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?
I said that not enough info was provided by the OP to determine whether this patient in particular should be in ICU. I am stating however that in general patients cannot just be sent to ICU to be "watched" unless there is reason to believe something major is going on with them....once again I give the example of the post op patient that MIGHT throw a PE, the chest pain patient with stable vitals and no elevation in trops that suddenly goes into V-tach, the elderly patient with a hx of chf that goes into flash pulmonary edema...each and every patient in the hospital has a potential to go bad.
What I am trying to say is that these patients need to be evaluated on the floor first by a ICU nurse or rapid response team to see if perhaps something else could be done to treat the patient without a ICU admission.
In the case of the OP tell me what we would do in ICU that couldnt be done on a monitored bed with continous pulse ox providing that ABG's are within normal, vitals stable and no s/s of distress.
As far as my statement regarding the MD's transferring to ICU in order to avoid phone calls I was not implying that I would give drugs or start meds without a order but ICU's do have alot more standing orders than the floor do and face it........tell me that you have never had a patient that is running a low B/P and low urine output and you give a NSS bolus to see if that improves before calling the MD at 3am.
I am not saying that no patients should come to ICU for monitoring however there has to be a standard of care as to why.
The OP question was referring to why does ICU send nurses out to check out the patient prior to accepting patients in ICU and she felt it was because the ICU nurses were trying to avoid taking admissions. I was just attempting to give a reason as to why this is done and it is not done to avoid admissions to ICU and the floor nurses should not feel insulted by the fact that it is done however I do not believe any ICU nurse that says they have never received a patient that didnt really belong in ICU.
If it is a standard of the ICU to do this, then this should be well known as a hospital wide policy.
At my hospital, it is *not* a standard to do this. Our ICU and step-down are together in one unit, and we are a dinky little community hospital to boot. Stuff that is in our ICU would be tele floor or at most step down in a large hospital. It is very frustrating to have every single transfer challenged. Not in a "So, what's the history on this guy, what's going on with him now?" type of manner but a "Why does he need to come to us, can't you do that on the floor?" kind of manner.
It's the attitude that goes with the questions. The long sighs while I'm giving report, the assumptions that I haven't done everything possible to keep my pt stable and on the floor, the attitude that I haven't done a thorough assessment or that it is somehow through my inability to manage my time that I'm sending this pt over. I honestly assume that the ICU nurses know what they are doing; why can't they extend that same courtesy to me? It's very disappointing and disheartening.
I know it may seem trivial...but I think med-surg nurses do a great job in the vast majority...They do a job every day that I would not want, nor do I think I would do well. Try though to look at it from another perspective. As a charge RN and RRT, I have days that I spend more time on the floors helping with patients then I do in the unit. Not to mention that when I leave my floor to go on a RRT I am leaving 2 ICU patients that I am responsible for. Going to the floor because a patient will not stay in bed, the nurse does not know how to fill out DNR paper work, calling a doc to get ativan??
I mean of course we go out and help people that need it, and definately need ICU care. But just yesterday after spending hours on the floor, I get a call at 1815 for a pt with low BP. No problem, this can be a major issue and I know it!! I hustle up there, and this is a post op patient with a BP of 95/49...so slightly low. Gave fluid bolus...pt A/O the whole time. stating that her BP tends to run in the 90"s confirmed by family at bedside. Charge RN in room, comfortable with pt staying on floor. Pt's nurse never came in the room, would not give me any info on patient, I had to get it all from the PT. So I went back after pt stabilized and her charge cleared me. Well pt Rn went over my head and got admission orders from a doc...so I am forced to take this patient, who did not need to come to the ICU. Trippled up my night shift and took my last bed. Hopefully no real sick people came in last night....
Of course this does not happen all the time, and we do try to prevent it...and I am not at all saying that the OP pt did not need to come to the unit, I was not there so I really do not know the situation, but trust us I would say the majority of us that assess patients for ICU do not want to send away patients, we do however want to ensure that we have the correct patients on the unit.
After last night with a 1:1 patient "Iced" in the ICU for Hypothermia protocols and 9 drips, A line/CVP line , I wouldn't mind kicking back with a few observation patients....Just waaaiiiiting to see what goes wrong.
My sincere apologies to any M/S nurse I offended when I stated that M/S nurses do not have the skill or time to monitor this patient adequately. I was trying to make a point and realized it sounded offensive and that was why I stated "no offense intended". I should have taken the comment out or changed the term "skill" to "ability". I have the utmost respect for M/S nurses. I worked M/S for the first three years of my career, and quite frankly- I couldn't do it today.
However, I know that I would not want my mother left on the M/S floor in that situation, because of my experience in M/S. These patients are not monitored. There is nothing to call the nurse in the room, except maybe a frantic family member. When your time is divided between 8 or even 6 patients, you can not be there to monitor this type of patient adequately. In addition, I am shocked that several ICU nurses do not understand that a drop in SpO2 is often a very late sign of inadequate ventilation. The concern here is an elevated pCO2-which often goes undetected until the patient does become hypoxic or even anoxic in some cases. I have received patients transferred to me post-code in just those situations because of the reasons I stated above and not because the nurse was bad. M/S does not allow for frequent patient checks and the patient' s are not monitored or connected to an alarm to call the nurse in. Kudos to the nurse who caught this and was aware of the jeopardy the patient could be in. How unfortunate for her other patients that she had to neglect to appropriately moniter this patient that was left in M/S.
It sounds like this hospital doesn't have a rapid response program. Ideally, rapid response would see the patient, assess any medications received, administer narcan if appropriate, get an abg if not effective and then either have fixed the problem and safely left the patient there or transferred her to ICU. At the same time, even giving narcan with good results can still end up with the patient deteriorating again due to the short half-life of narcan and the longer acting narcotics. Even with a rapid response program, the patients outcome can depend on the efficiency and skill of the rapid response nurse. The ultimate goal of rapid response is to decrease patient mortality, not keep patients out of ICU (that is a secondary benefit).
I am a bit comforted in knowing this is not only an issue in my facility. I really do believe that rapid response teams assist the Med/Surg nurses in preventing detioration of patients and bad outcomes. It is important though for the Med/Surg nurses to feel supported in calling a rapid response from those responding. The best case scenario is the team responds, treatment or interventions occur and the patient stablizes. In our facility the recent focus has been on re-embursment. Simply stated if a patient doesn't meet certain criteria and should not have been admitted to the unit we do not get payment from insurance. The facility eats the loss. We aren't jokingly called the "Expensive Scare Unit" for nothing. :wink2: I think it is important also for the charge nurse to be competent in assisting the Docs in moving out the patients who do not belong in the unit. We must all work as a team for the most cost effective way of providing the required care. Sometimes Med/Surg nurses may find themselves in situations mid shift that require a redistribution of patient assignments. I know our floors assign nurses by room location, not acuity. As an ICU nurse this drives me buggy when I float. One nurse can become saddled with the highest acuity patients while another sails through her shift. In the ICU we often pass on a patient to another nurse when a higher acuity patient requiring 1:1 care comes in. When any patient arrives to the unit several staff members assist in the initial minutes with hooking up the patient, checking orders and helping out the admitting nurse. We all benefit from constantly reassessing the patient's needs and available staff as well as working together. Just my
This post should be about needing better staffing......not who should/shouldn't go in to the ICU.
Not to mention why there is a "shortage" of ICU beds.
There are several researchers that have noted that ICU populations mysteriously expand in areas where more beds are available, and contract in areas where there are fewer beds, all without major differences in mortality and morbidity.
One used populations in Massachusetts, comparing high tech Boston with lower tech Suburban areas, and they found that while a greater percentage of patients with equivalent diagnoses would end up in the ICU in Boston, that has a greater percentage of ICU beds. Yet the comparative morbidity/mortality rates were unchanged.
I have had surgeons send patients to the floor, that were extremely unstable and be very resistant to move them to the unit. They will ask us to see about a floor nurse to do a 1:1, or 1:2, "just this once". But is this fair to the other patients, ethically? They are paying a certain pay rate for their room that comes with a certain level of nursing care/amount of interventions. If we give "special care to one, are we not "cheating" the other, out of the value of their stay and giving it unfairly to another?
If I, as a floor nurse, am giving an excessive amount of monitoring/attention/interventions/care to a really unstable patient, I am generally cheating my other patients of care that they are entitled to. But not only that, my facility is being "robbed" of being paid for the full value of my services - because the floor bed stay costs the patient/insurance a lot less than an ICU bed stay. That could be argued as cheating the hospital for whom I am an employee.
We could also bring up, why in heck many patients are in the ICU to begin with. How many of those patients have no chance for a meaningful recovery? I have seen several cases recently where a family member was permitted to reverse a DNR order , made by the pt when they were fully competent, the family reversed the order and so the patient was shipped to the ICU WHILE THEY WERE ACTIVELY DYING.
By the same token, I have leukemia patients that are not facing imminent death, that required transfer (pulmonary leukostasis or tumor lysis and in need of CVVHD) to the ICU....and had to fight to get them an ICU bed, because "they have cancer and will probably die from it eventially".
Not to mention why there is a "shortage" of ICU beds.
There are several researchers that have noted that ICU populations mysteriously expand in areas where more beds are available, and contract in areas where there are fewer beds, all without major differences in mortality and morbidity.
One used populations in Massachusetts, comparing high tech Boston with lower tech Suburban areas, and they found that while a greater percentage of patients with equivalent diagnoses would end up in the ICU in Boston, that has a greater percentage of ICU beds. Yet the comparative morbidity/mortality rates were unchanged.
I have had surgeons send patients to the floor, that were extremely unstable and be very resistant to move them to the unit. They will ask us to see about a floor nurse to do a 1:1, or 1:2, "just this once". But is this fair to the other patients, ethically? They are paying a certain pay rate for their room that comes with a certain level of nursing care/amount of interventions. If we give "special care to one, are we not "cheating" the other, out of the value of their stay and giving it unfairly to another?
If I, as a floor nurse, am giving an excessive amount of monitoring/attention/interventions/care to a really unstable patient, I am generally cheating my other patients of care that they are entitled to. But not only that, my facility is being "robbed" of being paid for the full value of my services - because the floor bed stay costs the patient/insurance a lot less than an ICU bed stay. That could be argued as cheating the hospital for whom I am an employee.
We could also bring up, why in heck many patients are in the ICU to begin with. How many of those patients have no chance for a meaningful recovery? I have seen several cases recently where a family member was permitted to reverse a DNR order , made by the pt when they were fully competent, the family reversed the order and so the patient was shipped to the ICU WHILE THEY WERE ACTIVELY DYING.
By the same token, I have leukemia patients that are not facing imminent death, that required transfer (pulmonary leukostasis or tumor lysis and in need of CVVHD) to the ICU....and had to fight to get them an ICU bed, because "they have cancer and will probably die from it eventially".
There are a lot of issues with this.
I can remember nursing texts talking about the 80/20 rule. On any given shift, there's going to be a patient that takes up 80 % of your time, while the other patients take up 20 % of your time. There's no stewardship for your facility involved in that.......that's just the way it is. Are you going to tell a patient "sorry, you've reached your allotted time this shift.....I must now turn my attention to my other patients in the interest of good stewardship."
Specializes in NICU, PICU, PCVICU and peds oncology.
After last night with a 1:1 patient "Iced" in the ICU for Hypothermia protocols and 9 drips, A line/CVP line , I wouldn't mind kicking back with a few observation patients....Just waaaiiiiting to see what goes wrong.
That describes about 70% of our patients at any given time, although they'll probably also have an LA line, at least 1 chest tube (probably a sump needing irrigation every 15 minutes), an open sternum, 3 or 4 more drips and being paced.
That describes about 70% of our patients at any given time, although they'll probably also have an LA line, at least 1 chest tube (probably a sump needing irrigation every 15 minutes), an open sternum, 3 or 4 more drips and being paced.
Yes. :redbeathe So you get my point about having an easy patient come in once in a while...............(Not that it's an appropriate admission, but......hmmmmm......gee, maybe I need a day or two off LOL)
Specializes in NICU, PICU, PCVICU and peds oncology.
I sure do!! I get a little irked at the junior staff who get themselves all torqued up when they have an "easy" patient for a few shifts, when they should be thankful for the reprieve. Give ME that RSV baby in the isolation room with the two IV meds and the tube feeds. I can do that!
Kymmi
340 Posts
I said that not enough info was provided by the OP to determine whether this patient in particular should be in ICU. I am stating however that in general patients cannot just be sent to ICU to be "watched" unless there is reason to believe something major is going on with them....once again I give the example of the post op patient that MIGHT throw a PE, the chest pain patient with stable vitals and no elevation in trops that suddenly goes into V-tach, the elderly patient with a hx of chf that goes into flash pulmonary edema...each and every patient in the hospital has a potential to go bad.
What I am trying to say is that these patients need to be evaluated on the floor first by a ICU nurse or rapid response team to see if perhaps something else could be done to treat the patient without a ICU admission.
In the case of the OP tell me what we would do in ICU that couldnt be done on a monitored bed with continous pulse ox providing that ABG's are within normal, vitals stable and no s/s of distress.
As far as my statement regarding the MD's transferring to ICU in order to avoid phone calls I was not implying that I would give drugs or start meds without a order but ICU's do have alot more standing orders than the floor do and face it........tell me that you have never had a patient that is running a low B/P and low urine output and you give a NSS bolus to see if that improves before calling the MD at 3am.
I am not saying that no patients should come to ICU for monitoring however there has to be a standard of care as to why.
The OP question was referring to why does ICU send nurses out to check out the patient prior to accepting patients in ICU and she felt it was because the ICU nurses were trying to avoid taking admissions. I was just attempting to give a reason as to why this is done and it is not done to avoid admissions to ICU and the floor nurses should not feel insulted by the fact that it is done however I do not believe any ICU nurse that says they have never received a patient that didnt really belong in ICU.