RN REFUSES to give REPORT.

[JJR512]

Having transported a few thousand IFT patients myself, for three different companies, here's what I have to offer.

Suppose you are working 911 and get called to a street corner with a man down. You get there and find the unconscious man. Somebody found him and called 911; nobody knows what happened to him, who he is, why he's unconscious on the ground, or how long he's been there. Do you argue with the bystanders, demanding to know why they can't tell you anything?

In a situation like this, just ask the nurse for the info. If they can't or won't give it to you, call your dispatcher or supervisor and explain that the facility is unwilling to provide the info, and ask your company if they have enough info for billing. After all, your dispatcher didn't send you there on a whim. Somebody at that facility called your company to arrange for this transport, and all the info necessary for billing may already be at your company. So find out if they have what they NEED, and ask if they want you to transport or what.

Some facilities are now sending information to other facilities electronically. This is to save the cost of paper and also to reduce the chances of private information falling into the wrong hands. Like it or not, but many places feel the transport team doesn't need to know the information. And the truth is, the transport team probably does not really need to know it. If your patient "goes south" then you tell the ER whatever you know, and it's the same as that random guy found unconscious on the street corner. You can tell the ER where the patient came from and maybe they can fill in the ER on some of the details, maybe that's a waste of time and it certainly would be easier if they'd just send the info along with you in the first place.

It's not worth getting bent out of shape because you will rarely win these fights. Fighting these battles is not part of the job description or training for the field transport teams, either. If you company doesn't like a facility or the way they work, your company can refuse to do business with them in the future.

 

[JPINFV]

After all, your dispatcher didn't send you there on a whim. Somebody at that facility called your company to arrange for this transport, and all the info necessary for billing may already be at your company. So find out if they have what they NEED, and ask if they want you to transport or what.

It's really going to depend on the company. At my first company I've been in dispatch when calls for discharges came in, and general all that was gotten at that time was location, destination, name, diagnosis, and insurance company. So, sure, you aren't being dispatched on a lark, but dispatch isn't always a limitless fount of information.

Some facilities are now sending information to other facilities electronically. This is to save the cost of paper and also to reduce the chances of private information falling into the wrong hands. Like it or not, but many places feel the transport team doesn't need to know the information.

It also doesn't help when crews accidentally drop the face sheet in the parking lot, which forced one hospital to change the social security number on their face sheets from 123-45-6789 to XXX-XX-6789.

 

[MrBrown]

A guy with 100 hours of training and somebody who sounds like they got thier nursing qualification in the Weet Bix box .... hmmm, Brown thinks that combination just can't end well no matter what is done.

Our Patient Transfer Officers get three days of medical training. Why? Because they are Patient Transfer Officers and not Ambulance Paramedics, they transfer patients.

Now Brown may or may not be a B2 BN qualified intensive care RN (and/or HEMS Doctor) but lets say you roll up to take a patient who is being discharged from the ICU home and Brown hands you a tree worth of notes and says something like "this is Sam, ten days post sepsis, was on ceftriaxone, lorpressor, dopamine and we had him in an induced coma for ten days, really hard to wean off the vent, lactate and WBCs were sky high, did have leukocytosis and neutrophilia however last CBC was normal. We have arranged outpatient labs in a week and an appointment with his GP"

Is that going to change anything during your ride home? Is knowing his sedementation rate or medical history from the eighties going to change how you give him some oxygen if he needs it or zap him with the AED? No.

 

[WTEngel]

Whether or not a full patient report is given is not the decision of the nurse any more than it is the decision of the paramedic or other health professional to decide how much info the nurse needs for their report.

Full patient report at transfer of care is a patient safety goal and the standard of care, whether you think the person you are transferring care to understands the report or not.

It is a little worrisome to me that people here think it is acceptable for them to pick and choose what they report at transfer of care. A full report, every patient, every time...anything less endangers the patient and your license.

 

[Journey]

Full patient report at transfer of care is a patient safety goal and the standard of care, whether you think the person you are transferring care to understands the report or not.

It is a little worrisome to me that people here think it is acceptable for them to pick and choose what they report at transfer of care. A full report, every patient, every time...anything less endangers the patient and your license.

As an RN do you spend 20 minutes giving a report to an EMT-B for every routine transfer? Do you cover the entire medical history and hospital stay? Do you review all the patient labs? Do you cover every medication with the last times given? I&Os? Do all the EMT-Bs interact with questions about your report to ensure they understand everything you have stated? Do they make their own detailed notes on everything you have told them? Are all the EMTs eager to sit through a 20 minute detailed report or would most prefer to get the bare bones version and get on their way?

ALS and CCT reporting will be different if there are providers such as an RN or a Paramedic on those transports. But even then, one can see the difference in comprehension or expectations of the reporting. There is another thread on this forum that had this comment.

I think IFT is best served by EMS but would be better served if additional education was directed at transporting patients inter-facility.

I'll use myself as an example, I started working for an ALS service (FD) that does IFT from a rural medical center to actual hospitals with more capabilities. The hospital sends their IV pumps yet there is no formal in-service training whatsoever on the IV pumps. Granted, the pumps and drips are already set but the Medic needs to know how to troubleshoot the pump, clear errors, etc. I at least took the effort to talk to the nursing staff in the ED and got a quick "review" of the pumps and asked for the number to the medical centers education dept.

This is an ALS service and it seems there are a lot of expectations placed both on the Paramedic and the RNs. These RNs should also not be expected to be educators for the Paramedics at the time of a transfer of a patient.

Some Paramedics will understand some of the labs, medications and disease processes but sometimes, even with a very thorough report they will not get that much out of the report except the patient has to go to another hospital and the RN is reponsible for setting everything up. For most, it will be on the sending hospital until the ambulance drops the patient off at the accepting facility. This also puts the sending RN in the sending facility in a bad situation and it is possible this is not the best crew choice but may be the only choice in town.

It probably is not the Paramedics' fault but the way their curriculum has prepared them and some may not know what their own expectations are to know what should be acceptable and what is not.

 

[JJR512]

As an RN do you spend 20 minutes giving a report to an EMT-B for every routine transfer? Do you cover the entire medical history and hospital stay? Do you review all the patient labs? Do you cover every medication with the last times given? I&Os? Do all the EMT-Bs interact with questions about your report to ensure they understand everything you have stated? Do they make their own detailed notes on everything you have told them? Are all the EMTs eager to sit through a 20 minute detailed report or would most prefer to get the bare bones version and get on their way?

As someone who has done thousands of BLS IFT transports, I have never had a report take as long as 20 minutes. Not even half of that.

My major concerns were why is the patient here, why are they going where they're going, am I likely going to have any problems and if so what, and is there anything special I need to be aware of. By "anything special" I mean does the patient spit, does the patient say strange things, does the patient prefer to sit at a particular angle of recline, is the patient going to want me to crank the heat up, etc. I don't ask each of those questions; I just ask if there is anything special I need to know about this particular patient.

As for the full details, in my experience, they are all contained the in the charts and reports that accompany the patient. Unless the facility transmits them electronically, but this was rarely the case in my experience. Probably will be a growing trend, though. In fact I only recall the VA facilities being ones that did electronic chart transfers, and only between other VA facilities.

I feel that all I need to know is enough to explain why I was transporting the patient if I need to take that patient to an ER. Why were they in my ambulance to begin with. Basically, a brief summary that I can give to the ER charge nurse when I roll in. The details are all in the charts and reports that go with the patient, and the ER can get them from there. This 20-minute-long super detailed report you're talking about is something I don't feel is appropriate for me, as an EMT-B, because I lack the background to understand most of it, therefore I'm not likely to remember it well and won't report it accurately.

 

[WTEngel]

If it is taking 20 minutes to give a full detailed report on a BLS transfer then you must be taking your time. 20 minutes or more on a CCT is the minimum sometimes.

The point I am trying to make is that it is not the right of the nurse giving report to pick and choose what they feel is important, thus impacting what is and is not included in report. A full report on transfer of care is best practice, a safety standard, and the best thing for the patient. Had the nurse in question here acted the way she had in any of the hospitals I have worked in, she would have been sternly disciplined and counseled about how she should interact with fellow health care professionals (whether the EMT was acting professional is beside the point) when transferring patient care.

I have participated in CQI and root cause analysis of near misses and sentinel events and many times the ultimate conclusion is that there was a miscommunication, often occurring at the time patient care was transferred.

To address whether or not the nurse should educate the person they are giving report to if they do not understand something they are saying, if it is pertinent, absolutely. When I give report and transfer care, you better believe if the healthcare professional has questions regarding the patient's condition, labs, or studies, I will clarify it for them. If they don't seem to understand what I am explaining, and it is something that will effect patient safety, then I would be compelled to speak with the charge nurse or unit supervisor and discuss the matter with them. This is not an insult to the provider, but hopefully will prevent them from getting in over their head. The same should be true of nurses giving report to IFT crews. If there is something notable regarding HPI, patient condition, labs, or studies, and the crew does not seem to be getting the picture, then they may not be the appropriate level of care for that patient. Or maybe it is something that just needs to be passed to the person they will transfer care to...

Picking and choosing what information you give to the person you transfer patient care onto is dangerous. If they don't understand or don't care to listen to your patient report, that does not mean you should dumb it down for them. I choose to bring people up to my level, not arbitrarily decide that someone is below me and deserves less of a report.

 

[Journey]

If it is taking 20 minutes to give a full detailed report on a BLS transfer then you must be taking your time. 20 minutes or more on a CCT is the minimum sometimes.

The point I am trying to make is that it is not the right of the nurse giving report to pick and choose what they feel is important, thus impacting what is and is not included in report. A full report on transfer of care is best practice, a safety standard, and the best thing for the patient. Had the nurse in question here acted the way she had in any of the hospitals I have worked in, she would have been sternly disciplined and counseled about how she should interact with fellow health care professionals (whether the EMT was acting professional is beside the point) when transferring patient care.

I have participated in CQI and root cause analysis of near misses and sentinel events and many times the ultimate conclusion is that there was a miscommunication, often occurring at the time patient care was transferred.

To address whether or not the nurse should educate the person they are giving report to if they do not understand something they are saying, if it is pertinent, absolutely. When I give report and transfer care, you better believe if the healthcare professional has questions regarding the patient's condition, labs, or studies, I will clarify it for them. If they don't seem to understand what I am explaining, and it is something that will effect patient safety, then I would be compelled to speak with the charge nurse or unit supervisor and discuss the matter with them. This is not an insult to the provider, but hopefully will prevent them from getting in over their head. The same should be true of nurses giving report to IFT crews. If there is something notable regarding HPI, patient condition, labs, or studies, and the crew does not seem to be getting the picture, then they may not be the appropriate level of care for that patient. Or maybe it is something that just needs to be passed to the person they will transfer care to...

Picking and choosing what information you give to the person you transfer patient care onto is dangerous. If they don't understand or don't care to listen to your patient report, that does not mean you should dumb it down for them. I choose to bring people up to my level, not arbitrarily decide that someone is below me and deserves less of a report.

You stated "Full patient report". What do you consider "full patient report" for an EMT-B? To an RN that means labs, meds and a detailed history. CCT reports can extend over 20 minutes and then are continued on at bedside as each med and equipment setting is checked during the transfer. 10 minutes probably would not be enough time to cover everything safely.

But, for an EMT-Basic on a routine transfer to the Radiation Therapy center 1 block away, how much time and what would you cover for that transfer? Do you really think a detailed history and all the medications would be necessary when the center probably has that data and the EMTs would not be pushing any medications at all?

RNs and/or Case Managers are required to also give a full report to the receiving center. This is not something that can or should be delegated to an EMT-B.

For the EMT-B and a BLS transfer, 100 hours of training specializing in first aid does not even give them a good anatomy base to understand most disease processes so I fail to see what telling them a bunch of lab numbers would be of value to them. Diagnosis, code status, condition stability and reason for transfer should be adequate along with a face sheet if permitted by the facility depending on security issues. Many facilities are now utilizing secure electonic transfer of documents for billing rather than the paper system. They may present a transfer sheet which may have an established account number for reference.

We also don't know the exact details of what happened in this particular incident since we are only reading one side of the story nor do we know what the prior arrangements are between that facility and the ambulance service. The original poster seems to also have been having a bad day which probably contributed to the situation. It is very difficult to give a report to someone who also wants to find fault in everything you do just because you are an RN. If you have been an RN for any length of time, this is something you should already have picked up on.

There is also a difference between active interaction during a report with clarification and that where you have to teach someone to operate an IABP, ventilator, IV pump or how to titrate medications. You can not always teach someone to be a critical care provider in 10 minutes or even 20 but the transfer may have to go on. Then it can come back on the sending facility which includes the RN who didn't push enough meds for the Paramedic to get through the transport or didn't tell them everything about the IABP when there should also be a point where the Paramedic should tell his employer or the sending hospital, this transport is out of his comfort zone. But, sometimes the ego also gets in the way. However, no, it should not be the responsibilty of the RN to teach a Paramedic everything about critical care medicine at the time of the transport. The Paramedic and the ambulance company should realize this and see that a properly educated and trained provider is responding to these transfers.

If you company doesn't like a facility or the way they work, your company can refuse to do business with them in the future.

I do agree with just about everything JJR512 has posted except for this. If the ambulance service has a contract with all the Tenet facilities in the area and runs across one problem at one facility, is it really worth it to the ambulance service to flush away a contract of that size over what just could be a personality conflict between two people having a bad day? Several EMTs might lose their jobs which means trying to get hired with the next service that lucks out and gets the contract. Go through the proper channels to get a problem solved and you might also find out something about the arrangement between the facilities and the ambulance service that you didn't know before.

 

[Sasha]

The point I am trying to make is that it is not the right of the nurse giving report to pick and choose what they feel is important, thus impacting what is and is not included in report. A full report on transfer of care is best practice, a safety standard, and the best thing for the patient. Had the nurse in question here acted the way she had in any of the hospitals I have worked in, she would have been sternly disciplined and counseled about how she should interact with fellow health care professionals (whether the EMT was acting professional is beside the point) when transferring patient care.

When nurses give me a full report, I often find myself with a deer in headlights stare that just screams "I don't know half of what you're talking about" I prefer when nurses ask me what I need to know, and I tell them and ask questions. That way we are not going off into "I'm an idiot land" and I can find out what I need to.

I'm not going to say that nurses are more or less educated then EMS providers, but they are educated differently and about different things.

 

[Sasha]

I mean does the patient spit,

I always love the last minute mention of "Oh yeah, she swings/bites/kicks/hits/spits/pulls hair" while you're partner is in the room trying to get vitals

 

[JJR512]

If you company doesn't like a facility or the way they work, your company can refuse to do business with them in the future.

I do agree with just about everything JJR512 has posted except for this. If the ambulance service has a contract with all the Tenet facilities in the area and runs across one problem at one facility, is it really worth it to the ambulance service to flush away a contract of that size over what just could be a personality conflict between two people having a bad day? Several EMTs might lose their jobs which means trying to get hired with the next service that lucks out and gets the contract. Go through the proper channels to get a problem solved and you might also find out something about the arrangement between the facilities and the ambulance service that you didn't know before.

When I said that if your company doesn't like the way a facility is run, I didn't mean just on that one call. Naturally I did not mean that if your company is unhappy about ONE call. I mean if it is an ongoing issue, especially if what the facility is doing makes it very difficult for your company to bill and collect. Of course the company will need to weigh the difficulty they are having with a particular facility with the cost of losing business with that place. If it is a single facility that's not part of a contract and only uses your ambulance service occasionally, but every single time it's a hassle, it might not be a big deal to cut the off, but if it's a major contract that provides a lot of income despite some occasional hassles, it might be in the best interest of the company to keep that contract. The point is, I said the company "can" refuse to do business, not that they should.

One of the other points I was trying to make, and I don't think I really got to it much, was that the field crew really should not be arguing with the facility staff. Field crew rarely win these fights. Call your supervisor or dispatcher, explain the situation, and find out what they want you to do.

I come from a customer service background and to me, IFT is much more of a customer service job than an EMS job. An ambulance crew being rude or argumentative is something that can eventually find its way up the chain of command of a facility or chain of facilities, especially if the staff on duty at the time is really good at painting pictures. The field crew needs to remember that they are the public face of their company. They very well can cause a facility decide to drop, or not renew, their contract with the ambulance service, or to place them last on the call list. If an ambulance company loses a contract, people can lose their jobs, because they just aren't needed anymore. And it isn't fair to one's coworkers for them to lose their jobs, and possibly much, much more as a result, because one couldn't keep their temper in check, and couldn't remember that as with any job, it's not what the worker wants that matters, it's what the boss wants that matters.

 

[Journey]

, and I tell them and ask questions. That way we are not going off into "I'm an idiot land" and I can find out what I need to.

That is definitely one of the best ways to approach it since it is difficult to keep track of the many different services that come in to pick up patients from the condo courtesy vans, retirement centers, wheelchair or stretcher vans to CCTs. Sometimes I don't believe EMTs or Paramedics are aware of the many other types of transports there might be in an area. Someone driving a shuttle bus for a retirement residence probably would not need to know labs either or billing information. Hospitals also may have their own courtesy vans to get patients back home after appointments.

I'm not going to say that nurses are more or less educated then EMS providers, but they are educated differently and about different things.

In a hospital or LTC facility attached to the hospital such as a SNF or Rehab center calls a Rapid Response Team for a patient that may be requiring immediate higher care, the RN and Respiratory Therapist responding will each have their own set of questions for their own focus. The Respiratory Therapist who intubates, assists with bronchoscopies, nasally suctions and does arterial sticks may want to know when the patient last ate, if the patient is on heparin or similar meds and platlet count. The RN will want to know the INR. Both will want to know the labs such as CBC and chem panel but with a focus on different values. They will have more questions once they do a quick assessment of the patient and see pitting edema (?diuretics, ?I&Os), sternotomy scar, irregular pulse (?meds, EKG on file), dialysis catheter (?last dialysis), distended abdomen (?BM, meds). cool mottled skin (?rectal temp) etc. Our CNAs usually know when a Rapid Response team is about to be called they need to get a rectal temp, vitals and have the I&Os ready.

The amount of information on a nursing flow sheet can even be a little overwhelming unless you are used to looking at it and so can an RN to RN report. Some patients also come with over 80 years of medical history and some is of importance and some gets left off but may be important later. Just reading some of the topics on this forum criticizing RNs about being concerned about stuff like BMs, urine output, food, psychosocial issues, comfort and palliative care shows either a lack of education about the importance of these things or their focus is very narrow. One would not think a Respiratory Therapist would be asking about BMs either but if there is abdominal discomfort or distention, it can interfere with the cardiopulmonary system. They definitely want details for the dialysis patient such as the last time and the most recent K+ to initiate treatment if needed but then other issues might also have to be addressed which the RN is probably already checking out as well.

When an ambulance team does come for a patient, the chart may be pretty massive even for transfer with months at maybe 3 -4 different hospitals and LTC facilities. There might also be hx summaries from each of these facilities with the patient starting with pneumonia at one, had a CABG, had sepsis and finally had a big toe amputated. The ambulance crew may pick one hx summary that seems to be the easiest to get some information from. When an RN might try to show them the most recent, the EMTs might just say they only need something to fill in the blanks on their report and don't need all the rest. However, the EMTs will probably type something on this forum complaining about a pushy RN who was trying to tell them how to do their job. But, another RN would thank that RN for showing them the rest of the story.

I come from a customer service background and to me, IFT is much more of a customer service job than an EMS job. An ambulance crew being rude or argumentative is something that can eventually find its way up the chain of command of a facility or chain of facilities, especially if the staff on duty at the time is really good at painting pictures. The field crew needs to remember that they are the public face of their company. They very well can cause a facility decide to drop, or not renew, their contract with the ambulance service, or to place them last on the call list. If an ambulance company loses a contract, people can lose their jobs, because they just aren't needed anymore. And it isn't fair to one's coworkers for them to lose their jobs, and possibly much, much more as a result, because one couldn't keep their temper in check, and couldn't remember that as with any job, it's not what the worker wants that matters, it's what the boss wants that matters.

Well stated.

It seems so many forget the customer service part which is why hospital staff get constant reminders and inservices. It is disheartening to read some of the topics and posts on this forum where the EMTs and Paramedics dislike doing routine calls. That dislike is bound to show to the nursing staff and the patient especially if you hear then next truck in rotation getting a cool trauma call while you get to take someone back to the nursing home. That nursing home patient is still a human being and still matters as a customer who also deserves some respect.

 

[rescue99]

All the while, amongst all the bicker, one must do what is best for the patient. Poor sick guy has nothing to do with your argument de poids...

Was the tiff being held in front of the patient? Musta missed that part.:sad:

 

[LuvGlock]

The "base" I work at involves mostly taking pts from a freestanding ER to the main hospital (9 miles away), and the occasional walk-in MI to the cath lab. Needless to say, since these people are all being admitted to the hospital (usually a tele floor), most are ALS trips. When we walk in the door, the RN usually spends at least 5 minutes giving a quickie report, and then answers any questions we have.

When I was doing D/C->SNF, my only question of the RN was usually "Anything medically important we need to know?", and that would usually suffice. That being said, the large majority of those trips were BLS, and the MedNec was usually Dementia, so there wasn't a huge expectation of emergencies during transport.

As far as your situation goes, I wasn't there, but, I've found that being sugary sweet with RN's will get you a long way. The same applies to Unit Secretaries usually. Even when they are total blankety-blanks, I just kill them with kindness and I can usually get what I need.

Could you not have taken your own blood sugar?

How would his own BS help him with pt care?

 

[Veneficus]

How would his own BS help him with pt care?

You are your first patient

 

[JJR512]

I come from a customer service background and to me, IFT is much more of a customer service job than an EMS job. An ambulance crew being rude or argumentative is something that can eventually find its way up the chain of command of a facility or chain of facilities, especially if the staff on duty at the time is really good at painting pictures. The field crew needs to remember that they are the public face of their company. They very well can cause a facility decide to drop, or not renew, their contract with the ambulance service, or to place them last on the call list. If an ambulance company loses a contract, people can lose their jobs, because they just aren't needed anymore. And it isn't fair to one's coworkers for them to lose their jobs, and possibly much, much more as a result, because one couldn't keep their temper in check, and couldn't remember that as with any job, it's not what the worker wants that matters, it's what the boss wants that matters.

Well stated.

It seems so many forget the customer service part which is why hospital staff get constant reminders and inservices. It is disheartening to read some of the topics and posts on this forum where the EMTs and Paramedics dislike doing routine calls. That dislike is bound to show to the nursing staff and the patient especially if you hear then next truck in rotation getting a cool trauma call while you get to take someone back to the nursing home. That nursing home patient is still a human being and still matters as a customer who also deserves some respect.

There is another aspect as well to what we are both talking about here, and that is work ethic. This transcends customer service experience or any other kind of experience; it has nothing to do with the kind of job one has, just the fact that one is an employee with a boss (supervisor, manager, whatever). As you are talking about, what many employees forget is that they don't go to work to do what they want to do; rather, they go to work to do what the boss wants them to do. If you don't like the job, either find another job, or grin and bear it. Besides customer service, I also come from a management background, as well as a crew-level background before that, and I understand both sides of the employee-employer relationship. And just like you are saying, Journey, I see so many fellow employees getting frustrated and angry at the job, and deciding to do things their own way, or deciding what they will and won't do, and that just is NOT the way it's supposed to work.

That's not to say that employees should just blindly follow orders. Obviously, no employee should ever do what they're told if it's illegal, immoral, unethical, or unsafe. Aside from that, pretty much every job description I've ever seen always includes some kind of mention of "and other duties as needed". Also, if an employee thinks he or she has a better way of doing something, they can mention it to the boss, at the appropriate time, or if they don't understand something, they should ask why. So I'm not saying to just blindly follow orders. But remember there is a time and place for asking questions and it isn't always the exact moment they occur.

 

[RanchoEMT]

Was the tiff being held in front of the patient? Musta missed that part.:sad:

Absolutely NOT. Crew had NOT made patient contact prior to Nurse vs. EMT.

 

[rescue99]

Absolutely NOT. Crew had NOT made patient contact prior to Nurse vs. EMT.

I thought not...just making sure I read your concerns correctly. I stand by my original thoughts...nurses are often lacking in when it comes to actual patient care capabilities. It's that null curriculum shining through again!

 

[Journey]

I I stand by my original thoughts...nurses are often lacking in when it comes to actual patient care capabilities. It's that null curriculum shining through again!

Looks like someone didn't get accepted into nursing school. Too bad. You could have learned alot.

 

[rescue99]

Looks like someone didn't get accepted into nursing school. Too bad. You could have learned alot.

Never considered nursing so no, I guess I never have been accepted to nursing school My degree is in accounting and in just a few more credits, EMS.... but thanks for playing anyway