Just a vent... medical vs psych

[Mandychelle79]

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.

From the ED perspective, these patients suck because they suck... far more resources than we really have available. Really tough to have a trippin tweaker with a meth heart that really should have a sitter (yeah, right... the floor gets sitters we get... us) and then have a stroke alert dropped in the next open room... who is, of course, a tough stick... and a nurse transport to CT... and maybe MRI... and, oh heavens, tweaker man slipped his lap belt and is nowhere to be found...

[Mandychelle79, ASN, RN]

From the ED perspective these patients suck because they suck... far more resources than we really have available. Really tough to have a trippin tweaker with a meth heart that really should have a sitter (yeah, right... the floor gets sitters we get... us) and then have a stroke alert dropped in the next open room... who is, of course, a tough stick... and a nurse transport to CT... and maybe MRI... and, oh heavens, tweaker man slipped his lap belt and is nowhere to be found...[/quote']

In our ER the security staff will sit with psych patients who may be a flight risk.

[Mandychelle79, ASN, RN]

Don't quite see why that's a big deal... you know 2 seconds after looking at the patient whether they have access... and with EMR it's right there in black and white.[/quote']

Because not all of the staff is comfortable looking into the EMR of a patient who is not on our floor yet because of HIPAA. I have been told that once we have assigned a bed to a patient, we are permitted to look into their E-chart to get the information we need, but some staff just wont do it or dont have access or want access to it.

I guess I think it is a big deal that the nurse sending the patient to our unit lied directly to us. We specifically asked if the patient had IV access and was told No. When asked about the PICC line, that the nurse didnt know we already knew about, we were told it was for blood draws only. Not that we were going to be infusing a medication daily through it. That would be like me sending one of our patients over to be worked up due to a change in medical status and when asked if the patient is oriented saying yes times 4 when they dont even respond to their name.

Because not all of the staff is comfortable looking into the EMR of a patient who is not on our floor yet because of HIPAA. I have been told that once we have assigned a bed to a patient, we are permitted to look into their E-chart to get the information we need, but some staff just wont do it or dont have access or want access to it.

Well, that's just a systems issue and education issue.

And it takes no time at all to discern if a patient has a line.

I guess I think it is a big deal that the nurse sending the patient to our unit lied directly to us. We specifically asked if the patient had IV access and was told No.

Well, if you're certain that it was a blatant lie, I'd probably raise a ruckus. Seems more likely, though, to have been a mistake or oversight. I'm sometimes forced to give report on patients that I barely know and have been mistaken before regarding access.

Just doesn't seem like that big a deal to me. If they don't need the line, d/c it. If they need one that's not there, stick 'em. If you can't get access, tell the doc that it's not happening.

In our ER the security staff will sit with psych patients who may be a flight risk.

Boy, that would be nice.

I wonder what percentage of EDs have sitters. Very small, I'd guess.

The funny thing is that we get admitting orders that require a sitter, which is not available, and end up holding the patient because the floor won't take them sans sitter... So we keep them... without a sitter.

The system is broken... very broken.

[Mandychelle79, ASN, RN]

Well, that's just a systems issue and education issue.

And it takes no time at all to discern if a patient has a line.

Well, if you're certain that it was a blatant lie, I'd probably raise a ruckus. Seems more likely, though, to have been a mistake or oversight. I'm sometimes forced to give report on patients that I barely know and have been mistaken before regarding access.

Just doesn't seem like that big a deal to me. If they don't need the line, d/c it. If they need one that's not there, stick 'em. If you can't get access, tell the doc that it's not happening.

You are right, it doesnt take much time at all to know if a person has a line. One of the ED/BH transfer items, our staff has to go over and have patient sign the voluntary, and has to make sure that the IV line has been D/c'd, when getting report we ask if they have an IV and remind the staff to get the order from their doctor to get the iv d/c'd before coming to the unit ( unless it has already been agreed that the IV will be maintained). Yes, I do believe it was a blatant lie, based on passed experience with some of the nurses in our ER. The only way it could not be is if the person giving report had just picked the patient up, but it wasn't shift change. We have been working on bettering the communication between units and it has gotten better, but things still pop up.

[Irish RN]

just to clarify: I have no problem caring for a patient with acute medical issues with a hx of psych issues on a medical floor. BUT their psych issues need to be controlled....it's very difficult to have a little old dementia lady trying to climb out of bed every 5 minutes and biting the LNA. If the LOL with dementia is sitting in her bed pleasantly confused, I have NO problem with that.

I can certainly see both sides. I think psych units should be able to care for basic medical issues and medsurg units should take acutely sick psych patients (who are at least somewhat stable as far as PSYCH goes).

What it comes down to for me is patient safety. I often feel I neglect my other patients because of my uncontrolled psych pts and to be quite honest, most of their acute medical issues are minor such as UTI.

Wanted to add... we even have "sitters" who consist of housekeeping staff and dietary staff who do 1:1s. I HATE this. They are NOT trained whatsoever as far as medical/surgical and certainly have NO idea how to handle psych patients. ughh *cringe*

[Mandychelle79, ASN, RN]

just to clarify:

I can certainly see both sides. I think psych units should be able to care for basic medical issues and medsurg units should take acutely sick psych patients (who are at least somewhat stable as far as PSYCH goes).

What it comes down to for me is patient safety. I often feel I neglect my other patients because of my uncontrolled psych pts and to be quite honest, most of their acute medical issues are minor such as UTI.

The unit I am on does treat the basic medical issues. We do wound care ( even though we usually have to scrounge around for supplies and beg, borrow and steal from the rehab units), we treat brittle diabetics, we run IV fluids and ABX when the medications do not require the patient to be monitored. We treat UTI's, dehydration, etc. However, what typically happens, is that a patient comes into the ER with an increase of mental health issues, they are "medically cleared" and sent to our unit within an hour or two. Within 12 hours they tank, sats not leaving the low 80's even on 02. Guess what a person with the Sats in the low 80's is going to have mental changes. So yes the patient may be acutely psychotic but its an underlying medical issue causing the problem, not the psych issue so to speak. Kinda like someone who begins hallucinating after not being able to sleep for a few days. Yes they are acutely a psych patient, but its insomnia that is causing the psych issue. If a person presents with hallucinations, without a psych history, they will most likely go to the medical floor to r/o any underlying medical issues. However if another person presents, with a psych history, they automatically get oh that is how so and so is and gets labs drawn, UDS and sent over, before the labs are back, and when they get back they have a critical values.

[Pudnluv, ASN, RN]

I think it is interesting that this is such a universal problem between ED's and pysch units. I believe a big part of the problem is communication and understanding between departments. This is true not only of pysch units but also all units. The ER is for emergency treatment, stabilize the patient and send them where they need to be. Throughput is a biggie for us. We need to move patients, so we have room to see the new patients that are coming through the door. We do not have the luxury that so many other units may have, of saying that the unit is full and we cannot take another patient. If all our rooms are full, they go to the hallway. If the hallway becomes full, they sit in the waiting room. We are still responsible for those people in the waiting room. My ED has two dedicated pysch rooms. Pretty much every pysch patient that comes in, needs a 1:1 watch. We do have people trained to do these watches, usually one of our techs. This leaves the ED without a tech many times. A big problem happens on the weekends when there are no psych beds available. We have had up to 8 psych holdings at a time, sometimes for 2 or 3 days. Then when we finally get beds assigned, the psych unit gives us a hard time about spacing the admissions out, usually an hour or so between patients. This is silly. Imagine if you are the patient, signing yourself in for treatment and then waiting 2 or 3 days to get to the unit, only to be told that now you have to wait in line to get to your bed. The ED does not get to tell incoming patients that they must wait an hour between patients to be seen. This is not conducive to patient care. I have always contended that part of orientation, all nurses need to spend a couple of shifts in the ED, just to see how we operate. The wouldn't be so quick to stall admissions if they saw what goes on down there.

[Mandychelle79, ASN, RN]

The ER is for emergency treatment, stabilize the patient and send them where they need to be. We have had up to 8 psych holdings at a time, sometimes for 2 or 3 days. Then when we finally get beds assigned, the psych unit gives us a hard time about spacing the admissions out, usually an hour or so between patients. This is silly. Imagine if you are the patient, signing yourself in for treatment and then waiting 2 or 3 days to get to the unit, only to be told that now you have to wait in line to get to your bed.

The ED does not get to tell incoming patients that they must wait an hour between patients to be seen. This is not conducive to patient care. I have always contended that part of orientation, all nurses need to spend a couple of shifts in the ED, just to see how we operate. The wouldn't be so quick to stall admissions if they saw what goes on down there.

Yes I understand what the ER is supposed to do. To send to patients to the appropriate unit where they need to go which may be a MEDICAL unit, not the PSYCH unit, but a lot of times it is a psych patient so nothing is ruled out medically. I dont mind getting the truly sick psych patients, but when I am calling a RRT/ CODE whatever within 12 hours after an admission, the patient should not have been sent to us in the first place.

Our ER doesnt hold psych patients, if we have beds we take them ( unless against policy/ pts best interest to go elsewhere for whatever reason) they begin a bed search.

Yes, I have asked our ER to stagger the admissions, because not only am I in charge and have to do the three admits they are sending to me, but I have a full patient load. and I may be the only nurse on the floor so I also have to pass meds ( depending on what unit census is, if we have 12 or less patients there may only be 1). And no you cant tell anyone they have to wait for an hour, but you do triage them and people do wait hours in the waiting room.

You want us to come and see what your end is like during orientation. I want people from the ER and Medical floors to come and see what we end up doing.

[alb402]

Yes I understand what the ER is supposed to do. To send to patients to the appropriate unit where they need to go which may be a MEDICAL unit, not the PSYCH unit, but a lot of times it is a psych patient so nothing is ruled out medically. I dont mind getting the truly sick psych patients, but when I am calling a RRT/ CODE whatever within 12 hours after an admission, the patient should not have been sent to us in the first place.

Our ER doesnt hold psych patients, if we have beds we take them ( unless against policy/ pts best interest to go elsewhere for whatever reason) they begin a bed search.

Yes, I have asked our ER to stagger the admissions, because not only am I in charge and have to do the three admits they are sending to me, but I have a full patient load. and I may be the only nurse on the floor so I also have to pass meds ( depending on what unit census is, if we have 12 or less patients there may only be 1). And no you cant tell anyone they have to wait for an hour, but you do triage them and people do wait hours in the waiting room.

You want us to come and see what your end is like during orientation. I want people from the ER and Medical floors to come and see what we end up doing.

Amen. I really wish people (upper management/the admissions department/ERs) knew what goes on on a daily basis on a psych unit. There are not numerous nurses waiting to take admissions. There are 1-2 nurses who are responsible for med passes, verifying orders, talking with the physicians, discharges, etc. on top of having a patient assignment, managing the milieu, leading groups, doing q15 safety checks on patients, talking to families, de-escalating and talking with patients who are in a current crisis... The list goes on and on. On top of that an admission takes time and extra staff to perform skin checks and body searches. It's unrealistic and unsafe to have admissions back to back without the extra staff to do so. We briefly had an "admissions nurse" in house that was a lifesaver when the floor was acute, but management felt this was a waste of money so it was done away with. Bottom line - every floor/unit poses their own challenges and as nurses we need to work together instead of pointing fingers at one another.

[TerpGal02, ASN]

Ugh honestly this grinds my gears. I work in a small psych hospital in the sticks, have very limited psych resources in this area, we get admissions from everywhere. The EDs that refer to us blatantly lie, all the time. The truth of the matter is that WOE CAN'T deal with medical problems unless they're stable. Sure we can deal with accuchecks and insulin, sure we can deal with pts on O2 or need neb's, but the stuff we get sent, just omg. One guy came with what the ED said were "healed over self inflicted wounds". What we GOT were 10 stab wounds to the abdomen, multiple to the arms and legs that were down to adipose tissue, massively infected and gaping. We had a pt come in that hadn't had medical care in years with "just some wheezes. She was a full blown untreated COPDer with says in the low 80's. We had an ED try to send us an adolescent PT who OD'd on a handful of Vyvanse with a HR in the 130s and no LFTs or renal panel done. If she becomes an acute cardiac issue, were at least 20 mins from the closest ED. I don't have ap lot of time to manage major medical stuff. I've usually got 20 acutely ill, many times actively psychotic pts to deal with. When they become acute medically (diabetic with BGs ranging.from 36 to 450 in half an hour, kid with a CPK in the thousands, elderly dementia PT with aspiration pneumonia) the EDs give us a rash of hell for sending them, and sometimes they are sent back with basically no treatment. And.many.of the dementia pts really get me. There is really nothing we're going to do for a dementia PT. They are still going to sundown, we aren't making them better. No matter what anyone does they are just going to decline. We push fluids for low BPs. If someones not drinking we bolus with IV fluids. We do ECT so have quite a few nurses with excellent IV skills. Psych patients get substandard care and that's a fact. We can't handle them with acute medical issues and medical floors don't want them. Adults with serious medical issues die 25 years younger than non mentally ill.

Oh and please, if a psych patient is combative in the ED, please feel free to medicate them with anything you want. We usually request it, actually.