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?

[DusktilDawn]

ZASHAGALKA: Right now, they can play ignorant ("The nurses never told us this wasn't acceptable.")

And that's exactly what they'll do. If there is not documentation about what occurred, they will claim ignorance.

These patients required ICU level care, if a nurse is not qualified on a GPU to provide ICU level care to patients that require it plus the other patients on that unit, she/he does have the right to refuse that assignment. That IS patient advocacy, you are advocating for a qualified person to take care of those patients in the appropriate setting. If you don't refuse, you accept responsibility and are held accountable.

[tridil2000, MSN, RN]

write up an incident report and list everyone who was aware of the situation. make a copy of it and keep it.

write the entire incident down and send it to the the vp of nursing.

then, call you state.

your situation was completely unacceptable.

never ever accept an assignment like this again. just say no. no. no. no.

[amnesia]

You worked very hard for your liscense, Right ? So, you need to protect it at all costs. I would definately refuse similiar assignments in the future.

[fergus51]

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?

Contact your BON about the specifics, but if you have not received a full report and accepted care of the patient you can refuse. My refusal would come about a milisecond after hearing "you're going to take an ICU patient because the doctors won't agree to transfer him" because you know right away that is unsafe if you're on a med-surg floor and will have other patients. 99% of the time nurse managers are just trying to intimidate you if they tell you it's patient abandonment. It isn't. It's patient advocacy and that's what we're supposed to do.

[maythen]

I had no idea how critical these pts were untill after report. The day shift RN was relatively flippant about their status. By the time I came racing out of my resp distress pts room day nurse was long gone. Because we don't have a step down unit, my hospital sometimes uses ICU like a step down. Since the resp distress was supposedly stable and oriented with a 50% venti mask (according to report) I didn't realize she really needed ICU level care. The other pt had been converted from SVT in ER (which normally would have bought him at least an over night in our ICU since he had no previouse known medical problems and no known cause for the SVT). I was not told in report that he was combative, mentally challenged, or blind.

I recieved report (inaccurate though it was) and assumed care. I've had a couple issues where I refused to accept care (the first when I was a brand new grad being preceptored) so I would have done it.

I know I should have filed a report. But, honestly, when I left work that morning I was worn to a frazzle. All I could think of was that I was going to get away from there and thankful that nobody died. It was my 4th shift after 3 REALLY nasty nights and very little sleep at home. I know, it's not an excuse, and that it wont help me or those pts. But I also knew that I didn't have anything left to give right then.

After hearing the rules for the day shift RN and the attempted lecture... well... it was either walk out the door, dissolve in a tear puddle, or leap on the day supervisors head like a rabid squirrel and start beating her senseless (too late). None of those would have helped me OR my patients.

I prioritized, everyone survived. But I just hate the feeling that No One got good care. And the sense that it didn't really matter how inapropriate it was for me... it's not like I'm day shift... all my pts are sleeping right? How hard could it have been?

It could have been worse. But it shouldn't have to be.

[fergus51]

You did the best you could and shouldn't feel bad about that. Now, the question is what will you do next? Will you follow up with your manager? Will you be able to brainstorm some ways to avoid this happening in the future together? Will you adress the inacurate report you received? Or will you simply thank your lucky stars no one died and cross your fingers hoping you don't get another assignment like that tomorrow? You and your patients were treated unfairly. That is not acceptable and the fact that you didn't adress it as soon as your shift ended doesn't mean you can't adress it tomorrow.

Maybe it means the day shift should have to walk into an ICU/stepdown worthy patient's room with you BEFORE you assume care. Maybe it means the nurses should have a bigger voice in when patients must be transfered (since no one knows when a nurse can provide safe care better than the nurse). Maybe it means your hospital needs to establish some iron clad rules about which patients can NOT be cared for on your floor (the SVT pt for instance). You're a bunch of smart people obviously (if you survived that assignment you'd have to be pretty sharp) so I'm sure you can come up with something.

[CritterLover, BSN, RN]

what about the er? in my hospital system (and every other hospital i have ever worked at), icu patients stay in the er when there are no icu beds. no, we don't like it, but we do it (i work er sometimes). the er docs don't like it, the attending docs don't like it, but we all deal with it. to send an icu pt to a floor bed is insane!

edited to add: this is true for direct admits, as well. no icu bed? they go through the er and wait there for one.

[Thunderwolf, MSN, RN]

What about the ER? In my hospital system (and every other hospital I have ever worked at), ICU patients stay in the ER when there are no ICU beds. No, we don't like it, but we do it (I work ER sometimes). The ER docs don't like it, the attending docs don't like it, but we all deal with it. To send an ICU pt to a floor bed is insane!

Edited to add: this is true for direct admits, as well. No ICU bed? they go through the ER and wait there for one.

This is what our hospital does...bunk in ER. Unfortunate, but...it is the closest thing to an ICU bed. As far as day shift goes and your coming on 3-11, how about a walk through report where you and the day shift nurse "walk the beat" together BEFORE he/she leaves. Just an idea....especially if you're getting dumped on, the report is minimal or downplays actuality, and the day person is long and gone. Again, just an idea. Wish you the best. Believe me...alot of us has been there some time or another in our career. You're in good company.

[MandyInMS]

maythen....I KNOW where you're comming from (((hugzzzzzz)))

After being in similar situations time, after time, after time, I finally had ENOUGH. It wasn't fair to me nor to my pts.When you realize care is compromised it's time to go. Resigned my position last month after management changes made things soooooo ridiculously dangerous with no hope of change in site. I've been a housewife for about 3 weeks now,and I actually feel kinda "human". No job is EVER worth compromising your health,sanity,and values......best wishes to you!

[canoehead, BSN, RN]

That assignment was dangerous for an ACLS, old, seasoned nurse. Not even one of those patients were safe for a newbie, alone. What did they think you were going to do with the SVT guy if you weren't experienced in reading moniters.

I can see landing with that assignment, and the sup realizing what they did and then moving people, getting sedation orders, throwing the vag bleed to OB, and generally making herself useful and supportive. But raging because of yur time management? Heck, I'm completely impressed with your time management, based on the fact that no one died! you should get a raise!

Crazy. You need the skills of a ten year veteran to survive this hospital; just the staff, let alone the patients. Do you really need this stress?

[mattsmom81]

Medsurg and stepdown/tele nurses are dealing with ICU type patients more and more because of bed issues.

Three years ago when I was charge on a tele/stepdown, we always had a few patients who 'should' be in ICU. My managers and the docs really liked the fact that I (an old ICU nurse) was in charge and could manage these situations; but it really got old after awhile. Along with the sheer numbers of patients (my nurses had 6 each already) to deal with, we also had to deal with ER admits who were 'really ICU but no beds, so put them on PCU.' You can imagine how my shifts went...continuously putting out fires and managing things that we should not have been expected to manage. In retrospect, I was too easy going in this issue and should have objected more strenuously.

PCU and medsurg are not set up like ICU's and it was very difficult for me to manage these situations, but my decades of experience got me through. Trouble is, once one has handled a flash pumonary edema on PCU with bipap and IV vasoactives emergently, or intubated a patient and managed him out there a shift, TPTB think we can do it all the time...and the expectation goes up for ALL stepdown and medsurg nurses, so we must think carefully how we react in these situations, and make sure our bosses know this should never be an expectation in a non ICU setting. If we accept it we risk it being the norm. JMHO.

To the OP: I agree with other posters that this is not a good environment. Take care.

[Daytonite, BSN, RN]

Medsurg and stepdown/tele nurses are dealing with ICU type patients more and more because of bed issues. Three years ago when I was charge on a tele/stepdown, we always had a few patients who 'should' be in ICU. My managers and the docs really liked the fact that I (an old ICU nurse) was in charge and could manage these situations; but it really got old after awhile.

Wonderful post and insight! Let me add that I was a stepdown nurse who got promoted into supervision. From the supervision perspective of this issue I can tell you that we supervisors worried about these kind of situations also. One of our job duties as supervisors was to start off each shift assessing the situations in the critical care areas (ICU, CCU, and ER). We always started working on contingency plans to make ICU beds available when ICU was full because the time to work those situations out is not when a critically ill patient is hanging around on stepdown or a medical unit waiting for his ICU bed. Because the supervisors are usually on the off shifts we also had to keep track of the bed situation. When ER told us they needed an ICU bed and we knew there were none we were on it. If the ICU nurses and stepdown nurses couldn't get any of the doctors to budge on transferring their patients to the appropriate units we called the doctor who was the ICU chief of staff. We would tell him the situation and often he would have more success in getting an uncooperative doctor to allow one of his patients to be transferred into or out of one of these units. Meanwhile, we'd also be looking for a spare nurse somewhere to send over to help the nurses who were drowning in providing the necessary care to those really critical patients. We had some real hair-raising situations.

Unfortunately, the staff nurses who are caught in these predicaments don't get to see the amount of work that the supervisors put into trying to help them, so some feel that they are forgotten and left to cope with the mess they are in. I guess I worked in a really nice place that cared about these things. Having been at that position I have to wonder that there is a breakdown in managment and communication in some of hospitals the posters have written about. The fact is that the doctors who are put in charge of medical staff know very well how dangerous it is to keep patients on an inappropriate unit of a hospital. They learn this when they are in their residencies. They know when they take a position as a chief of staff of any particular medical service that these are issues that they may have to deal with.