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How The Other Half Lives

I read a lot of ER nurse blogs. I know I’ve seen a lot – and I know they’ve seen much more. You think it’s an some kind of urban legend when you hear about patients coming in with a
broken nail
(by ambulance no less! Where do these people come from?) but no – apparently it happens.

I’ve also noticed that some blogger ER nurses are frustrated by floor nurses. Girlvet says that floors in her hospital “refuse patients” or won’t take report because the admitting nurse is “busy” or “at lunch.” This causes a delay in getting the patient to the floor and ties up the ER bed even longer, causing patients to back up in the waiting room, patient dissatisfaction, the whole sequelae.

And ERnursey says, “Plenty of times when we are holding patients due to staffing there are nurses on the floors with all their work done sitting around the nurses station.” The title of that post is Why Nursing Ratios Are Failing Patients.

I won’t lie. I have seen charge nurses refuse patients to ICU (let’s see… supervisor calls over wanting to send us a 70 year old man who originally came in with low BP and low oxygen sats, but is tuned up after some IV fluids, is on no pressors, stable on some nasal O2 and yet he still has to come to ICU? Why?? Sorry, but I only have one bed left, and he ain’t takin’ it.) Tell me – what are the reasons given for floors refusing patients? I honestly don’t know.

In the past, I have seen instances of the nurse not being available to take report from ER. Yes, sometimes they’re at lunch. Before nursing ratios were actually enforced in my ICU, the person covering the nurse at lunch ALSO had their own patients in addition to watching the other two. That’s 4 critically ill patients. ICU patients are supposed to be at a ratio of 1 RN to 2 patients max. And those patients were wives, husbands, mothers, daughters, etc. Would you want your critically ill beloved family member being watched by a nurse who also has to watch 3 other critically ill patients? When they finally decided to start honoring staff ratios, we got a “break nurse.” This nurse watches patients for RN’s who are on a break, at lunch, etc. This means that when ER calls over to give report on a patient we’re getting, there is someone there to take report.

Nurses are also busy sometimes. Too busy to take report, even. I know ER likes to say that it doesn’t matter how busy they are, the patients still roll in. It also doesn’t matter how busy we are when there are critically ill patients in the hospital. We’ve had patients come over on balloon pumps from the cath lab with about 5 minutes notice, and code blue’s can happen any time. We have to respond to those and shift our staffing accordingly. So we are aware of what it’s like to receive very sick patients at a moment’s notice. But honestly – if we’re stuck in a patient’s room, elbow deep in poop, are we really supposed to drop everything to come and take report? I know in our unit, if the admitting nurse will be more than a few minutes, someone else will take report on his/her behalf. Sometimes there simply is no free nurse to do that. We do the best we can. It’s drilled into our heads on a daily basis that the ER is backed up and whenever they “go red,” all of the charge nurses find out about it and we try to help however we can.

As for nurses who are just sitting around on the floors while the ER is holding patients – come on now. I do believe you when you say that you’ve seen nurses sitting around, and when the opportunity arises for me to actually sit down and shoot the breeze with my coworkers, I take it. I also know that I have gone over to ER to borrow equipment to find them sitting around doing nothing while we’re 50 feet down the hall drowning in sick patients. It does go both ways. Are there patients backed up and waiting because the ICU is drowning? No, not always – but I say this to demonstrate that we do know what it’s like to be busy while other units are twiddling their thumbs. It happens in almost every unit.

Another reason for back-up is late transfers and discharges that go home later in the day. Docs discharge patients, but their ride can’t come and get them til the afternoon. Or placement has to be arranged, including transportation. ICU can have 5 patients that are able to transfer to the floor, but there will be no beds to transfer them to until later in the day. That causes back-up on our unit. I’ve also had this situation to deal with more times than I can count: ICU is full to the brim, with several patients to transfer out to med/surg, but there’s not a bed to be had by anyone. The supervisor will tell us time and time again: “Nowhere to transfer patients, all units are full (no beds) or no nurses to take the patient.” Then ER has a patient for us and viola!!! Somehow a bed has opened up on med/surg! Yes, a bed has just appeared out of nowhere, complete with a nurse to take the patient. Where was that bed/nurse combo 5 minutes ago? Who knows. We’re told, “Hey, ER has a patient for you, so go ahead and send bed 5 up to med/surg.”

All I know is that ER has been notified that ICU now has a bed and 30 seconds later calls to give report, but I haven’t even gotten the patient out yet! Why? Because I have to get the patient on a gurney, call the flex nurse to accompany if necessary, call transport to take the patient up. And I have to try to call report, too. I also used to get a lot of “the nurse is busy, she’ll call you back” or “the nurse is at lunch” before break nurses (ie, keeping-us-within-ratio nurses). I still get it when the nurse is there on the floor but is truly busy with one of his/her other patients. Maybe she’s in the middle of an important conversation with a family member, discharging a patient, teaching someone about how to prevent pneumonia, drawing up insulin, whatever. Am I supposed to insist on disrupting patient care? Well, sometimes I have. Sometimes I’ve begged someone, anyone to take report and give it to the accepting nurse when she gets a chance. Sometimes they’ll do it, sometimes they won’t.

And THEN we have to wait for housekeeping (sorry, Environmental Services) to come and clean the room. There are so few of THEM on the off-shift that you could wait up to an hour… and don’t even ask them to come when they’re at lunch. Forget it. You can say that you need the room cleaned emergently to admit an ER patient and if they’re on minute 5 of their lunch, the rest of the 25 minutes will be taken.

And it sounds bitchy to expect someone to come back early from their lunch. But I can guarantee you that almost every nurse has done it when the need arose. As a nurse, I have taken the patient up to the floor myself when flex and/or transport is tied up. I have even seen other nurses take a mop to the floor when EVS won’t or can’t come.

My point is that if we could have just transferred the patient when we got the orders, the patient would be out of the room and the bed cleaned and ready to go by the time ER calls with report.

There are many pitfalls to this system. Every unit experiences frustration with how things are done. I like the idea of having a person on-call to deal with admissions, but honestly? Sometimes we don’t even have enough nurses to deal with the patients already on the floors. Please don’t knock ratios, though, until you’ve walked in a mile in our shoes. You wouldn’t want your family member’s nurse to have 7 other post-op patients to take care of when research has shown lower rates of mortality if that nurse only has 4 other patients.

I’m not trying to pick on the ER nurses… we all have our perceptions. I appreciate reading about the frustrations of their jobs and hope they don’t mind hearing about the frustrations of mine. Any med/surg nurses want to chime in?

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Excellent post!!! We have a system in place that works amazingly well, although at first we thought it was cumbersome.

We write our reports out, fax them to the unit where the bed has been assigned, call and say “fax is coming through” and then take the patient up 30 minutes later! The nurse gets 30 minutes warning, the report is at his/her fingertips and there is no reason to stop anyting for report.

And I have never begrudged any nurse time to sit. Believe me, the house above my ER can be hell and we will have no one in our department or there are 20 beds available and we are running.

I’ve done med/surg, Corornary Care, Intensive Care, Psych, clinic and Emergency. So I’ve seen it from all angles.

It’s funny, we are astounded in ER when people expect everything immediately and yet we have a tendency to expect everything to be immediately ready for us when a patient is ready to go up. I know, I’ve done it. Not proud of it, but there you are…

Here in CA, ratios are the best thing that has happened to us. I’ll check out the links you provide to get an overview of the dialog.

One of the things nurses need to do is to start treating other nurses with more respect. As the posts point out, we all have our pressures, needs, and demands. Give each other a break folks, you are not the only person under stress, your patient isn’t the only one dying. Talk to your peers, and work out a plan that everyone can deal with.

We have the same system that Kim mentions. It works well. Even before it we had a pretty good relationship with the ER.
There are bottlenecks gumming up patient transfers on both sides.
Floors can be unreasonable, ER’s can be unreasonable. The blame is probably equal in most cases.

I have more problems with ancillary departments, like radiology who, I understand are crammed with orders to fill, call up for a patient with the grating assumption that you’ll drop everything to bring them down.
Their world seems more disconnected from direct patient care, thus making their ‘requests’/’demands’ all the more annoying to me.

That’s the clusterf**k of daily hospital life. It’s just grand.

Well said. I tend to think of the way patient flow occurs in the hospital as a series of negotiations. Everyone is approaching it from a different angle. That being said, nurses should respect where one another is coming from. I’ve heard ICU nurses trash-talk ER nurses (and vice-versa) and it really comes down to not thinking about what it’s like to be on the other side of the fence.

Nicely written. I have heard similar complaints in the opposite direction as well. Floor nurses complaining about the ER nurses dumping patients on them, or during times when the ER is in “critical overload” the nurses sitting there cheering as every unit in the hospital comes down to take at least one patient. It is unfortunate that different units seem to often be pitted be against each other…. instead of working together….

Dont know how i came across this blog but i did! Im a charge nurse in ICU in england and the problems you talk about seem to exist the same the world over!Funny really, we in england always think that the US health care system is much slicker ecteria than that of the good old NHS, but alas! the nurse ratios you talk about would not happen where i work, only very rarely would an experienced ICU nurse take 2 level 3 patients (vented etc). Normal is 1:1 for vented and 1:2 for HDU patients. But it makes me laugh how ICU and AE (ER) nurses hate each other the world over! Si

i have a very long comment, so i will spare you the boredom and put it in my own blog one of these days.

I’m one of those notorious ER nurses. Like Kim, we write our reports out on a form, fax it to the floor and they have 30 minutes to get ready for the patient. It seems to work out far better than calling report and being told that the nurse is at lunch or busy or…. you get the idea.

As I read your post though, I thought about one of the posts I read in the “Nursing Voices.” This attitude we have with EACH OTHER merely helps perpetuate the hunger that causes us to eat our young. Our anger should not be towards each other, but towards the ones that cause us to have these difficulties. Am I allowed, this one time, to blame “administration” for putting us in such dire straits?

I just switched about a month ago to OB after working 2+ years in med/surg and I really appreciated this entry. It IS tough on both sides–yes, the ER doesn’t get a break, and it sucks for them—but when it comes down to it, I’m going to prioritize the patients I see in front of me over the ones down stairs. And if I can’t keep up with the ones I have—because there’s a confused, septic 90 year old in 4 point restraints, a vomiting quad with diarrhea and a painful bedsore that has to be changed every hour, along with “just” a routine hysterectomy or mastectomy and all the pain control, movement, much less emotional issues that go along with those—well, it’s not for lack of sympathy that I refuse a patient.

When I worked in the ED, the big complaint from the floor and ICUs was “I’ve got too many patients, that’s not safe.” While that is true, what we often saw in the ER was an even LESS safe situation where the nurse trying to get rid of the patient might have had 3 or 4 ICU patients. I don’t know what the answer is though…

Sounds like those nurses who use the fax report then deliver patient 30 minutes later seem to think it works well. I’m trying to imagine such a system on the OB unit where I used to work: we often didn’t even have a unit secretary on nights. Who would get the fax? Everyone was loaded down with labor patients or too many post partum clusters, charge nurse with her own patients, nurses answering the ringing phone when the passed by the desk.

The fax would hit the floor and when the patient arrived on the unit, there would undoubtedly be no clean room, (housekeeping would be at lunch or not answering their page), and there would certainly not be an available nurse. I miss nursing, but not scenarios like these!

my sister works in er, and I work in icu. I tell her that if her staffing is bad, and she is caring for 4 icu pts then she needs to fix that within her own dept. push for more staff? Just because her work environment isnt the best, doesnt mean we should endanger our pts by accepting someone we know we cant care for. some do take advantage of the veto power (refusing a pt)and should be more flexable. My hat goes off to er nurses, they are a special breed of people.

I have been working both critical care areas for 30 yrs and I finally came to the conclusion a couple of decades ago that if I just tell the ER nurse to not tell me her problems,and that it’s fine on this floor, she goes away.
Not happy, but the important thing is, she finds something else to do with her spare time.

i don’t want to hear sob stories about being buried in poop, there is someone on the unit who can take report. if a trauma rolls in there is always a nurse there to run the code. it’s simple to take off the gloves and put on new ones. i have gotten the most lame excuses for not taking report….putting a pt in restraints, starting a line, one heifer even said she was at lunch.. lunch break? what’s that? i ate my sandwich in two bites on the toilet. and they say they’ll call back, they never do. or it’s shift change, they’re in report. yeah, your report takes half an hour mine will take two min. no, i don’t know the last bm, the pt came in dead now has a pulse, i’m sending him up. further more, it does take a good half hour to get a pt up, espec if on a vent. so, in conclusion, when i have an acute mi in one room, two strokes in the other two, and one baby tripoding and breathing 50 times a minute, i don’t give a damn that the poor ICU nurse already has 2 pt, one which is down graded to tele and doesn’t count because ems is coding a pt on the wall because we don’t have a room. all nurses should have to do a month in the er before they dictate protocol.

I have worked on a Med/Surg/Rehab floor and TCU floor. The only time I have heard of us refusing to take a patient from ER is because they were too unstable for our floor and needed to go to the ICU instead.

Okay thanks Bryan and Jill. I have recently (in the last year) changed from floor nursing (oncology) to ER. I remember bad mouthing the ER for sending up a patient without having their stat orders done or complaining because of the lack of report but now�. I know better.

Okay when we are up to our elbows I can have:
rm 6 a confused GI bleed playing in his bloody poop with blood hanging (your pt)
rm 7 a patient actively seizing despite medical interventions
rm 11 trauma (count the holes and pluge em)
rm 12 overdose

oh and ems just called with a cardiac arrest and its got to go to rm 6 but the nurse wont take report so I move the patient to the hall space by the nursing station on portables, Cleaned the room (yes me not the EVS folks remember he�s been flinging bloody poo), and prepare for report of about two seconds as they wheel the guy in.

AND YOU SAY GET BETTER STAFFING?!? Who? Where? Show me a hospital not in need for staff ! Its just not that simple if there is not a qualified person to fill the hole!

Oh and I would love to count the number of times I had only a cup of juice to keep my blood sugar from dropping.

(BTW I Still LOVE my job)

the answer is “see you when you get here”. always. if everyone practices this like ER nurses the flow would go a lot smoother. we don’t NOT work up an active cp b/c we’re out of monitored rooms or heck, even a room! we don’t ask an ambulance to circle the block. we say “see you when you get here” we never ask a medic to wait on the dang phone while we find the nurse that is going to get that patient. in the moment its so busy everyone running with their heads cut off. but you hurry and tackle it then it’ll calm down again. if you take “no” and all the excuses out of vocabulary, the people that matter would be happier, the patient and administration. i’m sorry i’m saying we don’t in this equation, but it’s a voluntary army. if patients aren’t happy, then they aren’t returning. and if patients aren’t happy and / or returning, then administration REALLy isn’t happy, and guess what, they PAY us! so, i’m all about making the two happy. and i’ve never seen administration encourage pt holding in ed. i’ve never seen a press ganey with glowing scores when a pt waited 8 hours in ER for a bed. i work for a private one owner hospital and i realize how pt satisfaction and paying the bills of the hospital go hand in hand. there are studies out that say holding a pt in ED tacks on admittance hours of total stay. this is a constant battle and its senseless. the answer is “yes”,, always “yes, i’ll see you when you get here” or “i’m an RN and can take report”

Okay–so I’m weighing in on this issue. I have a lot of good friends who work ER, and I’ve done it myself. That said, my home is ICU. The paperwork and the expectations of care are different between ICU and ER. In ER the mentality generally is (with good reason) stabilize and transfer. In the ICU we get the (sometimes) stabilized patient in addition to having other critical–i.e. not stable–patients to care for. I have never refused report from ER though I have told them–”Listen, you understand that this makes my third critical patient. I don’t have a doc right there beside me, and I don’t have a tech.” The moral? Don’t bitch about it until you’ve been there.

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  • profileI am Gina. I have been a nurse for 15 years, first in med/surg, then CVICU, inpatient dialysis, CCU and now hospice. This blog is about my experiences as a nurse, and the experiences of others in the healthcare system - patients, nurses, doctors, paramedics. We all have stories!

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