Unstable Admission

[ptsfirst]

Hi everyone. I need some input. Today I was told I was getting an admit from the ED (no big deal). They had been hypotensive for over 3 hours after 2 boluses and by hypotensive I mean a Map of less than 58 (and ESRD). Would you question the patient coming to you with this low of a blood pressure or would you have just kept your mouth shut? I work on a PCU floor - but we don't do Levophed, etc. I asked the ED RN how we were to treat the hypotension since pt was ESRD and bolus wasn't going to be an option. They said MD is ok with patient coming up like this.... ultimately I was told that I should have just taken the patient and we will deal with it when it arrives... I'm so confused and got severely reprimanded for questioning this... I did not refuse to accept assignment - only wanted a viable way to treat BP. I am not a new nurse... more than a decade of experience, mostly ICU. What would you have done?

[winniewoman9060ret]

I would have questioned the appropriate of the admission too.

[Wuzzie]

Other symptoms that indicated instability?

[ptsfirst]

"Extreme" Lethargy and just completed home HD.

[Wuzzie]

So they pulled off too much fluid then. What is the patient's normal BP? I'm not trying to bust your chops but a low BP isn't necessarily an indicator of instability. My BP runs 90/50 which gives me a MAP of roughly 63. Not much higher than your patient's. Don't misunderstand me I don't think you were wrong to question the admission and you certainly shouldn't have been punished for using your nursing judgement but I think sometimes we get focused on one thing and forget to look at the big picture. How did he do?

[JKL33]

I wrote out a bunch of stuff but erased it because this actually boils down very neatly, for better or worse. I guess at least you can know where you stand:

You were reprimanded because your own administration feels you should have taken the patient without knowing the answer to your question. This whole thing likely is a result of CMS' Core Measure regarding Admit decision to departure time for ED patients.

Anything else that could be said about this is just both sides venting frustrations. And, by the way, I understand your concern and think it is perfectly reasonable. If it makes you feel any better, the ED deals with some similarly frustrating initiatives. Our various timers start when the patient walks in the door.

Hang in there ~

[PeakRN]

In defense of the ED, we do not make inpatient treatment plans. I would not expect the ED nurse to know the plan of treatment on admission. Hypotension is not uncommon after dialysis, in the ED we may take a wait and see approach or treat with small fluid aliquots (typically 250-500 mL). As an ER nurse I would have suggested that you ask that question to the admitting physician.

I do think that this comes down to your system. In ours if a floor nurse is concerned about an admit then they can deffer to their charge RN and the house supervisor. From the ED perspective I don't have any problem with watching that patient, but I also different tools and responsibilities than on the floor. We do not hold it against anyone when they have a concern about an admission and we have to send it to a different floor or up to the units.

[MrNurse(x2), ADN]

This whole thing likely is a result of CMS' Core Measure regarding Admit decision to departure time for ED patients.

~

This is the main reason I left the hospital setting. Our ED went from a top cardiac provider to sending infarcts to the floor, in a tertiary center. Throughput put patients and my livelihood on the line. Don't stop asking, it is your license. This is the real reason written report has become the norm, less chance to question and reduced wait times.

[ICU-BSN]

What was the goal MAP for this patient? I often have patients where my goal is 55. It all depends on the patient's presentation and the goals of care, there is no blanket statement for all.

[brownbook]

I don't understand why you were questioning the ER nurse?

I would find out the patient's code status, and tell my charge nurse my next admit had a MAP less than 58, was ESRD, and I felt it was unsafe. I wouldn't refuse to take the patient, just be ready to call Rapid Response, or a code.

How did he do when he got to your unit?

[psu_213, BSN, RN]

I have both ED and Stepdown/PCU experience, and I have sent pt's to SD/PCU with this BP, and I have received pt's from the ED with a similar clinical picture. A lot depends on other factors...what does their BP usually run, what is their normal mental status, what have they looked like on previous admissions? I think it it right to question this admit--go to the charge, and if you don't get a satisfactory answer, then go to the nursing supervisor. If they come to floor and look inappropriate for your unit (every PCU has slightly different rules for acuity) then call at RRT.

Also, I need to address report, throughput times, etc. It more than the ED wanting to get pts. out. It is not about the ED nurse trying to dump the pt on floor nurse. It is more than Medicare rules. Recently a local TV station in my area compared ED times of various EDs. The thing was, their report was based on the random charts that were "pulled" by Medicare. So this news report basically ranked (and, and in some cases, slammed) EDs based on very limited data and random reports. In a competitive market, with local news pretending that their report provides an accurate picture of the "best" EDs, there has to be a focus on throughput times, even if it comes in the way of patient care.

[xoemmylouox, ASN, RN]

It's ok to question admissions. I don't see anything wrong with asking the ED nurse. She might know what the plan is. Now that doesn't mean to grill them and give them a hard time - they didn't pick you to get this admit, but you can say "Hey do you know what the plan is to keep this B/P from tanking".

You certainly shouldn't be reprimanded for asking questions. That's a warning flag for me.