Non-critical pts in ICU

[st4304]

I was working ICU yesterday (I floated from the cath lab). In a 16-bed unit, we had 12 pts (8 on vents) and 6 RNs, no care partner or USP. I did not get to the unit until 0930 so the charge RN did not assign me any patients; I was the "helper." The patients were all pretty critical, with 3 very unstable, so I was kept hoppin' running for supplies, suctioning, giving meds, checking beeping pumps, etc.

Around 1100, the charge RN asked if I would admit a transfer from the cardiac floor. No problem; I was glad to help. So what's the problem? This is the report I received from the transferring nurse: The patient was an elderly lady who was admitted that morning at 0600 because her hemoglobin was low and her doc wanted her to have 2 units of PRBCs and watched as an observation patient overnight. The reason she was being transferred to the ICU was because the RN giving me report stated she had 3 other patients and had not even seen this lady yet and the doc told her to transfer the woman to ICU because he knew she would get her blood there in a timely manner. I asked, "You mean this woman is being transferred to ICU because you have 3 other patients and do not have time to take care of her?" Her response was whiney and pitiful. I told her I could come over there and help her with the patient because they were pretty busy over here in ICU, but she said the doc had already written transfer orders and she was bringing her over in the next few minutes.

Upon arrival, the patient did not have an IV yet, had not been T&C'd, nor was any of her admission history started. Within a few minutes, I had an IV in her, the lab was called re the T&C, plus I got her something to eat (since she had not eaten since the night before.) She told me she arrived on the floor at 6am, was put in a bed and did not see anyone until her MD showed up at 1030. She was from a ECF and none of her family had arrived yet.

As I was leaving her room, I happened to run into the Med Director of ICU. I explained to him what had happened. He replied that I should tell the cardiac floor's nurse manager and let her take care of this. My response was that I was no one to this manager and it would have more effect if HE called and complained to the nurse manager. He then proceeded to tell me that this was a nursing issue and to leave him out of it. My response to that was that a nurse cannot transfer a patient to the ICU, only a MD can do that so that makes it an MD issue too. I told him I did not think it was right for an MD to send a non-critical patient to the ICU just because that doc felt his patient would receive better treatment there than on the floors. About that time the ICU's nurse mgr got involved and I returned to my patient. I do not know the outcome of this.

I do not know what the night nurse's excuse for not seeing this patient was, but I did find out that the transferring RN went into her taped report at 0730 and came out at 0830 (an entire hour for report on 4 patients? -- puh-leeze! Honestly - when was the last time you had only 4 patients!) then spent the next 30 min looking at her Kardexes and MAR, so it was 0900 before she started assessing her patients. This is a nurse that is always unorganized. Whenever I work with her, it seems to me she stands around complaining about all the work she has to do instead of doing it! The floor she works on has a really good group of experienced nurses and I guess they were tired of picking up her slack yesterday morning. I really don't want to turn this into an issue about this one nurse (isn't there one of these on just about every unit?)

I guess what I want to know is is this a problem in other hospitals about non-critical patients getting admitted to ICU? Is this a nursing issue, a MD issue, or both? This patient was charged an ICU bed just to receive 2U of PRBCs. When I worked ICU full-time, we would get admissions for DNR patients because the docs did not believe their patients would get good end-of-life care on the floors. I know DNR does not stand for "do not treat", but I am talking about those patient's who just need a bed, privacy, and their loved ones surrounding them as they take their last breath. Not bells and whistles and "codes" being called in the next room.

What do you all think out there?

[JennieBSN]

WOW. My head is still REELING with this one. I think it was totally inappropriate for the pt. to be in ICU for that reason, and the nurse who reported off sounds like she needs to be worked over a few times by her fellow staff AND nm. I do get this kind of stuff in my line of work, though. A lot of times the docs will send pts. who just need 23hr. obs to us simply because they have 'no confidence' in the skills/compassion/abilities of the floor nurses on the particular unit where the pt. BELONGS. It's sad and it irritates us all that we have to pick up for another's slack all the time. It is a nsg issue to some extent, but you're right...it's the MD who writes the admitting orders. Yeesh. Hope your week gets better.

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[natalie]

I work in the ICU and I routinely see the transferring of patients from med/surg floors because docs are commenting that these nurses do not have the skill/abilities, etc.

Now I am not directing my message personally to the 2 previous posters, so don't take it that way, but there is a hint of something here that riles me.

It's called ICU snobbery. I see and hear it all the time. And it's particularly painful to hear these nurses agreeing with the docs instead of defending their co-workers on the med-surg floors. These are the same nurses that rail against being floated to these floors because they know they can't do it. They know it is out of control on those floors. They know they can't take on 7-10 patients with some of them as critically ill as an ICU patient. Some of these patients just have a DNR tagged on to them, but the care needed is just as involved.

Guess what the problem is? Is it the nursing staff on these floors? (I've met some of the best nurses in med-surg.) I'd say there's a staffing problem and the door to knock on is administration. The majority of new nurses coming into hospitals land on these floors, not in ICU. That puts a tremendous strain on the veterans, as well as the new nurses.

st4303-your quote "I do not know what the night nurse's excuse for not seeing this patient was..."

Maybe you'd do well to find out what the reason was.

kday-I take it back. You sound like you have a case of ICU snobbery and should take this personally.

[prmenrs, RN]

Maybe the best thing would be to focus on the pt's needs, which it sounds like you did, and don't waste your energy on all the other stuff. The "other stuff" in this case involved ~ 3-4 other people getting exercised about the transfer, floor nurse, etc, etc... Just a thought...

[Lynn Casey RN]

First of all st4304 I'm thanking God for that elderly woman that she got you for a nurse!What a great patient and nursing advocate you are !!! Kudos for standing up for what is right instead of bitching about it!This dilemma that you were faced with is a horrible reality these days.I am disheartened because I believe that nursing needs to address these problems.Why is it that we are all "held hostage" because of a lazy,disorganized,apatheic, or disinterseted nurse?If a stock broker didn't make money for the company they would be toast!I wish we could follow suit.How about prioritizing?I can bet you this nurse had her 10 am meds all out by 930 and her baths were being done while this lady suffered!I would report this to the nursing supervisor and go to the floor's manager personally and report this as well.Even if this is an MD issue,they don't like us reminding them our our issues.Get my drift?Anyways,this is not ICU snoberry,it's reality.This lady is the one paying in the end physically,emotionally and financially!All of this because a nurse "known" for this ineptness happens to be working?Do you guys have work situation reports or professional practice reports to fill out?I would also chart in a professional manner that this lady looked like s@#$!She must have felt unworthy of this nurse's time!SHAME!WE have to stand together and during these times say...shame on you!This patient could have died,but at least you got to coffee break!

[JennieBSN]

Natalie--I can't have 'ICU snobbery' because I don't work in an ICU. I work L&D. We frequently are asked to keep patients who are postpartum/do not have and obstetric problem because the docs lack confindence in the pp/GYN staff. And yes, I did realize someone's toes would get stepped on because they would think I was saying floor nurses are all lazy and can't give good patient care. I realize the med surg floors are packed to the gills and the nurses are overloaded. HOWEVER....even if the floor is overloaded, if the nurses are GOOD, the doc will still have confidence in them to at least make an EFFORT to give the best care possible, high census or not. What I was speaking of are floors that, even at their lowest point in census, do not give good care. Case in point, whenever the nurses from this particular pp/GYN floor are floated to other units on the hospital, the nurses on the floated-to unit complain these nurses are lazy, unorganized, and whiney. They cannot handle even the simplest of tasks and pt. assignments well. The patients complain all the time, as well as the docs. Now, whether or not it is MY unit or some other unit picking up for their slack, it's sad. They should be at least ATTEMPTING to do the best they can, but this is not the case in either my situation OR st4304's. I float to both pp/GYN and med surg floors, and can do just fine, even when it's busy. I am not super nurse, but geez, there's something to be said for at least making an EFFORT. I don't know what the solution to st4304's problem is. She asked what we thought, so I gave my opinion. Sorry if that upsets you.

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[This message has been edited by kday (edited February 24, 2001).]

[Tiara]

An inappropriate transfer to the ICU because of some doctor's perception of nursing staff is not really right but it's a lot less dangerous than the many, many inappropriate transfers from ICU to the med/surg floors. Every time I got a transfer who should have been on telemetry, I wrote it up. Lost count. Even the best nurse cannot deal with eight or nine med/surg patients and unstable transfers. In many ways, med/surg nurses have to have excellent assessment skills simply because they do not have monitors on which to rely.

[fergus51]

I have to say I do think med-surg is the HARDEST area to work in which is why I don't .

When you get 10 pts, half of whom should still be in ICU but are transfered early, even trying your best doesn't do jack. A pt doesn't care if you came in like a peppy cheerleader and did you honest to goodness best. They care about whether or not they got the care they deserved.

If this nurse has no legitimate excuse for transfering this pt she should be disciplined along with the doc. (who I do believe has a case of ICU snobbery). ICU nurses do have AWESOME skills, but that doesn't make them the best to look after every pt. They should look after the types of pts they are trained to look after. Isn't that the point of being in a specialty?

[Zee_RN, BSN, RN]

Oh my word. This happens ALL the time in my ICU unit. We get a lot of inappropriate transfers and many of the docs come right out and say it's because they know the patient will have someone keeping a "closer watch" on the patient. And because the med-surg units are so packed, there frequently are no available beds...so the patient comes into the ER and they make up a DX to get pt. admitted to ICU just so they get a bed. Happens ALL the TIME! It's driving us nuts. And not because of ICU snobbery (although I understand the concept ), but because our staffing sucks too and the individuals who really NEED intensive care aren't getting it because our time is now divided, sometimes over 3 to 4 patients. So much for q15 min vitals on those patients who need them! Just titrate yer own dopamine, buddy.

I'd also like to say Hats Off to med-surg nurses; did it for 3 years before transferring into ICU. They are the most overworked people in the hospital. Yes, it's awful to have 3 ICU patients (in a different sense) but I couldn't return to med-surg. You folks don't get a pittance of the respect you deserve.

[bunky, BSN, RN]

Here's another question: Why are pt's being admitted for blood transfusions at all? I work on Med-Surg and those admits can throw your entire day into a tailspin. These pt's come to the floor often times with only a few minutes warning, and we must drop whatever we're doing for our truly ill pt's to give blood and send them home when it's done?! Surely to goodness someone out there can come up with a better place to send these pt's rather than to the floors. People who come in for outpt surgery don't come to the floors so why do people who only need a transfusion come to the floors?

[JennieBSN]

Originally posted by bunky:

Here's another question: Why are pt's being admitted for blood transfusions at all? I work on Med-Surg and those admits can throw your entire day into a tailspin. These pt's come to the floor often times with only a few minutes warning, and we must drop whatever we're doing for our truly ill pt's to give blood and send them home when it's done?! Surely to goodness someone out there can come up with a better place to send these pt's rather than to the floors. People who come in for outpt surgery don't come to the floors so why do people who only need a transfusion come to the floors?

Bunky--good point. I was wondering the same myself.

[Stargazer]

What is apparent to me here is that the ICU Medical Director completely abdicated his responsibility. I don't know how this position works in other hospitals, but in mine, one of his/her most important duties (as far as we're concerned) is to function as the "gatekeeper" and explain the facts of life to docs who want to do inappropriate transfers because they think their pts will be watched more closely in ICU. Every medical director with whom I have worked has done this task (sometimes grumpily, sometimes cheerfully, but always)IMMEDIATELY. This medical director failed miserably. To call this a "nursing issue" was to completely shirk his responsibility. It sounds as though the ICU nurse manager needs to have a chat with him and explain that they need him to be a little more assertive to prevent critical care resources being used inappropriately. An uncomplicated transfusion does not make a pt an ICU player by any stretch of the imagination.