When Intensivists don't want to accept a patient...

[1fastRN]

So I've had several sick patients who were decompensating... Hypotensive and only able to hold a decent BP with aggressive fluid resuscitation.

So far, they're in for a step down or maybe just a unit bed and the ICU team comes to evaluate the patient. Now in my mind I have that feeling that the patient needs ICU and probably pressors at some point. We can't just keep bolusing the patient with liter after liter!

So I get frustrated, the patient is getting 2 liters wide open and is maintaining a "decent" BP... maybe in the 90s. If I slow down the rate of fluids the BP will continue to drop. And this patient has already had several liters.

I feel like I always get the run around with these ICU docs. They see the BP and think that magically the BP will hold after another liter. In my mind, I can already tell this won't be the case! I've been aggressively working on this patient and I know they need ICU. But the ICU doc will "refuse" the patient and ask me to monitor.

How can I better advocate for these patients? Have you run into this situation? I am literally running around trying to keep this patient stable and I'd like to get them up to the ICU so they can get the care they need and deserve. Yet I have to play the waiting game with the ICU doc.

I have other patients who need me, and I don't want this patient to crap out on me completely. Especially if that means starting a central line in the ED and starting pressors. Things could get much more complicated and it takes away from my time with my other patients.

Suggestions?

Sorry if this is scatterbrained, had a long couple of shifts in a row. :)

[Emergent, RN]

In my facility, it's the ER doc who makes the decision as to the level of care the patient will need. Yes, it sounds like that pt may need pressors. We communicate with our ER doc, he or she contacts the admitting doc. If pressors are needed, they are ordered by the ER doc. At my hospital we don't start a lot of central lines in the ER, only if no other access is obtainable. All ICU admits must have 2 sites. Pts on pressors will get a central line up in the unit. We try to get them up there ASAP.

It sounds to me like your system is flawed where you work.

[CodeteamB]

We have the same system as 1fast in my ER. Emergency Doc consults ICU, but the ICU doc makes the decision whether to accept.

We're not gun shy about starting central lines and pressors, we get about 4-5 liters in ( of course this varies widely based on complaint and comorbidities) and then bust out the norepi (or whatever).

Once they are on the pressors it makes the decision to admit to ICU a little simpler. We occasionally will get an order to try and wean in the ER in an attempt to downgrade to medicine/tele, but I actually haven't had a case where my pt on pressors didn't go to the ICU.

It can be frustrating when ICU is stalling, but they often have their reasons. When a patient is borderline and the unit is already packed (as is the case right now at my hospital and probably many others due to flu season) it makes some kind of sense to really be certain that they can't be well cared for elsewhere. Doesn't mean we have to like it, but I get the rationale.

[bebbercorn]

I agree with above, the ICU decides whether or not they accept. So, exactly what you wrote is the best advocacy. If you really feel ICU is warranted, corner the doc and say exactly what you said here... "His pressure is 90 systolic with 2 liters running wide open." Some doc are really responsive to this "I have a feeling about this patient " (only say this if it's true!) Voice your concerns and document what you said. Take names. Don't be afraid to go over docs heads with patient safety issues. Yes, I have barked and barked about pts and been wrong, but I'd rather be wrong than having guilt about not following through on what was right.

[BSNbeauty, BSN, RN]

What is the patients map ? Just because the systolic is low doesn't mean there is not enough organ perfusion . Make sure to document everything and go up the chain of command

[Esme12, ASN, BSN, RN]

Tell your ED doc. Tell your charge nurse. Call supervisor if they are inclined to help. As a ED nurse, ICU nurse and supervisor I will go and corner the ICU doc and let him know the stalling techniques have ended and the patient will not be going to the floor. Grrrrrrr they are so frustrating....I have also gone to the ED Dr. and let them know that this patient cannot go to the floor and let them deal with their "colleague"

[Pudnluv, ASN, RN]

We have hospitalists that come down and do the admission for all patients. Once the patient gets to the ICU, the ICU doc takes over. So it is up to the hospitalist to make the initial determination, although the ED doc usually is the one to make the recommendation when he/she first calls the hospitalist. Also, sometimes it is floor policy that determines where the patient will go. In the case of the OP, the floor would be well within their right to refuse accepting that patient.

I've been in that situation where I felt my patient should go to the ICU, but the doc insists that the patient can go to the floor. I gently let him know that if the patient goes to the floor, the floor will surely call a rapid response and then the doc will have to go running to the floor and the patient will end up in the ICU anyways. This usually gets them to change their mind, especially when they see it happen.

[1fastRN]

I've been in that situation where I felt my patient should go to the ICU, but the doc insists that the patient can go to the floor. I gently let him know that if the patient goes to the floor, the floor will surely call a rapid response and then the doc will have to go running to the floor and the patient will end up in the ICU anyways. This usually gets them to change their mind, especially when they see it happen.

Exactly! I've actually said that. Just because I FINALLY got there BP WNL doesn't mean it's going to stay that way.

Yes, their BP is finally 92/50 after 6 liters.... but unless a miracle happens it's not going to stay that way and they're going to end up a rapid response.

I just hate getting the run around!

[That Guy, BSN, RN, EMT-B]

Our floors wont take the pt if they are on pressors, get them to start them earlier and solve that issue ha

[msn10]

I am sure you have tried many different ways to be heard, but when conversations or collaboration do not work, then I do something called "Chart clarification."

Dear Dr. Smith, as I have reported, I feel this patient needs one on one nursing care because of x,y, and z. So as I am charting, what should I record as your reason for not wanting this?

I always tell them what I am going to chart about our interaction so that if the patient does crump, the paper trail leads to them. This is done only after repeated attempts to be heard, of course, but sometimes they need to be reminded that what they do (or do not do) will be recorded.

[1fastRN]

I am sure you have tried many different ways to be heard, but when conversations or collaboration do not work, then I do something called "Chart clarification."

Dear Dr. Smith, as I have reported, I feel this patient needs one on one nursing care because of x,y, and z. So as I am charting, what should I record as your reason for not wanting this?

I always tell them what I am going to chart about our interaction so that if the patient does crump, the paper trail leads to them. This is done only after repeated attempts to be heard, of course, but sometimes they need to be reminded that what they do (or do not do) will be recorded.

Brilliant.

[zmansc, ASN, RN]

I must be lucky, we don't typically see this issue here. Our hospitalists come down, consult with the ED provider and nurse, examine the pt and admit to the floor or ICU. If we disagree with the admission, we as nurses, ask the ED provider or hospitalist (depending on who has the pt at that time) why a pt with x, y, and z, would not need this different tx. Usually get a teaching moment or a change in plan because of what we brought up.

As for ED provider not doing things quickly enough, we again, go to provider, explain our concern and the reasons behind it and are either taught or given orders.

That even goes for when the provider is overwhelmed with critical pts, and a new one comes in. If I do a good assessment, present it to the provider and give them my suggested plan, I can often get a stopgap set of orders to keep this pt from getting more critical while the provider takes care of the pt he already has.

IMO, one of the biggest plusses to working in the ED is I tend to get really good teamwork from the providers, both the ED providers and the hospitalist/specialists that come in to examine/take my pts.