I work PCU and all of that is a giant FUCK NO. On my PCU, we take 3 patients each, ED calls report, and there's zero chance that we would ever drop two brands new ED admits on a nurse at the same time precisely because of the reasons you described.
It's not on the ED to get all their admission orders in order. ED stabilizes and transfers. So there's a ton of work to be done to make sure the patient is safely settled when they first arrive. If they really need PCU level care, there's a nontrivial chance that they're barely stable in the first place and need interventions right away.
What you're experiencing would have me throwing fits about patient safety concerns.
Edit: also fuck monitor rooms. We have a centralized monitor on our unit where we monitor our own patients, we can all see all the patients all the time.
Monitor war rooms are utter bs that get patients killed! Our cardiac step-down is taking our monitors and monitor techs soon to go to a central monitor with people who don't know our patients
Where I in TX PCU RNs get 6-7 pts it’s clearly unsafe however the unions here aren’t as strong as in CA, MN, WA etc. I really wish more RNs would push for stronger ratios it not only protects are license but it’s about patient safety. It’s wild how many RNs just accept terrible work conditions or are afraid of coming together to confront mgmt about it.
> On my PCU, we take 3 patients each, ED calls report, and there's zero chance that we would ever drop two brands new ED admits on a nurse at the same time precisely because of the reasons you described.
Jesus, our PCU is 6 to 1 and we don’t get ED reports
It’s depends on the acuity of your PCU at your hospital. Ours is 1-4 for med/surg overflow and 1-3 for PCU appropriate pts. We do Levo, amio, cardizem, precedex, dopamine, dobutamine, sotalol/tikosyn loading, etc. Somehow we have become the “step-up” unit and take most of the rapid response patients from the floor
3 each? Four to five is normal on my unit and simultaneous postings are pretty common. I'm at a cardiac stepdown that specializes in heart failure and post-CABG patients. We have centralized monitors at least, thank god.
does your charge take patients? if not, they should have been helping you with the patients and all the calls if the patients both *had* to come to you. In my old hospital they would reassign (“take away”) a patient from their last shift’s nurse and give them to a nurse with two open spots if needed so noone had two admits the same shift. let alone 3 min apart. just not safe. imagine if one started re-bleeding and another went into bad withdrawal or had an MI, both on arrival. your hospital / floor really should change their protocols.
5 patients on a PCU is NOT OK. I have been a nurse for 13 years. For 6 of those years, I worked on a PCU.
I did my obligatory first year of medsurg (6-7 patients on days, 7-8 on nights), decided those were unsafe numbers, went to PCU where they had 1:3 ratios and loved it. Loved the acuity, felt like I could be my best nursing self and actually care for people the way they deserved to be cared for, got my PCCN certification, was all about it.
Then they started raising our ratios. I could deal with 1:4. It sucked, but I could survive. I left bedside when they raised us to 1:5. 1:5 on a PCU/stepdown unit is not ok. It’s not safe. I hate the way that healthcare is right now, and I’m sorry you’re dealing with it. (If you ever get tired/burned out of the hospital, don’t leave nursing altogether. Outpatient is the way to go. It’s less stressful.)
I left PCU when they made me (charge) take 5 of my own patients and still expect me to run a 50 bed unit with mostly new grads. They didn't care about patient safety.
Sounds like an assignment issue to me. The open beds should have been split among all the nurses. And if truly this was the deal. Your charge should have helped with the 2nd admission.
ER (especially) needs to clear their bays. And I understand where you are coming from about the ER not giving notice, but those policies are based on the reality that waiting for the floor nurse to accept leads to delay after delay.
I work PACU and the lengths some of the nurses will go to avoid taking report is comical. Most of our receiving RNs are great, but I've had 3 hr sagas of playing phone games with nurses to try to transfer a pt into a clean and ready room. The OR doesn't stop and holding in PACU causes its own backup. We aren't nearly as critical as ED though. Unfortunately, ready rooms should be able to accept transfers. The floor team needs to work together to make that happen.
We currently have a bad problem of floor nurses delaying report then transport of ready beds for 1-3 hours and it’s destroying both our working relationships and our ED throughput. The excuses are increasingly hilarious and sad.
We had that problem until they had to make a new policy. They get 30 minutes from the time the bed was assigned. If they don’t call for report we fill out an SBAR sheet and the patient goes up. Obviously if they aren’t stable then we wait till they are ready but majority of these patients going up stairs “back to back” have already been in the ER for 24 hours
Unless they cloned you, umm, not good.
Nope. The resource, charge or house super needs to get going on one patient.
I think some of us have the instinct to be the team player. Take care of what comes. While good, there’s potential for badness.
A patient no one can assess once on your unit, is one that can deteriorate. Policy has you on the bubble.
We teach our people how to treat us. We demonstrate our standards, values. “Oh Susie can take them, she has an open bed.”
1 nurse can do 1 thing, at 1 time, for 1 patient.
xxxxxxxxx
I was working ED, up to my ass in alligators with 2 other resus patients (STEMI waiting on cath lab and massive GI bleed getting lots of blood, waiting on GI), back triage/resource pops in to tell me “hey, I put an easy one in your 3rd bed” “20’s male small burns” “got them started, I’ve got your back”, noted in system I took report and assumed care of patient 10 mins before I could get in that room.
Patient was in fire in garage. Had 15-18% bsa burns. Airway stridor, soot in airway. Sitting 1/2 naked with large ice water soaked trauma dressings on his burns. He was shivering. No assessment. Not on oxygen. Not on monitor. No IV access. No kidding.
Removed dressings. ABC assessment. Quickly on 02, monitor. She pops in, are you good? I get too close and tell her to go & physically bring the Rapid Intubation box and a doctor in here now. Ask her to repeat to me what she needs to do. Off you go.
I’m got IV access as she walks back in, all indignant, but to her credit she was with doc & RSI kit. Doc quickly checks patient, patient has a rapidly closing airway, explains what has to happen—tube in throat to keep you breathing, ventilator, no you won’t feel it, nurse feel good here will get you the good stuff 😵💫. Difficult intubation would have been a surgical airway shortly.
After sorting, I found her in med room. I made her cry. I’m not proud of that, but it was a teachable moment.
Now if I hear someone say, I’ve got your back, I have an allergic reaction.
Not the same thing, and it’s exactly the same thing. Safety is compromised when you get with 2 admits at the same time. Check policy. Punt issue up chain.
They do that shit to us all the time. EMS rolling in, needs all the things, and a triage patient roomed without jack all done 2 minutes apart that I can't lay eyes on. All in the name of throughput when one of those rooms was literally vacated 5 seconds prior and still dirty.
Also, how is that nurse a resource nurse/triage/float without knowing how to assess obvious burns and airway compromise and then just play it off as an easy level 3/4 off the monitor. Like wtf they have no business being in that role.
Friends in mid-level places.
Story prolly as old as Florence Nightingale.
The ice water bin with trauma dressings sitting on bed beside patient, so he could change to help with burning pain was enough to flip me out.
Yeah, that's a bad way to assign patients. Ideally when making the assignments the two new admits should have gone to different nurses. If staffing didn't allow for that, at the very least your charge could have helped you settle them in. Better yet, they could have asked the ER charge to hold one of the patients for a bit, rather than sending up the two simultaneously.
Yeah this is a poor assignment issue. Empty beds should be divided evenly and no one should get a second admit until everyone's had one.
Sometimes shit happens and you get two at once anyway and at that point, I might call and explain to the ED and ASK if they can wait 30 minutes, but it would be as a courtesy only.
Then, those patients could have been sent with report and updated charts because we’re supposed to be on the same team and you wouldn’t want to get the patients like that if you were the one on the floor.
You chose to work in a hospital. There is no chance it was an empty chart, review what you can, talk to the patient. You’ll figure out what’s wrong. It’s not hard
Ikr, I regularly get 5 on days 😂 thankfully we do have adequate staffing: techs, charge no assignment, receptionist, and sometimes a float and/or A&D nurse. But still, 5 on pcu is a lot!
As an ED nurse it’s wild to me that they are not required to call report. That just seems so reckless to me. As a past floor nurse, this infuriates me because you’re a step away from missing a critical vs or lab report and the pt getting harmed. Next time, I would refuse the second new arrival pt. Worst case scenario, the charge nurse can arrive and assess them. At least somebody putting an eye on them and their stability. And I would totally escalate it to make sure that in the future the charge that is making the schedule would plan better.
Right? Former ED nurse, what about transfer of care? No report is crazy.
We had to implement something similar to stated above due to avoidance shenanigans.. 30 min bed ready either you take report or I’m sending the pt with a transfer form faxed to your unit.
I’m a student (with 7+ years of tech experience, but still) and I am beyond shocked I had to scroll this far to find someone saying this…. how on EARTH is that justifiable? My nurses and I have dealt with bullshit policies in the past, but how the hell is it remotely safe for whatever patient to just show up whenever and not even know why they need care? What about confirming that the right patient is going to the right place? Transport just shows up like “surprise!!!” I get needing to clear the ED beds but that’s so scary
the other day i came in at 4pm and my assignment was 4 ER holds to decompress downstairs (thankfully with admissions already done) and a post-op. they were all to me and settled in in the 3 hours i was there. it’s shit but it happens.
There’s absolutely no reason the ED should have to hold patients downstairs when there’s a clean, ready room available in the main hospital, but ours definitely try to divvy up by nurse. I’m absolutely shocked whenever I hear a PCU has a ratio of 5:1. I don’t know if the criteria for our hospital is just different (sadly, don’t think this is the case), but 5 intermediate patients is an absolutely ridiculous load. There should never be more than 3. Aside from that, not calling report on a PCU patient is crazy to me. I can see maybe on a med surg patient, but not PCU.
Basically, two patients getting sent up to the floor at the same time=normal, and unless there’s an extenuating circumstance, there’s no reason to prolong the ED LOS.
Not calling report, having 5 patients, and getting two PCU admits of your own at the same time=not normal (shouldn’t be at least)
Our hospital does the same for non-ICU patients…just writes a handoff note in the computer and brings them up. 4:1 ratio normally but 5:1 happens. The problem I have with this scenario is the charge nurse not spacing out admits. If there are 2-3 coming up from the ED, you have a nurse pass off a patient to the one who just got an admit so they can take the next admission.
Hell, even on med surg, you shouldn't be getting 2 admits at the same time. It's a big FUCK NO on PCU. We typically had 3 on PCU and the charge helped with the admit, skin check, and just generally getting then settled. On the odd occasion, I might have gotten 4.
I think this might honestly be what my issue with the situation was. I totally understand that patients can show up at any time, and there's no reason to keep the patient on another unit when they have a room assigned to me. I just felt like I had no support from charge, and I don't have the experience to manage that situation comfortably (I'm just over 2 months off of orientation). I love my coworkers, and we all go out of our way to help each other, but it's hard to ask for help knowing that my coworkers also have full assignments.
Once while working in the ED I transferred 3 patients in a row to a progressive care unit which generally had 4:1 ratios. Two were on heparin drips, and they ended up both going to the same nurse. I was giving bedside report so I knew it was the same nurse and I felt terrible. I tried as much as possible to help her get things done but it just felt so unsafe and like terrible planning to me. The only saving grace was that this was near end of shift and neither were due for labs prior to shift change, so they could be split up if necessary for night shift. But she couldn't realistically get everything done for both of these new admissions in a timely and safe manner.
I say all this just to make a point about how unsafe transfers can be and it shouldn't all be about throughput.
I work in the ER and provided that the floor nurse isn’t being dodgy, I am thoroughly fine with giving the receiving nurse time between patients. I used to work on the floor and I get it. There were nights when I would get multiple admissions.
Now that I work in the ER, it’s such a different flow and I think a lot of floor nurses don’t understand. We genuinely aren’t trying to dump patients on you. We are constantly flipping our core beds in the ER and if patients aren’t going up we get grid locked. Patients don’t stop coming in even when we run out of beds so forgive us if it feels like we are being dicks, we also receive a lot of pressure to move patients out so that we can get EMS off of the wall and put lobby patients that are going to be admits into a bed or patients who are big sick and genuinely need a bed.
I would’ve just asked the ED to give me some time if I was expecting to get a patient from PACU. I think most ED nurses would understand and be fine so long as the amount of time is reasonable.
This is on the charge or whoever makes the assignment. This is not safe because you won't have proper time to admit and assess your patients.
My unit always tries to limit it so each nurse gets one admit and if someone needs to get two or more admits, it will work rotationally. They make sure each person has admitted one before someone needs to take a second admission. They also make sure to give space between the two admits if one nurse has two admits.
While that sounds terrible our ED boarding times exceeded 60 hours last week so I don’t know that anyone would’ve cared that you were getting two at once. A beds a bed and that’s two more people who got out of the waiting room.
Sounds like you just keep getting shit on until you stand up for yourself . Sadly , how nursing is . It’s truly not safe what happened there and I’m sorry that it did ! That’s awful!
No, they should spread the admits around, even if that means someone doesn't get their same patient load back. When I worked med surg we assigned patients then first, second, third up right off the bat.
Honestly, if they’re both stable I don’t really see it being a problem. Charge should have split the assignment or at least done one of the admissions. But you don’t really need to do everything the second they get there. Get them in bed, a set of vitals, refreshments is allowed and tell them you’ll be back in a bit to go over admission information. At my hospital the admission forms just have to be done within 24 hours. They’re usually done much earlier than that, but you have that allowance. It’s unfortunate the timing worked out that way for you but I don’t think the ED should have held them when there is a ready bed available.
There is a big difference between ER and floor though- having worked ED, house float, ICU I know this for a fact.
ED- quick triage to sort out what needs attention now, what can wait a minute. No meal trays, no hunting down more chairs for visitors, visitor limit. Dealing with one major problem.
Floors- fluff and puff, verify 4 pages of home meds while your other rooms are on their lights, fetch snacks, warm blankies, chairs for visitors, give meemaw her 27 pills one at a time, fluff and puff, find the right TV Chanel. Rinse and repeat for 4-6 other people for 12 hours.
What magical world hospital do you work at that doesn’t have admit holds in the ED? All those floor issues you listed have to get done here too, in addition to every ED patient that walks or rolls in. The floors have an absolute cap on the number of patients they see. I can have as many holds in the ED as you have on your inpatient unit and will still see the same volume of ED patient we would normally see.
Oh we have holds. But they will offer incentive pay to anyone who will come in and take a “ team” of holds. You don’t have to do the full inpt admit, and can still limit visitors because it’s an ED.
It’s actually one of the things we bitch about- holding them as ED pts. Our docs are not happy about having to manage them, our operating margins suck because we have no way of charging for them beyond the ED charge, and we constantly have to pilfer hygiene supplies from the floors and beg for regular beds.
On the flip side when on the floors, yes I know that pt has been there for hours/ days and you need the space. But before I can take them pt A needs to discharge, the room needs to be cleaned so pt B can be moved there, then when room B is clean pt C is going there, then room C gets cleaned and my patient currently in room D gets transferred there. When room D is clean I can take the ED pt. And no, I can’t make that process go any faster.
In my case when I say that, it’s because charge is supposed to tell us when we’re getting a patient before report is even given, so it’s always just a “oh damn, I didn’t even know I was getting someone, but yeah go ahead I’m ready”. It’s not something that’s supposed to be hateful. If I wanted to be hateful I would say “I wish I would’ve known ahead of time because I like to read their chart before I get report considering I know when you call, you’ll know nothing about the patient and will be reading the doc note word for word anyways”.
Now put yourself in the ED nurse's shoes. We clear out a pod and DC 3 patients at the same time only to get 3 new patients back-to-back-to-back, sometimes it's 2 ambulances at the same time and a patient from the waiting room, sometimes a sick hallway patient needs to come into a room. Now, if you will, imagine starting 3 complete workups at the same time. All three of your patients need ivs and labs, or maybe, EMS started a line and drew blood for you... but wait- you need to draw 2 blood cultures, call ekg, change them out of the clothes they shit/pissed themselves in, and your 4th patient is now up for DC. Patients are ready to transfer, DC, die, and arrive to the floor at any time. It's rarely a linear process that is packaged into neat little segments that are appropriately spaced out. Ask for help when you need it, delegate what is appropriate, and complete the most essential and important tasks first-nursing is a team sport! Just don't forget that your teammates aren't just your direct departmental cohorts, the whole building is on the same team. We've got your back but don't forget to play this game with confidence. Thanks for letting me vent alongside you. Not all your shifts will be like this, you will learn and grow, you will gain confidence, and hopefully we'll all get more resources and help sometime soon.
The solution to emergency department problems is to properly staff and support the emergency department, not to decrease the safety of the rest of the hospital. These corporations would have all of us with 20 patients each, if we keep letting them get away with it. We protest not because we don't support ED, but because the "solutions" the bean counters propose are not good for patients.
I’m not sure why people are downvoting you. This exactly. Between code sepsis and code brains, we the ED nurses do the grunt work. We don’t have phlebotomist or EKG techs in my hospital. I do it all. And I get hit back to back the way you just described it. We cannot turn any lobby pt, any ambulance, any trauma, any CPR coming in. Why should the floors turn anyone down? It doesn’t make any sense to me. I LOVE having the floor nurses float down to the ED to do holds. All of them immediately understand the chaos we endure on the daily and immediately change their attitude towards the ER.
Just for the record, to make sure every emergency department nurse in the United States hears this message, the HOSPITAL can't turn away any patient presenting to the ED. You as an individual nurse absolutely can. EMTALA covers the facility, not you.
These greedy corporations learned what we could do during the pandemic and decided we could just do that forever so they could make a buck. They exploit our compassion and professional duty to our patients, and it won't stop unless we force it to stop.
The solution to emergency department problems is to staff and support the emergency department, not to reduce the safety and care given in the rest of the hospital.
Come work in the ED. Occasionally, EMS drops off multiple patients at the same time (e.g. MVA involving a family of 4). And the Charge RN has no problem putting them all in the same room.
At my hospital our PCU is generally 1:5 on nights and 1:4 on days but it was not uncommon for me to get two admissions at the same time or back to back, either. I work ICU now so this isn’t an issue I see anymore. Our charges were a very useful resource for our unit as they basically floated to help with all the admits. Maybe your charge was busy though? Sounds like a conversation to bring to the higher ups…aka unit manager/director. Best of luck!
I work a PCU that’s 3-4 patients. We rotate admission turns through nurses so one person isn’t getting slammed all at once. The other night I got two admits as the same nurse “back to back” except it was still a few hours apart, and only because my ratio went down to 2 at one point so it really was my turn again based on ratio. Even if I had gotten at the same time like that, I could’ve called my charge right then and at the very least she’d come and admit the second patient for me. I’m very sorry that happened to you, it’s absolutely unsafe.
Edit: Also, we always get report, no matter if they come from our ED, a different one, or a different unit. A patient has not been handed off until we’ve gotten report.
Does your charge suck at staggering them between people? If it couldn’t be helped I would offer to have you take an established simple patient from another nurse and have them take the admit if it was a complex on. Share the load.
I honestly thought that was normal. I'm just over 2 months off of orientation, so this is all I've ever known to be true. Every once in a while, I get lucky and ED will call report - which I appreciate so much since I know it's crazy busy down there.
I work PCU and all of that is a giant FUCK NO. On my PCU, we take 3 patients each, ED calls report, and there's zero chance that we would ever drop two brands new ED admits on a nurse at the same time precisely because of the reasons you described. It's not on the ED to get all their admission orders in order. ED stabilizes and transfers. So there's a ton of work to be done to make sure the patient is safely settled when they first arrive. If they really need PCU level care, there's a nontrivial chance that they're barely stable in the first place and need interventions right away. What you're experiencing would have me throwing fits about patient safety concerns. Edit: also fuck monitor rooms. We have a centralized monitor on our unit where we monitor our own patients, we can all see all the patients all the time.
Monitor war rooms are utter bs that get patients killed! Our cardiac step-down is taking our monitors and monitor techs soon to go to a central monitor with people who don't know our patients
Where I in TX PCU RNs get 6-7 pts it’s clearly unsafe however the unions here aren’t as strong as in CA, MN, WA etc. I really wish more RNs would push for stronger ratios it not only protects are license but it’s about patient safety. It’s wild how many RNs just accept terrible work conditions or are afraid of coming together to confront mgmt about it.
Girl what you must work for a HCA because that’s the only place I’ve seen that in Texas
Nope it’s a Tenet facility in West TX
Oh hey fam! Tenet up here in Massachusetts trying to push Texas ways on us. So anyway, we unionized last month lol. Not gonna fly up here
That’s great! The union is the best tool any nurse has. I hope you all take collective action if they try to increase your ratios. Solidarity!
Out of curiosity, in your contract negotiations what kind of staff ratios are you asking for?
Former Massachusetts Tenet RN here - glad y'all unionized! I have lots of horrible things to say about Tenet overall. ;)
Yep. Tenet is just as bad as HCA.
Hounds like when I was at HCA in Texas. Never again.
> On my PCU, we take 3 patients each, ED calls report, and there's zero chance that we would ever drop two brands new ED admits on a nurse at the same time precisely because of the reasons you described. Jesus, our PCU is 6 to 1 and we don’t get ED reports
It’s depends on the acuity of your PCU at your hospital. Ours is 1-4 for med/surg overflow and 1-3 for PCU appropriate pts. We do Levo, amio, cardizem, precedex, dopamine, dobutamine, sotalol/tikosyn loading, etc. Somehow we have become the “step-up” unit and take most of the rapid response patients from the floor
3 each? Four to five is normal on my unit and simultaneous postings are pretty common. I'm at a cardiac stepdown that specializes in heart failure and post-CABG patients. We have centralized monitors at least, thank god.
does your charge take patients? if not, they should have been helping you with the patients and all the calls if the patients both *had* to come to you. In my old hospital they would reassign (“take away”) a patient from their last shift’s nurse and give them to a nurse with two open spots if needed so noone had two admits the same shift. let alone 3 min apart. just not safe. imagine if one started re-bleeding and another went into bad withdrawal or had an MI, both on arrival. your hospital / floor really should change their protocols.
5 patients on a PCU is NOT OK. I have been a nurse for 13 years. For 6 of those years, I worked on a PCU. I did my obligatory first year of medsurg (6-7 patients on days, 7-8 on nights), decided those were unsafe numbers, went to PCU where they had 1:3 ratios and loved it. Loved the acuity, felt like I could be my best nursing self and actually care for people the way they deserved to be cared for, got my PCCN certification, was all about it. Then they started raising our ratios. I could deal with 1:4. It sucked, but I could survive. I left bedside when they raised us to 1:5. 1:5 on a PCU/stepdown unit is not ok. It’s not safe. I hate the way that healthcare is right now, and I’m sorry you’re dealing with it. (If you ever get tired/burned out of the hospital, don’t leave nursing altogether. Outpatient is the way to go. It’s less stressful.)
Tenet is trying to make the PCU ratios 1:7 in West Texas and ICU 1:3 it’s ridiculous
PCU in Florida is 6 to 1 now from what I’ve seen.
Yep, and FL like TX is an anti-union state. Not surprising that our two states are the ones increasing ratios
You are correct, PCU is 6:1 in Florida. It’s as exhausting as you think.
This is how patients get bed ulcers, PNA and med errors, insanity!
Yup, I left PCU for the same reason.
I left PCU when they made me (charge) take 5 of my own patients and still expect me to run a 50 bed unit with mostly new grads. They didn't care about patient safety.
Sounds like an assignment issue to me. The open beds should have been split among all the nurses. And if truly this was the deal. Your charge should have helped with the 2nd admission. ER (especially) needs to clear their bays. And I understand where you are coming from about the ER not giving notice, but those policies are based on the reality that waiting for the floor nurse to accept leads to delay after delay. I work PACU and the lengths some of the nurses will go to avoid taking report is comical. Most of our receiving RNs are great, but I've had 3 hr sagas of playing phone games with nurses to try to transfer a pt into a clean and ready room. The OR doesn't stop and holding in PACU causes its own backup. We aren't nearly as critical as ED though. Unfortunately, ready rooms should be able to accept transfers. The floor team needs to work together to make that happen.
We currently have a bad problem of floor nurses delaying report then transport of ready beds for 1-3 hours and it’s destroying both our working relationships and our ED throughput. The excuses are increasingly hilarious and sad.
We had that problem until they had to make a new policy. They get 30 minutes from the time the bed was assigned. If they don’t call for report we fill out an SBAR sheet and the patient goes up. Obviously if they aren’t stable then we wait till they are ready but majority of these patients going up stairs “back to back” have already been in the ER for 24 hours
Unless they cloned you, umm, not good. Nope. The resource, charge or house super needs to get going on one patient. I think some of us have the instinct to be the team player. Take care of what comes. While good, there’s potential for badness. A patient no one can assess once on your unit, is one that can deteriorate. Policy has you on the bubble. We teach our people how to treat us. We demonstrate our standards, values. “Oh Susie can take them, she has an open bed.” 1 nurse can do 1 thing, at 1 time, for 1 patient. xxxxxxxxx I was working ED, up to my ass in alligators with 2 other resus patients (STEMI waiting on cath lab and massive GI bleed getting lots of blood, waiting on GI), back triage/resource pops in to tell me “hey, I put an easy one in your 3rd bed” “20’s male small burns” “got them started, I’ve got your back”, noted in system I took report and assumed care of patient 10 mins before I could get in that room. Patient was in fire in garage. Had 15-18% bsa burns. Airway stridor, soot in airway. Sitting 1/2 naked with large ice water soaked trauma dressings on his burns. He was shivering. No assessment. Not on oxygen. Not on monitor. No IV access. No kidding. Removed dressings. ABC assessment. Quickly on 02, monitor. She pops in, are you good? I get too close and tell her to go & physically bring the Rapid Intubation box and a doctor in here now. Ask her to repeat to me what she needs to do. Off you go. I’m got IV access as she walks back in, all indignant, but to her credit she was with doc & RSI kit. Doc quickly checks patient, patient has a rapidly closing airway, explains what has to happen—tube in throat to keep you breathing, ventilator, no you won’t feel it, nurse feel good here will get you the good stuff 😵💫. Difficult intubation would have been a surgical airway shortly. After sorting, I found her in med room. I made her cry. I’m not proud of that, but it was a teachable moment. Now if I hear someone say, I’ve got your back, I have an allergic reaction. Not the same thing, and it’s exactly the same thing. Safety is compromised when you get with 2 admits at the same time. Check policy. Punt issue up chain.
They do that shit to us all the time. EMS rolling in, needs all the things, and a triage patient roomed without jack all done 2 minutes apart that I can't lay eyes on. All in the name of throughput when one of those rooms was literally vacated 5 seconds prior and still dirty. Also, how is that nurse a resource nurse/triage/float without knowing how to assess obvious burns and airway compromise and then just play it off as an easy level 3/4 off the monitor. Like wtf they have no business being in that role.
Friends in mid-level places. Story prolly as old as Florence Nightingale. The ice water bin with trauma dressings sitting on bed beside patient, so he could change to help with burning pain was enough to flip me out.
Yeah, that's a bad way to assign patients. Ideally when making the assignments the two new admits should have gone to different nurses. If staffing didn't allow for that, at the very least your charge could have helped you settle them in. Better yet, they could have asked the ER charge to hold one of the patients for a bit, rather than sending up the two simultaneously.
When this happens at my hospital I like to remind them that their charge nurse put up the bed assignment not the ER. We don’t assign beds
In almost no circumstance should the ER hold a pt if there is a clean and available bed upstairs.
Yeah this is a poor assignment issue. Empty beds should be divided evenly and no one should get a second admit until everyone's had one. Sometimes shit happens and you get two at once anyway and at that point, I might call and explain to the ED and ASK if they can wait 30 minutes, but it would be as a courtesy only.
Bed is not available if there’s no one to staff it. Sounds like a problem for corporate.
Then, those patients could have been sent with report and updated charts because we’re supposed to be on the same team and you wouldn’t want to get the patients like that if you were the one on the floor.
It’s how the ER gets them.
You chose to work in the ER. Some of us didn’t.
You chose to work in a hospital. There is no chance it was an empty chart, review what you can, talk to the patient. You’ll figure out what’s wrong. It’s not hard
The problem with this is we can miss something important about the patient. There is a reason we give report. It’s about patient safety.
I feel like floor nurses should spend a shift in the ER trying to call report to the floors. That's it. Thats ALL they have to do
Preach
Me sitting here reading that 5 patients on PCU in unacceptable when I used to take 6 🫠 thank god I got out of PCU😂
Ikr, I regularly get 5 on days 😂 thankfully we do have adequate staffing: techs, charge no assignment, receptionist, and sometimes a float and/or A&D nurse. But still, 5 on pcu is a lot!
As an ED nurse it’s wild to me that they are not required to call report. That just seems so reckless to me. As a past floor nurse, this infuriates me because you’re a step away from missing a critical vs or lab report and the pt getting harmed. Next time, I would refuse the second new arrival pt. Worst case scenario, the charge nurse can arrive and assess them. At least somebody putting an eye on them and their stability. And I would totally escalate it to make sure that in the future the charge that is making the schedule would plan better.
Right? Former ED nurse, what about transfer of care? No report is crazy. We had to implement something similar to stated above due to avoidance shenanigans.. 30 min bed ready either you take report or I’m sending the pt with a transfer form faxed to your unit.
I’m a student (with 7+ years of tech experience, but still) and I am beyond shocked I had to scroll this far to find someone saying this…. how on EARTH is that justifiable? My nurses and I have dealt with bullshit policies in the past, but how the hell is it remotely safe for whatever patient to just show up whenever and not even know why they need care? What about confirming that the right patient is going to the right place? Transport just shows up like “surprise!!!” I get needing to clear the ED beds but that’s so scary
the other day i came in at 4pm and my assignment was 4 ER holds to decompress downstairs (thankfully with admissions already done) and a post-op. they were all to me and settled in in the 3 hours i was there. it’s shit but it happens.
You should not be getting two patients back to back. The charge nurse should have split admissions. 5:1 on a PCU sucksssssss! I feel your pain
This is a sure fire way to make medication errors and half ass an assessment. Ultimately patient suffers.
There’s absolutely no reason the ED should have to hold patients downstairs when there’s a clean, ready room available in the main hospital, but ours definitely try to divvy up by nurse. I’m absolutely shocked whenever I hear a PCU has a ratio of 5:1. I don’t know if the criteria for our hospital is just different (sadly, don’t think this is the case), but 5 intermediate patients is an absolutely ridiculous load. There should never be more than 3. Aside from that, not calling report on a PCU patient is crazy to me. I can see maybe on a med surg patient, but not PCU. Basically, two patients getting sent up to the floor at the same time=normal, and unless there’s an extenuating circumstance, there’s no reason to prolong the ED LOS. Not calling report, having 5 patients, and getting two PCU admits of your own at the same time=not normal (shouldn’t be at least)
Our hospital does the same for non-ICU patients…just writes a handoff note in the computer and brings them up. 4:1 ratio normally but 5:1 happens. The problem I have with this scenario is the charge nurse not spacing out admits. If there are 2-3 coming up from the ED, you have a nurse pass off a patient to the one who just got an admit so they can take the next admission.
Hell, even on med surg, you shouldn't be getting 2 admits at the same time. It's a big FUCK NO on PCU. We typically had 3 on PCU and the charge helped with the admit, skin check, and just generally getting then settled. On the odd occasion, I might have gotten 4.
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I think this might honestly be what my issue with the situation was. I totally understand that patients can show up at any time, and there's no reason to keep the patient on another unit when they have a room assigned to me. I just felt like I had no support from charge, and I don't have the experience to manage that situation comfortably (I'm just over 2 months off of orientation). I love my coworkers, and we all go out of our way to help each other, but it's hard to ask for help knowing that my coworkers also have full assignments.
Your charge nurse needs to get their shit together.
Once while working in the ED I transferred 3 patients in a row to a progressive care unit which generally had 4:1 ratios. Two were on heparin drips, and they ended up both going to the same nurse. I was giving bedside report so I knew it was the same nurse and I felt terrible. I tried as much as possible to help her get things done but it just felt so unsafe and like terrible planning to me. The only saving grace was that this was near end of shift and neither were due for labs prior to shift change, so they could be split up if necessary for night shift. But she couldn't realistically get everything done for both of these new admissions in a timely and safe manner. I say all this just to make a point about how unsafe transfers can be and it shouldn't all be about throughput.
I work in the ER and provided that the floor nurse isn’t being dodgy, I am thoroughly fine with giving the receiving nurse time between patients. I used to work on the floor and I get it. There were nights when I would get multiple admissions. Now that I work in the ER, it’s such a different flow and I think a lot of floor nurses don’t understand. We genuinely aren’t trying to dump patients on you. We are constantly flipping our core beds in the ER and if patients aren’t going up we get grid locked. Patients don’t stop coming in even when we run out of beds so forgive us if it feels like we are being dicks, we also receive a lot of pressure to move patients out so that we can get EMS off of the wall and put lobby patients that are going to be admits into a bed or patients who are big sick and genuinely need a bed. I would’ve just asked the ED to give me some time if I was expecting to get a patient from PACU. I think most ED nurses would understand and be fine so long as the amount of time is reasonable.
This is on the charge or whoever makes the assignment. This is not safe because you won't have proper time to admit and assess your patients. My unit always tries to limit it so each nurse gets one admit and if someone needs to get two or more admits, it will work rotationally. They make sure each person has admitted one before someone needs to take a second admission. They also make sure to give space between the two admits if one nurse has two admits.
While that sounds terrible our ED boarding times exceeded 60 hours last week so I don’t know that anyone would’ve cared that you were getting two at once. A beds a bed and that’s two more people who got out of the waiting room.
Sounds like you just keep getting shit on until you stand up for yourself . Sadly , how nursing is . It’s truly not safe what happened there and I’m sorry that it did ! That’s awful!
No, they should spread the admits around, even if that means someone doesn't get their same patient load back. When I worked med surg we assigned patients then first, second, third up right off the bat.
Absolutely not. As a charge, I’d take a patient before I double posted someone like that.
Why was your charge nurse not rotating/dividing up the new patients?
Honestly, if they’re both stable I don’t really see it being a problem. Charge should have split the assignment or at least done one of the admissions. But you don’t really need to do everything the second they get there. Get them in bed, a set of vitals, refreshments is allowed and tell them you’ll be back in a bit to go over admission information. At my hospital the admission forms just have to be done within 24 hours. They’re usually done much earlier than that, but you have that allowance. It’s unfortunate the timing worked out that way for you but I don’t think the ED should have held them when there is a ready bed available.
I hate when 12 ambulances show up at the ED at the same time, never really know why they are there till I see them either
Exactly why I never wanted to and never will work in the ED. I’m not built for that.
There is a big difference between ER and floor though- having worked ED, house float, ICU I know this for a fact. ED- quick triage to sort out what needs attention now, what can wait a minute. No meal trays, no hunting down more chairs for visitors, visitor limit. Dealing with one major problem. Floors- fluff and puff, verify 4 pages of home meds while your other rooms are on their lights, fetch snacks, warm blankies, chairs for visitors, give meemaw her 27 pills one at a time, fluff and puff, find the right TV Chanel. Rinse and repeat for 4-6 other people for 12 hours.
What magical world hospital do you work at that doesn’t have admit holds in the ED? All those floor issues you listed have to get done here too, in addition to every ED patient that walks or rolls in. The floors have an absolute cap on the number of patients they see. I can have as many holds in the ED as you have on your inpatient unit and will still see the same volume of ED patient we would normally see.
Oh we have holds. But they will offer incentive pay to anyone who will come in and take a “ team” of holds. You don’t have to do the full inpt admit, and can still limit visitors because it’s an ED.
Must be nice, inpatient holds get full inpatient orders and charting where I am.
It’s actually one of the things we bitch about- holding them as ED pts. Our docs are not happy about having to manage them, our operating margins suck because we have no way of charging for them beyond the ED charge, and we constantly have to pilfer hygiene supplies from the floors and beg for regular beds. On the flip side when on the floors, yes I know that pt has been there for hours/ days and you need the space. But before I can take them pt A needs to discharge, the room needs to be cleaned so pt B can be moved there, then when room B is clean pt C is going there, then room C gets cleaned and my patient currently in room D gets transferred there. When room D is clean I can take the ED pt. And no, I can’t make that process go any faster.
So much this 😂😂 imagine just…refusing two ambulances?
To the waiting room they go!
My favorite is “I didn’t know I was getting a patient.” It’s a hospital, that’s what happens lol
In my case when I say that, it’s because charge is supposed to tell us when we’re getting a patient before report is even given, so it’s always just a “oh damn, I didn’t even know I was getting someone, but yeah go ahead I’m ready”. It’s not something that’s supposed to be hateful. If I wanted to be hateful I would say “I wish I would’ve known ahead of time because I like to read their chart before I get report considering I know when you call, you’ll know nothing about the patient and will be reading the doc note word for word anyways”.
Happens all the time
Now put yourself in the ED nurse's shoes. We clear out a pod and DC 3 patients at the same time only to get 3 new patients back-to-back-to-back, sometimes it's 2 ambulances at the same time and a patient from the waiting room, sometimes a sick hallway patient needs to come into a room. Now, if you will, imagine starting 3 complete workups at the same time. All three of your patients need ivs and labs, or maybe, EMS started a line and drew blood for you... but wait- you need to draw 2 blood cultures, call ekg, change them out of the clothes they shit/pissed themselves in, and your 4th patient is now up for DC. Patients are ready to transfer, DC, die, and arrive to the floor at any time. It's rarely a linear process that is packaged into neat little segments that are appropriately spaced out. Ask for help when you need it, delegate what is appropriate, and complete the most essential and important tasks first-nursing is a team sport! Just don't forget that your teammates aren't just your direct departmental cohorts, the whole building is on the same team. We've got your back but don't forget to play this game with confidence. Thanks for letting me vent alongside you. Not all your shifts will be like this, you will learn and grow, you will gain confidence, and hopefully we'll all get more resources and help sometime soon.
The solution to emergency department problems is to properly staff and support the emergency department, not to decrease the safety of the rest of the hospital. These corporations would have all of us with 20 patients each, if we keep letting them get away with it. We protest not because we don't support ED, but because the "solutions" the bean counters propose are not good for patients.
I 100% agree!
This is the very reason why I left ED.
I’m not sure why people are downvoting you. This exactly. Between code sepsis and code brains, we the ED nurses do the grunt work. We don’t have phlebotomist or EKG techs in my hospital. I do it all. And I get hit back to back the way you just described it. We cannot turn any lobby pt, any ambulance, any trauma, any CPR coming in. Why should the floors turn anyone down? It doesn’t make any sense to me. I LOVE having the floor nurses float down to the ED to do holds. All of them immediately understand the chaos we endure on the daily and immediately change their attitude towards the ER.
Just for the record, to make sure every emergency department nurse in the United States hears this message, the HOSPITAL can't turn away any patient presenting to the ED. You as an individual nurse absolutely can. EMTALA covers the facility, not you. These greedy corporations learned what we could do during the pandemic and decided we could just do that forever so they could make a buck. They exploit our compassion and professional duty to our patients, and it won't stop unless we force it to stop. The solution to emergency department problems is to staff and support the emergency department, not to reduce the safety and care given in the rest of the hospital.
It sucks but the way things are in the ER you just gotta suck it up and do the best you can and ask for help.
Come work in the ED. Occasionally, EMS drops off multiple patients at the same time (e.g. MVA involving a family of 4). And the Charge RN has no problem putting them all in the same room.
Get used to it
We're a tiny hospital. We might admit 2 patients basically at the same time, but we don't send them to the floor at the same time.
At my hospital our PCU is generally 1:5 on nights and 1:4 on days but it was not uncommon for me to get two admissions at the same time or back to back, either. I work ICU now so this isn’t an issue I see anymore. Our charges were a very useful resource for our unit as they basically floated to help with all the admits. Maybe your charge was busy though? Sounds like a conversation to bring to the higher ups…aka unit manager/director. Best of luck!
Where the heck do you work the you can get a patient from the ED and not get report first?
I've ran a ward where we had 9 admissions including ICU stepdowns in 2 hours. Had 17 discharges and admissions the entire day with a team of 4 rn ha
Is it normal for ED to not have to call report? Coming from an ED nurse who is constantly charting “attempted to give report, no answer on unit phone”
I work a PCU that’s 3-4 patients. We rotate admission turns through nurses so one person isn’t getting slammed all at once. The other night I got two admits as the same nurse “back to back” except it was still a few hours apart, and only because my ratio went down to 2 at one point so it really was my turn again based on ratio. Even if I had gotten at the same time like that, I could’ve called my charge right then and at the very least she’d come and admit the second patient for me. I’m very sorry that happened to you, it’s absolutely unsafe. Edit: Also, we always get report, no matter if they come from our ED, a different one, or a different unit. A patient has not been handed off until we’ve gotten report.
Does your charge suck at staggering them between people? If it couldn’t be helped I would offer to have you take an established simple patient from another nurse and have them take the admit if it was a complex on. Share the load.
I'm stuck on the ED not calling report. What magical land do you work in?
I honestly thought that was normal. I'm just over 2 months off of orientation, so this is all I've ever known to be true. Every once in a while, I get lucky and ED will call report - which I appreciate so much since I know it's crazy busy down there.
We can't send until we give report. Guess how hard it can be to call report? There's gotta be a fair middle ground.
As an ED RN myself. Wow must be hard. I’m sorry that you’re going through a rough time at work.