied.
I would like to extend your proposal to the report that happens on the "front end" of the ER patient transfer - the one that happens between EMS and the ER. Why should EMS be wasting everyone's time calling ahead? What info could they provide that can't be found in the paperwork they leave when they drop the patient? You'll be able to see what lines (if any) are present, whether or not intubated, etc. when the patient rolls in. When was the last epi given? It's right there in the paperwork... just scan the paperwork for 2 minutes and you can know just about everything.
Ha. This is what happens in my ED. We get a text page (no more than 250 characters) with basics. An example: "Med 21. Male found down, CPR and intubated. 5-10 out."
First of all, I consider myself lucky if I get a handoff from the ER on a new admit...I am happy with whatever info you can pass because I often get less than 5 minutes notice that I am getting a new patient and if I am in the middle of trying to pass meds or other patient care, I may not even have time to look up the patient's name before the gurney hits my floor. Also, in our system, I have to go to the ER patient list to look up a patient until they are admitted to our floor (which means they are sitting in the bed in front of me)...no, it isn't a fast task to look up anything. I often have patients arrive with IVs that are not documented yet...and I can't verify the new orders until the patient is admitted to our floor so I don't know what are ER orders and what are inpatient orders prior to the patient arriving. I am constantly being surprised with patients who were started on blood in the ER and arrive without a pump nor anyway besides eyeballing the bag to determine how much blood is still in the bag...this patient becomes my priority patient even if I have phone calls out to doctors for other patients who have suddenly spiked a fever, have out of control blood sugars, or have unaddressed pain needs....and I am trying hard not to let my computer go to sleep while figuring out things that a good organized SBAR handoff would have included....like why this patient with the diagnosis of "FEVER of unknown origins" has been afebrile since she arrived in the ER 10 hours ago (I can only assume that she was admitted based on throwing a fit in the ER because no one handed her off to me).
I agree, as have worked all levels of care also. And working in the ED I know what each one needs to know, versus what they want to know. Wanting and needing are to different things. Wanting to know what gauge the IV is…is not important unless it directly related to the plan of care.
IV gauge is very important if Hmg are low and the patient may be getting blood (fairly common reason for admission onto my floor) or the patient may be getting a contrast dye for a scan...it also prepares us for how hard this patient will be to get IV access in. If a patient is coming up with a 22 gauge from the ER, I know that they are either very dehydrated or may be a potential PICC line patient since I know that ER nurses are experts at placing IVs.
I have two serious, not intended to be snarky, questions too.
Why does the ER try to call report ahead of shift change as in:
"he won't be coming on your time but can I give report now?"
The receiving nurse on the next shift is the one who needs the report, not me, in order to provide basic nursing care.
Is the oncoming ER nurse expected to assume responsibility for a human being in her care and know nothing about the patient?
example:
I admitted a GI hemorrhage pt with an INR of 8 and the ER nurse responsible for this person had no idea how many units of blood products were given and actually said "I don't know anything about this patient." The off going ER nurse called "report" to the unit on the previous shift and apparently forgot to address the orders for blood products.
I read the chart, which was a waste of time, because nothing was documented about transfusions, there was a triage note, two sets of VS three hours apart by the tech and not one other factual piece of information to go on.
^^^THIS!!!
I WORK in the ER and THIS is one of my pet peeves!!! I'll get change-of-shift report from the previous shift RN on a SUPER sick patient
ANO NOTHING HAS BEEN CHARTED!!!
No assessment, no clinical notes....just a set of vitals sprinkled every 2-3 hours and MAYBE a GCS.
On SUPER SICK patients that have been "taken care of" for several hours.
WTH?!?!?!
If I have this problem IN THE ER from ANOTHER ER nurse, I can sadly assume floor nurses sometimes face the same problems.
My take-away from this?? We are ALL busy nurses, no matter what floor we're on. Let's be considerate of each other and give the type of patient report WE would like to receive, yea??
One of the facilities I work contingent at just recently addressed this via a committee of med-surg, ED, and ICU RNs. Per that facilities new protocol the ER nurse is only responsible for transmitting patient's age, name, chief complaint, allergies, last vital signs, what tests were performed via circling them on a sheet and what treatments they got in ed. They also list the results of any critically abnormal, though not necessarily abnormal tests. The ed RN may list abnormal labs that they did not treat such as low k etc. and whether or not a field start IV is present or not. This is it. There was quite a bit of grumbling from the ICU and med surg RNS to which the committee members sent us a letter that stated:
"We expect that all nurses in all levels of care are performing critical assessments on each of their patients, including their response to any ordered interventions. You should be assessing your own body systems and if a change is noted from what was charted in the ED, alert the covering resident. The ED RN is not required to note the location or gauge of IV. Each nurse should be assessing the location, gauge, and functional status of IVs for themselves, every shift."
When word got back via the ED RNs that it wasn't working out via phone they changed to a faxed report only and then the ED RN only calls the floor to alert that the patient is on their way up in 15 minutes. For ICU they still do a nurse to nurse hand off with that sheet and to verify what tests have been completed. They trace lines together and verify what meds are running and let the ICU know what still needs to be done.
This facility also mandates that whoever admits the patient medicine, surgery, ICU, etc. have a complete H and P and completed med rec as well as an admission progress note in the computer prior to moving out of the ED.
This facility also requires centrals and arts to be started in the ED by the admitting team if deemed necessary.
The ED RNs do us a great service in that most of them always start a second PIV. So even if a patient arrives with a field start all we have to do is pull it within 24 hours. Most of them also include extra data in the notes section of the faxed sheet. Most of them will also alert the floor to problem family members etc.
It has worked out surprisingly well and has resulted in an increased amount of communication between the admitting medical team and receiving floor taking the ED nurse out of the equation all together. I do both med surg and ICU at this facility and it works well in both areas. It puts the responsibility of communicating vital treatment information on the physicians via notes and orders which is where it belongs in my opinion. When I get a patient on med surg I can see via the doctors notes and the orders what their plan for my patient is. When I get a crashing patient in ICU I already know I have a verified usable central line and can hit the ground running.
One of the facilities I work contingent at just recently addressed this via a committee of med-surg, ED, and ICU RNs. Per that facilities new protocol the ER nurse is only responsible for transmitting patient's age, name, chief complaint, allergies, last vital signs, what tests were performed via circling them on a sheet and what treatments they got in ed. They also list the results of any critically abnormal, though not necessarily abnormal tests. The ed RN may list abnormal labs that they did not treat such as low k etc. and whether or not a field start IV is present or not. This is it. There was quite a bit of grumbling from the ICU and med surg RNS to which the committee members sent us a letter that stated:
"We expect that all nurses in all levels of care are performing critical assessments on each of their patients, including their response to any ordered interventions. You should be assessing your own body systems and if a change is noted from what was charted in the ED, alert the covering resident. The ED RN is not required to note the location or gauge of IV. Each nurse should be assessing the location, gauge, and functional status of IVs for themselves, every shift."
When word got back via the ED RNs that it wasn't working out via phone they changed to a faxed report only and then the ED RN only calls the floor to alert that the patient is on their way up in 15 minutes. For ICU they still do a nurse to nurse hand off with that sheet and to verify what tests have been completed. They trace lines together and verify what meds are running and let the ICU know what still needs to be done.
This facility also mandates that whoever admits the patient medicine, surgery, ICU, etc. have a complete H and P and completed med rec as well as an admission progress note in the computer prior to moving out of the ED.
This facility also requires centrals and arts to be started in the ED by the admitting team if deemed necessary.
The ED RNs do us a great service in that most of them always start a second PIV. So even if a patient arrives with a field start all we have to do is pull it within 24 hours. Most of them also include extra data in the notes section of the faxed sheet. Most of them will also alert the floor to problem family members etc.
It has worked out surprisingly well and has resulted in an increased amount of communication between the admitting medical team and receiving floor taking the ED nurse out of the equation all together. I do both med surg and ICU at this facility and it works well in both areas. It puts the responsibility of communicating vital treatment information on the physicians via notes and orders which is where it belongs in my opinion. When I get a patient on med surg I can see via the doctors notes and the orders what their plan for my patient is. When I get a crashing patient in ICU I already know I have a verified usable central line and can hit the ground running.
This is exactly what we did and it worked out remarkably well despite initial push back. Instead of playing phone tag (or patient hot-potato as the case may be) we used the time to fill out the info sheet (that the floor nurses designed) and added anything we thought pertinent. Of course if there was anything that really needed communicated verbally we or the floor nurse would call. The floor nurses got the info needed and a 15 minute heads up. It did much to improve the peer relationships between the floor and the ED which led to less untrue generalizations (like ED nurses holding onto patients until shift change) and when something untoward happened like an IV infiltrating or a patient soiling themselves on the way up there was much less hard feelings about it. That being said I never sent a patient up with a sketchy line (unless a hard stick but then I let the floor nurse know) or soiled briefs/linens and the floor nurses knew that.
eroc
218 Posts
I agree, as have worked all levels of care also. And working in the ED I know what each one needs to know, versus what they want to know. Wanting and needing are to different things. Wanting to know what gauge the IV is…is not important unless it directly related to the plan of care.