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?