ICU pts on the floor

[maythen]

I'm a relatively new nurse (a little over 1.5 years) working at a small rural hospital in Northern California. I work med surg night shift. We have no ward clerk, 1 aid (approx 40 pts) and one respiratory therapist for the entire hospital (ER, OB, ICU, Peds, and med/surg). Our average pt load is 5 (which I know is ridiculously low for most states, but it's the legal max in CA) and I've never personally had to take care of more than 7.

I recieved report that I had 2 pts that were supposed to go to ICU but we didn't have any ICU beds so they sent them to the floor. One is respiratory distress, the other is a recently converted from SVT blind elderly mentally challenged combative male. I'm also getting an Enemas 'till clear psych pt and an icu transfer (right at shift change) CHF COPD mildly confused female.

All are full codes.

I check my resp distress and she's on a 50% venti mask and satting in low 70's. I call RT STAT, get her on 100% NRB and now she's really struggling, satting in low 80's and attempting to rip off o2. Notified supervisor and MD. MD tells me that he knows she needs to be in ICU and vented, but we don't have any ICU beds and to call him when she codes.

I'll spare the blow by blow details. But here's a basic: resp distress eventually ends up sedated and on 100% o2 BiPap (way out of parameters for floor) with sats that unexpectedly plumet into low 70"s but never get higher than 88% (also has to be transferred to different room because the hall I'm in is dependent upon portable O2 takns due to remodeling). My SVT starts having chest pains, rips out his IV, and keeps spitting Nitro pills while attempting to beat staff to a bloody pulp. My 350+ lb psych pt alternates between screaming her head off and rolling on bed snoring and laughing, my ICU transfer gets even MORE confused and, frightened by BiPap alarming and psych pt, attempts to make a run for it. I recieve an ER pt (no report by the way) vag bleed that needs blood and is weeping hysterically. ER also attempts to send me a confused parapelegic enemas till clear. EVERYONE is incontinent.

Two of these pts were KNOWINGLY placed on floor despite that their conditions required ICU levels of monitoring and care. There are two large hospitals (one owned by the same company that owns my hospital) less than an hours drive away. Neither were on diversion, both had staff and facilities to handle these guys.

I gave report to a day shift RN that is ACLS certified, has over 10 years experience on me, and frequently floats to ICU. She recieved only 2 pts, was PROMISED that she would recieve no others unless they were transferred, and she would be paid as though she was in ICU as that was the level of care they required (this was after I finally got them both stable).

I however, recieved a brief lecture on the importance of better organizing my time because I had not clocked out for a lunch break.

I know, it could have been worse. There could have been 12 pts not just 5. But why is it ok to place ICU pts on the floor? Why was it ok to give ME those pts but not the more experienced day shift nurse?

I've never been so terrified since I started working. The MD and charge nurse knew how unstable these pts were and admitted them to the floor anyway. Charge knew I'm relatively new and gave me this load anyway. I keep telling myself it could have been worse. But it just makes me so angry and frightened feeling that "it could have been worse" is the best I can do. I'm supposed to be taking care of these people, not just madly dashing about attempting to keep their heads above water while I drown.

Is this a normal practice to put ICU pts on the floor? Am I totally out of line for being upset?

[Katnip, RN]

Does your hospital have no way to send out critical patients that your hospital can't handle? Why not?

Are you the only nurse in the entire hospital all night? No matter what the patient load is, that seems very wrong.

[DusktilDawn]

You have every right to be upset. Those patients needed to be monitored in an ICU setting. I wonder if the Charge didn't take advantage of you because your new, since you got both patients that should have been sent to ICU. Who had the gall to lecture you about better organization because you didn't clock out for lunch, the Charge? I'm willing to bet you didn't clock out to lunch because you probably didn't get one.

First, you would have been well within your rights as a nurse and a patient advocate to refuse this assignment. It was unsafe for the patients and yourself. When you "accept" care of a patient, you assume responsiblity and accountability.

Second, write up the incident and report it to your UM, if she was the one who lectured you, go to her immediate superior. Also include the fact that ER sent a patient up without report. Also include the fact that the EXPERIENCED ACLS nurse only received the 2 patients and was not to be assigned any others until those patients were transfered.

Third, reconsider whether you want to work for an institution that would place patients in this kind of danger without regard for their well-being or your license, and then have the nerve to lecture you about better organizational skills.

It make me angry Maythen that anyone is subjected to this. :angryfire

[maythen]

cyberkat asked :

Does your hospital have no way to send out critical patients that your hospital can't handle? Why not?

We have transport available. Our sister hospital has a helicopter (which has been used several times this week alone). We also have ambulances available. My hospital routinely ships pts to one of the larger hospitals a short drive away for increased care or procedures that our facility doesn't have the equipment for. These MDs Chose not to send these ICU pts. Transport was available but we are not allowed to transfer without MD orders. Both the ER doc and attending MD flatly refused.

I'm not the only nurse, EVER. We always have at least 2 RNs in our ICU (depending upon how many pts in there), several in ER, and never less than 3 on the floor. Last night there were 5 other nurses besides me (4 RNs one LVN) and one new grad RN being precepted. At least one other nurse (my hall mate) got an ICU pt as well, though she had 4 pts and got her ICU person about 3 hours before shift change. My hall mate is the only reason I'm sitting here typing instead of lying in a puddle of tears. She's been nursing since the 1950's and she saved my hiney last night helping me as much as her own pt load allowed. I'm not sure I or my pts would have survived the night withou her. At the very least I would have probably cracked under the pressure and said something unprofessional to my supervisor, the MD, or the psych pt.

I got the lecture from oncoming day shift charge nurse (my supervisor who was giving report told her to shut up and approved my over time). I'm not sure what the heck was going on last night. My hall mates pt would normally have gone our ICU not because she was as unstable as mine, but because the pt was more step down appropriate ut we don't have a step down unit.

I love my co workers and, for the most part, my hospital. Being employed elsewhere is also an "it could be worse" because both the larger facilities have worse working conditions and more unsafe staffing. I can't move out of the area because husband is finishing his masters program and we Desperatly need health coverage with no lag due to his medication costs.

I'm just scared that this is a new trend I'm seeing.

[Daytonite, BSN, RN]

These, unfortunately, are the joys of working in rural facilities. I worked in the only acute hospital on a mountain here in southern California and had similar experiences. We always seemed to have a couple of patients who really needed ICU care, but there were never any available beds in the ICU. All you can do is prioritize and ask for help and advice from the supervisor. Quite honestly, enemas until clear are on the low end of my list, especially if the patient is uncooperative and I've got one or two others in the wings hanging on by a thread. I'd give it a couple of tries and then call it quits and let the doctor deal with it. I'm glad to hear that your supervisor defended you to the oncoming charge nurse.

FYI. . .that particular hospital ended up having a nursing strike and the nurses got unionized because the administration consistently refused to listen to and empathize with the kinds of situations the nurses were having to endure shift after shift.

[fergus51]

If this ever happens again you need to refuse to accept the assignment. Period. "I would take these patients, but that would put my lisence at risk because I can not provide them with safe care". Repeat it in the mirror at home to get comfortable saying it if you have to. Day shift will need to stay over to help or the docs will have to transfer the patient or hold them in ER. If you do wind up with an assignment like this and the doc does not want to transfer despite being informed that you can not provide them with safe care, ask if they mind you writing that in the chart to cover your butt? If not, THEY can stay at the bedside and try to help these patients.

[NannaNurse]

After that last remark.........I would also be looking for another job. At that rate, your going to be totally stressed, a nervous wreck and age at a dramatic rate..........it's not worth it :angryfire

We get treated this way because we allow it. If we all got together and made a stand AND STOOD FIRM, we would be heard the next time we said something.

[sharann, BSN, RN]

In California ratios in the ICU are 1:2. If you have 2 pts who are ICU boarders, you should never take another. This is a state law. Even if you are in MAternity, you still need to stay with those ratios. You must work at my hospital, sounds so much like it. You can't win unless you all stand up for eachother and yourselves. What a rotten thing to happen to you though.

[ZASHAGALKA, RN]

If they're on the floor, by all means, pick them up and put them in a bed. . .

Every hospital I've worked in has rules prohibiting overflows to 'lower standards of care' you can only overflow upwards. I work in CCU and get lots of tele overflows, but CCU pts cannot be overflowed to tele.

It's a huge liability issue. If you don't have critical care services available, those pts must be shipped.

At a minimum, I'd complain in writing at the start of each shift I was required to take a pt beyond the capability of that unit. (send an internal email to your unit manager and the administrative supervisor on duty and print it off and keep a copy).

On the stand, you are going to be asked, "What would a prudent nurse have done in your place?" At a minimum, I'd be able to answer "Well, tell TPTB that this isn't acceptable."

Besides, when you shift the burden to management, they have risk managers telling them not to be so stupid. Right now, they can play ignorant ("The nurses never told us this wasn't acceptable.")

~faith,

Timothy.

[Burnt Out, ASN, RN]

If this ever happens again you need to refuse to accept the assignment. Period.

But would this not be abandonment if you have received report on part or all of your patients? I know if you have been off from work for a few days and have no clue to what kind of patients you are assigned to and you start getting report, where is that fine line between being a prudent nurse and patient advocate and/or risking your license for patient abandonment?

[caroladybelle, BSN, RN]

Refuse to take the patient.

And has anyone say....talked to JCAHO about this???

As well as the fact that it still violated the set ratios.

As an aside, in many hospitals, PACU sometimes gets pulled in on this cases, or an ICU nurse gets sent to the floor. Why were these not done?

[Thunderwolf, MSN, RN]

Excellent feedback everyone. You all echo my thoughts and feelings on this.

Wolfie