Does an empty bed justify admission?

nrsang97, BSN, RN · Feb 3, 2009

I think you administration is crazy. I have feelingthis is going to end badly one night, a pt go bad and there will be failure to rescue, or a confused pt really doing a number and breaking a hip or ending up with a SDH due to fall. You sound way overworked. Not safe at all. I would hope the house supervisiors would advocate for all of you.

ohmeowzer RN, RN · Feb 3, 2009

yes this is a dangerous game the doctors and your charge nurse is playing. you cannot admit if you donot have the staff. i am a charge nurse and the most our nurses take is 6 to 1 on a med surg unit. if i don't have the staff i don't admit. and 9 to 1 is way to high of a nurse pt ratio during the day on a acute care unit. do these people they admit even meet critera for admission? are they doing this to keep the numbers up in the hospital?

man , they are crazy. what does your dept manager say about this? please keep me posted on whats going on ..

Jolie, BSN · Feb 3, 2009

I'm not sure I understand your question. Do you believe the ER docs are admitting patients unnecessarily just to fill beds? Or do you believe that patients are being rightly admitted to the floor only to receive poor care due to inadequate staffing?

hdhnurse · Feb 3, 2009

First of all, the house supervisor also has the title capacity manager. A couple of them were questioning admissions due to the patient's conditions (for example we have no icu and sometimes the patient is better off transferred) These house supers got into trouble from admin and was told they could not refuse admissions if the doctor wants to admit. Our hospitalist will accept anything and he is definitely not on the nurses side.

Just the other day I received a patient from er with a BP of 69/36, lungs full, O2 sats in the 80' s on 40%. But he was stable according to the er doc. I spent most of my last couple of hours trying to keep him from coding. (by the way he died the next day)

The nurse manager is told she has to do what admin wants. We are told that if we have a negative attitude we can hit the door. We also recently went to pay per performance in an effort to make us keep our mouths shut.

The criteria for admission goes by Interqual so actually almost anyone can meet an observation admission at least. I have a sneaking suspicion that the floor is being kept full to make money. We get a lot of medicaid so that is guaranteed payment of some sort.

All I know is that I dread going to work and I leave with such a stress headache every day that I am sick to my stomach. What does it take for someone to be able to stand up for the nurses and the patients to protect us both? I know if anyone in my facility would take any type of action they would be promptly fired.

so as it stands right now....we could have ten empty beds a census of 15 patients and two nurses on the floor and they would still admit ten patients to those empty beds.

Katnip, RN · Feb 3, 2009

You know you can always report this to CMS, your state's Office of Healthcare Quality (or eqiuvalent), and/or Joint Commission. Be very specific about dates and staffing ratios. Even though none of them require a particular ratio, they will come down on them for it.

If you have cases of near misses, you can also report that. Just make sure things have been documented in the chart. You are allowed to use patient names in these cases without violating HIPAA.

Also, if you get several people to complain separately, that will light a fire under them and get them moving a bit faster.

Your admin is clearly playing a dangerous game.

hdhnurse · Feb 6, 2009

Just wanted to give an update on the situation at my hospital. I worked yesterday for twelve hours as a nursing assistant...I am an RN but they are constantly pulling us to work in NA capacity since they are short on NA's Horrible day. I had nine patients with two getting blood and one receiving platelets.

We had a ventilator patient and another pt. that is on an amiodorone gtt. , cardizem gtt, TPN and numerous antibiotics. There were two other patients besides the ones that I had getting blood. One was a GI bleed that the house doc decided he wanted to bowel prep before he transferred her to the "city" for her scope the next day.

Bowel prep + Lower GI bleed = increased risk for bleeding which then results in more blood being needed, falling BP, unstable patient then the need for immediate transfer.

We had a floor census of 27 patients....three nurses coming in on nights with only two NAs scheduled....Now mind you this census includes the critical "ICU" patients. (we don't have an ICU, but the doc tries to act like we do).

ER was trying to admit more patients and I blew my stack. I told the house super that she needed to call admin and let them know about the situation. WE could not safely take anymore patients. Heck, we weren't safe the way we were working now.

Her solution to the problem was talking a 12 hour nurse into working 18 hours and calling everyone that was off to try to get help. They were pulling NA from OB and the geriatric psych dept. to try to cover.

She would not call admin. for whatever reason (maybe afraid of them?) I am so frustrated I don't know what to do. I could file a complaint with JCHO but I know the hospital would find out and fire me. JCHO says that you can't be fired for filing a complaint but everyone knows they will find another reason to fire me.

There is the only hospital in my immediate area. The others are over 50 miles away. I have been at this hospital for over 12 years and I don't really want to drive long distances and I don't want to work in a Nursing home. So short of packing up and moving (which I don't have the money to do because I am the sole supporter of my family) I feel that I am stuck.

Is this really what healthcare has become? What can we as nurses do to make it better without fear of losing our jobs? I know for a fact that if the hospital gets sued they will point the finger at the nurses first. We have a doctor right now that has told the family of a recently deceased patient that it is the nurses fault.

Sorry for the long post ......just trying to vent and ask if anyone else has the same insane working conditions and if there are any solutions to the problem without fear of being fired.

patwil73 · Feb 15, 2009

I trulydon't know if you can do anything without the fear of being fired. However, can you ignore the phone calls from ER? See if it is them calling and just don't pick up? I agree your staffing is very dangerous. Did the person on amiodarone have a monitor where you can see the rhythm?

I keep reading these horror stories of staffing and wonder how people can realistically do this. As a house supervisor at my hospital - I have refused to allow ER to admit when it overburdens the floor. I have called managers at home to come in when they are dangerously understaffed. I have taken care of 3 ICU patients at once and responded to codes and MRT's. Of course my staff feel put on when I ask them to take 7 patients with their own cna on nights - they would honestly lynch me if I tried giving them 9, 10 or more.

Of course it is alway a balancing act - I have to weigh what is happening in ER with my capacity on the floors - but I always tell them, this is what I have for you - use it wisely.

I do know for me I couldn't work where I felt my presence was increasing the danger to my patients. In other words if the staffing was so bad that by accepting it I was putting my patients into danger - I would drive however far I needed to find a job that did not put me in such a position without a large scale disaster to back it up.

The only other thing I can think of is try to talk with HR (and maybe a lawyer) regarding a hostile work environment. If you are so afraid that even complaining about truly unsafe conditions is going to result in you being fired - you are working in a hostile environment.

Hope it helps

Pat

ChristineN, BSN, RN · Feb 15, 2009

Just wanted to give an update on the situation at my hospital. I worked yesterday for twelve hours as a nursing assistant...I am an RN but they are constantly pulling us to work in NA capacity since they are short on NA's Horrible day. I had nine patients with two getting blood and one receiving platelets.
We had a ventilator patient and another pt. that is on an amiodorone gtt. , cardizem gtt, TPN and numerous antibiotics. There were two other patients besides the ones that I had getting blood. One was a GI bleed that the house doc decided he wanted to bowel prep before he transferred her to the "city" for her scope the next day.
Bowel prep + Lower GI bleed = increased risk for bleeding which then results in more blood being needed, falling BP, unstable patient then the need for immediate transfer.
We had a floor census of 27 patients....three nurses coming in on nights with only two NAs scheduled....Now mind you this census includes the critical "ICU" patients. (we don't have an ICU, but the doc tries to act like we do).
ER was trying to admit more patients and I blew my stack. I told the house super that she needed to call admin and let them know about the situation. WE could not safely take anymore patients. Heck, we weren't safe the way we were working now.
Her solution to the problem was talking a 12 hour nurse into working 18 hours and calling everyone that was off to try to get help. They were pulling NA from OB and the geriatric psych dept. to try to cover.
She would not call admin. for whatever reason (maybe afraid of them?) I am so frustrated I don't know what to do. I could file a complaint with JCHO but I know the hospital would find out and fire me. JCHO says that you can't be fired for filing a complaint but everyone knows they will find another reason to fire me.
There is the only hospital in my immediate area. The others are over 50 miles away. I have been at this hospital for over 12 years and I don't really want to drive long distances and I don't want to work in a Nursing home. So short of packing up and moving (which I don't have the money to do because I am the sole supporter of my family) I feel that I am stuck.
Is this really what healthcare has become? What can we as nurses do to make it better without fear of losing our jobs? I know for a fact that if the hospital gets sued they will point the finger at the nurses first. We have a doctor right now that has told the family of a recently deceased patient that it is the nurses fault.
Sorry for the long post ......just trying to vent and ask if anyone else has the same insane working conditions and if there are any solutions to the problem without fear of being fired.

Your hospital and doctors are insane if they are going to try to keep these critical patients in a rural med-surg floor. These pt's need to be transferred to an ICU unit. Is there some sort of policy you could maybe refer to at your hospital stating what isn't allowed on the floor (ie no vents, no drips, etc). Maybe you could use a policy like that to your advantage to refuse the admission, stating it is not acceptable for your floor. I feel for you and all you're going through. :icon_hug:

systoly · Feb 18, 2009

My present job is 48 miles from where I live. On the way, I pass by previous places of employment and each time I am so thankful that instead of trying to hang on to my sanity and fighting nausea, I am enjoying the music. I have come to enjoy this time to myself. Would it be possible for you to check out the drive to other hospitals?

caringchic · Feb 19, 2009

I worked in Ontario OR a small rural town and that is exactly what it was like there, very scary, I ended up moving far away d/t no change in the admin policies r/t admissions. I was terrified someone was going to die on my shift. I had one pt code after shift change d/t the meds that had been given on my shift b/c the doc wouldnt come see the pt and there was two of us- me the RN and one NA. 24 pts on the floor, 1 vented, 2 psych, a few orthos, a peds pt RSV and some random med pts, a couple crawlers bed alarms, tag alarms ya know... It was absolutely nuts, since then I hear a few docs have left and it isnt getting any better.