Unstable Admission

MrNurse(x2), ADN · May 10, 2018

The responses reveal that I made the right decision leaving acute care. Don't question and call an RRT? This makes me fearful if I ever was a patient. Even nurses are now callous to patient care for throughput and patient satisfaction. It was my belief and a source of contention that every RRT called within 30 minutes of arrival from the ED should have generated an incident report. The floors have become a triage center and the ED just a gatekeeper. The lack of care by these policies is frightening.

Twinmom06, ASN, APN · May 10, 2018

you just described 75% of my dialysis patients. Some of them run that low, especially if their adrenal function is ALSO compromised (not every HD patient has adrenal issues). If he ER bolused him, he may need a bit more, or a dose or 2 of Midodrine to recover.

as for reprimand - I don't think that's appropriate.

brownbook · May 10, 2018

The responses reveal that I made the right decision leaving acute care. Don't question and call an RRT? This makes me fearful if I ever was a patient. Even nurses are now callous to patient care for throughput and patient satisfaction. It was my belief and a source of contention that every RRT called within 30 minutes of arrival from the ED should have generated an incident report. The floors have become a triage center and the ED just a gatekeeper. The lack of care by these policies is frightening.

I do agree with you. I don't see a lot of options for the floor nurse or ER nurse. Is the ER nurse supposed to override the admitting physicians orders and refuse to call the admit to the floor?????

Is the floor nurse supposed to refuse the admit? Tell her charge nurse I refuse this admit it is inappropriate? Maybe???? So the charge nurses changes the assignments and gives the patient to another nurse?

Maybe the charge should have, could have, gone to the ER and assessed the patient herself. Yes there were a lot of options.

Meanwhile the patient is being held in a busy ER, on a gurney , most likely not being watched or assessed as closely as would be desirable due to the normal, acceptable, flow and function of an ER.

I completely agree a Code Blue or Rapid Response called within 30 minutes of arrival to a floor should generate an incident report. It was obviously an inappropriate admission.

So we all need to know how did the patient do once he got to the floor

Wuzzie · May 10, 2018

Is the floor nurse supposed to refuse the admit? Tell her charge nurse I refuse this admit it is inappropriate? Maybe???? So the charge nurses changes the assignments and gives the patient to another nurse?
Maybe the charge should have, could have, gone to the ER and assessed the patient herself. Yes there were a lot of options.
I completely agree a Code Blue or Rapid Response called within 30 minutes of arrival to a floor should generate an incident report. It was obviously an inappropriate admission.
So we all need to know how did the patient do once he got to the floor

Sometimes outrageous things need to be done to affect change in a system that clearly needs it. The OP should never have been chastised for questioning the admission.

Beyond that it still isn't very clear if this patient really was unstable or just had a low BP. We've had a few dialysis nurses pop in and tell us that this is very normal. There was no other indication given to support an assessment of instability other than the BP being a little low. We really do need to know how the admission went to more accurately respond.

ETA: I re-read the OP and noted that she works in a PCU. In my neck of the woods that is a step up in care from a general med-surg floor but not quite an ICU/Step down. Seems to me this type of unit would be perfect for handling this patient.

Snatchedwig, BSN, CNA, LPN, RN · May 10, 2018

Can you tell us what happened to the patient? Okay-ish prognosis?

MunoRN, RN · May 10, 2018

There's far more information needed to say whether this was an inappropriate admit for a progressive care floor, but based on the information given there was nothing inappropriate about this admission. As a measure of perfusion, MAPs are of little use in ESRD patients given that a significant subpopulation of these patients have chronically low diastolic pressures, so a MAP of 58 could well mean a BP of 100/37, which might be an unusually good pressure for an HD patient right after dialysis. Based on what we know, a level of care between a medical floor and ICU (progressive care) is appropriate.

Crush · May 10, 2018

I just take issue with the OP being reprimanded for questioning. Regardless of stability, any concerns should be raised without fear of reprimand.

psu_213, BSN, RN · May 10, 2018

I just take issue with the OP being reprimanded for questioning. Regardless of stability, any concerns should be raised without fear of reprimand.

I totally agree that the accepting nurse should question an admission that he/she feels is an appropriate; my issue, however, is with questioning the ED nurse. The ED nurse plays very little role as to the type of floor to which the pt is admitted. In the OP, it sounds like the ED nurse could have handled it better, but ultimately he or she is not making the call on where to send the pt. Question the admission? Absolutely. Just make sure you asking the questions to the right people.

MunoRN, RN · May 10, 2018

I'm not sure that being told the patient was OK to come up was really being "reprimanded". How to treat chronically low diastolic pressures in HD patients is something the entire field of nephrology has yet to figure out, so the appropriate response wanting an answer to a question with no answer would be that there is no answer, which apparently is what the nurse was told. That's not really a reprimand, just reality.

JKL33 · May 10, 2018

I read the part about being reprimanded as part of a discussion that happened after the shebang was over. I didn't read it as the ED nurse being involved in delivering the reprimand. But maybe I misunderstood "ultimately I was told I should have...." and "we will deal with it when it arrives..."

JKL33 · May 10, 2018

Based on the OP's limited portrayal of her own understanding about the patient's condition and what kind of treatment would be required, the question was reasonable even if it was the result of a knowledge deficit. In other words, it doesn't appear to have been a stall tactic but a genuinely asked question. She thought the patient might need levo, and she knew they couldn't administer levo. Whether she was right or wrong about what the patient might need is a bit immaterial.

I will say that if the question about how to handle the b/p was "asked" as more of a sarcastic or frustrated retort or a challenge, that probably wouldn't have gone over too well.

Other than that I still kind of think this was about the hold-up. Knowledge deficit is usually handled with education that doesn't leave people feeling as perplexed and upset as what I felt like the OP portrayed.

MunoRN, RN · May 10, 2018

Based on the OP's limited portrayal of her own understanding about the patient's condition and what kind of treatment would be required, the question was reasonable even if it was the result of a knowledge deficit. In other words, it doesn't appear to have been a stall tactic but a genuinely asked question. She thought the patient might need levo, and she knew they couldn't administer levo. Whether she was right or wrong about what the patient might need is a bit immaterial.
I will say that if the question about how to handle the b/p was "asked" as more of a sarcastic or frustrated retort or a challenge, that probably wouldn't have gone over too well.
Other than that I still kind of think this was about the hold-up. Knowledge deficit is usually handled with education that doesn't leave people feeling as perplexed and upset as what I felt like the OP portrayed.

Based on the description given it doesn't appear clear that this was necessarily anything more than the appropriately handled correction of a knowledge deficit, which the OP then possibly took as a "reprimand".