Sorry for the long post in advance. But I have to share two incidents I recently experienced concerning transfers to and from the ward and even if you are nice to hear I'm not a complete ***hole these two nurses claim I am.
Admission of a patient from the "medium care"
So we are told in advance that there is a patient with a probably pneumonia in the medium care thoracic surgery that isn't satting well on 15 L O2 and he is a possible admit in the near future. So 5 hours later still no word on this patient.
Then 5 minutes before visiting hour (which is ironically 30 minutes) we get a call from the medium care stating the patient needs to be admitted to the ICU. I ask the nurse if in her opinion they can wait another 5 - 10 minutes at the very least so we can get our families in to visit and have us do the admit then. Or even better to wait another 40 minutes and admit him after visiting hour. She replies "I can barely hold him", which would relate to something along the lines he is crashing fast not sure if I make it out of here alive. So she gets the go ahead to come right away.
We warn the waiting families they'll have to wait for about 30 - 45 minutes extra before being able to visit due to an emergency admission. So here the entire nursing team of the ICU is ready for this admit. Crash cart is close by, emergency intubation has been set up for... you know the works.
So after 15 minutes the doors to the ICU open and in comes the nurse with the patient. (the medium care is a 2 minute walk away even with a bed) The patient isn't monitored, is not showing any signs of shortness of breath, dyspnea or cyanosis. He is sitting up in his bed greeting us warmly as we look at him and the nurse is standing behind the bed with no visual of the patient because that is blocked by about 5 pillows.
So at this time I'm getting a bit annoyed but decide against lashing out. And I tell the nurse that I expected a more unstable patient based on her report. So at this point the nurse is idling in the hall asking if she can give a hand-off. So I let her know that in the ICU we do bedside hand-offs even on alert and oriented patients so all the nurses can hear it.
She tells me this patient has not been satting well on 15 L O2 (true as our monitor reads SpO2 in the low 90's). And that he needed to come to the ICU. So I ask her what happened in the mean time because 5 hours ago I heard the same thing not satting well on 15 L O2. And I ask what the rationale is that the patient needs to come at this point in time. Basically it boils down to nothing has been done and the only thing that changed was the on call surgical resident giving the green light on ICU admission. So I tell her that I really don't understand this reasoning and as I check the forms there is literally nothing done: no chest X-ray, no cultures, no labs, no antibiotics. So at this point she is getting annoyed for some reason and states she no longer wants to give a hand-off and if I have questions to contact the surgical resident (which I did afterwards and questioned his medical skills but that's bringing us to far).
So a few hours later the patient is satting better etc. I am doing a hand-off to the night nurses and the door literally flies open and in comes the same nurse yelling: "I still have a few pieces to pick with you". So before I get anything out of my mouth I hear her ranting and I make out: "You made me feel like a goat standing there doing a bed-side hand-off", "I would report you to management if you weren't a nurse", "How dare you disagree with my decision that this patient belongs in the ICU".
So now it's on and I tell her that we do a bed-side hand-off period no exceptions and that is done in all of the six ICU's in our hospital. And that secondly I stress that I don't disagree this patient belonged in the ICU but that I did and do question if he needed to be announced as unstable and be brought up to the ICU at that point in time especially if he remained "baseline" for 5 hours before. And that it is her job as a professional nurse to question a MD if he decides on the telephone that this patients needs to come right away. She should have done her own assessment and decided that either this patient was stable enough and could wait another 15 minutes or to call the rapid response team or MD and bring some monitoring for transport or at the very least be able to see the patient while transporting (if she was truely convinced this patient was so unstable). So basically I then tell her to get out of the ICU as she is disrupting hand-off and that is a potential risk for the patients and against hospital policy.
Discharge to a general ward
So a few days later I have the honors of discharging boy X (basically a frequent flyer that gets passed between all the ICU's in the hospital and nobody is happy to see this guy). Boy X is a 19 yo guy that suffers tetraplegia after a diving incident has pressure sores everywhere that resulted in osteomyelitis and endocarditis so far. Has contractures everywhere and on top of his pressure sores when he is home he rubs with his open wounds over the carpeted floor to get around and he has a big dog running around in his house. Oh and he is from a very difficult family with poor insight into his sickness. I get along great with boy X and his family (must have something to do with doing CPR on their mom when she was in our ICU a few years back, a story for another time). So generally when he is in the ICU he is mine and I am his, for better or worse...
So again an evening shift and when I get in all hell broke loose on the department, we discharged 5 patients during the day already (7 beds in total in our unit), he is the 6th but "there is no bed yet". And we have had 3 admissions already (2 hearts and a OHCA).
So as the shift progresses they decide to throw in another OHCA and a DKA. So slowly we (3 nurses in total) are rushing to get everyone stabilized and keeping them alive basically. So at 4 pm I get a call that the ward can now accept the new patient.
I go to tell him the good news only to find he has had a massive bowel movement (3 days worth) that's gotten into all his wounds. And I see the ward bed they brought has no AD-mattress. So I order an AD-matress find a willing nurse to come get him out of his mess and redo his wounds that I did 2 hours prior. All that in between alarms from other patients. So at around 6 pm he is cleaned up transferred to the ward bed and on an AD-mattress. But one of our patients codes so he is pushed back on the priority list.
So now it's 8 pm and I call the ward if he can come over. They agree and before leaving I'm changing him in position again, do the 8 pm care (refreshing, mouth care etc). So only as I leave the department I realize the evening meal cart came and went and I didn't feed him. But as he is very unpredictable in eating habits and generally his family brings something from their restaurant for him at 9 pm I'm not too worried about it.
So we arrive on the ward they take one look at him and go "oh it's boy X *sadpanda face*". So I start installing everything in the room, call sign, bottle of water, the works... In the ward we do hand offs in a separate room so as we leave the room I hear boy X call out: "*my name* you forgot about my food and I'm hungry and I don't want to wait an hour for my brother bringing food". So before I can say anything the ward nurse bursts out: "YOU DIDN'T FEED HIM! *angry/shocked face*".
So I'm doing my hand-off explaining what happened to him while he was in the ICU and the nurse keeps interrupting me telling to her colleagues, "and they didn't even feed him in the ICU, can you believe it". So after the fifth time I'm mad. So I ask her if she'd rather had I brought him at 4 pm which meant he would be on a normal mattress, still having to do his wound care, clean up a three day bowel movement, redo the wounds, pick him up to place him on an AD-mattress, do the 8 pm care and on top of that FEED HIM. Or as it is now just feed him or ignore him for another 45 minutes and wait for his family to bring food. (You should be aware they have nutritional assistants on the wards so they don't even have to do it and they have food even after the meal cart is gone. The ICU has nothing like that). So I tell her I'm genuinely sorry but I can't magically make food appear and that in the ICU things were exploding and nobody had food yet no patients and not the nurses either. So she tells me "even if the ward is busy I have to think about the food". So trying to get out of there quickly and avoiding pointless debate I ask if she has additional questions and she keeps stating this patient didn't get proper care and she demands a solution for him not having eaten yet. So I just pack up my stuff tell her to let it go fix the issue herself and to give me a call if she needs additional information.
We can read the nursing notes from the wards (via computer) and a few days later I check up on boy X and I read: ICU nurses didn't feed patient at MIDDAY and EVENING. patient was famished and cachectic on admission. Which wasn't true as I fed him myself at 2 pm for his midday...
So both these issues were reported by the ward nurses to management and thank god ICU management backed me up both times but when I see them in the hallway I get urges (and not the nice ones).
I try to be the understanding ICU nurse and to understand when things are a bit substandard or overlooked that it probably was busy or something. But it seems some people just want to yell when there is no reason to yell. And I'm pretty much convinced I do a lot more than some of my colleagues on discharges they'll drop the patient in the room and not care to plug the bed, give the call light, adjust the shades...
Guess it just wasn't my week...
P.S. Sorry for the long post but I do like to vent/rant. And if things look a bit odd English isn't my primary language.
Last edit by Joe V on Feb 15, '12
: Reason: formatting for easier reading