I feel that I may have made an error in judgement and made myself look incompetent to my supervisors. In the interest of not stirring up any drama at work, I want to post the situation here in order to gain insight about what you all think.
I am new to the ICU, but not a new nurse.
I took care of a patient going through ETOH withdrawal. This was my second day of having the patient. The patient was originally admitted to a step-down unit, but later transferred to ICU with uncontrolled withdrawal symptoms.
The patient slept through most of the first day. I titrated the sedative drip down. Towards night shift, the patient became less groggy. The next nurse kept the sedative drip on the same level overnight. The next day, I knew that the MD would want the patient transferred back to the floor (no other medical issues requiring ICU care). I decided to stop the sedative drip and begin giving Ativan, so that I could give the MD an accurate picture of how the patient would tolerate the Ativan. The patient was cooperative and nonviolent but restless and impulsive when awake. The patient was in a vest restraint.
The MD came in that afternoon and as I suspected, wanted the patient transferred back to step-down. I shared my concerns with the MD that I felt that the patient may require higher levels of Ativan than are safe to give outside the ICU. The MD saw the patient awake, restless, but also A & O x 3. I decided while waiting for a room assignment to give the patient the max dose of Ativan our protocol allows just to see if that would help the patient stay calm. I gave the patient the max PO dose three times in the next three hours, but it didn't help the patient's restlessness. The patient had now learned how to un-snap the vest restraint!
I called report to the step-down RN and I was honest in my report (i.e. patient is able to unsnap vest restraint despite receiving the max dose of Ativan). Immediately after speaking to me, the receiving RN called my charge and protested the assignment, stating that she felt the patient was too high of a fall risk to come to step-down. (BTW, my charge nurse and my assistant supervisor were already aware of the situation). I paged the MD and had him come down again to re-assess the patient and see if he still felt that the patient was stable to go to step-down. At that time, the MD saw the patient again attempting to remove the vest restraint and get out of bed. I informed the MD that the patient had receivied the max dosage of Ativan for the past 3 hours. The patient was still A & O x 3. The MD stated that he still wanted the patient to transfer to step-down. We placed wrist restraints so the patient could not unsnap the vest restraint.
I did end up transferring the patient, but the situation became a mess. The charge RN of the step-down unit made some angry comments to me when I was transferring the patient. The receiving RN paged her nurse manager, my nurse manager, my nurse educator, and the MD to have a meeting about the appropriateness of the patient being transferred to step-down. (The patient was not transferred back to ICU). My nurse educator spoke to me afterwards and said that a patient receiving such high doses of Ativan should never leave the ICU. She called it a "learning experience" for me. I felt like she was frustrated with me. I have never had any issues with my educator before; she has always been supportive.
It has been several days but I am still upset over the situation. I am a sensitive person and I do not feel confident about being in the ICU already. Now, I feel that I have a target on my back and that my supervisors will not trust me to make good decisions. I am angry because I feel that I was talked down to by my nursing educator. As I said, I am not a new nurse. There is no protocol at my hospital for when a patient receiving high doses of Ativan can or can not leave the ICU. It is entirely MD judgement. I know that there are risks to giving large doses of any sedative, but I felt that I did all I could by sharing my concerns with the MD and having him come back and re-assess the patient. Theoretically I could have refused the MD order, but I was not 100% convinced that the patient needed ICU care. Even though it was against my better judgement, I followed the MD order.
Thank you to anyone who read this long and winding post. All comments or suggestions are appreciated.
You actually did a great job - the MD ordered the transfer, not you. I'm wondering exactly why the nurse educator is involved... shouldn't she be teaching somewhere else in a classroom?
Step down units and med/surg regularly care for ETOH withdrawals and/or extremely high fall risks... it's par for the course. Unless someone needs ventilating, why would they be in the ICU?
Agree with the posts. You did the right thing, and it sounds as though the Step Down unit wanted to be on an Acuity Holiday for awhile.
Just as a sidebar, if my best judgment tells me that I am not in total agreement with the Docs, I always contact the Charge RN or other Clinical Leader to talk about it. However, I work in a facility where we are fortunate to have a working relationship with the Docs that allow us to address these issues one-to-one. It doesn't always work out the way we want, but at least the Docs listen. And, we have fully advocated for our patients.
Our facility also has a protocol that allows us to bypass the Doc and go higher if necessary to address issues that we feel might be a bit troublesome with no fear of retaliation for doing so.
I work Stepdown from time to time and our hospital will admit all ETOH w/d to the Stepdown unit. They are never admitted to our ICU.
And they come up from the ER with restraints and ETOH w/d protocol. And if they are violent they get a 1:1. I've given enough Ativan IV to sedate an army on just one pt.
I think you did the right thing. There was no reason for this pt to stay in the ICU. He was no longer on the vent, nor was he on a pressor, so he was stable enough to be moved to Stepdown. The Stepdown unit just didnt want a difficult pt. And I think it was completely out of line for the Stepdown RN to page all those people in hopes of getting the assignment cancelled. Instead of paging the NM to try to get the assignment cancelled, the RN should have been asking for a sitter for that pt instead.
Just because the pt was a fall risk and trying to get out of bed is no reason to take up an ICU bed.
Just my opinion.
I agree completely. The stepdown unit where I work is always kvetching about "difficult" patients that we send them. To the OP, you went out of your way to present your concerns to the doc and he/she still wanted the patient transferred. You did everything right. In my opinion, you deserve an apology from your nurse educator for getting all huffy with you.
Afrocentric, I once had a stepdown RN complaining to me that the patient I transferred was not oriented to place, he thought he was at home!! Of course, that's what I said in hand-off report . . . if all our transfers had to be A&O x3, we'd never be able transfer anyone!!
I dont understand ETOH withdrawal pt taking an ICU bed just because he was on a drip & no req. for vent or dialysis?
The drip pt. would have been admitted to step down at our hospital or even med/surg if no beds available at step down. I used to take care of ETOH withdrawal pt all the time in med/surg floors. We get 1:1 sitter for fall risk, restless with other 4 patients ranging from post-op to DKA.
Our ICU mostly reserved for pt. with vents/dialysis and multiple drips simultaneously. Our step down for multiple drips. All the rest gets dumped to med/surg floors.
That step down nurse probably is lazy and your nurse educator needs to be educated herself that it was MD who transferred the pt. and not you. Why would you want to hold that pt. in ICU for PO ativan just because he is restless??
Maybe you should have told the MD that you refuse to transfer the patient because- nurse to nurse there was a concern. Ha! How's that for a choice? This is not your fault, although I'm sure you know that. You communicated properly, informed all parties, and did what the MD ordered. Whether that patient belongs in the ICU or not is really beside the point. That is not your decision. You should ask your educator what she would have done. What were your choices? Let's see, transfer the patient, or, transfer the patient. I hate this kind of Monday morning quarterbacking. Unfortunately the educator has shown you what level her bar is raised to. Just try to let it roll off your back, you don't need her to think you were right- to be right. It's unfortunate that any of this came your way. Since they were probably afraid to complain to the MD, they complained to you. Ineffective, useless, and petty.
Yeah, it really does sound like the step down nurse played some power politics on you. It's not a telemetry med-surge unit were talking about here, its a transition from ICU to the real world of floor nursing. In other words step should have taken the patient, it's under the step down protocol; a/o x3 and restrained, 'nuff said. Sheesh!
I think you made the right decision. Proof is in the pudding, the patient remained in step down, never to return to ICU!
Sorry that your educator gave you a rough time, sounds unjust and unfounded.
These patients would never be in the ICU at my hospital either. I think you were right in having the MD evaluate and then re-evaluate. Sounds like the receiving unit just didn't want to deal with it.
Ultimately the doc has the say legally--RNs practice under them. Yes if its a resident maybe getting the attending involved can be appropriate--but if you are already dealing with one--they do have the final say legally--which is why you document to cover yourself. That RN can be mad but RNs practice under MDs.
Umm, RNs DON'T practice under the doctor. At least not in the US. We might carry out their "orders" or prescribed treatment, but I certainly don't "practice under them." Last time I checked, I have a nursing license with my name on it from my state's BON.
Wow were u made the ham in the sandwich! I would honestly get all ur managers together & tell them all - or write out a statement - re how all this made u feel. U were definitely made the scapegoat in all of this. And does the Dr take no responsibility in this? They were all venting their anger pretty much onto u. I for one would not stand for it. Can u transfer to somewhere else out of ICU? Sounds like it might not be for u.
I was going to say the same thing. My floor we can have 6 pt's with one of them being ETOH constantly climbing out of bed, cursing, swearing, etc....I would think they would give a 1 to 1 sitter before holding an ICU bed.
I'm just a nursing student and a care aide at the local hospital, but in my experience there is scarcely anytime my hospital would keep at pt. in the ICU just because they are on heavy meds and out of control behavior wise. The ICU, in my experience, is for the seriously incapacitated pt.'s - i.e. ventilated/comatose/severe bodily injury type stuff - not out of control behavior type pt.'s. This pt. would normally be transferred to another floor and some care aide such as myself would be assigned as a 1:1 sitter to watch this pt. (not a fun job, but thats the way it goes). JMHO according to my limited experience. I'm sorry you got in trouble for this whole situation.
It sounds as though the patient may have qualified for a sitter, but that by no means indicates a need for ICU placement. Where I work, this patient would have been on a regular floor, not even the step down unit, regardless of the ativan (or valium) dose they were requiring to control their symptoms.
You should refer the educators and managers involved to the policies that support what they are telling you (my guess is there aren't any).
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regularRN
400 Posts
You actually did a great job - the MD ordered the transfer, not you. I'm wondering exactly why the nurse educator is involved... shouldn't she be teaching somewhere else in a classroom?
Step down units and med/surg regularly care for ETOH withdrawals and/or extremely high fall risks... it's par for the course. Unless someone needs ventilating, why would they be in the ICU?