Doc freakout

[CNL2B]

I work in a busy SICU. Routinely all our patients go to the recovery room for an hour or so before they come to us. Per hospital policy, any patient that is going to be admitted to the ICU post-op needs to be 1:1'ed for their recovery period (which is a nursing ratio they can provide in PACU.) In SICU, we are generally 1:2 so this doesn't work for us usually with the number of nurses I have to work with. We only take post-op OHS direct from OR and they are 1:1ed for 8-12 hours anyway.

I sent my patient from the SICU to the OR today for a sternal I&D (I was also in charge). I had discussed with the SICU NM and the PACU ANM on the day shift where that patient was going to end up post-op and both agreed that the patient should recover in PACU. We were planning on this, as was the PACU staff. Patient goes in for the case -- the lead CRNA comes out, condescending and nasty, wanting to know why we aren't taking the patient back direct. I told her that where he was going to be placed had already been decided, that PACU was expecting him, and if she had a problem with it, she needed to go over my head (I meant, go to the nursing supervisor since it was after hours. She went to the staff doc.) The staff surgeon comes out, wants to know why we can't take him back direct, yelling, generally acting like an ass, I personally feel she was borderline abusive. I explained that it hadn't been my decision. Her perspective was that the nurse managers should have no authority as far as patient placement goes (hello, does she not know that nurses do 100% of the bed control for the entire hospital?) This apparently was not acceptable because about 10 minutes later the doctors (staff, fellow) pushed the patient out themselves (with the room CRNA in tow, who was completely fine with sending the patient to PACU and had tried to call the patient out to them --- until his efforts were sabotaged.)

I am sick of this. Any advice on how to handle besides passing this off to the nursing supervisor and my NM? I totally feel like this was (verbal) workplace violence. I don't think I should have to put up with that kind of garbage.

[mindlor]

Document, Escalate, and let it go

[neutrophil]

I come from the automotive business, Technician, service adviser, service manager, store manager. Bureaucracies are like that. I find the medical field even worse in this sort of thing. It will happen again, hopefully not soon. Document, CYA and move on.

[scoochy]

You are not alone in your frustration. I worked in a PACU for 19 years, and determining where patients (such as the ones you've described) would go post-op was always a challenge. Rather than tie up the charge nurse with this unending problem, the hospital created a "bed control" manager to deal with this issue. The surgeons and anesthesiologists HAD to come on board with this plan, and for the most part, it worked. What was different was that ICU patients RARELY stopped in the PACU for a 1 hour stay; it was not cost-effective, and not in the best interest of the patient. It also helped to relieve the backlog of "holding" patients in the OR d/t lack of space in the PACU. The PACU cared for 50-60 patients/day; the hospital was a 600 bed facility.

[littleneoRN]

I'm sure it's beside your point, but it surprises me that a hospital wouldn't staff it's SICU to be able to accommodate 1:1 care PRN. (Not your fault, I'm just saying...) After all, it is an ICU...

[shiccy]

We use incident reports for inappropriate behaviors as well as med errors and such

[CNL2B]

We have a bed coordinator, nurse managers, and a nursing supervisor that control bed flow for the hospital. Unfortunately when physicians come throwing a hissyfit, they usually get their way. We don't have a lot of management presence after hours -- we are lucky if the nursing supervisor even stops by once a shift. So, mostly, what happens gets left up to the charge nurses and has a lot to do with how big their balls are and how much they can stand getting yelled at. I can take the abuse but sometimes I feel like the issue just isn't worth the confrontation on my end. What am I personally going to benefit from by going head to head with a doctor? What is the unit going to get out of it? (Likely, nothing.) I am not (personally) the sole hospital policy enforcer, although we all are to some degree.

My facility is 267 beds. We only have a MICU and a SICU. The MICU keeps the crash bed and generally should always have the capability to 1:1 a patient. We generally don't plan for 1:1's unless we know we have CABGs coming. We are only 8 beds, down from 13 two years ago. We have had staff and budget cuts like everywhere else in the country and the hospital has responded accordingly. We are frequently full, near full, or in overflow. We typically staff 5 RNs which gives us the ability to take 1 CABG, have the charge nurse take 1 patient, and have everyone else be paired up. We have no assistant nurse manager so the charge pretty much controls the bed flow in and out of the unit, hence the lighter assignment (and we generally don't give them 1:1's either.) The nurse manager only works day shift and is very busy doing other projects and off the unit about 75% of the time (she is trying to move up in the system.) She pretty much only gets involved when we are over census (happens frequently, yesterday we had 10 patients) or we are so busy the hospital is looking at cancelling surgeries.

Anyway, the rationale for SICU patients going to PACU is that 1. We generally do NOT have room for a 1:1, even for a few hours and 2. PACU provides specialty care for the immediate post-op period as well as we do and the care there should be as good or better than what we can provide (our PACU is good. That is my boss's answers, anyway, and I agree for the most part.)

[SandraCVRN]

Any pt's that come to our OR from MICU or SICU go back to where they came from. No stops in PACU, that's just the way we do it here. I think our ICUs staff for a mix of 1:1 and 1:2.

Also, anyone that is going to SICU post op goes directly there no stops in PACU

[zedekias]

That's never fun, but you just have to learn how to not let those things get to you.

[CNL2B]

I am trying not to let it get to me. Mostly, I can see through the crap, but I still feel like it doesn't make a very happy working environment and that bothers me.

It looks like from all these posts that different PACUs/SICUs do it both ways (either direct admission or a PACU stop-over.) I think it is pretty clear from thinking about it now that perhaps my facility just needs a policy that addresses this so the confusion goes away. It's pretty easy to turn away a patient by just citing "policy" and the management backs you up on that.

I don't think that PACU provides inferior service to SICUs as far as recovering ICU patients. They are all well trained in their specialty and most of them have ICU in their background anyway. There are a few things they don't do -- balloon pumps and VADs being two of them. But, for the average ICU patient, I think PACUs are fine, they usually do a better, faster job of extubating them than SICUs do (at least ours does because their nursing ratios are better and they have anesthesia backing them up) and it just seems to be easier and more efficient for them to expedite things like post-op xrays and labs. Obviously, every facility is different, and perhaps I work somewhere with an outstanding PACU - don't really know. That's my one opinion anyway.