Vent...long, you have been warned.

Specialties Emergency

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I had a patient the other day that although I worked my butt off, but I was made to feel like I did a bad job with, and it's still nagging at me.

Pt was a sixty-something year old male, lifelong smoker, not been to a doctor in YEARS, who had been having SOB, productive cough, low-grade temp and chest tightness for two days. Seen in another ER day before, and dx with bronchitis, given a mega-dose of steroids/IV antibiotics, and discharged with amoxicillin.

Showed up at my ED with same complaints, RR of 26-30, sat of 90%, rhonchi and audible wheezing, yellow sputum, fever, so I did the complete pneumonia bundle on him, as well as a full cardiac workup. His labs came back crappy... 18000 WBC, K of 3.2, slightly bumped troponin (0.19), CPK of 1800, a pro-BNP of 1800, and a d-dimer of 1.3. But his x-ray didn't show an infiltrate, he responded very well to duoneb tx/solu-medrol, and his ct chest was negative for PE. Pt was actually wanting to go home...he didn't look as bad in person as he did on paper! He kept insisting, "I'm alright, I'm okay." I spent a lot of time with him, explaining lab results/medicine, talking about smoking cessation, the importance of getting a PCP and having regular checkups, etc. We had great rapport...he was getting a kick out of me fussing at and over him.

Every single issue that arose with him was addressed in the ED. He got two lines, BC x 2, sputum culture, Vanc, Levaquin, aspirin, NTG paste, Lovenox, K-Dur, and Lasix just in the ED. His admission orders were dx: bronchitis/chest pain, written for bedrest, serial cardiac enzymes, scheduled steroids/duoneb treatments, IV antibiotics, and an echo in the AM, and a stress test as soon as his respiratory problems improved. He literally had three pages of orders, and I checked off every single thing I could do in the ED, got all his meds, etc.

When I called report on him, his vitals were actually pretty good. HR of 96, RR of 24, 02 sat of 95-96% on 2 liters, BP of 130/80 and temp down to 99. I called report, and noticed that he was due for an albuterol/atrovent treatment. I called respiratory to meet me upstairs, and me and the pt went up. I put him on the monitor, hooked up his 02, bid him goodbye, went to the desk and gave additional report to the nurse, and told her respiratory was on the way for his treatment. When I left him at 2am, he was sitting in bed, laughing and talking, watching some infomercial on TV, and had only slightly increased work of breathing. Still some expiratory wheezing in his upper lung fields, but not audible without a stethoscope.

Then I get a call 20 minutes later from the nurse, yelling that this patient is too sick, he needs to be in ICU, why did I leave him up there, etc. I can hear him in the background saying, "I'm alright, I'm okay." Unbeknowst to me, the admitting nurse didn't go right into his room, and neither did the CNA. The patient took off his 02, went to the bathroom, then walked all the way down the hall because he wanted some juice. Respiratory never showed up to the room for the treatment, and by the time the pt was seen in the hallway and escorted back to his room, he was very SOB, audible wheezing, etc. Instead of calling respiratory, the nurse on the floor called the medical response team and the ICU doc to come see this patient that was probably going to need to be intubated(!) She pitched such a fit that the critical care hospitalist agreed to take him to the ICU. I went right up, and he was in ICU, FINALLY getting his breathing treatment, laughing at me, joking "Why didn't you tell me that I was going to get a tour of the whole place, I've done been in three rooms tonight already!" Sure enough, after the breathing treatment, he looked and sounded much better, and it was time for his steroids, so the ICU nurse gave them to him. I went back at 7am before I left, and they were going to downgrade him back to a tele bed after his echo was done. He spent less than four hours in the ICU.

Yet...I still got written up by the nurse on the floor. I feel like this patient was completely manageable. I took care of him along with my four other assigned beds in the ED most of the night, and we also had a full arrest and a STEMI come in that I worked on. I'm mostly just pissed that the patient really had confidence in me, and then it got undermined as soon as the admitting nurse called me yelling in FRONT of him.

Unfortunately, it's all about CYA. Sounds like your charting was spot-on. You left thinking it was all in hand: RT was on their way, you gave report, VSS...yah maybe should have stayed but hindsight's 20/20.

Write up the nurse for not at least peeking at him and RT for not going to him when they said they would.

You did nothing wrong, as best I can tell.

You sound like a wonderful nurse and I know I'd feel very confident in your care. God bless you and please do not take this sitting down.

Solutions need to be sought. No one needs to be fired or punished but answers must be found to prevent recurrences.

Ha! Like having sufficient staff is really going to happen. But do try. Keep professional. As you said, let your charting protect you. You might want to keep a copy of that charting, too.

Looking back, yes, there are things that I could have done better. If the pt's respiratory status was that labile, I should have pushed for a bed near the nurse's station, or if he was really that 02 and bedrest dependant, maybe I should have called the pre-code team myself down in the ED. When I inherited him at 7p, I thought he might end up needing ICU, but he responded so well to the meds and treatments that the ER MD and the admitting MD agreed that tele was appropriate. I do feel for the nurses on the floor. 8 or 9 patients is a huge load...That floor is a medsurg/tele, and basically gets dumped on. Lots of total care pts...he might have been the straw that broke her back.

I spoke to my supervisor yesterday before I left for vacation, and she assured me that I have nothing to worry about, the 'write-up' was basically going nowhere. My charting from the ED reflected that pt had been non-compliant with the 02 and had ambulated without assistance twice. I had also assessed the pt and charted vitals 5 minutes before admission, and another nurse had charted on him 30 minutes before admission because she had interacted with him, and had charted that the pt was resting quietly, no c/o pain, RR 22, 02 sat 96%, etc.

So I'm going to take this as a lesson, and be more diligent in the future, and also know to watch myself with this particular nurse, because I was told that she basically writes everything up. I'm just grateful that the patient is okay and didn't suffer any permanent or serious injury.

She probably has lots to write up but maybe doing so keeps her from seeing her patients in a timely manner.

at our facility we are always reminded that a write up is about the process not the person. if you submit an incident report it may get management to pay more attention to that floor and their staffing problems and may be able to get them some much needed help. (sounds like you did everything you right at the time.-- good luck!)

Specializes in Tele, ICU, ER.

I have learned through the sad experience that the nurses on the floor may NOT see the patient the moment the pt hits their bed. Even the CNA may not wander in. Can't tell you how many times me and my tech had to completely set up the patient in their floor bed, with nary any help to be seen, let alone the nurse.

Most times it's because they're swamped too, with 6 other patients, families, etc - but sometimes (only sometimes), they're sitting at the station charting or chatting, and will "get there in a minute".

You charted everything, and even went out of your way to call RT yourself for the tx. How much more could you have done while you had 4 other patients in your zone in the ER?? Probably 5 cause you know the second you get an empty bed, it gets filled!

The only thing I do now, if there's something like a tropo c EKG or a tx pending, I keep them in the ER the extra 15-20 minutes and get it done down there. I do my very level best to make sure there is NOTHING immediately pending when they hit the floor bed. It's the only way I can be sure the patient gets what they need in a timely manner. The result of this is: The floor nurses take my report and my patients with little if any grumbling, knowing I do as much as I can to make their life easier, and when I AM beyond swamped and HAVE to send a patient up with stuff pending, they say "send 'em up and do'nt worry about it - we got your back". It's a two-way street and it doesn't come overnight.

End of the day -we're ALL overworked, understaffed, underpaid... and we AND the patient suffers!

As for the write-up -she's covering her butt, badly I might add. Trust that you did everything you could. You did.

Kudos for being so thorough for that patient!

maybe I should have called the pre-code team myself down in the ED

I don't understand the reasoning for that, since you have a doctor right there assessing him. What exactly is the purpose of the pre-code team? Isn't that for when you don't have a doctor right there and need help?

I don't understand the reasoning for that, since you have a doctor right there assessing him. What exactly is the purpose of the pre-code team? Isn't that for when you don't have a doctor right there and need help?

It's not exactly the 'pre code' team, it's more like a medical response team, consisting of two to three critical care/ER nurses, a respiratory therapist, and the nursing supervisor. We call them whenever we have an ICU admission, or the pt has a diagnosis of sepsis, new onset CHF, pneumonia, any of the JCAHO core measure diagnoses. Their role is to expedite room assignments and make sure that BC have been done, antibiotics started in the 4 hour window, basically, they make sure all the appropriate measures for a better pt outcome have been taken in a timely fashion.

They also want nurses to call them when something "ain't quite right." Lots of people call them for this purpose, and supposedly another function is for them to intervene BEFORE a critically ill pt codes, and avert it. No doubt this man was sick, and even though technically he had none of the above admitting diagnoses, he certainly received all the workups and was being treated for them.

I always look for things I could have done better with my patients, whether something like this happened or not. Even with the smoothest STEMI, up in less than 25 minutes, I still think, "Damn! I could have given him another warm blanket because that cath lab is COLD!!" Or if I discharge a young female with PID, I wish I had more time to sit and plead with her to be safe, and vainly try to educate her about birth control. Just one of the downsides of being Type A, I guess! Hahaha!

Specializes in Med/Surge, ER.

Once you have reported off on your patient, and the nurse on the floor accepts the patient, you are no longer responsible for him/her. It was not your responsibility to make sure that patient received that treatment....it was his primary nurse (the nurse who accepted your report). You should politely remind that particular nurse of that next time you come in contact with him/her. Once the patient is out of your dept, his/her care is out of your hands.

Specializes in Cardiac ICU and now QA for ICF/MR.

REMEMBER: Can't copy charts, it is a HIPPA violation!

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