Use internal-disaster’ mode to move patients upstairs

How to address turn-down tactics’

By Colleen-Bock-Laudenslager, RN, MSN


Bock-Laudenslager & Associates

Redlands, CA

Every ED bed is full, and additional critical care bays have been created in the hallways. The EMS radio is quiet for a moment because your ED is on diversion, but the walk-ins keep coming in. ED resources have been exhausted, and the team is experiencing intense fray. You are attempting to mobilize patients to their inpatient beds when you are told the following: The bed is not clean. The nurse is on break. We are in the middle of report. We don’t have a nurse for that patient.

These turn-down tactics are the moment of truth for every ED nurse. It is a time to question the profession entirely: How can one unit of the hospital enjoy a pristine existence while the other is bulging at the seams in sheer terror? What ever happened to the days when inpatient nurses pulled beds into the hallways with a portable white screen? What about the bed-cleaning bucket pulled out when housekeeping couldn’t move fast enough? (I know; I was one of those inpatient nurses!)

Of all conflicts arising in the ED, situations with floor nurses are the most difficult to resolve. This is the No. 1 conflict EDs have, and the most emotionally embroiling. It’s extremely frustrating when the ED nurse might have four monitored patients at one time, and a phone call to the critical care unit creates an obstacle for immediate transfer of the patient to the unit.

Encouraging floor nurses to be open and receptive to ED patients is very difficult, and the problem affects patient flow in the ED. The conflict between nurses overflows into the physician’s schedule, because patients are not getting moved out in a timely fashion.

How have health care financing, managed care, and "doing more with less" created such barriers to being team players? Don’t get me wrong; I spent years in critical care, and I admire my colleagues who value control and calm and tout the laws of nurse/patient ratio. But don’t they care about the ED critically ill patient who is on an RN list of five to seven monitored patients?

When conflict exists within the hospital setting, I encourage staff to ask: What is best for the patient? If this were considered, many delays would never exist. Is it fair for inpatient nurses to harbor the attitude, "their problem should not be our problem?"

I believe a plausible solution to this ongoing dilemma is to develop a Staffing Internal Disaster Plan. A team of nurses could be corralled in a continuous quality improvement format to develop objective scoring guidelines/criteria for internal disaster on their particular unit. Critical care units and the ED could agree on an appropriate nurse/patient ratio. In addition, each area could establish points for intense procedures like resuscitation, administration of thrombolytics, placement of hemodynamic lines, admission to the unit, etc.

If both departments agreed on internal disaster criteria, the point system could drive which unit needs to accept or keep the patient. For example, the ICU or ED would get five points if a nurse was in the process of placing an IV line and four points if a nurse was admitting a patient or titrating medications every five minutes. If the point total in the ED was 12 and only 9 in the ICU, then ICU would have to take the patient immediately. A systematic point system for internal disaster would lend objectivity during chaotic times.

The plan could be reasonable and fair for all units. The unit with the highest score or the one most obviously under the greatest disaster condition would receive resources mobilized from the other units. In the situation of the critical care units, they may be forced to immediately accept the ED patient(s) and/or attend patients in the ED.

By calling it an internal disaster, critical care would not be violating laws against having more than two patients at once. Under internal disaster-like conditions, they can briefly have three patients at once. Critical care nurses are vigilant and hate to violate rules, but if they knew they were on internal disaster, they would have to move in that mode for a legitimate reason.

A team working together at this level of collaboration has many benefits:

It allows team members to understand the needs/values of all the nursing units. What a fabulous team-building exercise that would foster better working relationships!

It gives nurses practice at prioritizing and mobilizing resources under disaster-like conditions. How many of you are thrilled with your current disaster planning?

It equalizes the playing field between the ED and the nursing units. The ED will not be the only unit bulging at the seams . . . when only we can’t put a "closed" sign up!

It provides a more systematic approach to resource allocation and makes decision-making less emotional.

It would allow nurses to work briefly on different units to round out their experiences. Nurses would benefit from this form of cross-training.

There is no question health care has recently presented challenges never experienced before. I believe in the power of teams, and I hope professional nurses can collaborate on an internal disaster project such as this.

[Editor’s note: Colleen Bock-Laudenslager is a consultant who specializes in staffing and workplace issues in the ED. For more information on creating an internal disaster mode, contact Bock-Laudenslager at P.O. Box 7303, Redlands, CA 92375. Telephone: (909) 798-4969. Fax: (909) 797-2768. E-mail:]