Who to blame- MD or ER nurse??

RN1982 · Feb 6, 2009

Incident report needs to be filled out. I would have called the supervisor also.

Hoozdo, ADN · Feb 6, 2009

IMHO, it is the mistake of whoever writes the orders and assigns the pt to whatever unit. This pt should have gone to your ICU instead of your unit. Does your facility have a sepsis protocol? If not, then you need one!

The acuity of your pt's demands a better than a 1:4 ratio - titration of vasoactive drips, alines, CVPs, etc.........sounds like a 1:3 ratio would be better. It's the old staffing by numbers rather than acuities BS. I hope you don't have Swann-Ganz catheters too!

I once worked in an ICU that had a sepsis protocol and part of it was that the pt was a 1:1 when admitted to ICU for as long as necessary. It was the right thing to do - hard to implement in a profit based hospital that gets by with minimal staffing. That young man could have been saved if a sepsis protocol was in place. It's a sad state of affairs in nursing these days. :crying2:

Rotifer · Feb 6, 2009

It is everybody's fault, including yours. I see this happen, particularly with nurses new to the ER and young Hospitalists. I have also seen admitting send septic patients to the stepdown/tele floor mistakenly. You and, more appropriately, your charge nurse should then recognize the error and get the house supervisor's eyes on the patient you are attempting to stabilize. This is how we learn, congratulations on a job well done.

Wile E Coyote, ASN, RN · Feb 6, 2009

Sorry, Rotifer, I don't follow your line of thought above. You start out by blaming the OP, then end by praising him/her for a job well done? Perhaps you were being helpful, or facecious, I'm not sure.

Rotifer · Feb 6, 2009

I wasn’t being facetious, the original poster kept the patient alive under stressful circumstances – job well done. He/she deserves part of the blame because had this nurse been more experienced, he/she would have hastened the transfer to CCU. You are right, not a well written paragraph. Note that I also assigned blame to everyone, particularly the charge nurse.

freedom22 · Feb 6, 2009

IMHO, it is the mistake of whoever writes the orders and assigns the pt to whatever unit. This pt should have gone to your ICU instead of your unit. Does your facility have a sepsis protocol? If not, then you need one!
The acuity of your pt's demands a better than a 1:4 ratio - titration of vasoactive drips, alines, CVPs, etc.........sounds like a 1:3 ratio would be better. It's the old staffing by numbers rather than acuities BS. I hope you don't have Swann-Ganz catheters too!
I once worked in an ICU that had a sepsis protocol and part of it was that the pt was a 1:1 when admitted to ICU for as long as necessary. It was the right thing to do - hard to implement in a profit based hospital that gets by with minimal staffing. That young man could have been saved if a sepsis protocol was in place. It's a sad state of affairs in nursing these days.

What does your protocol loook like?

freedom22 · Feb 6, 2009

I wasn’t being facetious, the original poster kept the patient alive under stressful circumstances – job well done. He/she deserves part of the blame because had this nurse been more experienced, he/she would have hastened the transfer to CCU. You are right, not a well written paragraph. Note that I also assigned blame to everyone, particularly the charge nurse.

Thanks for being honest.

The problem was that ER reported great vital signs. That's s/t we do on our unit- i.e. take pt's with decent vitals and suspected sepsis. I usually get them to out unit, bolus them aggressively, start abx... and they almost always do well after the initial day. We usually run after the MDs untill they give us adequate fluid orders.... before the pressure drops, and the pt's tend to stablize.

However, in the case I listed above as an example, over the last 6 months, ER keeps on giving us V/S that sound great. But when the pt comes upstairs, they crash. Maybe out ER nurses know that an ICU bed is difficult to obtain. When we get a call from the ER we try hard to open beds- see what pt can be moved to a med/surg floor... So ER knows we take pt's sooner. Or maybe they dont have time to take vitals all together?

Anyhow, as soon as the pt got to our unit, the charge and I kept calling the MD saying he needs ICU. They doctors were less than helpful. At some point, the MD said, "the longer you keep me on the phone, the longer it'll take me to come up there." So we called his senior..... Apparently he was rounding on his pt's on the med/surg floor- a sure priority in this situation! After about 40min we got the ICU doctor from our SICU over to assess pt, but didnt want to help Tx him because he's only a consult. They refused the pt since it was a medical case. So we called MICU who opened a bed by transfering a pt to another step-down area. Finally, after about an hour the pt's MD showed up with his senior.

michael79 · Feb 6, 2009

what is MODS?

**canoehead, BSN, RN** · Feb 6, 2009

It sounds like everyone involved was too busy. A 30yo with sepsis but good vitals- I would have also made him less of a priority than a 75 yo with almost any admittable diagnosis I'd assume that he has more reserve. Unfortunately his normal BP might have been 130-140 systolic, with a HR of 60, which would have meant he was shocky when the ER nurse took her vitals, but no one realized it. Then the stress of transfer (standing and turning, possibly IVF were saline locked) may have pushed him over the edge. I can easily see vitals "just" taken in a busy ER being 30-60 minutes old. Yep, it's one of those disasters that could have easily happened to me, especially with 3-4 others just as sick under my care.

I also see the 20 minute delay in getting the patient upstairs as being a result of frantic busyness, especially since the ER nurse tried to negotiate with you to come get the patient. Bet she know perfectly well you don't usually come down, and that if it's a monitered floor you need a moniter on the patient. I speculate that at that point it's safer to get the patient out to a floor bed than to spend 15 minutes trying to get a moniter and a free RN to go with him.

The ER I work in now has 4 moniters for 16 beds, and 2 of those are hardwired. We can borrow from ICU, but that takes time, and someone to go get them. It's so busy I'm just crossing my fingers sometimes, and playing the odds that someone won't crash. Odds also say that whipping him up to the unit in 5 minutes will be safer than taking 30 minutes to hunt up a moniter, go get it (no one else is likely free at that point), hook him up, and make my way (slower speed) to the unit, unhook, and return the moniter whence it came. Yep, totally not in the protocol, but I'd be rolling the dice to buy an extra 30 minutes RN time for my other patients that I really think may crash when I'm away. I'd be relying on my my experience and instincts. After 20 years I can see very subtle cues but seriously there would be no cushion for error. If a new grad tried it, (I'd fire her) or even a 5 year veteran, the chances of a patient crashing enroute get higher and higher.

And all of that is unfair to you, but I would make a damned good effort to let you know I was busy, and to have the next few patients fluffed and puffed perfectly, and to stay a few minutes extra to settle them after transfer. That's what I'd plan on if the same thing happened to me. If you are getting multiple transfers like that it's likely the ER is beyond frantic on a daily basis. They must have ambulances lined up, people in hallways, poor staffing and people with not a lot of experience. The fact that the docs were too busy and slow to respond makes me think that the whole institution is run on a wing and a prayer. Your ratios need to be 1:3, bet you've seen some hair raising days too.

Health care shouldn't be a high wire act, but it IS, frequently.

You are right to be frustrated and frightened. You are right to write the whole thing up and send it through channels. The doc(s) should be disciplined, and the nurse didn't follow protocols (but she has my sympathy). Odds are that if you investigate the patient waited longer in the lobby than he should have, and longer for his antibiotic dose, but you'll never be able to prove it. It's happened before. Some of the patients squeaked through. It'll happen again, and most will live, but some definitely won't.

Institutions saves millions by short staffing consistently. They've crunched the numbers on lawsuits, believe me, and on who they can blame for not following policy. When the heat is on people skip steps to get things done. If you are too busy to go get a moniter you are too busy to write up the situation, notify the supervisor, discuss your options, go through the phone list again, etc, etc, etc, and then be the one with a difficult reputation and miss out on your raise for your "inability to manage time wisely."

Try to place the blame where it belongs when you send this through channels. The ER nurse may have been lazy, or she may have been overwhelmed. If you can stick together as nurses you will make a greater impact.

blondy2061h, MSN, RN · Feb 6, 2009

I agree that you guys need better staffing if you've doing art lines and drips and stuff. We do that stuff and have 1:2 staffing generally.

alwayslearnin · Feb 6, 2009

Just a few thoughts-first off, I hope that you are doing ok-I know I hate being in these kinds of situations. My hope is that everyone involved will step back and assess the situation and use it as a learning now (not as a time to blame) I work in the ER and can understand the situations from that experience. I have worked the floors too and have some experience there.

Thankfully, we have a sepsis protocol that we follow. We immediately put in two large bore needles (18 g) for fluids and give two Liters of Ns for just the same reason you state. We get a sepsis panel for labs including lactate and two blood cultures. We know to be prepared to put in Central Venous Acess. There are perameters for placement, but we are prepared-and depending on the situation-pt hx, current situation etc, we might just go ahead and do it right away. If there is a way to get your institution to institute a sepsis protocol, it would really help all concerned.

I can't believe you were asked to p/u the pt. I don't work in your facility but as you stated, you are responsable for the other patients-I've just never heard of that bieng done. Was there a stat nurse that could have been called to transfer the patient (also another experienced set of eyes and New set of eyes to assess the patient)

When you take a report from someone, would it be helpful to ask when the last set of vitals were taken as a routine question? I know how time can get away from you in the ED.After you call report you have to copy chart, hook pt up to monitor (not done in this case) take them off all equipment. It usually takes alot of time and if the ED is slammed, you might not get help.

Incident report-Definetely!

I never know all of the circumstance in these situations. Sometimes I find out later bits and peices that change some of my thoughts-but always it is good to review, question and try to see what can be done better-is it ultimately r/t staffing ect ect. I keep thinking back to the MD reassuring you the patient was appropriate for your floor (stable) yet the ED so busy he is hanging fluids.

Anyway, good work taking care of your patient once he was presented to you-it sounds like you did all of the right things-and I am sad to hear of the loss of your patient.

Blessings, alwayslearnin