Vent: Downgrading patient from ICU status

[ukjenn231]

I'm a med/surg tele nurse by origin, but I also float in ER, ICU, as well as all of the floors.

One thing that irks me more than anything is being asked by management to call a physician and ask to "downgrade" a critical care status patient to a tele floor. Especially when the patient has just received admission orders for critical care. I understand the necessity of opening up unit beds when there are more patients than rooms and prioritizing, but this is how I feel.

1. If the doctor wants them on tele, they would have ordered admit to tele or transfer to tele.

2. If something happens to the patient when they are sent to the floor, then the doctor's going to be all mad at me because I called and asked.

3. There is no true step down or progressive care here so there is a huge difference between a 1:2 nurse-patient ratio and a 1:6 nurse-patient ratio.

4. Why can't management or especially the charge nurses, who have a better relationship with the docs, call instead of ol me, the float tele nurse who walks into a new shift and is pressured to call for downgrade orders?

OK that's my vent... And yes I have told management and charge nurses before I wasn't comfortable with doing this and they tell me, "Oh, just throw it off on administration making you call..." Yeah, well I still get chewed out, not administration.

[rnlately]

If they want to send critical care patients to the floor, they should send an ICU nurse along with them.

What does happen to patients needing an icu bed when none ate open? Do they just stay in the ER.

Downgrading the level of care to me is as bad as admitting a patient to general medical floor when they need telemetry just to "save" beds.

We get this a lot where I work. I work tele/acute and we get a lot of unit patients before they are ready. Our ratio is also 1:6 and I usually keep my fingers crossed praying nothing serious happens to the unit patient. While I effectively try to manage my whole team. Dangerous situation.

[Double-Helix, BSN, RN]

Our Peds floor doesn't even have monitors, so sending an ICU patient there, even with a nurse, really isn't a good option for us. The patient stays in the the ER (where they have monitors and are more prepared for an emergency) until we can admit to ICU.

[ChristineN, BSN, RN]

I work ER and frequently when all of our ICU's are full we will be the "code bed" for the hospital, meaning if a floor pt coded they would come to us instead of going to ICU. We also occasionally board ICU pts.

When I worked med-surg I was also in the position where the ICU had sent a pt out too early and the pt had decompensated, but they did not have room and would not take her back. That was not a safe night

[missej2002]

I have seen both sides of this working in an ED. The only time that ever asked a doctor to downgrade is if the pt is stable. I have seen so much insurance fraud that it is crazy, pt's being admitted med tele that does not need a tele; pt has not been on tele since in the ED and doc didn't even order an EKG, but the pt is admit with tele orders, how do you justify this fraud, and lets not forget the pt's admitted for observation, majority of these admits are fraud.

[HouTx, BSN, MSN, EdD]

In the US, every hospital that is accredited by the JC must have formal Admission & DC criteria for ICUs and other specialty care units (burn, Behav health, etc). Make sure you are familiar with those criteria. If it is not a 'disaster' situation and anyone is trying to DC a patient from ICU & that patient does not meet DC criteria - it will open up the potential for huge liability for the hospital & for the physician who OKs it.

Policies are your friend. If all else fails, just go all passive-aggressive and refuse to take actions that are not covered by hospital policy.

[hodgieRN]

I think it's a little different from this side. If there's a pt with multiple trauma and gtts vs the guy that's there because his hemoglobin is a low, well, one pt takes priority for the bed. I totally agree if there are open units beds, but docs will send pts to the unit so they won't get called at night for a tylenol order. They will send a pt to the unit and then ship them out first this in the morning (8 hrs later). The ER isn't supposed to be a holding area for unit pts. You can't let an ICU pt sit in ER for 8 hrs because some pt who is confused in restraints will be better monitored in an ICU bed. Where I work, I don't see pts being send out that are truly critical. But one doc in particular... I'll ask "Can we move this guy out. We aren't really doing anything." He tells us to keep the pt there so we can see to it that the pt gets physical therapy. Meanwhile, there's an ER pt that got ran over by a boat. We get bogus admissions too.

[Good Morning, Gil]

I've done this before, and see nothing wrong with it. (Not the charge nurse, just the staff nurse caring for the patient). When all ICU's are full, they need to make room for critical patients, so non-ideal things need to occur for that to happen.

I will only call if I'm comfortable sending my patient out, and my supervisor would only expect that (not to send out an inappropriate patient). Usually, it's someone who will be transferred the next morning, and has been stable all day, no issues, not for someone that was just admitted to ICU. If they admitted them to ICU, it was for a reason, even if we think it's unnecessary, they made that call.

[MomRN0913]

Well, as an ICU nurse we have been pressured by management to get PFT's downgraded. I do remember a time that happened to a newly admitted patient and the patient ended up back to the ICU and the family was ******, understandably so.

To answer the question to what happens to when the ICU is full.... Yes, they stay in the ER and an ICU nurse gets floated down to the ER to be with them. I will tell you this much, this is when the ICU nurse takes it upon herself to get the patients downgraded so she can go back up to the unit.