adult patients admitted to a pediatric hospital

KelRN215, BSN, RN · Apr 16, 2012

The oldest patient I ever took care of when working in a pediatric hospital was in his mid-30s, older than a good percentage of our staff. Patients should not be older than the nurses in pediatrics. The medical floors would routinely get patients in their 40s or older because CF patients never leave.

This is how I look at it. The pediatric hospital I worked at was attached via a bridge to an affiliated adult hospital. There was another adult hospital directly across the street. If a 13 year old presented to one of the adult hospitals in need of treatment, they would be transferred to the pediatric hospital. So why not transfer the 40 year old to the adult hospital when they present to the pediatric institution?

Adults- even those with pediatric diseases- have adult problems that pediatric institutions are simply not equipped to handle. I just imagine an adult on my old floor having an acute MI... we did not have nitroglycerin in our code cart or our pyxis and the pharmacy could easily take 2 hours to deliver a "stat" med. In fact, we didn't stock ANY of the medications you'd need to treat an acute MI on the floor other than aspirin (but being a pediatric institution, all we had was "baby" aspirin) and morphine.

Double-Helix, BSN, RN · Apr 16, 2012

We take care of adult patients in our PICU on a fairly regular basis. 99.9% of the time they have congenital cardiac defects and never transferred from the pediatric cardiology service. Since our hospitals basically bends over backwards to make our cardiologists happy, they come to PICU because we have better nurse/patient ratios.

We are used to it by now, and usually there isn't too much difference in the care we are giving to an adult post cardiac catheterization and a child. However, where we do get a little upset is when they schedule adult post-op patients to come to us. We recently had a 45 year old post open heart surgery admitted to our unit. That was a source of tension, since adults can react much differently than children post-surgery and it takes more time/nurses to manage. There's no reason that this patient could not have done to the adult cardiac ICU, where they are more than capable of handling a post-op open heart adult.

Very rarely, we have to take overflow from the adult ICU. So we've actually had an 80 year old on our unit before.

umcRN, BSN, RN · Apr 16, 2012

I work at a childrens hospital. We ALWAYS take the adult congenital hearts on our unit. No matter what their admitted for. Post op, cardiac cath, fever, kidney failure. Once a heart patient always a heart patient at my hospital. I recently took care of a 26 year old who, in my opinion, his heart was the best thing he had going for him, he was in for severe graft vs host after a BMT. Not a heart patient at all, and very difficult to care for. There are many nurses on my unit who used to work adults and they will generally get the post op patients but not always and we adjust. Do I like taking care of adults? Not really, but like I said, we adjust.

Ashley, the reason they come to us, and maybe this is the same for you, is because surgery for congenital heart disease is so much different than for your cabbages and valve replacements in the adult world. The adult cardiologists and nurses don't know how these hearts work and don't know the seriousness of certain complications. These patients have to be ventilated differently, resuscitated differently, everything is different. A 28 year old fontan is going to be handled post op very differently than a 28 year old normal heart. And their history is going to make any little procedure much more complicated than it would be on a normal adult. We recently had a 28 year old fontan in for a "simple" pacemaker placement. She wound up with a ruptured aorta before they could even get into her chest because of all the old scar tissue she had...she survived, but it was definitely not the simple procedure everyone had been anticipating.

Pediatric Critical Care Columnist · Apr 17, 2012

We recently had a 28 year old fontan in for a "simple" pacemaker placement. She wound up with a ruptured aorta before they could even get into her chest because of all the old scar tissue she had...she survived, but it was definitely not the simple procedure everyone had been anticipating.

Whoa... deja vu! But ours was a slightly younger previous Mustard. The patient wasn't supposed to need a bed... simple pacemaker swap. Famous last words! At our hospital there have been enough adults with congenital heart disease needing hospitalization as adults that they don't come to PICU anymore, but in this situation, when the fertilizer hit the ventilator there was no room at the adult inn. The poor guy was with us for months.

rnsusan · Apr 17, 2012

We do not get adults very often. The adults we get usually have a diagnosis in which we have had trouble finding care in the adult world for them. A few of them have chosen to go out of state to be seen by an adult physician at an adult hospital.

KelRN215, BSN, RN · Apr 18, 2012

http://www.nytimes.com/2011/06/14/health/views/14klass.html

There's an article that was in the NY Times last year on this topic. I never particularly enjoyed taking care of adult patients when I worked at the pediatric hospital but this article does make some valid points.

hiddencatRN, BSN, RN · Apr 18, 2012

I work in a peds ED, so we get adult walk-ins that we stabilize ad ship out (per EMTALA) as well as family members visiting our peds patients who become sick (or go in to labor- definitely my least favorite!). We recently had a adult GSW present who was too unstable to be transferred for a few days so was admitted to surgery from our ED and stayed in the hospital until he was well enough to be transferred to adult care.

It makes me nervous because I went straight to peds from nursing school, so my adult care knowledge is based on nursing-school-level information that is collecting cobwebs. I just don't have a solid grasp on the assessments and little red flags to look for (and most of the sick adults will have little red flags, not the big obvious ones). I'd love to become proficient at treating adults as well but it's definitely outside of my comfort zone to get a random adult patient with little preparation.

mellzie22 · Apr 20, 2012

I'm going to be an adult patient at an adult hospital in a few months. I am having a complex surgery that is normally done in children, but I am a couple years older than the cutoff. I'm not too far out of range, but still not under 21. I find it amusing to go into the clinics and then being serenaded by clowns.

phillycpnp-pc, MSN, RN, NP · Apr 22, 2012

The oldest patient i took care of was in her mid 50's who was rude and threw things a me. Also, i use to get spina bifida patients in their late 20's to mid 30's. It is frustrating when i have male adult patients that make inappropriate sexual comments. I know some of these adults have pediatric diagnoses but this is the reason i chose to do pediatrics because i cannot stand adult patients that act like this.

platon20 · Apr 22, 2012

As others have alluded to, there are 2 main reasons this happens:

1) Adult patients with peds conditions are generally covered by Medicaid. Adult doctors dont like Medicaid and a lot of them refuse to see those patients.

2) Adult patients with peds conditions generally make adult doctors uncomfortable. Adult cardiologists for example are essentially coronary artery plumbing experts, but they get nervous with complex congenital heart disease becaues its a completely different animal to them.

These 2 explanations account for why we have 25 year olds who cant be transitioned over to an adult service. Its particularly bad for pulmonology, cardiology, and heme/onc patients (sickle cell particularly bad).

KelRN215, BSN, RN · Apr 22, 2012

As others have alluded to, there are 2 main reasons this happens:
1) Adult patients with peds conditions are generally covered by Medicaid. Adult doctors dont like Medicaid and a lot of them refuse to see those patients.
2) Adult patients with peds conditions generally make adult doctors uncomfortable. Adult cardiologists for example are essentially coronary artery plumbing experts, but they get nervous with complex congenital heart disease becaues its a completely different animal to them.
These 2 explanations account for why we have 25 year olds who cant be transitioned over to an adult service. Its particularly bad for pulmonology, cardiology, and heme/onc patients (sickle cell particularly bad).

As an addendum to #2, it's also that people with many of these conditions didn't use to LIVE to adulthood so adult doctors are sometimes not the best to treat these patients. Cystic fibrosis, for example... CF patients used to routinely die in their teens. Now it's not uncommon to see CF patients in their 40s/50s. Adult pulmonologists don't know how to care for these patients because they've never had to.

That said, I do still think it's a disservice to some of these patients to keep them in a pediatric hospital for EVERYTHING. For example, if a 40 year old with a history of CF has a stroke, they should be seen by an adult neurologist. Same for if they had a heart attack- they should go to the adult hospital. PALS and ACLS are not the same thing and I don't even want to think about what would happen in the event of an acute MI at my former hospital.