Just a vent... medical vs psych

macfar28 · Jul 15, 2013

Mandychelle:

My first reaction? Preach on! After giving it some thought though I do believe there is a huge lack of knowledge, at least where I work. We are a free standing behavioral health "hospital". We used to be a "center" which is more accurate but the powers that be thought "hospital" sounded better. The problem is, the rest of our health system has a lack of understanding about what we can and cannot manage here. It's not a lack of skills on the nurses' parts. We don't have a lab, IV capabilities, xray, an MD/NP/PA on site, etc. I have to call 911 for any kind of emergency and generally EMS takes its sweet time getting here. I then have to endure the 20 questions from the ED nurse as to why we're sending a patient with a BP of 205/140 who is symptomatic, a blood sugar in the 500s or sats in the 60s. Our patients and the accompanying staff talk of how differently psych patients are treated in the ED. As TerpGal02 said, psych patients get substandard care.

I will never forget the 15 year old male I received one night with 80% of his back side skinned. He had jumped from a moving car after arguing with his parent only to be drug on the ground. Nicest kid, just depressed. They said, "well he's suicidal." No xray, no skin consult, no pain meds, no nothing. Left him in a patient gown and his jeans, hand cuffed him and sent him to us by law enforcement. The report we received from the ED? He has some "minor abraisons." This is one of a million scenarios I can provide.

We all (hopefully) want what is best for the patient. It's not about you and me. We all have patients - medical and/or psychiatric - who are challenging or who may be milking the system but the fact is we have to work together and get through it.

TerpGal02, ASN · Jul 17, 2013

And yet another example. On Saturday I got report from night shift on a adult PT with COPD on 2L O2 via NC. She had developed a dry nonproductive cough overnight, woke IP at 4 am with SOB, sats in the low 80s. Night shift got her to do some deep breathing, gave her albuterol inhaler and she went up to 95. Our on call doc refused a duo neb order. I go to check on her at 0800 and she's coughing her head off, sats in the low 80s again, goes to 92 with deep breathing but can't sustain it. Gave her some more albuterol, or helped some. She was white as a ghost, couldn't say more that he's or no. Got weekend doc to agree to send her out (still no neb order). Unit clerk calls EMS, I get paperwork ready and call ED to give report. ED nurse was sighing and giving me the 20 questions. When EMS arrives I'm grilled. She's up to 92 again."Well she looks ok now". That's NOT THE POINT. She cannot sustain that,Zithromax and a gonna be calling you in a few hours anyway when this happens again. She ends up getting admitted with ABGs totally out of whack. RN one course of IV Solu Medrol. They send her back the next day. Nurse reporting to me says, "She stops coughing I'd you tell her to". OMG whatever. She has bilat pleural effusions. Not requiring thoracentisis but still. Breeding ground for infection. At one point down to 81 today. And now on PO Prednisone to meaner than a snake too.

Mandychelle79, ASN, RN · Jul 17, 2013

i was shocked, after talking all day with the hospitalist *who never laid eyes on the patient* running 1000 ml of NaCl wide open, and bp/ pulse in the toilet. Not to mention the complaints of the patient and the pt asking if we can even handle pts in his "stable" condition, the evening hospitalist came over, and the patient was immediately admitted to the medical side. well after fighting with the floor about it of course. i bet the pt is back by thursday at the latest.

New Angel · Jul 18, 2013

I work in a very small psych hospital and we also have had disgruntled interactions with the local ER.

My coworker has been suggesting for months that we do a training experience where the ER nurses spend a few hours on our facility and our psych nurses spend a few hours shadowing the ER nurses so we can learn how to work together better. That's a fat chance, I know. I do my very best to have polite & cooperative diction with my transferring facilities. There's no reason not to work together. It is bothersome when ER.'s think we are stalling to not take a pt. because we don't feel like it or something...We are here to work and to care for pt.'s just like you are in your facility. To assume or make statements about us stalling to take pt.'s is wrong, rude, and breaks down any team work we could bridge. Likewise, For my facility, it is damaging to the fabric of our working community to make statements about the ER lying/exaggerating about a pt.'s condition to get them out of their hair and into psych. I try to see both sides, yet my priorities of care of course, are in my facility/pt.'s.

edie1 · Jul 18, 2013

well well at my facility the staffing is so poor the nurse giving report may not know if the patient has an access so it may be ignorance rather than lying. what a dilemma and poor patient all the way around.

gcupid · Jul 19, 2013

I am getting so fed up with the medical portion of our hospital. We are NOT a medical psych floor. Patients we have are SUPPOSED to be medically stable. When we send a patient to the medical side for something it would be AWESOME if all the testing was completed before trying to send back to us, in less then 24 hours. Oh the patient medically stable, what did the CT say, oh you havent even done the CT yet. Call back when its read and we will be up.
Call the admitting doctor- are you aware so and so has a PICC line for daily infusions. Yeah, I didnt think they told you ( from our own ER, not a transfer, those we pick threw with a fine tooth comb to find out if the people are telling the truth). Getting report... an IV line- no? really what about the PICC, oh thats just for blood draws. Gotta love being lied to over the phone in report.
Yes, I understand that I went through the same training as other nurses. Yes I can start an IV if needed ( but we do so few of them, is it fair to the patient to be pretty much a practice arm), we dont have monitors to keep tabs on them. Hell our patients dont even have standard call bells or electric beds.
I understand that they are busy with their 5-6 patient assignment, but I may be passing meds to 24 patients. We have higher ratios because our patients are MEDICALLY STABLE. Any time there is a psych patient on a medical floor, its usually within 12 hours that the nurses and doctors are chomping at the bit to get them off their floor and over to us. But if one of our patients decide to get sick while there it is like pulling teeth to get someone transferred medically. Or if they are being aggressive in the ED, they want to send them over before they are medically cleared. Nope, sorry I need the results and the precert information. BTW you have the man power over there and a doctor right there to give orders, I dont.

This can be fixed by having a smaller unit (med-psych) inside of the psych floor. It could be staffed by nurses with a mix of med/psych background & have the charge nurse be a designated med/surg/tele nurse. Problem solved..... After you adequately orient the nurses & provide supplies as well as come up with criteria that states a clear cut acuity level cutoff that pertains to staffing and resources to make sure that the unit does not get abused...

Oh yeah there would also have to be a physician agreement/communication among psych & medical cases.

gcupid · Jul 19, 2013

I have never believed that psych nurses were just lazy and did not want to take an extra patient. I am familiar with psych and know that main issues are staffing, paper work management, and available resources to take care of issues that may arise. I believe the main problem is that psych facilities vary in a range of ways in regards to acuity, care, resources, and protocols.

People tend to go off of what has been acceptable in the past. So because the culture from facility to facility is different and even with time may change, it requires that a nurse (A case manager with bedside experience in both psych & medical) and a doctor collaborate by making appropriate suggestions from assessments on where the patient should ultimately reside for care. Admissions should not be based on administrative/marketing calls.

macfar28 · Jul 21, 2013

Yeah we have a med-psych unit. It's honestly a dumping ground. Baffling to me.

TerpGal02, ASN · Jul 23, 2013

Admissions should not be based on administrative/marketing calls.

THIS!!!!!!!

This is how psych beds get filled. If an ED, no matter what medical issues they have, decides a PT needs psych care, its basically a shot gun approach to all psych facilities within oh, 70 miles to see who will bite. Without the referring facility really knowing AT ALL about what medical acuity these facilities have.

On the other hand, our admitting docs are under HUGE pressure by our admin to keep beds filled, so they might say yes, when if they had it their way would decline.

And then there's that odd PT that an ED will send before he/she is even accepted at our facility. Had that happen recently with a very aggressive autistic child. We just don't have the right programming for severe autism and these types of PT just take resources away (staff doing 1:1's) from the rest of the kids. Our doc had denied and the referring ED just sent the kid before our admissions person could call back to say no.

Orca, ADN, ASN, RN · Jul 29, 2013

I have run into dumps from both ER and other floors. First, the ER dump:

A patient was admitted to our floor (adult/CD unit) with suicidal ideation. He had deliberately driven his car into a tree. When he came up from ER he was in a wheelchair with a blanket draped over him, so I didn't immediately see his lower extremities. He complained about bilateral ankle pain. I lifted the blanket and saw that both of his ankles were discolored and extremely swollen. I checked the computer for x-rays and, not seeing any, I called the ER physician to ask if they had ordered any. His attitude was "How dare you question my assessment." I called the admitting psychiatrist, explained the situation and got orders for bilateral ankle x-rays. Both of his ankles were shattered, and I sent him to surgery the next morning. The ER physician apparently ended his assessment as soon as the patient said that he was suicidal and sent him to us, never looking at his ankles.

The floor dump came from our telemetry unit. They had an unruly patient who had been running around the unit, disrupting the staff and bothering other patients. The report from the floor said that he had run into a door facing and "bumped his shoulder". When he was brought onto the unit by wheelchair, from just a glance I immediately knew that something was very wrong. My LPN immediately said "His shoulder is in the wrong place." The patient was crying and wincing in pain. The shoulder that he "bumped" was in fact fractured and displaced, and the tele nurses did not get an x-ray order or do anything else other than obtain an order to immediately get him off their unit.

LisalaRN99, BSN, RN · Aug 3, 2013

I work as one of the psych admission nurses. Our area is in the ER. We process all the psych patients in the ER and sometimes have to advocate for the patient to go to the medical unit. One of our psychiatrists likes to joke that our ER would "medically clear a corpse!" Bottom line, I am not the MD so I do not accept or refuse the patient, although you would think I do based on the harrassment we sometimes receive from the ER staff! We do not accept blood alcohol levels over 150. We do not accept drug overdoses straight from the ER. They must go to the medical telemetry unit at least overnight for monitoring. Of course many of them are intubated and go straight to ICU. We have a medical unit where all the psych patients who are involuntarily committed will go until seen there by our psychiatrist. Many of these patients were just seriously drunk with BALs over 300 and not really suicidal although they said so. These patients get released from medical. I also admit the "medically cleared" psych patients from the medical floors if the psychiatrist wants them admitted. But just this week, the internist medically cleared a demented elderly diabetic woman who was refusing all medical treatment including insulin. She came in with a lady partsl bleed and refused all diagnostics. Hemodynamically she was stable but what was going on? Her daughter had to go to a lawyer to pursue healthcare surrogacy but hadn't done so yet. So why would they "medically clear" this woman to go to psych??? What were we supposed to do with her?? Her blood sugars would not magically go down for us and we can't give IV fluids. We would have had to inevitably transfer her back to medical. Fortunately the psychiatrist who had authorized the transfer changed her mind once I informed her of these important details, which she was unaware. So with healthcare surrogacy in place, this woman can be properly treated, and then, when appropriate, transferred to psych. I watch for those so-called "dumps" to psych, but I like to think what I am really doing is advocating for appropriate patient care.

Mandychelle79, ASN, RN · Aug 8, 2013

recently it was the pt who stopped drinking and was starting to go through the DT's. Luckily, the admitting dr agreed that the pt needed to be on a medical floor where they could be on an ativan drip.