Safe Harbor and a Pedi/ICU harbor

brownbook · May 5, 2018

Your charge nurse is terrible. She should be more supportive for any issues or questions staff has.

However I am confused. Were you expected to care for a 16 year old, trauma, intubated, fresh lady partsl delivery? Or an intubated newborn? Or both of them?

Or are you saying "pediatric" because she was 16? I think that is where my confusion comes from.

Were you on call and called in to care for this patient. Or was it during normal hours of operation and there were co-workers and medical staff nearby?

RECOVERYPACU · May 6, 2018

Hi Brownbook,

to answer your questions:

1. I was expected to care for the 16 year old, trauma, intubated, fresh lady partsl delivery. Not the newborn. The newborn was sent to NICU.

2. Yes, I am saying pediatric because she had recently turned 16.

3. This occurred during normal business hours, and there was 3 other nurses working in our PACU (including the charge nurse).

brownbook · May 6, 2018

Thanks, I know next to nothing about Safe Harbor. Just a quick Google search.

I am assuming you were concerned about the worst case scenario, this 16 year old patient needing critical nursing and medical interventions, drugs, etc. and due to her age she would require staff familiar with pediatric interventions, doses, etc? You are trained in ACLS, but not PALS?

As far as ACLS is concerned "adult" is someone who has entered puberty and older.

What exactly were your concerns?

Wuzzie · May 6, 2018

Honestly the way your charge nurse handled it leaves a lot to be desired. I probably would have felt the way you did with that hand off. But, coming from a nurse with loads of peds experience, that patient really didn't qualify as a pediatric patient especially in the acute phase of her care. Certainly there are differences in the way we care for adolescents but that generally comes later on and almost always deals with psych-social issues rather than medical. I think the bigger issue was the postpartum aspect of her care given that you mentioned you mostly only dealt with cerclages. I really believe that had your charge nurse approached you differently it wouldn't have been a problem. As it stands you probably felt unsupported and on your own which would have been very uncomfortable and maybe even scary so I don't blame you one bit and I'm sorry it happened to you. Going forward what do you think the solution would be for any of our members here who might face a similar situation?

Kooky Korky, BSN, RN · May 7, 2018

How did it go?

Kooky Korky, BSN, RN · May 7, 2018

Hello everybody,
I work at a Level I trauma center in the recovery room. We care for patients of almost every specialty, including MICU, SICU and Neuro ICU (rare). We do not care for PICU, NICU or OB patients (we'll get the occasional cerclage, but nothing more complicated than that).
Last week, I was asked to recovery a 16 year old, pregnant who emergently delivered in the OR, motor vehicle accident patient that was vented. I have no issue caring for vented patients, I have no problem caring pedi patients, and I have no problem caring for ICU patients. But I do have a problem caring for a vented, Pedi/OB ICU patient that just delivered.
I made the very difficult decision to call safe harbor. My charge nurse did not offer any assistance or support from her. I was told, "Bad news: you're getting the Pedi/OB ICU patient".
I said that I did not have the training, experience or qualifications to care for a pediatric ICU patient, much less one that was an emergent/traumatic delivery. She was pissed and called our boss, to whom I explained that same thing. I told my boss, I'm not refusing this patient, but I can't lose my license over this. If I miss something important, I'll be held to the highest standard of care".
What do you guys think? Did I make the right call? My charge nurse told me, "We are expected, at a level I trauma center, to care for ANY patient that comes out of the OR". Is this true? Is there such a thing as a limitless or boundary less PACU, where anything goes?
Your honest feedback and honest criticism are all welcome.

What a stupid way to tell you you were getting a new patient. Instead of portraying this as a good learning experience, instead of telling you she'd be there to help and back you up and teach, instead of her telling you you would care for this patient jointly, instead of all that, she tells you, "Bad News". What does she THINK your reaction would be? Well, she apparently DIDN"T think.

I hope the patient and you did well.

you do understand that the RR was likely pretty chaotic and even a seasoned nurse can handle only so many patients, right?

Double-Helix, BSN, RN · May 8, 2018

I agree that this patient, excepting the postpartum status, was an adult trauma patient. This entire situation likely could have been avoided by some open dialogue and by having a postpartum nurse come to the PACU to assist with monitoring for the immediate postpartum complications.

Here.I.Stand, BSN, RN · May 9, 2018

16 -- or recently 15 -- is physiologically an adult pt. As said before, had she coded you would use ACLS protocols -- not PALS. Pediatric is a physiological state, not a legal one.

Whenever we get an OB pt in the SICU, we have an L&D/mother-baby RN come periodically to assess and chart the female stuff and call the OB-GYN if needed. We don't do anything with it (except for the obvious call for a big pool of blood on the chux).

ThatBigGuy · May 11, 2018

Invoke Safe Harbor if you feel like an assignment is unsafe. Whether or not you should have the skills to care for this patient is irrelevant in the moment. You first give your license protection, then go give the patient the best care you can. If the review board later finds that you should have had the skills to care for this patient and discipline or fire you, then so be it.

Just remember, you can't retroactively call Safe Harbor.

I would have been on the fence myself, considering the patient's condition. However, the lack of communication and support from my coworkers and charge nurse would have knocked me off the fence and squarely in Safe Harbor territory.

inthecosmos, BSN, MSN, RN, APRN · May 12, 2018

I think the situation was handled poorly and you made the right decision given all the mentioned details.

cayenne06, MSN, CNM · May 20, 2018

I agree that this patient, excepting the postpartum status, was an adult trauma patient. This entire situation likely could have been avoided by some open dialogue and by having a postpartum nurse come to the PACU to assist with monitoring for the immediate postpartum complications.

When I was an RN I used zip down to assess patients on other services regularly, including PACU. It might just be a quick check and consult, but if they were acute in any way (immediate postpartum period included), I'd stay at the bedside until things were obstetrically stable.

With a normal spontaneous delivery following a low risk pregnancy, maternal postpartum care is straightforward and relatively algorithmic, medically speaking (setting aside all the messy psychosocial components haha). So I don't really think this was an inappropriate/unsafe assignment for you. Certainly your unit sounds like the most appropriate place for her overall.

However. OB is outside your comfort zone, end of story. Your charge should ensure you have the resources and support to safely provide care. No ifs, ands, or buts about it. That's literally the job of a charge nurse.

I would have pushed for an initial assessment by a PP nurse, as well as the time to consult with her, develop an integrated care plan, ask questions etc. And a nurse from their unit should be available to consult and/or come over to take a look whenever you have questions or concerns.

Before you claimed safe harbor, did you brainstorm other solution? I know you said she didn't offer any support which is not cool AT ALL. But I was unclear if you took the initiative to brainstorm and present her with possible solutions yourself.

If your charge denied your requests for support outright, then I don't hink you were unreasonable for claiming safe harbor.