Question regarding ED holding orders

Esme12, ASN, BSN, RN · Apr 10, 2012

No flaming....the requirements for the MD to see a patient on PCU would be dependent on the drips. I had a set policy that any patient admitted on titrated drips had the same requirement as an admit to ICU. Nitro/heparin could be up to the discretion of the MD IF pain free, negative EKG, neg initial enzymes/troponin and Nitro less than 12 mcg/min.

maiday · Apr 10, 2012

Hmmm... that's an idea. Right now, it's just a blanket statement ICU or med/surg. Maybe adding in those exceptions (or something along those lines) could be a way to go. Thanks for the response.

Esme12, ASN, BSN, RN · Apr 10, 2012

PCU needs to be added to the policy. It's a specialty area and has already been addressed through pharmacy/therapeutics to allow these drips outside of ICU. Therefore there needs to be a policy that addresses them on the unit they have been approved to be monitored and admitted. You're welcome :)

thelema13 · Apr 10, 2012

Hi guys!
I am doing some research and I was wondering if you all could help me. I currently work in a PCU (progressive care unit), it's a step-down from ICU and when we receive pts from ED, they come with holding orders. Our holding orders state the Dr. needs to see the pt in 2 hours for ICU and 12 hours for a floor pt. The problem is PCU is not listed so some Dr.'s come see the pt quickly but sometimes we will have very sick pt's with multiple drips that do not see a Dr. for 12 hours.
We are working to change our ED holding orders/policy but of course it's a huge process. I am wondering if it would be possible to either get information or a copy of your holding orders if possible (blank of course).
My questions are:
1. How long are your holding orders good for?
2. Is PCU/step-down/intermediate care listed on your holding orders at all?
If anybody knows of any research regarding safe times for a pt to be on a floor with only holding orders, that would be great also.
Also, before I get flamed, I am doing more research than just posting on allnurses, but I figured it can't hurt to ask.
Thank you for any help/feedback.

When patients are put in a hold status, they are kept in the ED and their admission orders are intiated from the admitting doctor. There are times I have 2 ICU holds and 4 ED pts. I think it is unsafe and unfair, as the ICU nurses will never go above 2:1. It also trips me up that a patient on a diltiazem drip HAS to go to ICU, I guess the cardiac floor or PCU cannot manage a patient on diltiazem. They are pretty whiny upstairs.

If a patient is to be transferred to a higher/lower acuity, we must get a doctors order. There is no 'hold' orders like you speak of, we hold our ICU/PCU/CPCU/MS patients in the ED, nowhere else. As if we have time to do ED and floor patients.

Esme12, ASN, BSN, RN · Apr 10, 2012

When patients are put in a hold status, they are kept in the ED and their admission orders are initiated from the admitting doctor. There are times I have 2 ICU holds and 4 ED pts. I think it is unsafe and unfair, as the ICU nurses will never go above 2:1. It also trips me up that a patient on a diltiazem drip HAS to go to ICU, I guess the cardiac floor or PCU cannot manage a patient on diltiazem. They are pretty whiny upstairs.
If a patient is to be transferred to a higher/lower acuity, we must get a doctors order. There is no 'hold' orders like you speak of, we hold our ICU/PCU/CPCU/MS patients in the ED, nowhere else. As if we have time to do ED and floor patients.

Different hospitals have different policies and ways to word things. Not all hospitals have hospitalists. Not all hospitals require diltiazem to go to the ICU. I know of some pretty hard core PCU's which are really step down ICU patients (or ICU patients in some facilities with a 2:1 ratio) on drips and the PCU nurses have 4-6 patients a piece as well with......active chest pain, unstable rhythms with multiple drips, including diltiazem, nitro, heparin, dopa, dobutamine, as well as lido etc and give adenosine.

I believe the OP is not talking about ED holds, which I agree is not the best use of resources and can be an unsafe enviorment. The OP is talking about the ED doc notifies the admitting MD and they give "holding"/temp admitting orders, until they are actually seen by the admitting MD. When you have a multi drip patient that is not stable they may not be seen by the admitting for up to 12 hours by the current policy. The OP was asking if anyone else has this experience and what have they done about the situation.

I hope this clarifies this for you....:)

Altra, BSN, RN · Apr 10, 2012

Agree with Esme12's posts above. thelema13, I understand your frustration with the differences in mindset between the ED and inpatient units -- trust me, I get it. But after working the inpatient side, I've learned to be a bit more accomodating on certain things, one of which is making sure there is some order from some physician regarding drip titration before sending a patient upstairs. In my experience, to do otherwise, with my ED mindset of "just use your judgement" ... will always be a set up for bad karma between departments ... always, 100% of the time. And that doesn't do any good for me, my department, the receiving unit, that nurse ... or the patient.

Anna Flaxis, BSN, RN · Apr 11, 2012

9 times out of 10, the admitting physician sees them in the ED. On some occasions, like when beds are tight, the lobby is full, and the patient has an inpatient bed assigned, we will get our ED docs to write holding orders. We never do this for ICU admits or anyone unstable or on vasoactive gtts. If anything, the admitting physician will meet the patient on arrival to the unit, but that's if they're being nice and understanding that we need to clear beds fast. I'm not sure what official policy is regarding time frames, though.

MunoRN, RN · Apr 12, 2012

Our "transitional" orders are good for 12 hours. They can't be used for ICU, stepdown, tele, or med-tele. Patients admitted to each of those units are supposed to be seen by the admitting Doc prior to transfer out of the ER which we thought would delay transfers out of the ER, although for the most part it has actually sped things up since the ER docs often write their orders in clumps. This can often result in a couple of hours between when we know a patient is going to be admitted and when the ER doc actually writes transitional orders, as opposed to forcing the admitting doc to see them in the ER which usually produces immediate orders after the Doc sees them.

RoxCRN · Apr 14, 2012

At my facility if an ICU patient or any patient for that matter, tele or med surg, peds etc.. is admitted but must remain in the ER as a boarder patient, it is the responsibility of the ICU intensivist or the admitting physician to write those inpatient orders. There are no Transition order sets anymore because they were so limited and the hold times have become so long. They have even gone so far as that the orders that the ED physician writes in the computer DO NOT cross over once the paitent transitions to INpatient. and that sucks when we have a boatload of boarder patients because its not always easy to get a hold of some of these primary docs at night and they really dont like getting called by the ER nurse for inpatient orders. They don't know us like they do the floor nurses. Sometimes they have order sets that we aren't aware of in the ER and they get mad to be getting a call....my reponse is always "well sir/maam when the ED doc called to tell you that he was planning to admit your patient, you had to agree to admission, you could have gotten on your computer at home and entered those orders. Or you could have asked to speak to the nurse for that patient, me, and I would have been happy to take those orders at that time. You didn't and I dont want this patient to miss out on their treatment because they are here in the ER so could you please give the orders for this patient so we dont cause any further delays in their care?" I never apologize for calling a doctor at home, it's their job and they know when they are on call to expect to be called....why they can be sooo crabby is beyond me, but thats another thread.