[oneillk1]

Hi
I would really like some feedback on an incident that occurred yesterday. I was looking after my non ventilated patient, 8 days post a vascular procedure who had been extubated for one day.
When I arrived his RR was low 30s, chest sounded terrible, was on 50% o2 via venti mask, but Sao2 was in high 90s. Over the course of the afternoon his RR went up to mid 40s, he required increasing FiO2 (went onto NRB mask), ABG were very average (PaO2 =52), he complained that it was difficult to breathe and he didn't have strength to cough up his sectretions. I discussed with the registrar and we both were of the opinion that the patient was deteriorating and would more than likely need reintubation.

Anyway, at about 5:30 the Consultant for our unit (who had not looked at the patient all day) decided he should go to the ward. He did not perform an assessment, just stood at the door and said "oh the monitor says his RR is 29, send him" I pointed out that he had deteriorated over the shift, the monitor was inaccurate due to the position of his patient and I had manually recorded his RR to be 42 within the last 5 minutes, and I felt it was unsafe to send him to an unmonitored bed where the staff to patient ration would be 1:10. He said that he was aware that the patient would more than likely bounce back, but send him as we did not have any spare beds in ICU, just in case we get an admission.

I had a bit of a rant to the registrar, who said that he agreed with me but I had done all I could and we should send him because that was what the consultant said. I did not find this acceptable as I had real concerns for this patient's safety and well being, let alone his life, if he went to the ward at that point. Basically I got a bit angry and stroppy, told the in-charge nurse and the registrar that I did not think this was acceptable, we were not doing all we could for this patient, and we should not send him to the ward on the basis of what 'might' happen. Made a bit of a scene. So finally they each grew a spine and said ok don't send him.

My problem is that I am so angry that I had to make a scene for my concerns to be listened to. I feel that this is really bordering on negligence by the consultant concerned, and it is a huge slap in the face for all of the RNs in the unit - why do we bother being there and going the extra mile for the patients if the medical staff will not pay attention to our patient assessment skills, particularly concerning unstable patients? I know that I did the right thing for the patient, but I feel really bad and very disilusioned by this. I think I will be seeing the nurse manager to discuss this with her (because I have had a similar problem with this consultant previously), but as it is now I don't really know if there is a point.

Any feedback would be great!!
Karen

[sharrie]

Karen can I ask if you are a UK nurse, the fact that you use registrar and consultant makes me think you are.

the scenario you describe gives me huge concerns about patient safety and thank goodness you stood up and advocated for you patient who was clearly not fit to be returned to the ward. As a nurse practitioner if I was called to a patient with these clinical signs on a ward I would be calling ICU to review and admit so to discharge from the unit when the pateint is already demonstrating signs of clinical deterioration is unacceptable.

It is however somthing that I have expereinced from the other side, having a patient deteriorating on the ward with surgeon and medical docs all saying that the patient needs ICU but because there are no ICU beds the unit will not review.

THis is not an acceptable scenario, go through your incident reporting procedures and raise it to you senior nurse and clinical director.

[oneillk1]

Australian, but I suppose we have the same system here as there (or similar)

Thanks for that feedback, I just didn't know if perhaps I had overreacted. I personally thought I hadn't but I think a lot of things that aren't always totally accurate!!! Just wanted a fresh perspective, especially given that my fellow nursing staff were just so ambivalent about it.

Also, when I said that there were no free beds, we are staffed to run up to 14 beds. In emergencies we can (and do) have up to 16 ventilated patients, so this patient was not going to prevent another patient from being admitted if necessary

[sharrie]

I personally don't think you were over-reacting. We try to prevent cardiac arrests and recognise clinical signs of deterioration to stop preventable deaths on the wards using a criteria that your patient would have triggered an ICU referral, how then would it be acceptable to discharge a patient who clearly still needed ICU care.

I think that you were quite right and obviously so did the medics (eventually) or the patient would no longer be on the unit.

Can you discus your concerns with your lead consultant and senior nurse?

[Michigan RN]

You did a good job. If I had a patient like that and was in the same situation you were in, I would be ranting and raving until the docs finally would give in. It works. Sometimes you just have to tell these docs what your gut instinct says. I've done it before and they've listened..."Hey doc, this patient is not looking so good, come and see them........soon..might need intubation"...1 hour later patient intubated...