ICU fighting admissions?

Kymmi · Jan 20, 2009

Ok....let me address this as a ICU nurse. It is not that we don't trust everyone to be able to do accurate assessments and we are not trying to get out of taking admissions either. I can say however that more than once we've run into a situation where a patient came to ICU and really did not need to be there. ICU beds are very hard to come by and if we are using them up for patients that can be treated on the floor then the true critical patients sitting in the ER or on the floor waiting for a bed are not being treated to the best of the hospitals ability.

I have seen more than once where there has been a nurse for whatever reason whether it they were new, inexperienced or just plain paniced call a MD for a problem and the MD will elect to send patient to ICU because the MD quite often knows that if the patient is in ICU they will not receive as many phone calls from the ICU as they do floor nurses because ICU seems to have more protocols in place and ICU nurses seem to be given more leaway to do what needs done and phone the MD in the am.

There has been times that a patient might go into acute pulmondary edema, CHF and will respond quickly to a lasix dose and not really need to be in ICU.

I do believe that just like many patients do need to be in ICU there are just as many that really could be treated just as well on the floor therefore freeing up a bed for a very critical patient. Imagine if it was you or your loved one that needed to be in ICU however because the beds are full it doesnt happen as quickly as it should. I guarantee you that if I went into our 5 ICU's here I would find at least 5+ patients that are here however could/should be on the floor.

NurseyPoo7 · Jan 20, 2009

I see your point.

If you were an ICU nurse and were told there's a new admission and their respirations were 6/minute, what could a med surg nurse do?

I think sometimes as a Med Surg nurse, you almost take it as an insult and we get offended. Which maybe we shouldnt. It's just very hard when you have a patient who requires an INTENSE amount of attention and care, which some may not believe is enough for ICU on top of having to care for 5-7 other patients!

allnurses Guide · Jan 20, 2009

The role of ICU liaison nurses to transition patients in/out of ICU and to review patients on floors before sending to ICU has been described in the literature. I think the poster before was spot on - often they do need "intensive care", but not necessarily in the ICU. If close attention in a short term situation can solve the problem, it should be investigated prior to transferring to ICU to most appropriately manage ICU resources.

eg. in your example, is there a resp problem, or is the patient oversedated and will respond to a small dose of naloxone and be fine? Using ICU nurses as a resource on the floor to help assess and intervene is a good thing for both the ICU and the floor.

Pediatric Critical Care Columnist · Jan 20, 2009

Because I work in a pediatric ICU our protocol might be different, but I will describe it anyway. Before a patient can be admitted to our PICU one of our physicians must physically assess the patient. If, in the PICU physician's opinion, the patient can be managed outside the ICU with guidance and ongoing reassessment by PICU, the patient is not admitted to the PICU. This also applies to some surgical patients when a bed is requested pre-op for the post-op period. If we aren't able to accommodate the patient and they will need PICU, then they're rescheduled. Having said that, if a patient on the ward crumps and needs PICU stat, they get a PICU bed stat. That is whether PICU has a bed for them or not. Many times our beds are occupied by ward patients for whom there are "no beds on the ward", and it causes us a great deal of trouble. On my last night shift I had 20 minutes notice that the baby who had been screaming in my arms for the past two hours had to be transferred out so that I could admit a patient from the OR. It's not possible to do all the routine paperwork, hold the resident's hand while they write up the transfer orders, fill out and fax the "safe patient transfer" forms, pack the kid up, get them upstairs and set up for an admission in 20 minutes, even if you haven't been holding a screaming baby for 135 minutes.

Kymmi · Jan 20, 2009

Ok...let me ask you this.....if the patient's resp are 6 but the pulse ox sat's were 98% was her resp. status compromised? I realize you also said she was lethargic etc however was that due to medications? Was a CT done? Were her other vitals stable? If all vitals were stable, oxygen level was fine then what would you think we would do in ICU that you would not be able to do on the floor? ICU beds are to be used to treat patients that need interventions that are not safe to be done on the floor such as drips, vents, unstable vitals....but to send a patient to ICU just so we can "watch" them is a inapproiate use of a ICU bed.

APRN., DNP, RN, APRN, NP · Jan 20, 2009

Ok...let me ask you this.....if the patient's resp are 6 but the pulse ox sat's were 98% was her resp. status compromised? I realize you also said she was lethargic etc however was that due to medications? Was a CT done? Were her other vitals stable? If all vitals were stable, oxygen level was fine then what would you think we would do in ICU that you would not be able to do on the floor? ICU beds are to be used to treat patients that need interventions that are not safe to be done on the floor such as drips, vents, unstable vitals....but to send a patient to ICU just so we can "watch" them is a inapproiate use of a ICU bed.

I concur.

At my previous hospital, the MD had to get an okay from the Intensivist in order to get their patient admitted to the ICU. In addition, the Intensivist was required to do a physical assessment and write a full set of admission orders within one hour of the patient's arrival to the ICU bed.

Unless this patient had increased work of breathing and sat's were dropping or a blood gas showed compromised ventilation, this patient would not wind up in the ICU, they would go to Med/Surg with a continuous pulse ox monitor.

dorimar, BSN, RN · Jan 20, 2009

My first guess would be that the patient was oversedated, as a prior poster mentioned. However, we cannot know this with only the information available. My problem with everyone stating that ICU is only for nursing interventions not safe on the M/S floor, is that this is not true. Assessment and prevention is a huge priority of critical care nursing, and the floor nurses do not have the time or skill for this (no offense intended to M/S nurses). Quite frankly, I believe that many ICU nurses today don't understand that their job is not just following orders and titrating drips and pushing buttons. It takes a good deal of crtical thinking to prevent bad stuff from happening, and I see this skill lacking more and more in the critical care setting. I actually had a new ICU nurse tell me recently that she felt the SBAR communication was just a waste of her time. she stated, "Just tell me what I need to do, and don't give me all that other info".

ICU nurses that come up to the floor to assess the need fo ICU, could be a good thing or a bad thing. I guess it would depend on the nurse. What was the outcome of the ICU nurse's assessment in this situation? If the patient was left on the floor, hopefully the ICU nurse spoke to the physician for some other orders and interventions (ie... abg's narcan, etc.), because despite what you all are saying, 6breaths /minute is an unstable vital sign that could affect the PCO2 (SPO2 of 98 % means nothing). So much could be happening and missed. Don't forget these M/S nurses often have 8 other patients and may not be able to monitor this patient as she should be monitored to detect more serious symptoms or VS. Someone mentioned the loved one held in teh ED because teh ICU was full, but think about the loved one that was left on the M/S floor lethargic adn breathing 6/min that ended up emergently intubated with an anoxic event, because she was deemed not ICU material because she didn't require intubation per the ICU nurse's one time assessment at the time of that assesssment.

Virgo_RN, BSN, RN · Jan 20, 2009

Our ICU wouldn't take this patient either. Most likely, they'd transfer from M/S to us for "cardiac monitoring".

While I agree that this patient is not ICU material, I also would question the safety of this patient on a floor where their nurse has 7 other patients to care for.

mh356, BSN, RN, EMT-B · Jan 20, 2009

I have an example of a patient that I wanted to share that is similar to this situation. I work on a med-surg/tele floor and I had a patient (this past weekend) in resp distress. Lasix IV ordered stat-but we can't pull certain drugs from our omnicell even in emergencies and some drugs we just don't carry on the floor at all. Our floor also has long hallways and I can't see all my pts b/c they are expected to be for the most part walky/talky. This lady was at the end of the hallway and was climbing OOB, unresponsive at times. etc. I was in her room nearly every hour! Eventually I had to park myself outside her room to do my charting and listen out for my other 2-3 patients, while also being charge nurse.

Our ICU was full too, they basically told me to call when she was vented. Unfortunately we don't have an IMC type units.

Like somebody else said, it comes down to prevention and monitoring.

Reno1978, BSN, RN · Jan 20, 2009

Ok...let me ask you this.....if the patient's resp are 6 but the pulse ox sat's were 98% was her resp. status compromised? I realize you also said she was lethargic etc however was that due to medications? Was a CT done? Were her other vitals stable? If all vitals were stable, oxygen level was fine then what would you think we would do in ICU that you would not be able to do on the floor? ICU beds are to be used to treat patients that need interventions that are not safe to be done on the floor such as drips, vents, unstable vitals....but to send a patient to ICU just so we can "watch" them is a inapproiate use of a ICU bed.

I think Kymmi nailed it. These were my exact thoughts as I read the original post. I'm sure the patient status may be more complex than stated in the original post, but it seems like the priority was to get this patient off the floor because they required too much of the nurse's time than to figure out why there was a change in the pt's status.

Kymmi · Jan 20, 2009

My problem with everyone stating that ICU is only for nursing interventions not safe on the M/S floor, is that this is not true. Assessment and prevention is a huge priority of critical care nursing, and the floor nurses do not have the time or skill for this (no offense intended to M/S nurses). Quite frankly, I believe that many ICU nurses today don't understand that their job is not just following orders and titrating drips and pushing buttons. It takes a good deal of crtical thinking to prevent bad stuff from happening, and I see this skill lacking more and more in the critical care setting. I actually had a new ICU nurse tell me recently that she felt the SBAR communication was just a waste of her time. she stated, "Just tell me what I need to do, and don't give me all that other info".
Ok...let me rephrase my thoughts. In my original post I did not go as far as saying ABG's were good but I did mean to say that other than resp. at 6/min all other vitals were stable and I did mean to say gases were checked and also fine. My point was that there could be numerous reasons to cause this and if it was med related was narcan tried....if it was thought to be neurological considering she was lethargic was a CT done. I am not saying this patient shouldn't have gone to ICU-there isnt enough info in the OP to determine that. I was however responding in general that alot of ICU admissions are inapproiate use of ICU beds.
I disagree that ICU nurses think their job is just following orders and titrating drips....the ICU nurses I work with all have great critical thinking skills. I also disagree that the MS nurse lacks the skill to perform through assessment of patients...they are trained professionals that know the difference between what is normal and what isnt. I do agree that it is much harder to do with 5-6 other patients to watch after so maybe in some instances a patient that doesnt meet ICU criteria however needs more close monitoring due to a potential problem should go to a monitored bed where the ratio is lessened. Each and every patient in the hospital has the potential to go downhill fast...do we put all of them in ICU just in case? There is the young post op patient that throws a PE without notice...the patient that goes into flash pulmonary edema......the patient with chest pain that suddenly goes into V-tach...etc etc.....all those patients need to be observed.
I also know that there is that MD that has a patient on the MS floor and receives frequent phone calls from the floor nurse about issues that can wait until morning or from the nurse about a patient that very well might be having mild resp. distress and is in flash pulmonary edema in which 40 of lasix might be all that is needed to diuresis and relieve the resp. distress however that MD does not want to be called again in case the lasix doesnt work so their order is to send the patient to ICU because they know that ICU nurses tend to use the critical thinking skills and do what is needed.
The answer is not to send potential problems to ICU.....ICU is for patients that are currently having problems and need ICU intervention. The answer is to staff floors to be able to monitor all patients as needed.
I also think that floor nurses do have alot of clinical skills to perform ie meds, vitals, charting and I know I would not want to do that on 6-7 patients however I wonder if sometimes they get so overwhelmed with knowing it is 10 pm and they still have 4 patients to give meds to that they overlook that patient that is having a potential problem until that problems goes untreated and the patient goes downhill until a code or immediate transfer to ICU is needed.