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?
We have the same problem in our ICU. We have actually started a book of these admissions. We write down the doctor, date, time and why it was a inappropriate admit. I don't know if anything will be done, but I do see residents and doctors glancing at it from time to time.
Our floors have gotten picky also. We have a PCU floor for heart paitents, but they can't handle chest pain and heparin drips! God forbid they have a little trouble breathing, instead of using nursing measures, they want them transfered to the unit right away.
What really makes us mad is when a patient comes to the ER, the attending is to lazy to see the paitent, so he tells the ER doc to put him in the unit till morning. Then the doc comes in to see the paitent in the am, and sends him to the floor!
Our hospital used to have a policy that let the charge nurse ask certain questions, and if they weren't right, then the paitent went to the floor. We no longer have that, so we get dumped on. I am surprised insurance companys haven't clamped down on that.
We have a PCU floor for heart paitents, but they can't handle chest pain and heparin drips! God forbid they have a little trouble breathing, instead of using nursing measures, they want them transfered to the unit right away.
Yes! We get so many emergent transfers because the pt is "HYPOXIC!" and then we put the pox probe on right, lift the HOB up and whatcha know, the SpO2 is remarkably fine again! So, after giving us our urgent report at bedside, can you take the pt back now?
I can certainly sympathize with having inappropriate ICU patients;just last night I had one who I was told was to stay in the ICU because she had been hypotensive (sbp 80) and might become hypotensive again. She was running systolic of 120's for me; not on any drips, cardiac diet,saline locked.
The wonderful nurses on our telemetry unit would have been more than capable of handling this. Meanwhile we were getting two vented patients at the same time transferred to us from other hospitals, one which was fairly stable and the other very sick; everyone was running all night.
One of the best things they ever did was start a Rapid Response team at our hospital. We encourage the nurses on the med-surg floors to call if they have any concerns about anything at all. One ICU trained nurse is not assigned any patients so she's free to go on these calls and a respiratory therapist goes along also. We have protocols that the nurse can use to order some labs,give boluses,and some medications (nitro etc) The doctor is always called but this way if needed the pt gets treated more quickly. Sometimes all that is needed is a liter bolus and they're fine.
We can't do much about it once patients are already sent to the ICU although we do interdisciplinary team rounds every morning and one of the questions always addressed is does this patient meet ICU criteria and what needs to be done in order for them to go to the floor.
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.
Haha. I think you and I may work at the same hospital. That sounds pretty familiar.
Sometimes these patients are really quite stable once they arrive to the ICU, but it was the forethought of the doctors that they were unstable or could become very unstable when they decided to admit them to the ICU. So often patients are transferred to the floor right when they're what we like to call "stable," only to have them aspirate, or code suddenly after going to the floor and they come right back. We shouldn't always be in such a hurry to get these patients out when they usually have very complex medical issues-making them a candidate for ICU. Often times, the floor nurses may not have the time to check on the patient as often to pick up on minute changes that foreshadow a bigger problem developing.
By the way, a patient on a Nexium gtt could be having an upper GI bleed that all of a sudden blows up in your face...say this patient has trouble getting a hold of the nurse. How immediate do you think that response is going to be on a floor versus a unit? I've seen this happen on a patient with uppr GI issues before while in our unit, and only waiting for a room to transfer out!
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!
Sorry, but I am :) on this one. Pacer spikes are quite evident and I can see where the inexperienced eye at first would think it was vtach, but.....if one analyzes the rhythm properly v paced rhythms are easily detectable. This is so funny that there were that many *****'s that couldn't make this out. The resident, the charge nurse on that floor and the tech should all have to go through a review of rhythms. I would also report this to risk management as.. what if the CCU nurses had believed what they were told, not what they knew, this could have been a bad situation.
Awhile ago we had a post-op surgical patient hanging out on our PCU floor. We take post-op hearts on day 2 frequently so dealing with new onset rapid afib is not new and barely makes some of us bat an eye. Anyways when the nurse is doing her midnight assessment notes a fast irregular rhythm. She shoots a 12-lead and lone behold, the patient is in afib. So she calls the surgical resident. He throws out a bunch of orders intended to stabilize the patient then comes to the bedside. There, in spite of the fact the patient's heart rate is in the 80's, still in fib, but stable and her pressures are quite stable, he decided to transfer the patient to the ICU. The nurse calmly explained that we can handle it, the charge nurse dd the dame, even the house supervisor said so, but he persevered and off to the unit she went. She came back 12 hours later.
When the don't need to go, they do, but when they do need to go and they haven't coded yet, they don't. Makes no sense to me!
When I asked the attending if a patient could move out of the unit he said no. I must have looked at him in disbelief because he quickly said, "Well, he's on TPN."
All hospitals that are Joint Comission accredited have to have specific "admission criteria" for specialty units. Just out of curiousity - do your organizations take any type of action when admits do not meet criteria? If so, what type of action is taken?
dorie43rn
142 Posts
We have the same problem in our ICU. We have actually started a book of these admissions. We write down the doctor, date, time and why it was a inappropriate admit. I don't know if anything will be done, but I do see residents and doctors glancing at it from time to time.
Our floors have gotten picky also. We have a PCU floor for heart paitents, but they can't handle chest pain and heparin drips! God forbid they have a little trouble breathing, instead of using nursing measures, they want them transfered to the unit right away.
What really makes us mad is when a patient comes to the ER, the attending is to lazy to see the paitent, so he tells the ER doc to put him in the unit till morning. Then the doc comes in to see the paitent in the am, and sends him to the floor!
Our hospital used to have a policy that let the charge nurse ask certain questions, and if they weren't right, then the paitent went to the floor. We no longer have that, so we get dumped on. I am surprised insurance companys haven't clamped down on that.