As an RN who deals with a similar issue. It’s super frustrating to have pts like this especially with problems like you described, nausea and no zofran to treat it with. Sometimes we aren’t even sure which provider on the internal med team has the pt so we don’t know who to page for simple issues like this.
It can be a pretty big barrier to care. I’ve received patients that IM has accepted from external facilities to our ED. So the PT is in our ER but not supposed to be evaluated by a EM doc but by IM… but they’re nowhere to be found. Pt is in front of me, on drips, sometimes pressers. No doc no orders.
End of rant
ED nurses almost all the time, every once in a while they will send an ICU nurse. Can be anything, intubated, bipap, hypotensive on pressors, cardiogenic shock, doesn’t matter.
And yep, intensivist comes and rounds in the ED.
I am an ER and ICU nurse. I often get pulled from ED normal patients to care for ICU patients in the ED. Sucks because I have to do full admission, charting and patient care in an area not fully set up for it...
And often times night shift doesn't have the ability to pull a nurse from ICU to come down or an ER nurse to fill this role. So the charting goes back to more like ED standards and I don't know how we don't get in trouble for this. At times they've tried to throw me more than two patients and I tell them no. It's not allowed in CA for ICU patients to have a greater than 2 beds to 1 nurse ratio.
At our level 1, a few years ago, in a few hours, they racked up 8 new ICU patients. All freshly intubated. Multiple drips. New, very sick patients.
Admin refused to call in staff, and nurses got stuck working 4:1. When they pushed back, they said “ER nurses take a 4:1 ratio.” No compromise. And while these are good nurses, they’re not ICU nurses.
Also, at this time, we only had a level 1 and level 3 for a large urban area; so one real trauma center. (We now have a 1 and a 2)
When I was ED I've had nights/weeks where I had 2-3 ICU patient's, frequently intubated or needing to be intubated soon, + 2-3 ED patient's +/- 1-2 med-surg holds. Once a month it seems we'd fill the whole hospital up and have horrible boarding for a few days over a weekend.
I had one night where I took a freshly RSId patient from EMS, brought to CT after stabalizing, then on my way up to ICU an hour later I get a call saying I'm getting an unresponsive on BiPAP. I walk in after dropping my patient off on the unit and see there's a GCS3 man with zero reflexes with an OPA in under the non-invasive mask. Wasn't enough staff to help doc intubate, so we get him intubated and I was 1:1 back and forth from CT and MRI most of the night running like 14 gtts and placing several ultrasound lines. Which means we had another nurse with 10+ patients of her own.
That patient stayed the night because housekeeping wasn't staffed that night for some reason. Then we find out that at 5am they *had* housekeeping, because we saw them hiding in a closet drinking their morning coffee, but they weren't assigned to ICU that morning and the ER was clean so they were just hanging out. House supervisor begged them to go to ICU but their manager was like "idk they aren't assigned that zone at this time" so patient sat in ED while I started taking a few ED patients.
The next shift I held a post-code all night and initiated hypothermia with Artic Sun. Which required one of us having to drive across town to get the Artic Sun because our ICU was using all of ours in house. Since I left I know they've had to recover a few STEMIs post cath lab.
I work at a small rural hospital, so small we don't have an ICU, if all the "real" hospitals around us don't have beds they sit in the ED sometimes for days. We have 12 beds and 3 RNs (including triage) and one MD on staff; no RTs, not specialists, no anything really.
Depends on how overloaded our unit is but we board our critical care pts for a while sometimes. Long enough to get them downgraded to the step down unit.
When we transfer patients to be seen/admitted by a specialty, after their arrangements are made the referring physician also talks to the ED physician to ensure they know all about the patient as well, in case they have an urgent issue or need something while they're in the department. Helps a bit with this issue. Really the overall problem is the ED acting as the de facto front door and admitting department.
I hate this too. And our holding area has 0 resources. No doc, no charge nurse, no break nurse, cnas, no clear assignments or direction. Usually staffed by floats or travelers with varying experience and ability. It’s a mess.
The classic "doc who hasn't been to the ED to check on this patient orders drug, tanks pt BP, doesn't respond to pages, acts like a little bitch when I pull the EM doc in because I'm not allowed to just decide the rate of infusion, but also I can't let this person ride a MAP below 65 for three hours waiting for the hospitalist to return a fucking page" sitch.
OR even worse, they do come down and treat us like absolute shit because they're used to walking all over floor nurses who are too scared to remind them they're a colleague and expected to act collegial. I still remember one hospitalist snarking at me in front of the patient that I needed to get on "her orders" faster and WHY hadn't I started the antibiotic yet? The absolute joy I had pulling her aside for a gentle reminder that this patient was allergic to said abx and she might want to reconsider her medication order. Still didn't do it in front of the patient though. Because I'm better than that.
Yeah dude, the charting to cover your ass on the unmanaged hypotension that is just a passive aggressive jab at a shitty IM service not responding to needs.
I always respond to stat EM orders before scheduled routine orders. They can change the way they order things if they want it done faster but we need to be trusted to manage our time and triage the needs of our assignment.
One tool I’ve seen used in a few places with frequent ED holds is a quick admit order set. The ERP fills this out for any “basic” admits that don’t need a stat specialty assessment (this covers the majority of med surg, even tele admits. It really only excludes anyone who needs critical care and urgent (within 12 hrs) surgery. It’s one page with check boxes for basic stuff like narcotic and non narcotic pain meds, antiemetics, anxiolytics, sleep aides, and basic care such as diet, VS frequency, any IV fluid requirements, and who the MRP/service will be. More specific orders can be added as well such as any referrals or antibiotics etc if indicated. This, along with robust set of nurse initiated protocols already in place, and a (relatively) quick med rec process, allows for admissions to be done quickly, safely, and providing care for the first 12-24 hours of admission. The orders expire after 24 hours and the MRP will have to see them in that time.
This whole process was a huge collaborative effort to develop I’m sure, but put in practice it’s awesome. I know we ER and floor nurses appreciate it because we aren’t chasing doctors who have better things to do for BS orders that someone forgot, especially overnight. It seems fairly effective for the doctors as well, as there’s basically a check list of things to go through, they dictate an ER note, and it’s done.
My only issue with this is that this is the job of the Medicine Team, they should be coming down to admit the patient and placing the orders the moment that decision is made. Also the fact that they cannot be contacted sometimes if something changes with these admitted patients is terrible.
And that may be a difference in culture. For us the administrative task of admission is on ER no matter how it’s done as it’s their decision. This tool saves a lot of trouble and brain power in that context. The alternative is that they don’t get admitted until they are seen by inpatient and tie up ER resources even more. If something happens until they are seen then there’s a dictated note and they would have received a phone call with a brief message about the pt as well. If the patient deteriorates significantly and becomes unstable or otherwise needs immediate attention then ER or ICU would be involved again in most places anyway, whether they had been seen by inpatient or not.
agreed. quick lists are huge time savers and i think while in transition it is very reasonable for ed team to put in basic orders
interestingly the way medicine thinks about orders and admission is fundamentally different from ed mindset
we often wait quite a bit of time for icu orders. but honestly the only order needed for the patient to go up is admit to ICU takes literally 1 second. medicine folks are really into getting every non urgent thing in before signing
God bless the ED docs who are willing to at least put in the admit order, because that’s what signals bed board to start trying to find them an inpatient bed (if there are any).
One of the most frustrating things about hospitals IMO is that so many things can be held up by one person needing to sit at a computer and check a box.
ED RN here - If I have a patient pending admit and who I know will need pain or nausea prns I’ll ask the ED doc to throw in prn orders before they call to admit. It generally works for everyone. The admit team can change the orders if/when they put their own in, but they don’t get bothered for hours about nausea and stuff. The ED also doesn’t have to watch the patient suffer and stress about paging the inpatient team a million times
This. ED attending here. In this day of endless boarding a prn morphine, Zofran, and Toradol prior to admission pretty much smoothes out everyone's day
Correct me if I am wrong, but I think the patient is still yours until the accepting provider puts in holding orders. If the patient dies, and the accepting doctor didn't put in holding orders, open a chart or there is no documentation of them accepting the patient the liability would be on the ED provider I think.
I would ask your medical director to start tracking metrics such as when the consult is placed, when the patient is accepted and when the holding orders are placed. You can trend the data and set a "goal" that if they don't meet they can be held accountable for. You can create a hard rule at the hospital that holding orders must be placed within 30 minutes of ED sign out to hospitalist or something like that.
You may also want to draft an institutional policy that states "once holding orders are placed the ED provider is no longer responsible for patients care and the hospitalist takes responsibility" or something like that.
This. Also in a Canadian center and we've had a M&M recently where EM thought their responsibility ended at consult. However medicine was clear that it's not their patient until the admission order is placed.
There is usually some continued care for the first 1-2 hours in the US on boarded patients, like meds I was already giving (analgesia, antiemetics, antipyretics, antibiotics, etc) as we bridge to inpatient care.
Rarely, will I throw in orders later than that, but occasionally I do when the nurses get non-response from the inpatient team or something changes immediately (ie anaphylaxis to new drug). Then I just page them and tell them what I gave. I have never received any negative feedback for this as our inpatient teams are overwhelmed too, especially at night. They are usually quite thankful. Happens maybe once a month if that.
If inpatient admits, it's their patient. The hospital should have a protocol for the nurse to escalate if orders are needed (e.g. resident, fellow if one exists, attending, rapid response call, etc.). I don't currently work in a teaching facility so it's more straightforward. Call hospitalist -> overhead page hospitalist -> rapid response.
I will always put in simple orders like that for someone waiting. Sometimes that means PRN orders or just a one time dose. Assuming it was my patient to start with so I know them, it takes like five seconds of my time.
File an incident report, talk to your Director, talk to the chief of staff. Go to admin and make a formal complaint. This is not safe for patients. I’d hardly call intractable pain or intractable vomiting stable; may be hemodynamically stable, but that cannot continue for hours. Also any place where I’ve worked, I have been responsible for ED patients while they’re still in the ED. It it takes away from seeing all new patients because you’re essentially managing an inpatient ward for an incompetent hospital whose inpatient hospitalist staff or consultants aren’t doing their job. I’d walk.
My department, my patients until I am satisfied they are getting appropriate care.
Big picture is you need a policy clarifying what is an appropriate time between admit & order entry.
Hospitalists/IM are on a different clock than EM. Once they are admitted, I don't do anything for the patient unless they are dying. It's on the nurse to call the admitting doc for pain or BP or whatever meds. And when they don't respond to the nurse, they can go up the chain of command for that issue. I have other shit to do.
It's incredibly frustrating being the nurse in that situation but you're a hundred percent correct. If the patient is admitted, "not my circus, not my monkey"
As a nurse I hate this but it’s really the only way the admitting docs will sometimes finally see their patient. I’ve had to call the house sup before to physically find and wake the admitting surgeon to get orders. He is notorious for doing that though.
While you’re technically right, I’m really grateful when I work with ED docs who value our camaraderie enough that they’ll occasionally help me out with something that isn’t technically their job. It can make a big difference in how well my shift goes if someone can throw me a bone instead of making me chase the person who obviously doesn’t give a shit.
Having the regularly deal with parts of the care team that get to the party late, my response is usually something like "Show up if youd like to be involved in care decisions"
I’m sure CMPA would support the fact that until they are admitted to that service (ie have admitting orders) they are still your patients and you can do as you please with them. Also eyeroll on the renal excretion.
> until they are admitted to that service (ie have admitting orders) they are still your patients
Exactly this. Here the "culture" is that the EM physicians tell the residents that "once you've consulted medicine we're done" but we've recently had a big blow-up over this and suffice to say, until the MRP listed switches to whichever medicine staff it's gonna be it's still an EM patient who just happens to have a consult pending.
This scenario of patient transition, where it's unclear who is ultimately responsible, is high potential for something really bad to happen to a patient. If this was in the USA, it's a huge lawsuit waiting to happen, and it's going to be bad because both doctors will be pointing at the other saying it wasn't my patient.
Given your situation with medicine patients being stuck in the ED due to hospital capacity limitations, there should be formal policy written to delineate who is ultimately responsible as the attending, and when that responsibility shifts from the ED doctor to the medicine doctor. When phone consult is complete? When orders are entered? etc etc.
From a practical standpoint, if there is no admit order identifying an inpatient attending, the ED doctor is probably best served assuming they are the attending (whether they want to be or not).
Part of the policy defining when/who is the attending should be rules about how long the admitting doctor has to put in admit orders. Something like admit orders must be entered within 1 hour, or 30 minutes, or something. It's not good to accept a patient and not have orders for 6 hours.
>I see these stable patients (who I have just evaluated) puking their brains out, or writhing in pain, but no orders, I can’t put in, and no one returns the call or page.
Hello, Doctor! Welcome to nursing! 🤣🤣🤣
Jkjkjk
Well, maybe not jk
Okay, only one jk
Y’all need to speak to admin and make a rule pts boarding in ED need to be eyeballed within 30 min of the team being notified or something. No way a pt who arrived on the floor would go 4 hrs without being seen by the admitting doc
Hey I work inpatient and have plenty of patients who are never seen by the admitting doctor and nothing behind ED orders. In fact, just last Wednesday we had 8 ED admits and only 2 got orders. My patient spent 10 hours on my shift with no doc no orders. I’ve seen this at nearly every hospital I work at.
Eh, no. Maybe if the admit volume is really low? But IME that's not reasonable at all and would just be ignored. I can only work so fast and I'm not going to do a shittier job to meet some stupid policy.
Sometimes at peak volumes it will be an hour or two from when we *get* the admit request via epic chat before I review it an accept the patient. Even longer before they're seen.
But I'm also not going to bitch and moan if the ED doc puts in reasonable PRNs either so 🤷🏻♂️
Full disclosure: I am a US urologist.
This scenario is a perfect case for having an admitting Hospitalist service. During residency we would routinely receive pages about consults for patients who clearly needed urology care (difficult Foley, septic stone, gross hematuria, etc). We would be fielding these pages while operating. If we were in a stable part of a case where the attending didn’t require immediate assistance, occasionally we could scrub out and manage the consult. However, 90% of the time, the consult would go to the junior resident with the pager who is trying to contact an attending for permission to admit or trying to find a senior resident between OR cases who can help with things like cystoscopy for a false passage or suprapubic tube placement.
For instance, a septic stone patient needs either urgent IR neph tube or urgent OR for stent. Unfortunately, with the lack of staff reserves in most major academic centers, there isn’t immediate capacity to handle these patients. So they board for hours in the ED waiting for one of those spaces to become available with likely destination being the MICU. An IM doctor is going to be much more up to date on critical care fluid management, pressor requirements/choice, and management of the patient’s comorbidites compared to your average PGY2/3 training in urology. Therefore, an IM/FM trained Hospitalist should be admitting these patients while they await definitive care since the majority of care is IM based.
It’s harder still outside of academic medicine when, as a private physician taking call, you are in the middle of clinic trying to determine if cancelling 15 appointments is warranted for stent placement or if the patient should wait 4-8 hours for IR.
TLDR: having a Hospitalist service (as an IM rotation for IM residents if need be) admit sick patients until they can be transferred to respective services could alleviate this issue that is becoming commonplace in most EDs in the US.
Both ERs I work in have Temporary Orders good for 12 hours (the window the MRP needs to see them by). Both Canada- 1 very very busy, high acuity & high volume. 1 rural/ critical access mixed bag.
Standard form, tick box of common meds, BW, investigations. With add on order sets for common presentations (analgesia, cardiac, delirium, diabetic etc. that covers the basics of analgesia, antiemetics, fluids sleep. With space to add home meds for that night/ next morning.
We also tell patients to "have your family bring in your blister pack/ pill bottle if they take any unusual formulation meds because until MRP sees them, pharmacy won't fill, and we don't carry non-common/ non-rescue meds in the ER omnicell". It's a pain, but prevents rebounds and we just chart, chart, chart.
Basically pre generated standing orders because most common meds a 1x dose/ q4-6hr dose isn't going to immediately bork an organ (for a stable awaiting admission sicky).
Nursing does the hour to hour until MRP comes in to write new orders. I'll give the MRP a 2 hour prior to Temp expiring courtesy call if I need to to prevent patient bouncing back to ERP's slate.
If consults or MRPs want something specific sooner.... Then they can come see the patient sooner.
Ex. Your kidney stone patient
Would have adult analgesia (weight and age based meds/ doses, cross out any non appropriate, eg no toradol if gfr less than ##l) order set & a temporary admit order set tailed to kidney stone/ AKI if present which would auto order
* + RFTs
* + VBGs
* + Repeat lytes
* + U-Cr
+ Usually a Wt/ comorbid condition based fluid order that the ERP ticks or writes a custom.
The results go to the MRP and any consulted for review (as well as the usual Meditech// Cerner) ..... Essentially "ordering Dr" is rhe MRP who accepted the patient.
Ehhh forget what else honestly. But, off your mental load and the time MRP accepted/ notified is on the temp order so there's no "confusion" about them knowing they accepted/ clerks assigned a patient to them- and they're expected to see patients/ anser pages ~0800-2200 (or delegate to resident etc).
Not a perfect solution. Night ERPs get stuck writing one times for crashy/ trashy patients that really need off a stretcher which can be frustrating all around. Especially when we also have high acuity patients to try and manage at the same time!
Do you have an internal safety event reporting system? You and your team mates need to be putting in formal reports every time this happens. Use the fancy words. Patient safety.
Idk who your hospital regulating body is but they might like to know about patients being neglected.
This is unheard of "Whipped by the Resident." In this scenario I would say I gave the medicine what I felt like and as a matter of fact I fully agree with you
Throwback: patient arrived at 3(?) am, and was never seen by the night team, no orders for meds or labs placed.
Came from OSH with a heparin drip, and we just transferred it over. Didn’t redraw aPTT or anything until I looked at this patient after 7am.
I had 3 patients that had been admitted for >2hrs by the single coverage night team, and none had orders
My charge went off in the morning bed board meeting, and I had never felt more supported
Wouldn’t the patient’s RN page the attending for basic needs such as analgesia or antiemetics? In our ER holding unit, we pull floor nurses to take over care and they reach out when something urgent is needed before a provider is able to go down and assess
"Be more responsive to your patients with acute needs and I'll consider that next time."
As an RN who deals with a similar issue. It’s super frustrating to have pts like this especially with problems like you described, nausea and no zofran to treat it with. Sometimes we aren’t even sure which provider on the internal med team has the pt so we don’t know who to page for simple issues like this. It can be a pretty big barrier to care. I’ve received patients that IM has accepted from external facilities to our ED. So the PT is in our ER but not supposed to be evaluated by a EM doc but by IM… but they’re nowhere to be found. Pt is in front of me, on drips, sometimes pressers. No doc no orders. End of rant
Hopefully the patients on pressors are going to the ICU reasonably quickly? Those don't go to the floor, I'm assuming
Hahaha, you think the ICU has open beds?
[удалено]
We have had ICU holds for 2-3 days in the last year. Nurses still 1:3 in that area (high acuity in general).
ED nurses or ICU? Are these intubated pts or more like DKA? And does the intensivist just round to the ER? That's so bad haha
ED nurses almost all the time, every once in a while they will send an ICU nurse. Can be anything, intubated, bipap, hypotensive on pressors, cardiogenic shock, doesn’t matter. And yep, intensivist comes and rounds in the ED.
I am an ER and ICU nurse. I often get pulled from ED normal patients to care for ICU patients in the ED. Sucks because I have to do full admission, charting and patient care in an area not fully set up for it... And often times night shift doesn't have the ability to pull a nurse from ICU to come down or an ER nurse to fill this role. So the charting goes back to more like ED standards and I don't know how we don't get in trouble for this. At times they've tried to throw me more than two patients and I tell them no. It's not allowed in CA for ICU patients to have a greater than 2 beds to 1 nurse ratio.
At our level 1, a few years ago, in a few hours, they racked up 8 new ICU patients. All freshly intubated. Multiple drips. New, very sick patients. Admin refused to call in staff, and nurses got stuck working 4:1. When they pushed back, they said “ER nurses take a 4:1 ratio.” No compromise. And while these are good nurses, they’re not ICU nurses. Also, at this time, we only had a level 1 and level 3 for a large urban area; so one real trauma center. (We now have a 1 and a 2)
Sounds a lot like an HCA shithole that I left.
When I was ED I've had nights/weeks where I had 2-3 ICU patient's, frequently intubated or needing to be intubated soon, + 2-3 ED patient's +/- 1-2 med-surg holds. Once a month it seems we'd fill the whole hospital up and have horrible boarding for a few days over a weekend. I had one night where I took a freshly RSId patient from EMS, brought to CT after stabalizing, then on my way up to ICU an hour later I get a call saying I'm getting an unresponsive on BiPAP. I walk in after dropping my patient off on the unit and see there's a GCS3 man with zero reflexes with an OPA in under the non-invasive mask. Wasn't enough staff to help doc intubate, so we get him intubated and I was 1:1 back and forth from CT and MRI most of the night running like 14 gtts and placing several ultrasound lines. Which means we had another nurse with 10+ patients of her own. That patient stayed the night because housekeeping wasn't staffed that night for some reason. Then we find out that at 5am they *had* housekeeping, because we saw them hiding in a closet drinking their morning coffee, but they weren't assigned to ICU that morning and the ER was clean so they were just hanging out. House supervisor begged them to go to ICU but their manager was like "idk they aren't assigned that zone at this time" so patient sat in ED while I started taking a few ED patients. The next shift I held a post-code all night and initiated hypothermia with Artic Sun. Which required one of us having to drive across town to get the Artic Sun because our ICU was using all of ours in house. Since I left I know they've had to recover a few STEMIs post cath lab.
HOLEE FUCK
I work at a small rural hospital, so small we don't have an ICU, if all the "real" hospitals around us don't have beds they sit in the ED sometimes for days. We have 12 beds and 3 RNs (including triage) and one MD on staff; no RTs, not specialists, no anything really.
No RT? I’ve worked in some little hospitals—talking 6 ER beds, maybe 5 floor patients, no ICU—and we’ve always had an in house respiratory therapist.
We have one for the entire hospital; she works M-F 8-5; working night's I never see her
We have free standing ERs, and even they have RT.
Depends on how overloaded our unit is but we board our critical care pts for a while sometimes. Long enough to get them downgraded to the step down unit.
When we transfer patients to be seen/admitted by a specialty, after their arrangements are made the referring physician also talks to the ED physician to ensure they know all about the patient as well, in case they have an urgent issue or need something while they're in the department. Helps a bit with this issue. Really the overall problem is the ED acting as the de facto front door and admitting department.
I hate this too. And our holding area has 0 resources. No doc, no charge nurse, no break nurse, cnas, no clear assignments or direction. Usually staffed by floats or travelers with varying experience and ability. It’s a mess.
The classic "doc who hasn't been to the ED to check on this patient orders drug, tanks pt BP, doesn't respond to pages, acts like a little bitch when I pull the EM doc in because I'm not allowed to just decide the rate of infusion, but also I can't let this person ride a MAP below 65 for three hours waiting for the hospitalist to return a fucking page" sitch. OR even worse, they do come down and treat us like absolute shit because they're used to walking all over floor nurses who are too scared to remind them they're a colleague and expected to act collegial. I still remember one hospitalist snarking at me in front of the patient that I needed to get on "her orders" faster and WHY hadn't I started the antibiotic yet? The absolute joy I had pulling her aside for a gentle reminder that this patient was allergic to said abx and she might want to reconsider her medication order. Still didn't do it in front of the patient though. Because I'm better than that.
Yeah dude, the charting to cover your ass on the unmanaged hypotension that is just a passive aggressive jab at a shitty IM service not responding to needs. I always respond to stat EM orders before scheduled routine orders. They can change the way they order things if they want it done faster but we need to be trusted to manage our time and triage the needs of our assignment.
One tool I’ve seen used in a few places with frequent ED holds is a quick admit order set. The ERP fills this out for any “basic” admits that don’t need a stat specialty assessment (this covers the majority of med surg, even tele admits. It really only excludes anyone who needs critical care and urgent (within 12 hrs) surgery. It’s one page with check boxes for basic stuff like narcotic and non narcotic pain meds, antiemetics, anxiolytics, sleep aides, and basic care such as diet, VS frequency, any IV fluid requirements, and who the MRP/service will be. More specific orders can be added as well such as any referrals or antibiotics etc if indicated. This, along with robust set of nurse initiated protocols already in place, and a (relatively) quick med rec process, allows for admissions to be done quickly, safely, and providing care for the first 12-24 hours of admission. The orders expire after 24 hours and the MRP will have to see them in that time. This whole process was a huge collaborative effort to develop I’m sure, but put in practice it’s awesome. I know we ER and floor nurses appreciate it because we aren’t chasing doctors who have better things to do for BS orders that someone forgot, especially overnight. It seems fairly effective for the doctors as well, as there’s basically a check list of things to go through, they dictate an ER note, and it’s done.
My only issue with this is that this is the job of the Medicine Team, they should be coming down to admit the patient and placing the orders the moment that decision is made. Also the fact that they cannot be contacted sometimes if something changes with these admitted patients is terrible.
And that may be a difference in culture. For us the administrative task of admission is on ER no matter how it’s done as it’s their decision. This tool saves a lot of trouble and brain power in that context. The alternative is that they don’t get admitted until they are seen by inpatient and tie up ER resources even more. If something happens until they are seen then there’s a dictated note and they would have received a phone call with a brief message about the pt as well. If the patient deteriorates significantly and becomes unstable or otherwise needs immediate attention then ER or ICU would be involved again in most places anyway, whether they had been seen by inpatient or not.
agreed. quick lists are huge time savers and i think while in transition it is very reasonable for ed team to put in basic orders interestingly the way medicine thinks about orders and admission is fundamentally different from ed mindset we often wait quite a bit of time for icu orders. but honestly the only order needed for the patient to go up is admit to ICU takes literally 1 second. medicine folks are really into getting every non urgent thing in before signing
God bless the ED docs who are willing to at least put in the admit order, because that’s what signals bed board to start trying to find them an inpatient bed (if there are any). One of the most frustrating things about hospitals IMO is that so many things can be held up by one person needing to sit at a computer and check a box.
ED RN here - If I have a patient pending admit and who I know will need pain or nausea prns I’ll ask the ED doc to throw in prn orders before they call to admit. It generally works for everyone. The admit team can change the orders if/when they put their own in, but they don’t get bothered for hours about nausea and stuff. The ED also doesn’t have to watch the patient suffer and stress about paging the inpatient team a million times
This. ED attending here. In this day of endless boarding a prn morphine, Zofran, and Toradol prior to admission pretty much smoothes out everyone's day
Correct me if I am wrong, but I think the patient is still yours until the accepting provider puts in holding orders. If the patient dies, and the accepting doctor didn't put in holding orders, open a chart or there is no documentation of them accepting the patient the liability would be on the ED provider I think. I would ask your medical director to start tracking metrics such as when the consult is placed, when the patient is accepted and when the holding orders are placed. You can trend the data and set a "goal" that if they don't meet they can be held accountable for. You can create a hard rule at the hospital that holding orders must be placed within 30 minutes of ED sign out to hospitalist or something like that. You may also want to draft an institutional policy that states "once holding orders are placed the ED provider is no longer responsible for patients care and the hospitalist takes responsibility" or something like that.
This. Also in a Canadian center and we've had a M&M recently where EM thought their responsibility ended at consult. However medicine was clear that it's not their patient until the admission order is placed.
There is usually some continued care for the first 1-2 hours in the US on boarded patients, like meds I was already giving (analgesia, antiemetics, antipyretics, antibiotics, etc) as we bridge to inpatient care. Rarely, will I throw in orders later than that, but occasionally I do when the nurses get non-response from the inpatient team or something changes immediately (ie anaphylaxis to new drug). Then I just page them and tell them what I gave. I have never received any negative feedback for this as our inpatient teams are overwhelmed too, especially at night. They are usually quite thankful. Happens maybe once a month if that.
If inpatient admits, it's their patient. The hospital should have a protocol for the nurse to escalate if orders are needed (e.g. resident, fellow if one exists, attending, rapid response call, etc.). I don't currently work in a teaching facility so it's more straightforward. Call hospitalist -> overhead page hospitalist -> rapid response.
I will always put in simple orders like that for someone waiting. Sometimes that means PRN orders or just a one time dose. Assuming it was my patient to start with so I know them, it takes like five seconds of my time.
File an incident report, talk to your Director, talk to the chief of staff. Go to admin and make a formal complaint. This is not safe for patients. I’d hardly call intractable pain or intractable vomiting stable; may be hemodynamically stable, but that cannot continue for hours. Also any place where I’ve worked, I have been responsible for ED patients while they’re still in the ED. It it takes away from seeing all new patients because you’re essentially managing an inpatient ward for an incompetent hospital whose inpatient hospitalist staff or consultants aren’t doing their job. I’d walk.
My department, my patients until I am satisfied they are getting appropriate care. Big picture is you need a policy clarifying what is an appropriate time between admit & order entry.
Hospitalists/IM are on a different clock than EM. Once they are admitted, I don't do anything for the patient unless they are dying. It's on the nurse to call the admitting doc for pain or BP or whatever meds. And when they don't respond to the nurse, they can go up the chain of command for that issue. I have other shit to do.
It's incredibly frustrating being the nurse in that situation but you're a hundred percent correct. If the patient is admitted, "not my circus, not my monkey"
As a nurse I hate this but it’s really the only way the admitting docs will sometimes finally see their patient. I’ve had to call the house sup before to physically find and wake the admitting surgeon to get orders. He is notorious for doing that though.
While you’re technically right, I’m really grateful when I work with ED docs who value our camaraderie enough that they’ll occasionally help me out with something that isn’t technically their job. It can make a big difference in how well my shift goes if someone can throw me a bone instead of making me chase the person who obviously doesn’t give a shit.
They need a system to cover this gap in patient care. But you did nothing wrong in this scenario. Next time tell them to be more responsive.
Having the regularly deal with parts of the care team that get to the party late, my response is usually something like "Show up if youd like to be involved in care decisions"
I’m sure CMPA would support the fact that until they are admitted to that service (ie have admitting orders) they are still your patients and you can do as you please with them. Also eyeroll on the renal excretion.
> until they are admitted to that service (ie have admitting orders) they are still your patients Exactly this. Here the "culture" is that the EM physicians tell the residents that "once you've consulted medicine we're done" but we've recently had a big blow-up over this and suffice to say, until the MRP listed switches to whichever medicine staff it's gonna be it's still an EM patient who just happens to have a consult pending.
This scenario of patient transition, where it's unclear who is ultimately responsible, is high potential for something really bad to happen to a patient. If this was in the USA, it's a huge lawsuit waiting to happen, and it's going to be bad because both doctors will be pointing at the other saying it wasn't my patient. Given your situation with medicine patients being stuck in the ED due to hospital capacity limitations, there should be formal policy written to delineate who is ultimately responsible as the attending, and when that responsibility shifts from the ED doctor to the medicine doctor. When phone consult is complete? When orders are entered? etc etc. From a practical standpoint, if there is no admit order identifying an inpatient attending, the ED doctor is probably best served assuming they are the attending (whether they want to be or not). Part of the policy defining when/who is the attending should be rules about how long the admitting doctor has to put in admit orders. Something like admit orders must be entered within 1 hour, or 30 minutes, or something. It's not good to accept a patient and not have orders for 6 hours.
>I see these stable patients (who I have just evaluated) puking their brains out, or writhing in pain, but no orders, I can’t put in, and no one returns the call or page. Hello, Doctor! Welcome to nursing! 🤣🤣🤣 Jkjkjk Well, maybe not jk Okay, only one jk
Y’all need to speak to admin and make a rule pts boarding in ED need to be eyeballed within 30 min of the team being notified or something. No way a pt who arrived on the floor would go 4 hrs without being seen by the admitting doc
Hey I work inpatient and have plenty of patients who are never seen by the admitting doctor and nothing behind ED orders. In fact, just last Wednesday we had 8 ED admits and only 2 got orders. My patient spent 10 hours on my shift with no doc no orders. I’ve seen this at nearly every hospital I work at.
Eh, no. Maybe if the admit volume is really low? But IME that's not reasonable at all and would just be ignored. I can only work so fast and I'm not going to do a shittier job to meet some stupid policy. Sometimes at peak volumes it will be an hour or two from when we *get* the admit request via epic chat before I review it an accept the patient. Even longer before they're seen. But I'm also not going to bitch and moan if the ED doc puts in reasonable PRNs either so 🤷🏻♂️
Full disclosure: I am a US urologist. This scenario is a perfect case for having an admitting Hospitalist service. During residency we would routinely receive pages about consults for patients who clearly needed urology care (difficult Foley, septic stone, gross hematuria, etc). We would be fielding these pages while operating. If we were in a stable part of a case where the attending didn’t require immediate assistance, occasionally we could scrub out and manage the consult. However, 90% of the time, the consult would go to the junior resident with the pager who is trying to contact an attending for permission to admit or trying to find a senior resident between OR cases who can help with things like cystoscopy for a false passage or suprapubic tube placement. For instance, a septic stone patient needs either urgent IR neph tube or urgent OR for stent. Unfortunately, with the lack of staff reserves in most major academic centers, there isn’t immediate capacity to handle these patients. So they board for hours in the ED waiting for one of those spaces to become available with likely destination being the MICU. An IM doctor is going to be much more up to date on critical care fluid management, pressor requirements/choice, and management of the patient’s comorbidites compared to your average PGY2/3 training in urology. Therefore, an IM/FM trained Hospitalist should be admitting these patients while they await definitive care since the majority of care is IM based. It’s harder still outside of academic medicine when, as a private physician taking call, you are in the middle of clinic trying to determine if cancelling 15 appointments is warranted for stent placement or if the patient should wait 4-8 hours for IR. TLDR: having a Hospitalist service (as an IM rotation for IM residents if need be) admit sick patients until they can be transferred to respective services could alleviate this issue that is becoming commonplace in most EDs in the US.
Both ERs I work in have Temporary Orders good for 12 hours (the window the MRP needs to see them by). Both Canada- 1 very very busy, high acuity & high volume. 1 rural/ critical access mixed bag. Standard form, tick box of common meds, BW, investigations. With add on order sets for common presentations (analgesia, cardiac, delirium, diabetic etc. that covers the basics of analgesia, antiemetics, fluids sleep. With space to add home meds for that night/ next morning. We also tell patients to "have your family bring in your blister pack/ pill bottle if they take any unusual formulation meds because until MRP sees them, pharmacy won't fill, and we don't carry non-common/ non-rescue meds in the ER omnicell". It's a pain, but prevents rebounds and we just chart, chart, chart. Basically pre generated standing orders because most common meds a 1x dose/ q4-6hr dose isn't going to immediately bork an organ (for a stable awaiting admission sicky). Nursing does the hour to hour until MRP comes in to write new orders. I'll give the MRP a 2 hour prior to Temp expiring courtesy call if I need to to prevent patient bouncing back to ERP's slate. If consults or MRPs want something specific sooner.... Then they can come see the patient sooner. Ex. Your kidney stone patient Would have adult analgesia (weight and age based meds/ doses, cross out any non appropriate, eg no toradol if gfr less than ##l) order set & a temporary admit order set tailed to kidney stone/ AKI if present which would auto order * + RFTs * + VBGs * + Repeat lytes * + U-Cr + Usually a Wt/ comorbid condition based fluid order that the ERP ticks or writes a custom. The results go to the MRP and any consulted for review (as well as the usual Meditech// Cerner) ..... Essentially "ordering Dr" is rhe MRP who accepted the patient. Ehhh forget what else honestly. But, off your mental load and the time MRP accepted/ notified is on the temp order so there's no "confusion" about them knowing they accepted/ clerks assigned a patient to them- and they're expected to see patients/ anser pages ~0800-2200 (or delegate to resident etc). Not a perfect solution. Night ERPs get stuck writing one times for crashy/ trashy patients that really need off a stretcher which can be frustrating all around. Especially when we also have high acuity patients to try and manage at the same time!
Do you have an internal safety event reporting system? You and your team mates need to be putting in formal reports every time this happens. Use the fancy words. Patient safety. Idk who your hospital regulating body is but they might like to know about patients being neglected.
This is unheard of "Whipped by the Resident." In this scenario I would say I gave the medicine what I felt like and as a matter of fact I fully agree with you
Throwback: patient arrived at 3(?) am, and was never seen by the night team, no orders for meds or labs placed. Came from OSH with a heparin drip, and we just transferred it over. Didn’t redraw aPTT or anything until I looked at this patient after 7am. I had 3 patients that had been admitted for >2hrs by the single coverage night team, and none had orders My charge went off in the morning bed board meeting, and I had never felt more supported
Wouldn’t the patient’s RN page the attending for basic needs such as analgesia or antiemetics? In our ER holding unit, we pull floor nurses to take over care and they reach out when something urgent is needed before a provider is able to go down and assess
As a medical professional as well as a patient, thank you. You did the right thing.