Inappropriate ICU transfers

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Specializes in ICU.

I have been so frustrated lately with transfers into the ICU that are totally unnecessary. One case was a sweet lady who had low urine output (20-30/hr) a day after surgery. They transferred her to the ICU, put in a central line to monitor CVP and consulted renal. I gave her a 500 ml NS bolus and within an hour her output had picked up (it wasn't all that horrible to begin with.) The poor lady went through an invasive procedure and was frightened out of her mind for no good reason, not to mention the huge bill she is going to get from the hospital and the renal guy (who did nothing, but still charged her).

The other day I got an admission from the floor whose sats were in the 80s on room air. His hands were cold and with the monitor on his ear, he was 100%. He ended up in the unit for 2 days because it was the weekend and no one got around to moving him out. It was ridiculous.

There have been plenty others, though those were the worst examples. We have a very busy unit and are always having to move patients out suddenly and quickly in order to open a bed for traumas or neuro patient or codes from the floor. So why are they stuffing us full with patients who are totally fine?

Is this a problem on your units? If not, what are you doing to make it that way?

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Specializes in ICU/ER.

I can totally relate, we get patients all the time that could easily be placed in Med Surg. Then we get pts who may really need ICU but once we get them stable they could go to MS, but they stay....We have had ICU patients who were not on tele and saline locked. Just taking oral meds.

We dismiss at least if not more than 1/4 of our ICU patients to home. One would think if your sick enough to be in an ICU you would then go out to a MS floor before being dismissed, but not here.

Sometimes we get the MS pts because MS is full and we have an open bed, then we do actually do med surg charting on them and they do not get charged for an ICU stay.

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Specializes in Cardiac.

I'm so sick of the endless debate on what can and can't go on the floor...

Because we try to get our pts to the floor, and inevitably the Dr will say, "oh, they can't go to the floor because this excuse or that excuse."

Like.......

They were tachycardic yesterday.

They H/H was low yesterday.

She has the potential to become sick tomorrow.

This pt has a dobhoff tube.

This pt may become septic sometime within the next week.

The pt had surgery (DAYS AGO!!!!!)

This pt is on a drip!!! (NEXIUM!!!)

And so on and so on....

What I usually say is this in return...

"Would you believe it? Those are real nurses up there and they can handle pts with dobhoffs, nexium gtts, sick people, etc, etc"

Isnt' it amazing how quickly they get a bed on the floor for the non-ICU pts once a code happens though?

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Specializes in SICU/CVICU.

That sucks, I guess I'm pretty lucky. 99% of our patients are POD 0 or 1 cabg/valve, sick sick AAA's (they normally hang out in PACU overnight), sick sepsis or resp failure post surgery. The patients that didn't just have surgery that are in our unit are on deaths doorstep. We have a stepdown unit for the ones you're talking about.

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Specializes in CTICU.

My hospital in Australia had this issue. We instituted "ICU Liaison nurses" who would go to the floor for people the nurses there were worried about, and assist with airway management, things like the sat probe issue you mentioned, etc. Along with an early medical intervention team for people who were "pre code" so to speak, we drastically cut down our "babysitting" patients in ICU.

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Specializes in ER/Critical Care.

We have the same issue! We get inappropriate transfers in (although our intensivist team is pretty good about filtering those, but they don't touch anything cardiac that comes through), can't get patients out when appropriate (one of our heart surgeons actually REFUSES to transfer his patients out of our unit), and we discharge from our unit every day. (Usually at least 2-3 people go HOME from our unit M-F.)

Right now we have a man that has been on our unit for 7 weeks from a AAA repair. Granted he was sick at first, but now he is completely stable (on vent at night) and the only reason he is still in our unit is because his psychotic wife didn't like the Kindred facility in our town, so she refuses to let him leave and the Doc is not willing to stand up to her. It's absolutely ridiculous.

I agree that it is completely frustrating, but besides us questioning the doctors on transfer status frequently I don't really know how to fix this. It really is a system wide problem in our hospital.

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Specializes in ICU, PACU, Cath Lab.

We have it all the stinkin time...I had a young guy come down becuase he was tachy...well he had been on con't nebs for 4 hours..gee I wonder why he is tachy..the RT told the floor doc that if we switched him to Q4 hour..he would drop (did not need the con't) they did not believe her...shipped him to me, called the intensivist and told him that he needed to come and intubate this guy...it was 2 in the morning. So next thing I see is a vent coming into my room...I am like what the heck?? RT said that doc called and told her to set up for an intubation..the guy was 96% on 2L...needless to say when our doc got their he was ubber mad...called upstairs and ripped them a new one!! Shipped him right back. Or the LOL DNR who is sent down to do Bipap which she refuses...or the Knee replacement...I just want to watch her..well they can watch her upstairs..that is what they do!!

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Specializes in ICU/ER.

The Icu I work at has the same problem. We keep patients way to long. Sometimes we even have bariatric patients transfered to ICU because they take to much time and back muscles for the floor nurses, what a waste of bed and education. I have never worked an ICU that is such a step child. The housesupervisors will not let us move one out to the floor when they have orders to move until med/surg is ready or until it is an emergency and we have to so we can receive another. I get so tired of being taken advantage of and playing all of the games people play.

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Specializes in NICU, PICU, PCVICU and peds oncology.

I'm so glad to know that our unit isn't the only one that gets these kinds of admissions. We get a fair number of drunk teenagers who were intubated in the field for airway protection, then ER turfs 'em to us so that we can extubate a couple of hours later... And deal with the ornery twerp when s/he wakes up. Post-op anything that's sitting up talking should NOT come to PICU unless they're on pressors. And like others have said, once they're on the unit, they aren't going anywhere for days. I call our unit the Hotel California... You can check in any time you like but you can never leave.

Another thing that really cheeses me off is that our docs can't let go! We get kids from other provinces all the time for cardiac care. Once their hearts are recovered, if they still need ICU, they could go back to their home province, but our docs can't believe that any other PICU would give the same level of care we do. We have some kids sitting on our unit for MONTHS, because they're ventilator dependent from post-critical polymyopathy or because they need dialysis or whatever... things that could be provided in their own city's or province's PICUs. It's frustrating. We've had one kid, an infant, from BC for seven months. Sick heart, pooched kidneys and we transplanted him (heart) the other night. Now he'll sit on our unit until he's big enough for a kidney. Oh yippee.

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I think this is a problem in every hospital. I can recall this one patient on a Telemetry floor that had a permanent pacemaker. Every time his intrinsic rate would slow he would Ventricularly pace. The pacer spike was small, but it was clearly there. The Tele Tech was calling the V-paced rhythm V-tach. Well, the charge nurse on the floor agreed, and they called the resident on call. The resident came to review the strip and agreed, so the patient was woken up at 3:30 in the morning and rushed to the CCU for runs of V-tach. The only people that were able to correctly identify the rhythm were the CCU nurses. In the meantime the poor patient's family had been notified that the patient was being transferred to critical care, and they were on their way in. When the family arrived the nurses did their best to try and calm the family and explain the situation without making the physician and others look totally incompetent. How embarrasing!

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Specializes in ICU.
SWEnfermera said:
In the meantime the poor patient's family had been notified that the patient was being transferred to critical care, and they were on their way in. When the family arrived the nurses did their best to try and calm the family and explain the situation without making the physician and others look totally incompetent. How embarrasing!

I had a transfer in once who had been fine, gone for a test (don't remember what) that required conscious sedation, and had then gone unresponsive. They gave her Narcan, Romazicon, called a rapid response, called the family. In report before she came up they told me that they thought she was having seizures because her eyes were going crazy and in opposite directions. I looked at her eyes when she came up and if you checked them one at a time, they were rolling all over the place, but when you looked at them together, she would immediately go cross-eyed. Took us about 2 minutes to get her completely awake and fully functioning again (it's hard to fake with ICU nurses--we use noxious stimuli). She was an amazing actress, hadn't even flinched when they put in two new IVs. But she requested that nice "M" who had put in her IVs when she was unconscious to come and see her so she could say thank you because he had done it so fast. Mmm-hmm.

Anyway, for the next three hours I was getting frantic calls from families who said they had been told her life was in imminent danger and that she had had a stroke and they were on the plane. All I could say was, "Do you want to talk to her?" You would think they would be grateful that she was okay after all, but instead I would get a cuss-filled reaming about how I had scared them and was costing them all this money for the flights they had jumped on. Anyway, what you said about the families getting called reminded me. Not that this was really inappropriate because I would have done the same thing, but having to explain things to the family without saying, "well, she was playing possum" was kind of difficult.

I guess it is nice to know that mine isn't the only hospital, but it is also frustrating that this goes on so much. I mean, I don't mind having a nice med/surg patient every once in a while to slow things down (;)), but I've had friends end up in the ICU and it is crazy expensive and totally unfair to the patient to have to be charged for all this stuff they completely didn't need. I like the idea of an ICU liaison. They could even call the unit and ask for a nurse to come down if they wanted. They do it all the time for IVs. We have intensivists, but they don't see the patient unless they are specifically consulted once they are in the unit so they don't really act as gatekeepers. Do the hospitals make more money if the units are packed full?

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Specializes in Critical Care.

At my hospital, we often question what is med surg capable of taking care of because they seek to transfer everything to ICU-- calling rapid responses if necessary.

Yesterday they called a rapid response for a blood sugar of 64. Patient was asymptomatic. We told them to give the patient some juice and some crackers and recheck in an hour.

After we left, they apparently called the doc and got IMU transfer orders because the doc ordered Q2h glucose checks. What? Really?

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