No success in refusing admits inappropriate to the unit...

[NBMom1225]

I work midnights on a general Surgery/Med-Surg/Tele unit in a +400 bed suburban hospital. Our unit does not have any negative pressure rooms, though there are negative pressure rooms on other units in the hospital that also have telemetry.

Lately, we have been getting patients from the ED that should not be sent to our floor, such as rule-out TB and rule-out meningitis, both of which are airborne precaution situations. We have tried arguing against receiving these patient with the ED, who states "well, they're just ruling it out", and going over their heads to the Hospital Nursing Supervisor...only to be told we have to take the patient. Our hospital has portable HEPA filter units, but they typically aren't sent up to the floor for several hours AFTER the patient has arrived, not for lack of repeated phone calls to the appropriate supply department, and we still feel this is inadequate since the room is not negative pressure.

Inevitably, whatever physician is on consult for Infectious Disease will see the patient on day shift the next day and puts in an order for the patient to be transferred to another unit with a negative pressure room. We have even tried calling the ID physician as soon as the patient is admitted to try to have the patient rerouted before they even get to our floor, but the ID physician (if they even return our call) will usually just state that they have not yet evaluated the patient and will refuse to place any orders until they do.

Has anyone else had to deal with this type of situation? Our staff feels this is putting our other patients at risk and is unacceptable, not to mention preventable if the ED physicians would just put in an order for the patient to be admitted to a negative pressure room from the start.

We are taught in nursing school to advocate for our patients, we should be able to refuse admits that are so obviously inappropriate for our unit! Does anyone have any suggestions for dealing with this sort of problem?

[minnymi]

what about the ED doctors?

can they not make sure the pts are sent to the correct floor?

[RNHURT]

unfortunately I encountered same problem one day during my working days and we did have negative pressure TB room but it was busy with contact isolation pt in it. The problem was identified but still for 4-5 hrs TB latent I suppose was in same room with mask on him with other immunocompromised pt. I don't know how ED did not find out while going through history and this guy was constantly coughing with sputum etc.

We did put mask over us and pt till he got transferred to Neg pressure room but it was not right. May be different kind of orientation needs to be done for ER nurses for proper planning of rule out TB pt on arrival in ER. This is very common among ER to do this.

[Bec7074]

I thought meningitis was droplet though, therefore not requiring negative air-flow. I certainly would be uncomfortable with a r/o TB patient not in negative air-flow. I assume you still wear your fitted respirators, etc.

Here's a link to the CDC's website on isolation precautions. It also includes what to do if a negative air-flow is not available. CDC -Transmission-Based Precautions BICPP - HICPAC

It seems really awful and is uncomfortable, but I guess these patients come in through the ER with nothing and sit in the ER with nothing but a mask on. Maybe the docs think if they don't get TB that way, you won't get TB up on the floor. I am not a TB expert, but it still seems like a gamble, especially for other patients. Are the rooms at least private??? Otherwise I think you'd have a BIG case!

Have you discussed this with your manager? Filled out an incident report? Found out what the reasoning behind this is? Next time it happens, I would call the ER charge nurse and not protest and act upset, but find out what the reasoning is behind not admitting these patients to the negative air-flow. Do you have an Infection Control Nurse??? Certainly that person would be able to get you the help and answers you need. Finally, my hospital has an anonymous hotline for situations at your job that make you feel unsafe, uncomfortable, etc. I'd probably try that too, especially cuz it's anonymous. Keep us posted! I am interested in what you find out!

[ckh23, BSN, RN]

What does your manager say? Do you have an infection control nurse or department that you can contact?

I don't see how it would be the ED docs issue. Isn't there a doctor that writes admission orders? Usually the ER docs have their own orders for the ED and than the admission orders are turned over to the admitting doctor.

[NBMom1225]

As for why our ED physicians are not ordering the patient to be sent to a negative pressure room, I have no idea...I'm thinking ignorance of the types of rooms on the units are a part of it and that re-education of the entire ED staff is needed. They're also notorious for sending up patients with very unstable vitals, or at the very least incontinent patient that have obviously not had had their brief checked/changed in many, many hours (the +Cdiff ptwith stool head to toe comes to mind...the incident report on that one doesn't seem to have had any effect either).

We do have a couple of actual private rooms, and the remainder are considered semi-private, only there is an accordian-type "wall" between them (vs a flimsy curtain) that can be opened/closed if needed. While these semi-private rooms are sufficient for contact isolation, they definitely are not for airborne isolation...having come across a foley on a continuous bladder irrigation patient once-upon-a-time that was not clamped shut, I know for a fact that fluids will freely flow under the accordian wall and into the next room . So a rule-out TB patient should definitely not be put in there either.

There is no Infection Control staff available to the midnight shift, hence the reason nothing happens with transfers until day shift (more accurately, that's the excuse given by the midnight supervisor), and our concerns have been blown off by our unit manager...don't even get me started on the useless/ineffective management at this place. We did fill out an incident report online, but since it keeps happening that appears to be useless as well.

I really like the anonymous hotline suggestion, I do know that we have a Compliance hotline and I will definitely consider using it if (let's face it:"when") this type of issue arises in the future. Thanks for the suggestion!

[Been there,done that, ASN, RN]

Certainly, any patient with a rule out diagnosis, should be placed in the proper isolation.

Sadly, your institution is not following protocol ...and placing staff and patients at risk for contagion.

Notify OSHA.. it will remain confidential and things will happen.. as quickly as those government wheels can turn.

[KelRN215, BSN, RN]

Meningitis requires droplet (and contact) not airborne precautions so, as long as the patient is in a private room and staff are wearing appropriate PPE, no problems there. TB, measles and chicken pox all require airborne precautions and a negative pressure room.

Who decides where the patients are being admitted at your hospital? When I worked in the hospital, the ER had little to no say in where the patients were being admitted or what kind of room they were placed in- that was a nursing decision. If the patient needed an ICU bed, the ER would make that recommendation but, in a hospital with 4 ICUs, it was still up to the nursing supervisor where the patient ended up going. The nursing supervisor assigned the patient to whatever unit they needed to go to and then nursing decided what room they would go in. If the patient required airborne precautions, they had to go in a negative pressure room- no exceptions. If there wasn't one available, the patient went to a different unit or boarded in the ER all night.

[sauconyrunner]

ED docs don't admit patients. They call admitting MDs who write the orders. I'm infection prevention at my hospital, you need to call whomever is in that role, and get them to address it. That is really putting a ton of you at risk- if a patient Rules in- and was not really in a proper area, then you have to do an exposure tracing....and its a real pain in the rear.

[morte, LPN, LVN]

think this is another occassion for contacting the law firm that represents the hospital for risk management.

[sweet~revenge]

Write incident reports every time this happens. Make sure to include full names, times, every detail of what was said. Document, document, document!

As others have said, get infection control involved. Contact them through email if possible to have it in writing. Keep copies of everything. If a patient or employee turns up with TB after one of these incidents, you would do well to CYA in case of a lawsuit. Also if the hospital doesn't do anything about it, you'll need proof when you bring it to the attention of JCAHO and the state surveyors.

Good luck.

[sapphire18]

what about the ED doctors?

can they not make sure the pts are sent to the correct floor?

Where I work, the ED doctors recommend which floor/unit to have the pt admitted to, but ultimately that decision is up to the admitting physician.

ETA: Didn't realize that this point had already been made by previous posters. Also agree that meningitis is droplet precautions and doesn't require a negative pressure room. Whoever is in charge of assigning beds for admitting patients should refuse to assign a r/o TB to a non-negative pressure room. Send incident reports to risk management. This is a HUGE infection control issue!!!