Patient safety compromised

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Specializes in CrItical Care, Street Medicine/PHM, School nurse.

Hi all! Sorry but this is a long post.

I'm a new nurse (1 yr) who floats between units in our critical care department. I spend about 50-60% of my time on the CC step down unit. A couple of weeks ago I had a situation where I believe my patient's safety was severely compromised and I found myself jumping through hoops of fire trying to get her upgraded to the MICU. I will spare some details to protect privacy.

My patient had been admitted for several weeks due to sepsis/pancreatitis and had been jumping back and forth between MICU and step down due to all of the sequella of her condition (liver issues, perfusion issues, clotting issues, etc). One week she was improving and the next she would crash and burn.

When I first received her, the patient was on 3L NC, AOX3, unlabored breathing, HR in the 80's, afebrile, and with a BP that was on the softer side (low 100's). Assessment wise her abdomen was distended with hypoactive BS. She was jaundiced throughout.

At around noon I saw her heart rate increase to the 140's sustained. She was working with PT at the moment so I did not think much of it. She did not appear to be in any distress at the time. 20 minutes later, her HR is still elevated at rest. This time her breathing appeared more labored and I had to increase her O2 drastically to 15L on a NRB. Her BP was normotensive but she had a low-grade fever now. I immediately directly called the intensivist and received orders to r/o a PE amongst other things.

The scan was negative and the patient was stable. Upon our return, her oxygen demand increased to 40L heated high flow and she was now unable to maintain adequate blood sugar control (30's-300's within an hour). I called a Rapid and was given orders that would assist with BS control and nothing else. I expressed my concern about the patients declining status and the need for a higher level of care. I was told by the intensivist that the patient was stable enough at the moment. I was worried that this patient was going septic again or had developed peritonitis due to a now firm abdomen and almost absent BS - I told the MD this.

Then 3 pm came and the patient's blood pressure began trending down (into the 90's, high 80's with decent MAP). She remained on the same oxygen level. I again spoke with the intensivists - just monitor. I spoke with the specialist - just monitor. I spoke with a different provider on the case - just monitor. At 4 pm her O2 demand was increased to 60L HHFNC with 94% FiO2. The patients mental status seemed to be declining as well. Her blood sugar was again hypoglycemic. Her BP's was in the 70's-80's. Still tachycardic. I called another rapid. This time I received an order for blood pressure support (not pressors). I again expressed my concerns and need for higher care. I asked the doctors directly the reason for the delay and I was told in certain terms that they were trying to wait it out until the next morning. I can't really go into details about that part but let me just say that their reason for this was nonemergent and ridiculous. During this entire time, the house sup and the charge nurse were also doing their part to try to get the patient transferred through other avenues. At around 5:30 pm and after exhausting almost all of my resources I decided to call the medical director. I explained the situation and my concerns. Within 10 minutes the director was at the bedside and completely agreed with my concerns. At 5:45 pm this patient was finally transferred to a higher level of care. I transferred the patient and was greeted by the intensivist at the MICU. let me just say that he was NOT HAPPY that I had gone above him to get this patient moved.

I spent nearly 6 hours taking care of this one patient. My other 2 patients were still taken care of (wonderful teamwork!) but I felt they were much more neglected due to my snowballing situation next door.

One lesson I learned is that I need to be more aggressive with my concerns. I feel that this delay was completely avoidable. Was there anything else I could have done? Now I every time I see this particular intensivist, I feel like he still is very angry with me. It doesn't matter how he feels towards me but I do think it has affected our professional relationship.

Sorry for this long post!

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Specializes in CrItical Care, Street Medicine/PHM, School nurse.

Also forgot to add that I was so concerned about this patient going into respiratory or cardiac arrest that I placed the crash cart in the room and had the pads on her the entire time this situation was going on. I also placed the rapid intuabition kit at the bedside. Not even the site of this caused the providers to understand how concerned I was.

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You did the right thing. I thought the RRT(s) would end your nightmare but I'm assuming the intensivist had their Hands tied as well. The intensivist is just mad he was wrong and the lowly RN didn't let it go. Don't worry about him. Good job advocating for your patient and great assessment skills!

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Specializes in CrItical Care, Street Medicine/PHM, School nurse.
You did the right thing. I thought the RRT(s) would end your nightmare but I'm assuming the intensivist had their Hands tied as well. The intensivist is just mad he was wrong and the lowly RN didn't let it go. Don't worry about him. Good job advocating for your patient and great assessment skills!

Thank you! I figured the intensivist had other less obsvious reasons for delaying the transfer. The RRT were not as fruitfull either because the same intesivist also attended and ran the RRT. I now see that calling a RRT (or multiple RRT's) does not guarentee my concerns would be adressed.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.

Wanted to wait until the next morning? ***** To see whether she should be transferred to MICU or the morgue? You absolutely did the right thing and saved her life. Next time this happens, you will do the exact same thing. Your professional relationship is as good as you both make it. If he wants to play Russian Roulette with his patients and you don't want to play, then he'll just have to deal with it.

On your patient's behalf: Thank you.

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Specializes in CrItical Care, Street Medicine/PHM, School nurse.
Wanted to wait until the next morning? ***** To see whether she should be transferred to MICU or the morgue? You absolutely did the right thing and saved her life. Next time this happens, you will do the exact same thing. Your professional relationship is as good as you both make it. If he wants to play Russian Roulette with his patients and you don't want to play, then he'll just have to deal with it.

On your patient's behalf: Thank you.

I soon as he told me his "reasons" for the delay, I knew I was going to get nowhere with him. I 100% believed that this patient would code during the night, especially with her history of crashing and burning.

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Sometimes, you just have to advocate and do what you need to do for the patient. I've had to on several occasions. Sometimes I was right and the patient crashed, and others I've been wrong. I'm glad when I'm wrong. But 80% of the time if I feel something is going bad, it usually is.

I'm not there to pacify a doctor. I'm there to advocate for the health and safety of my patient. Sometimes, that means stepping on some toes.

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Specializes in Critical Care.

What qualifies as full ICU vs stepdown varies widely by facility. I've worked at places where the patient you described would not only be considered ICU, but they might also get shipped out to a larger ICU, but I've also worked places where the patient you describe is well within stepdown parameters, if they actually go on pressors or get intubated only then do they become an ICU patient.

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Specializes in CrItical Care, Street Medicine/PHM, School nurse.
What qualifies as full ICU vs stepdown varies widely by facility. I've worked at places where the patient you described would not only be considered ICU, but they might also get shipped out to a larger ICU, but I've also worked places where the patient you describe is well within stepdown parameters, if they actually go on pressors or get intubated only then do they become an ICU patient.

In this particular step down we can do certain pressors and very limited use of BiPap. This patient became MICU appropriate due to her

rapidly declining respiratory status. The MD

held off on putting her on Bipap (despite the confirming ABG's) because he was aware of the step downs limitations on BiPap. From what I know this patient was intubated within an hour of the transfer. As far as pressors go, I was trying to manage the downward trending BP's with very limited nonpressor BP support. I was basically implementing the highest non-MICU interventions allowed for this particular case. The MD was finding ways to delay the transfer while still keeping this patient "stable" despite the obvious. He straight out told me this.

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Awesome job advocating for your patient OP. You did absolutely nothing wrong.If it happens again, take the same steps.

The MD learned a lesson too: When OP calls for RRT or concerns about a patient, take them serious!

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Doctors are human too with poor judgment sometimes. Good job!

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Specializes in CrItical Care, Street Medicine/PHM, School nurse.
Awesome job advocating for your patient OP. You did absolutely nothing wrong.If it happens again, take the same steps.

The MD learned a lesson too: When OP calls for RRT or concerns about a patient, take them serious!

Thank you! This was the first time in my career that I've ever had to go through this much stress to get someone transferred. It was definately an eye opener!

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