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ICU Nurse Fired For Refusing 3rd Patient

Nurses Article News   (13,546 Views 132 Replies 840 Words)
by Nurse Beth Nurse Beth, MSN (Advice Column) Writer Innovator Expert

Nurse Beth has 30 years experience as a MSN and specializes in Med Surg, Tele, ICU, Ortho.

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Nurse Julie Griffin was fired for standing up for what she thought was the right thing. You are reading page 4 of ICU Nurse Fired For Refusing 3rd Patient. If you want to start from the beginning Go to First Page.

klone has 13 years experience as a MSN, RN and specializes in Women's Health/OB Leadership.

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21 hours ago, Nurse Beth said:
Should Julie have gone with the status quo and quietly accepted a 3rd patient, knowing that at least 1 of her patients was lower acuity? Or did she do the right thing?

False dichotomy

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17 hours ago, NotANewRN said:

So 1 patient was a floor patient and the other was a post-op patient that was continent and could request to go the bathroom.  Neither of those patients are ICU patients.  She refused a 3rd? Why?  Her assignment is a floor patient with transfer orders, a step-down patient and a potentially true ICU patient. 

15 hours ago, NotANewRN said:

The Heart was ambulatory and her concern was that she was a fall risk.  That is a legit concern but that is not an ICU patient.  After fully reading everything, I am very convinced she was not caring for even 1 ICU patient and refused the patient that may have been a real ICU patient.

14 hours ago, NotANewRN said:

I did re-read. I read the whole case and all her responses.  To answer your questions: Transport would transfer the patient because he had floor orders therefore he is a floor patient being held in the ICU.  The Heart on a diuretic was a fall risk, ok.  What patient in a cardiac area is not on a diuretic? 

1. Simple: They must have a unit policy that says patients waiting for a step-down bed are not subject to the direct cardiac monitoring and other ICU-specific policies, and they must have a routine process in place for getting them on tele instead. Then they need to get them out of there within X (short, defined) time frame so that those down-graded patients don't end up being an after-thought tacked onto an assignment where literally everything else is a higher priority than they are.

2. The statements in the OP make it sound as if their policy is that everybody gets direct cardiac monitoring because ICU. This is directly why I went off on my original tangent about having it both ways: They hold this patient in an ICU bed and by policy continue to demand of the ICU RNs certain interventions such as direct cardiac monitoring that are only expected with ICU-level care, but also want to be able to turn around and say "but s/he isn't really an ICU patient, so you can take another one." So how does that look when the nurse doesn't directly monitor the patient?

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TriciaJ has 37 years experience as a RN and specializes in Psych, Corrections, Med-Surg, Ambulatory.

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2 hours ago, NotANewRN said:

It wasn't triple ICU patients. A floor patient with transfer orders.  He doesn't get continuous monitoring. 

I don't think the actual acuity of the patient matters that much.  The fact is, this is the ICU.  It's reasonable to expect ICU patients to be legit ICU patients.  If you allow them to add a third patient, even a walky-talky, it's still a third patient.  That sets a bad precedent.  It's going to morph into "normal" for ICU nurses to take 3 patients, even when they're legit ICU patients.  And 3:1 is not a legit ICU ratio.

The line has to be drawn somewhere.  Don't make this about Julie not wanting the extra work.  Someone has to stand up for patient safety when the straws keep getting added to the camel's back.

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juan de la cruz has 27 years experience as a MSN, RN, NP and specializes in APRN, Adult Critical Care.

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24 minutes ago, JKL33 said:

The statements in the OP make it sound as if their policy is that everybody gets direct cardiac monitoring because ICU. This is directly why I went off on my original tangent about having it both ways: They hold this patient in an ICU bed and by policy continue to demand of the ICU RNs certain interventions such as direct cardiac monitoring that are only expected with ICU-level care, but also want to be able to turn around and say "but s/he isn't really an ICU patient, so you can take another one." So how does that look when the nurse doesn't directly monitor the patient?

I don't work for HCA (thank God!) but any patient with telemetry orders are monitored directly ICU or not. The difference is in the ICU, the assigned nurse is tasked with looking at their patient's monitor and in the event they can't do that, they ask a fellow nurse or the charge nurse to momentarily watch their patients for them while their eyes (or attention) are directed at something else. In the step down and tele units, there are staff (nurses in many cases) who sit in front of the monitors in various shifts 24/7.

I think the situation that the nurse was faced with is that she could only split her monitor to 2 patients at a time (as is usually the case) and could not watch the monitor for the third patient. Another poster said that what they usually do in these cases was to hook the non-ICU patient (one with transfer order) to the floor telemetry system so that they can be watched remotely that way. I don't know if this was explored at that hospital.

Having said that, I work in California where we have mandated ICU staffing ratios which are either 2:1, 1:1, or 1:2 no exceptions...an ICU nurse can have 2 "stable" patients waiting for a floor bed.

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MSO4foru has 10 years experience as a ADN and specializes in Hospice Home Care and Inpatient.

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Being in healthcare for as long I have whatever observation level a patient is physically on and what the real needs are are a matter of semantics.  Perhaps I am over simplifying,  but  any pt who is in ICU is there for a reason. Is this not why there are doctors who justify this level of care? Dosen't a doc have to give an order to transfer to lower level of care?

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6 hours ago, juan de la cruz said:

Another poster said that what they usually do in these cases was to hook the non-ICU patient (one with transfer order) to the floor telemetry system so that they can be watched remotely that way. I don't know if this was explored at that hospital.

I understand...the point I am making is that part of her concern beyond patient safety itself appears to be the things they were expected to do and document vs. the feasibility of actually doing those things. It sounds as though throwing someone on tele would not have been in line with her idea of the care she was expected, by policy, to provide and document.

Edited by JKL33

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12 hours ago, juan de la cruz said:

Fair enough, but that didn't stop that hospital from finding her replacement. Did that change anything?

It changed something! It changed a nurse from accepting the status quo and deciding she wasn’t going to just conform anymore. Then... her courage inspired another nurse to do the same and then her courage will inspire another nurse to do the same... and then....... we aren’t just a profession that takes it.. we begin to become a profession that is doing something about it. 

 

Again

i applaud her courage! 

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6 hours ago, MSO4foru said:

Being in healthcare for as long I have whatever observation level a patient is physically on and what the real needs are are a matter of semantics.  Perhaps I am over simplifying,  but  any pt who is in ICU is there for a reason. Is this not why there are doctors who justify this level of care? Dosen't a doc have to give an order to transfer to lower level of care?

Yes ma’am and amen! 

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12 hours ago, TriciaJ said:

I don't think the actual acuity of the patient matters that much.  The fact is, this is the ICU.  It's reasonable to expect ICU patients to be legit ICU patients.  If you allow them to add a third patient, even a walky-talky, it's still a third patient.  That sets a bad precedent.  It's going to morph into "normal" for ICU nurses to take 3 patients, even when they're legit ICU patients.  And 3:1 is not a legit ICU ratio.

The line has to be drawn somewhere.  Don't make this about Julie not wanting the extra work.  Someone has to stand up for patient safety when the straws keep getting added to the camel's back.

You are absolutely correct.

Also, the downgrade patient DID require monitoring. It’s a CVICU and the court documents line out how the down grades DID require monitoring. They had orders to be monitored and the hospital didn’t have the capability and didn’t provide a means to do so. 

Also, the court documents show HCA billed CMS at an ICU level of care 1:2 when the nurses had 3.  Assignment sheets were provided to the judge showing this.

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Nurses are forgetting the basic premise... it is doing the right thing.  Ethical thing.  Just because we don’t HAVE TO work at a crappy hospital does not mean we won’t or our loved ones won’t wind up in an unsafe hospital.  Hospitals receive emergencies.  A patient cannot choose where to have an emergency 

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juan de la cruz has 27 years experience as a MSN, RN, NP and specializes in APRN, Adult Critical Care.

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6 hours ago, JKL33 said:

I understand...the point I am making is that part of her concern beyond patient safety itself appears to be the things they were expected to do and document vs. the feasibility of actually doing those things. It sounds as though throwing someone on tele would not have been in line with her idea of the care she was expected, by policy, to provide and document.

I respect your opinion here and in other posts. I see your point. But I also feel that a lot of what is going on is conjecture. As a provider, when I write continuous cardiac monitoring on a patient, it doesn't matter what the location of the patient is -- it's just a billable order that the hospital can charge the patient for. That's why as a provider, you have to justify the order with an indication (i.e., risk for arrhythmia, electrolyte imbalance, etc.).

That order applies to ICU or tele and doesn't matter whether an ICU nurse does it or not. Of course, I don't know that HCA policy is. But could it be that the nurse was misinterpreting the order as she must be the only one watching the monitor? There were cases in the same ICU where 2 people died because they were "not being monitored" but then the circumstances weren't clearly stated - hard to make a judgement on those. Sorry, I'm too pragmatic.

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