Does anyone else seem to experience when a patient has orders (even if written by the MD) to be transferred to an ICU bed, sometimes ICU will send nurses/resp therapists to the floor to "check out" the patient to see if "they really need the ICU bed"?
I've seen this happen 2x recently, including today with a patient who they "werent sure if they needed an ICU bed" (even tho their resp. were 6/minute! Dont ask me how she maintain a PO2 of 98%!). The patient had also been seen by the attending at least 2x that day, and the last time was obviously to write the transfer orders, yet here comes an RT from ICU saying she was asked by the charge to check on the patient to see if they really needed to be transferred. She literally looked like a dying woman, barely able to speak, couldnt move and had been A&O, pleasant, chipper a few days before on her admission. Even for a med surg patient, the amount of care this woman needed was TREMENDOUS.
I just dont get why ICU doesnt trust us to accurately assess a patient and outright tries to get out of MD orders?
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.
Sometimes "watching" in ICU is what's appropriate. Med-surg is not the place for someone to be watched with a change in status, respirations of six and a potential to crash. The standard of care of med-surg is rounding q1hour minimum if there are techs, but mostly it's q2h. Close watching, even if the patient is "stable" is something in my opinion that shouldn't be done on a med-surg floor.
Sometimes it's safer to err on the cautious side and transfer the patient. Although I understand ICU beds are tight. I work in a large facility and you have to be practically dying and intubated to get an ICU bed. So we hold patients on the floor and "watch" them until they crash and then it's a 911 transfer. Other times there's things we can do on the floor that can fix them and they stabilize and a transfer isn't necessary. Probably it is best we work on the patient on the floor first. (For example the resp. of six could simply be high C02 and turning off the patients oxygen or making adjustments would help. Or a patient SOB could just need a hefty dose of lasix.) But doing one-on-one nursing on a med-surg floor with an unstable patient, and having four or five (or more if you work nights) other patients to "watch" can be tough.
Interesting post. A rapid response team would be helpful for a lethargic patient with a low respiratory rate. They could check an ABG, perform an assessment and decide what needs to be done.
I would not feel comfortable in a med-surg setting where I could not monitor someone like that more closely. In med-surg, no alarms are going to go off if that patient stops breathing, no EKG monitor is going to show you when heart rate drops into the 30's. I have found patients dead in med-surg and have had no idea how long they were gone.
I think a monitored bed in a stepdown unit would be a good choice.
"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...".
Bingo!
I also don't know how floor nurses do it. I'm afraid there's a lot of, "Well, we got through another shift without a catastrophe," practicing by the seat of our scrub pants.
And all the hospital the mission statements still proclaim,"We give our community the best of 21st century health care."
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.
Maybe in your hospital it is different, but where I work we have medicine teams and ICU teams-the physician for the ICU would not be dragged down to our floor unless it was to access a patient for admission.
If my patient doesn't respond to the medication as prescribed I will text page the medicine MD back and let them know. I have to have an order in the computer whether its written now or 10 minutes from now, but I am not about to just go give medications or treatments and call that using my critical thinking skills. I like my license and would like to keep it. :chuckle
As ER nurses should we be allowed to tell EMS that the one they are bringing in needs to be taken back and told to call a taxi not EMS for a ride to the ER
Specializes in School Nursing, Pedi., Critical Care.
We are a large trauma hospital and ICU beds can be hard to come by sometimes. You have to be half dead to be there! You must be assessed by an ICU doc to be admitted to the ICU. Pretty much how Planeflyer described his situations earlier.
I have worked ICU and ER many years. It's always interesting to me see each others ideas of what should happen. I know that there are sometimes pt's in the ER that could go to the floor (or step down at least) but, because the ER is backed up sometimes there is a hurry to just get the pt somewhere. On the other hand when a pt comes up to ICU and is not appropriate, then payment is less and someone has to answere as to why this pt came to ICU ( usually the charge RN), a bed is taken up for someone that may need it more. I know that our hospital has started the rapid resp. team. They do what was mentioned above. They do things as mentioned by other nurses above. That way they prevent an ICU admission by a frightened intern or an overworked intern that just wants to get the pt out of their hair. Non the less, in the ER, we also get arguments between floors as well, don't want to take pt because of this or that. It never ends. But I do have to stick up for the ICU nurse here. I can't tell you how many pt's we get from the floor that are not appropriate.
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).
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.
I completely agree with the second part of your post, but your first part is, indeed, offensive. Just saying "No offense intended" doesn't somehow negate the fact that you are offending all floor nurses.
A good Med/Surg Nurse is worth her weight in gold. I worked Med/Surg for YEARS before migrating to the ICU.
BTW - The RN to patient ratio in Med/Surg is 1:5 in California. (Tele is 1:4).
Despite what insurance companies would like you to think, each patient presents a unique set of circumstances at different stages of the illness. We shouldn't take one patients' scenario and extrapolate it to fit all denied ICU admits.
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Tweety, BSN, RN
36,273 Posts
Sometimes "watching" in ICU is what's appropriate. Med-surg is not the place for someone to be watched with a change in status, respirations of six and a potential to crash. The standard of care of med-surg is rounding q1hour minimum if there are techs, but mostly it's q2h. Close watching, even if the patient is "stable" is something in my opinion that shouldn't be done on a med-surg floor.
Sometimes it's safer to err on the cautious side and transfer the patient. Although I understand ICU beds are tight. I work in a large facility and you have to be practically dying and intubated to get an ICU bed. So we hold patients on the floor and "watch" them until they crash and then it's a 911 transfer. Other times there's things we can do on the floor that can fix them and they stabilize and a transfer isn't necessary. Probably it is best we work on the patient on the floor first. (For example the resp. of six could simply be high C02 and turning off the patients oxygen or making adjustments would help. Or a patient SOB could just need a hefty dose of lasix.) But doing one-on-one nursing on a med-surg floor with an unstable patient, and having four or five (or more if you work nights) other patients to "watch" can be tough.
It's tough out there in med-surg land. :)