ICU Admissions

[DidiRN]

Any of you nurses out there working in larger hospitals, do you have some sort of protocol that must be met in order for the patient to be admitted into an intensive care unit?

The reason I ask, I see so many inappropriate admissions anymore to the ICU, then when someone in ER or out on the floor desperately needs a bed, we have none. I hate to see that happen.

I'm guessing the reason I'm seeing more of this is because docs are so afraid of getting sued, they will do this. I can understand their fears of that in a sense, yet I'm tired of seeing completely inappropriate admissions. Sometimes too I think it's just because they want their patient there and that's it, bottom line. Not only do they get admitted, but they seem to stay several days even. Plus I feel bad for ER having to hold very unstable patients when they themselves are so busy (I'm an ex ER nurse myself) or if they are on the floor, the stress of having to stay out longer than they should while our supervisor desperately tries to find a patient to transfer out.

I'm just curious how larger hospitals handles docs who insist there patient must be in an ICU bed if they truly are stable.

Sherri

[NotReady4PrimeTime, RN]

To gain admission to our unit, our intensivist or the resident on call must be consulted and the patient must be assessed. Our inpatient units manage pretty sick kids quite well, but worsening respiratory distress, marked alteration in level of consciouness, prolonged seizure, shock states, and of course arrests are assessed quickly and transferred as soon as physically possible. As for patients coming in through ER, they will only come directly to the unit if they're intubated. All others must be seen by one of our docs. We do sometimes get inappropriate admissions but they're not the norm.

[Celia M, ASN, RN]

Sherri, it sounds like we have a similar problem. Our ICU is in a small hospital, 48 beds. We have 8 beds but staff for 4 patients since our average census is 3. The problem arises with some docs who want their patients observed just a little more closely than on the floor so they put them in ICU since we don't have a step down unit. This is fine until we get busy then we're either scrambling to find a bed or a nurse. We have a policy that sets forth the criteria for admission and we have had to go to the Cheif of Staff for an order to transfer out so we can get a "true" ICU patient in. It's really frustrating! :angryfire

[CarpeDiem2004]

The ICU I work in has a 12 bed capacity but we average 5-7 patients so we staff for this number. We frequently have patients that come into our ICU who are inappropriate admissions, and many who stay longer than they should and take up an ICU bed just because the MD wants them "watched closely for just one more night". This is a strain on our resources - staffing, supplies, available beds. We have a medical director who should be acting as the "gate keeper", but he doesn't want to make any of the physicians mad at him by not allowing their patients into the ICU. The nurses have no support when we question an admission to the ICU. We even have patients who spend at least overnight in the ICU on a ventilator post-op just because anesthesia wants to go home and doesn't want to hang around until the patient is extubated and recovered in PACU.:angryfire

What a waste of resources! Now our hospital is experiencing the usual yearly budget crunch and nurse managers are expected to find places in their budgets where they can cut supplies and people. We suffer because the Docs aren't held accountable for their waste of resources. Some days it makes me want to scream. (Or quit.)Unfortunately, I'm pretty idealistic and believe that if we keep speaking up making noise about the problem, there must be someone who will listen to us and stop letting the Docs trample over the nurses-even though I know that the Docs are the ones that bring the customers into the hospital and Administration bends over backwards for them.

[Tweety, BSN, RN]

Sometimes I think docs admit to ICU so they won't be called through the night by med-surg. Or if they feel the ratios on med-surg are too high.

[mattsmom81]

Most bigger ICU's have had to develop admission criteria. BUT usually these go to the wind when a doctor wants his patient in ICU...for whatever reason. Politics as they are and 'keeping the doctors happy.'

[DidiRN]

Your situation sounds very similar to mine!! Especially the part about anesthesia not wanting to hang around too.

Here's an example... one evening, I got a 80something with advanced dementia who was a DNR who just had a Peg tube insertion and used the very last ICU bed in the entire hospital with this. Just because the doc wants him "watched" overnight, which turned out to be 3 days!!Idon't know how the hospital is reimbursed for this stuff first thing, second, I just cannot understand how they can do this and get away with it, using the very last unit bed in this facility. That's what really makes me mad, when we are preciously low on available beds and this is allowed to occur. I feel it's actually putting peoples lives in jeopardy; when you already have an overburned, bulging-at-the-seams ER who has to hold ICU patients and they just can't be watched like they are in the unit of course, or someone on the floor who has to wait for a bed and delaying treatment (ie starting them on drips that can only be managed in an ICU setting).

I don't mind the occasion inappropriate admission, but it seems where I am at it is epidemic at times, even with 3 intensive care units available it still goes on.

The ICU I work in has a 12 bed capacity but we average 5-7 patients so we staff for this number. We frequently have patients that come into our ICU who are inappropriate admissions, and many who stay longer than they should and take up an ICU bed just because the MD wants them "watched closely for just one more night". This is a strain on our resources - staffing, supplies, available beds. We have a medical director who should be acting as the "gate keeper", but he doesn't want to make any of the physicians mad at him by not allowing their patients into the ICU. The nurses have no support when we question an admission to the ICU. We even have patients who spend at least overnight in the ICU on a ventilator post-op just because anesthesia wants to go home and doesn't want to hang around until the patient is extubated and recovered in PACU.:angryfire

What a waste of resources! Now our hospital is experiencing the usual yearly budget crunch and nurse managers are expected to find places in their budgets where they can cut supplies and people. We suffer because the Docs aren't held accountable for their waste of resources. Some days it makes me want to scream. (Or quit.)Unfortunately, I'm pretty idealistic and believe that if we keep speaking up making noise about the problem, there must be someone who will listen to us and stop letting the Docs trample over the nurses-even though I know that the Docs are the ones that bring the customers into the hospital and Administration bends over backwards for them.

[imnmk_rn]

I don't know that there is a good answer to the inappropriate admissions - I think they happen everywhere. I work in a 30-bed med-surg-neuro ICU, with two other ICUs available (CCU and CVICU) in the hospital, and although we don't have specific admission guidelines, a lot of our neuro patients automatically come to us after specific surgeries, ones that could have gone to the neuro floor. Luckily, some of that is beginning to change. And we have support from the director of our intensivists - if we get report on a patient that sounds like an inappropriate ICU admission, we usually are able to have someone (intensivist, house officer) assess the patient and kind of make the call. Often we are full enough that we have one admission bed, either saved for a code or neuro pt (we get a lot of outside hospital neuro admissions). Anyway, I wish there were good guidelines - but sometimes it's just politics or someone's gut feeling, whether it's right or not.