I'm a new nurse (1 yr) who floats between units in our critical care department. I spend about 50-60% of my time on the CC step down unit. A couple of weeks ago I had a situation where I believe my patient's safety was severely compromised and I found myself jumping through hoops of fire trying to get her upgraded to the MICU. I will spare some details to protect privacy.
My patient had been admitted for several weeks due to sepsis/pancreatitis and had been jumping back and forth between MICU and step down due to all of the sequella of her condition (liver issues, perfusion issues, clotting issues, etc). One week she was improving and the next she would crash and burn.
When I first received her, the patient was on 3L NC, AOX3, unlabored breathing, HR in the 80's, afebrile, and with a BP that was on the softer side (low 100's). Assessment wise her abdomen was distended with hypoactive BS. She was jaundiced throughout.
At around noon I saw her heart rate increase to the 140's sustained. She was working with PT at the moment so I did not think much of it. She did not appear to be in any distress at the time. 20 minutes later, her HR is still elevated at rest. This time her breathing appeared more labored and I had to increase her O2 drastically to 15L on a NRB. Her BP was normotensive but she had a low-grade fever now. I immediately directly called the intensivist and received orders to r/o a PE amongst other things.
The scan was negative and the patient was stable. Upon our return, her oxygen demand increased to 40L heated high flow and she was now unable to maintain adequate blood sugar control (30's-300's within an hour). I called a Rapid and was given orders that would assist with BS control and nothing else. I expressed my concern about the patients declining status and the need for a higher level of care. I was told by the intensivist that the patient was stable enough at the moment. I was worried that this patient was going septic again or had developed peritonitis due to a now firm abdomen and almost absent BS - I told the MD this.
Then 3 pm came and the patient's blood pressure began trending down (into the 90's, high 80's with decent MAP). She remained on the same oxygen level. I again spoke with the intensivists - just monitor. I spoke with the specialist - just monitor. I spoke with a different provider on the case - just monitor. At 4 pm her O2 demand was increased to 60L HHFNC with 94% FiO2. The patients mental status seemed to be declining as well. Her blood sugar was again hypoglycemic. Her BP's was in the 70's-80's. Still tachycardic. I called another rapid. This time I received an order for blood pressure support (not pressors). I again expressed my concerns and need for higher care. I asked the doctors directly the reason for the delay and I was told in certain terms that they were trying to wait it out until the next morning. I can't really go into details about that part but let me just say that their reason for this was nonemergent and ridiculous. During this entire time, the house sup and the charge nurse were also doing their part to try to get the patient transferred through other avenues. At around 5:30 pm and after exhausting almost all of my resources I decided to call the medical director. I explained the situation and my concerns. Within 10 minutes the director was at the bedside and completely agreed with my concerns. At 5:45 pm this patient was finally transferred to a higher level of care. I transferred the patient and was greeted by the intensivist at the MICU. let me just say that he was NOT HAPPY that I had gone above him to get this patient moved.
I spent nearly 6 hours taking care of this one patient. My other 2 patients were still taken care of (wonderful teamwork!) but I felt they were much more neglected due to my snowballing situation next door.
One lesson I learned is that I need to be more aggressive with my concerns. I feel that this delay was completely avoidable. Was there anything else I could have done? Now I every time I see this particular intensivist, I feel like he still is very angry with me. It doesn't matter how he feels towards me but I do think it has affected our professional relationship.
