Inappropriate ICU admissions

Fribblet · Apr 1, 2010

I'm an ER nurse in a trauma facility, and I see inappropriate ICU admits all the time. It drives me crazy as I'm sure it drives y'all crazy. I've heard the trauma docs say more than once "I'm just going to put you up in the ICU for observation and the nurses up there have less patients."

The ICU is not an observation unit! If they are not critical, the need to go to the floor. I agree with the above poster about the insult to floor nurses. I hear these same doctors in CT moan and complain about the floor nurses paging them for "stupid sh*t." "Why are they paging me for more pain meds?" etc. I've come close to saying "If you'd just write the order in the first place like we asked you to, you might not be disturbed during your nap."

As frustrating as it is for the ICU I'm sure, it's also frustrating for us in the ER. We frequently fill up our ICU in my hospital, and when a non-critical trauma pt takes up an ICU bed for "observation," we invariably end up holding a critical pt in the ER, which is not good for us or the patient.

Inappropriate ICU admits can clog up the ER and annihilate through-put. Just my two cents; thanks for letting me play. :)

sunnycalifRN · Apr 3, 2010

Inappropriate ICU admits can clog up the ER and annihilate through-put. Just my two cents; thanks for letting me play. :)

I've seen that happen in our ER, too. But, sometimes when we're full, the whole hospital is full . . . no beds anywhere, then a code rolls in to ER . . . . an amazing thing happens . . . voila, a bed opens up on med-surg and one of our transferrable patients is able to go to the floor so we can take the code . . . keep in mind, before the code . . . there wasn't a bed available anywhere!!!

I think that the bed control folks keep "secret" beds stashed away for emergencies because, when the code rolls in . . . the transfer bed appears . . . like magic!!

PrairieRN · Apr 7, 2010

Welcome to critical care nursing! The MDs at my hospital tend to admit to our ICUs so the won't be bothered by the floor nurses with problems ( we have intensivists and NPs that follow all of our patients)

sunnycalifRN · Apr 9, 2010

The thing I still don't understand is how the docs get away with it. Our basic ICU charge is $15-20K per day . . . I realize that is the "billed" rate and what is actually paid is less . . . but do the insurance companies not care that they're being billed $20,000 for severe constipation? (just an example of an inappropriate ICU admission)

IDoNotGiveOut · May 1, 2010

same where I work too! if floor nurses page a doc enough about any problem, chances are they'll get an ICU transfer order.

Lol so true. You can always tell that's the case when the patient is getting admitted for "respiratory distress" because their PaO2 is 60 on 2 L NC satting 95% (hmmm maybe you can turn it up to 4 L and treat that hemoglobin of 7.2? Yes this really happened) but you get report and surprise surprise the patient is agitated and stooling. Then looking at the charting you can see how much they've been paging the docs about minor "problems". They have their ways of getting rid of patients they don't want.

The ICU is not an observation unit!

Agreed! It's not observation and it is also not a rehab unit. I actually think it's terrible and huge disservice to the patient who just needs reconditioning to be in an ICU bed without a bathroom and with one PT and one PT assistant who only work M-F 7-3, getting Q1H vitals and I and O, Q2H blood sugars and head-toe assessments, tons of monitors and lines making it hard to move around and constant alarming. We are not a rehab unit!!! We're actually making the patient sicker by not letting him get any sleep or appropriate rehab. Then they end up with ICU psychosis which the doctors seem to think will be cured by keeping them even longer in the ICU!

sunnycalifRN · May 1, 2010

Lol so true. You can always tell that's the case when the patient is getting admitted for "respiratory distress" because their PaO2 is 60 on 2 L NC satting 95% (hmmm maybe you can turn it up to 4 L and treat that hemoglobin of 7.2? Yes this really happened) but you get report and surprise surprise the patient is agitated and stooling. Then looking at the charting you can see how much they've been paging the docs about minor "problems". They have their ways of getting rid of patients they don't want.

LOL! My favorite one is when we get a transfer from the another unit and the reason given is "the patient is too much work!!" No hypotension, no arrhythmia, no change in mental status, no respiratory distress . . . . no reason at all . . . just that the patient is too demanding and the ICU only has two patients per nurse!!! And, the triage doc approves the transfer!!!!! :uhoh3: :uhoh3: :uhoh3: :uhoh3: :uhoh3:

CrabbyPatty · May 2, 2010

LOL! My favorite one is when we get a transfer from the another unit and the reason given is "the patient is too much work!!" No hypotension, no arrhythmia, no change in mental status, no respiratory distress . . . . no reason at all . . . just that the patient is too demanding and the ICU only has two patients per nurse!!! And, the triage doc approves the transfer!!!!!:uhoh3::uhoh3:

Where is your manager in all this? That's absurd! How can you care for other patients in the ICU if you have to babysit someone's problem patient? Yes, I've had my share of patient's who are stable and should be transferred out of the unit, but the attending just wants to keep an eye one them for "one more day", but transferring patients INTO the ICU because they are "too much work" on the floor is ridiculous!

sunnycalifRN · May 3, 2010

Where is your manager in all this? That's absurd! How can you care for other patients in the ICU if you have to babysit someone's problem patient? Yes, I've had my share of patient's who are stable and should be transferred out of the unit, but the attending just wants to keep an eye one them for "one more day", but transferring patients INTO the ICU because they are "too much work" on the floor is ridiculous!

My sentiments exactly!! Our manager? Well, sitting on her *** in her office, of course. When we complain about these situations, we get "I hear your concerns and I will look into it . . . thank you for bringing it to my attention"

But, nothing happens. Somewhere I've read that feeling powerless leads to job dissatisfaction . . .

nitronymph · May 17, 2010

Our small 8 bed ICU has the same issues. We were recently schooled in the difference between a "DNR pt" and a "comfort measures only" pt. Our nurse pt ration is 3:1. The other week, there were 2 floor pts in the ICU so instead of having max of 3 nurses for 5 pts, there were only 2. One pt was on a vent and coding and another pt was in full blown DTs and trying to fight with the nurses. It was a total fiasco!!! One of the nurses turned in her notice....and they wonder about job satisfaction! Our docs are a piece of work...they put pts in ICU b/c we don't continually call on every little issue and according to them "they get better care back here." I resent them slighting the floor nurses b/c they can not help it if mgt staffs by numbers instead of acuity to save the almighty dollar! We are always excited to have a "qualified, real ICU pt"! I am, however, relieved to see that our unit is not the only one that has these issues.....some of our "non-ICU pts" stay there so long that they grow roots and sprout leaves and have to dug up from their bed and removed from ICU usually in protest to family and pt.

sunnycalifRN · May 18, 2010

Our small 8 bed ICU has the same issues. We were recently schooled in the difference between a "DNR pt" and a "comfort measures only" pt. Our nurse pt ration is 3:1. The other week, there were 2 floor pts in the ICU so instead of having max of 3 nurses for 5 pts, there were only 2. One pt was on a vent and coding and another pt was in full blown DTs and trying to fight with the nurses. It was a total fiasco!!! One of the nurses turned in her notice....and they wonder about job satisfaction! Our docs are a piece of work...they put pts in ICU b/c we don't continually call on every little issue and according to them "they get better care back here." I resent them slighting the floor nurses b/c they can not help it if mgt staffs by numbers instead of acuity to save the almighty dollar! We are always excited to have a "qualified, real ICU pt"! I am, however, relieved to see that our unit is not the only one that has these issues.....some of our "non-ICU pts" stay there so long that they grow roots and sprout leaves and have to dug up from their bed and removed from ICU usually in protest to family and pt.

Nitro,

that's hilarious!!! LMAO!! We've had many post-op patients who stay in ICU because the docs "like the care that they get" and they eventually discharge to home from the unit!!! I truly don't know how they can get away with it . . . some of these patients have only a heplock . . . no drips, no issues . . . they sit around reading the newspaper and complaining about the poor channel selection on the cable TV!!! It's so refreshing when we get real ICU patients!!

nitronymph · May 19, 2010

sunnycalifRN.....We also get post op hips and knees. The ortho used to be really bad to leave the pts back in the unit for 3 days! He is not as bad now but will not let them leave if there Hgb is 8! Apparently, he thinks floor nurses can't give blood! Just cracks me up! :lol2:

Penelope_Pitstop, BSN, RN · May 20, 2010

I know, guys, I'm out of my element here. I'd love to work in a SICU but until there is actually an opening in one anywhere near here (turnover is nonexistent!) I'm on the floor and I do like it. So, please, take what I have to say with a grain of salt!

I have received patients from the ICU and wondered why on Earth they were there to begin with. Most of the time, they're DKA patients whose chemistries are out of whack but are otherwise stable. No or low-flow oxygen, SR, maybe an insulin drip...which, guess what, we can have on the floor!

Maybe it's because we have no shortage of ICU beds at my hospital. At my old hospital, there were only ten beds in the ICU, and it was an everything ICU. My current hospital has CICU, CVICU, SICU/Neuro/Trauma ICU, MICU, NICU... each with loads of beds. So a patient had to be very very ill to be in the ICU at my old place (even though it's the same durned health care system).

Granted, I don't think I'm the biggest, baddest nurse around, but I know what an ICU patient is and what a floor patient is. I'm never afraid to call an RRT or to suggest transfer to a higher level of care to a doc. But come ON! I talked a hospitalist out of an ICU admission just because the patient required Q2 neuro checks. Good heavens, those take a few minutes, tops! And this patient was an otherwise stable walky-talky...she just had some weird neuro stuff going on that meant she had to be monitored closely. Maybe it's because I used to be a surgical nurse and was used to having 7 or 8 patients overnight who needed frequent post-op monitoring and now I have 5 medical patients so adding the extra assessments isn't a big deal to me.

There is another side to this, though...the patient who should have been in the ICU from the beginning. The vast majority of our RRTs are patients who come up from the ED looking like crap to begin with, and tend to crump overnight.

One time this patient arrived from the ED (I don't remember what her issue was, or why I was worried about caring for her), and I paged the admitting resident per order. When the residents arrived (goodness, they LOVE to travel in packs) I asked them to come in the room with me. Then I said, "don't YOU think we should have this patient on a stepdown floor? I don't think we can care for her here." Thank goodness they listened to me! She turned out to be extremely unstable and required closer monitoring than we could provide.

Another time a patient was admitted to the floor, sent from the nursing home because her AICD/pacer was messed up (I want to say failure to sense, but don't quote me). Well, yes, we do flex monitoring on our floor, but we don't have bedside monitors and our nurses aren't required to be ACLS (and we don't have to read our own strips). There are plenty of floors in my hospital that specialize in cardiac issues, have much better nurse to patient ratios, and bedside monitoring or at least a monitoring back on the floor and not a remote location. Well, two hours after arriving on the floor, she coded and died. I don't know if she could have been saved because of the comorbidities and all of that, but I think on a more acute floor, with more frequent monitoring...okay, I'm not going to play that game. But y'all get my drift.

Sorry that was so long. I just wanted to say, from the perspective of a lil' ol' floor nurse, I do feel your pain! Sadly, physicians don't understand nursing. Period. One time a doctor who didn't want to move his patient to a stepdown bed (she was a *******' HOT MESS and I spent just about the entire night in her room...forget my other patients!) said, "oh, this sounds like a nursing issue." Uhh, buy a clue, Marcus Welby, ACUITY IS A NURSING ISSUE!

Anytime y'all have an inappropriate admission, send 'em my way. They'll get their Q1 enemas or whatnot. Just be there to save me when my patient is circling the drain and I'm drowning with him!