Dangers of open ICU?

BeatsPerMinute, BSN, RN · Feb 9, 2023

I'm not a traveler, and am not sure if I understand what you mean by an "Open" or "Closed" unit - I've seen this stuff happen though in my nursing career.

Whenever you have a question: ask someone, bother the doctor (it gets easier with practice), escalate if you must, speak to your unit educator if you have one, the manager or unit director.

In doing so you're advocating for your patient, preventing harm, and protecting yourself.

One time while going through an upgrade in our doc system, we were asked to release orders in a certain way, and I did that. After receiving a patient s/p trach, and seeing that diff docs ordered diff things which ended up looking like I should administer multiple short acting insulin (some based on glucose and some not), plus long acting, plus metformin - my alarm bells went off. I went directly to charge and my manager and documented about the incident.

This comes with experience but def just double check with someone. It is not worth it to harm a patient and for you to lose your license.

Never avoid asking someone for their thoughts. Yes it can be hard and uncomfortable... it is better than the alternative.

Remind yourself that you can only control so much.

Remember to always remember to document objectively if there is a sincere concern about patient safety.

Finally... Be okay with giving notice and searching for a different place to work if the place is not a good place for you.

Aloe_sky · Feb 9, 2023

BeatsPerMinute said:

I'm not a traveler, and am not sure if I understand what you mean by an "Open" or "Closed" unit - I've seen this stuff happen though in my nursing career.

Whenever you have a question: ask someone, bother the doctor (it gets easier with practice), escalate if you must, speak to your unit educator if you have one, the manager or unit director.

In doing so you're advocating for your patient, preventing harm, and protecting yourself.

One time while going through an upgrade in our doc system, we were asked to release orders in a certain way, and I did that. After receiving a patient s/p trach, and seeing that diff docs ordered diff things which ended up looking like I should administer multiple short acting insulin (some based on glucose and some not), plus long acting, plus metformin - my alarm bells went off. I went directly to charge and my manager and documented about the incident.

This comes with experience but def just double check with someone. It is not worth it to harm a patient and for you to lose your license.

Never avoid asking someone for their thoughts. Yes it can be hard and uncomfortable... it is better than the alternative.

Remind yourself that you can only control so much.

Remember to always remember to document objectively if there is a sincere concern about patient safety.

Finally... Be okay with giving notice and searching for a different place to work if the place is not a good place for you.

Thank you, the problem is all Drs will give different answers. A patients MAP goal will be 65 with an order for pressors to start, cardiology will come in the morning and say SBP goal to titrate pressors. When you verify with critical care, they say no continue at the MAP goal but cardiology will say NO.

DKA patient will have critical care communication order to d/c insulin drip when the bicarb is 12, ignore the anion gap. nephrology will add a bicarb drip when critical care says the insulin will treat the acidosis and doesn't recommend bicarb, endocrine will say no bicarb drip and continue till the gap is 12. These orders are ALL on the SAME patient. Who do I turn to then? They are ALL Drs!

they only ADD orders, never d/c because they can't override or don't want to override another Drs orders. so there are orders from all Drs.

an open ICU means anyone can admit to the ICU and the critical care team is only consulted but closed ICU must go thru an Intensivist.

This is why the patient for hypernatremia had 2 different hypotonic fluids and water flushes, there'sno communication and all Drs put in their own orders.

also the Hospitalist is the admitting team and they sometimes butt heads with the critical care team and will remind them they are consulted, not primary. At first I was like huh? Because eg. critical care will want amio for a patient in Afib with RVR but the hospitalist will say no, give metoprolol.

Now somewhat understanding this is an open ICU so anybody and everybody gets a say in who is admitted to and how the patients are treated.

I just think open ICUs are unsafe.

JBMmom, MSN, NP · Feb 9, 2023

I can totally see the open ICU being a nightmare for complex patients, and let's face it- most ICU patients are complex. I didn't realize that in an open ICU there wasn't at least one attending assigned as primary and everyone could give input equally. It sounds like a very frustrating situation for nurses and almost dangerous for patients, when everyone is looking at things through the lens of their particular system there's a lot of potential for things being missed- or treatments causing more problems.

Career Columnist / Author · Feb 9, 2023

Aloe_sky said:

OK so I just learned something today and have been an ICU/ED nurse for a few years. A coworker that is a travel nurse just told me the reasons why me and her are frustrated is because this is our first job in an open ICU.

we use to complain that the critical care team never knew about a patient we were getting, how patients with no drips on room air were admitted to ICU by cardiology or the hospitalist without talking to the pulm/crit team. Then I'm told they are pulmonologist not intensivist. This is knew information to me!

I did research that open ICU have a higher mortality rate, I can understand why.

I've witnessed, the different specialists don't communicate. Atleast in the closed ICUs I've worked at, EVERYTHING must go thru the ICU Drs first before any orders are put in place. so all consulting providers must talk to the primary team.

here Nephrology, Cardiology, pulmonology can all input 3 different IV fluids. All 3 can order a head CT for a Neuro concern. Endocrinology can manage DKA but pulmonary can also D/C and add the fluids and insulin drip.

cardiac arrest patients are consulted to cardiology to determine if therapeutic management should be started. Which they never do because targeted temperature management "doesn't work" or they "don't believe in it" , there is never an input from neurologist, not even for stroke patients.

I had a patient admitted for hypernatremia and pulm/crit ordered water flushes, cardiology ordered 0.45% and nephro ordered D5W. No sodium rechecks ordered, day shift had them running 12 hrs and I almost lost my damn mind. I think everyone thought I was a mad woman. I was yelling this is dangerous.

The nurses that aren't travelers think this is normal. I am just baffled. I don'tknow if this is the norm for open ICUs but it is not safe at all.

I'm having anxiety just reading this

Angelica May · Mar 24, 2023

Wow. I've only been working ICU for a year, and I didn't realize open ICU was a model. Ours is definitely closed- the intensivist is the admitting doc and the one coordinating care with the specialists. Communication and team coordination-wise, my unit conducts nursing-led interdisciplinary rounds daily. The team (RN, charge RN, intensivist, dietician, pharmacist, case management…) meets, then the primary RN presents the patient, essentially gives report and the events of the last 24 hrs, then active issues, current treatment, concerns and plans are discussed and coordinated.

I'm not sure if other ICUs have a similar format.

LovingLife123 · Mar 24, 2023

I worked in an ICU where different specialties admitted but the admitting provider was the primary. ICU was usually consulted. So, if I had conflicting orders from different specialties, I went to the primary team. Then if their say was an issue between specialties they talked to each other and orders got clarified.

I also knew that if I had a neuosurgicsl patient, they set the BP parameters but that ICU managed the meds to get me to those target parameters. It's all about clear, concise roles and responsibilities.

delrionurse · May 11, 2023

Aloe_sky said:

Thank you, the problem is all Drs will give different answers. A patients MAP goal will be 65 with an order for pressors to start, cardiology will come in the morning and say SBP goal to titrate pressors. When you verify with critical care, they say no continue at the MAP goal but cardiology will say NO.

DKA patient will have critical care communication order to d/c insulin drip when the bicarb is 12, ignore the anion gap. nephrology will add a bicarb drip when critical care says the insulin will treat the acidosis and doesn't recommend bicarb, endocrine will say no bicarb drip and continue till the gap is 12. These orders are ALL on the SAME patient. Who do I turn to then? They are ALL Drs!

they only ADD orders, never d/c because they can't override or don't want to override another Drs orders. so there are orders from all Drs.

an open ICU means anyone can admit to the ICU and the critical care team is only consulted but closed ICU must go thru an Intensivist.

This is why the patient for hypernatremia had 2 different hypotonic fluids and water flushes, there'sno communication and all Drs put in their own orders.

also the Hospitalist is the admitting team and they sometimes butt heads with the critical care team and will remind them they are consulted, not primary. At first I was like huh? Because eg. critical care will want amio for a patient in Afib with RVR but the hospitalist will say no, give metoprolol.

Now somewhat understanding this is an open ICU so anybody and everybody gets a say in who is admitted to and how the patients are treated.

I just think open ICUs are unsafe.

Quote

I'd document this in the patients chart. The hospital is not a carnival. Patients are critically ill and they deserve safety. I would also write up an incident report. That is negligence on the doctors part for not reviewing orders.

WillResuscForCookies · May 12, 2023

Oh, this gets me right in the feels. I started in an open ICU as a new grad after completing my "senior synthesis" there, and it was all I knew. I've since worked in a handful of closed ICUs and much prefer the latter.

Hannahbanana, BSN, MSN · Jul 5, 2023

Never heard the term "open ICU" used to describe "does everybody have active malpractice insurance?”
If the nursing administration doesn't have representation on the medical staff meetings, s/he had better get to the next meeting stat, and bring the hospital risk manager (having prepped them as below). Outlining how this practice works (or "nonpractice”) in implementation may come as a shock to some medical staff members, and they may start quoting the current P&P (such as it is). However, the DoN should stand firm and come prepared c at least three examples such as the ones you describe that demonstrate how that's not working, demand (Yes, demand; this is not outside of his or her scope of practice) that this foolishness be resolved within, say, ten days, and ask to whom this task force will be delegated for seeing that it is. Then she or he should shut up and repeat PRN.

This might not get you immediate results but the med staff meeting are required by state regs and Joint Commish to keep minutes, and they (and all present) should get written copies of your examples to attach. That oughta get their attention.

As a legal nurse consultant the first thing I would ask for with a case involving this (after the charting, which is likely a mess, not nursing's fault) is a copy of the P&P and a copy of the meeting minutes. Dates on all of them. The risk manager will want to see those, too.