Should this patient be in ICU??

[TigerGalLE, BSN, RN]

Hello everyone. I work on a med surg floor. We usually have 6 patients per nurse. Today I was receiving a patient from another medical floor in the hospital due to the fact that the patient would be on an insulin drip. My medical floor accepts insulin drips for some reason. The only floors that accept insulin drips are ICU, CCU, telemetry, and my med-surg floor (we are actually renal/respiratory).

So when a patient is on an insulin drip they get Q 1 hour SQBS checks. This patient was admitted yesturday to that medical floor because she came into the ER via ambulance with a SQBS of 13 and was unconscious. She was recently discharged from the hospital 1 week ago after a long complicated hospital stay. She was in the hospital previously with UTI with group D enterococcus sepsis, diabetic ketoacidosis, GI ileus which resulted in a colostomy and an MI. This go round she was admitted with UTI and hypoglycemia. Apparently she is a very brittle diabetic and today her blood sugars where in the 500s. Due to her high BS they wanted to put her on an insulin drip. She was also growing gram neg rods in her urine, her BP was running 100/50, her PT was >63 INR > 6.8.

Anyways I tried to fight this transfer. Asking them to please send the patient to ICU due to being transferred with 3 pages of orders including 3 units FFPs, NS bolus of 1 liter, Mg bolus, insulin drip with Q 1 hour checks. They said she was too hemodynamically stable to be in ICU... But to be put on a med surg floor when I have 5 other patients? She was already oozing from her central line site and her previously stuck sites. She was slightly hypotensive and when she got on the floor i never even had to start the insulin drip because when I checked her sugar it was 123. All the insulin they had already given her was catching up with her..

I know they say she is "hemodynamically stable." But if there is an ICU bed, why not put her there where she can be closely monitered?? I know her sugar will bottom out tonight. Am I wrong in this situation? I just feel like she was a ticking time bomb.

Tiger

[blondy2061h, MSN, RN]

Do you have an ICU step down unit? Sounds like she should be somewhere in between. I definitely agree that's too much with 5 other patients.

So if she's not on the insulin drip, is she getting any insulin? She'll be right back to 500 or what not if not.

What's an SQBS? That's not a term I'm familiar with.

[HappyPediRN]

This is an extremely complex medical patient with a long PMH. You had every reason to fight this transfer and if she HAD to come to your unit they should have given you an assignment based on acuity not numbers because it isn't safe for you, her, or your other patients. My opinion is that she should have at minimum been admitted to a stepdown unit. I hope you documented your reaction (you know, saying it without saying it) to CYA if and when her hospital course likely becomes more complicated.

[TigerGalLE, BSN, RN]

Well we don't have a step down unit. They always dump on our floor like this. And the doctor that transferred the patients said to me. Well I feel better with her up here with y'all then down there (on the other medical unit.) And he said that because they always send us the sick sick patients and we don't let them die I guess. They think we are a step down unit but we have the same nurse pt ratio as any other med surg floor.

SQBS = sub-q blood sugar

[blondy2061h, MSN, RN]

I can understand taking those kinds of patients, but you need better staffing if you're going to. We get critical patients, vented and all, but when we have those patients our staffing reflects it. There's no way you could handle a patient like that and 5 other patients. It creates a slippery slope too. What if you get that patient, then are asked to take a 2nd or 3rd hat complex too?

[sissiesmama, ASN, RN]

This is an extremely complex medical patient with a long PMH. You had every reason to fight this transfer and if she HAD to come to your unit they should have given you an assignment based on acuity not numbers because it isn't safe for you, her, or your other patients. My opinion is that she should have at minimum been admitted to a stepdown unit. I hope you documented your reaction (you know, saying it without saying it) to CYA if and when her hospital course likely becomes more complicated.

I agree completely! That is too complex a patient IMO to have on a medical unit where the nurse would have 5 other patients. I know all patients have the potential to go bad on you, but this one just has it written all over her. In our region, all pts on an insulin gtt go to ICU automatically.

Anne, RNC

[RN1982]

That patient should have been in ICU.

[Elvish, BSN, DNP, RN, NP]

I completely agree - ICU all the way.

[cardiacRN2006, ADN, RN]

That patient should have been in ICU.

I agree as well. This pt needs to be closely monitored.

[woody62, RN]

I haven't worked in twenty years but I have been a Type 2 for the past eighteen. And on NPH for the past eight years. This patient should be in ICU. I realize the standards have changed but just being stable in one area shouldn't disqualify someone from an ICU bed if she requires the intestive one to one care this patient does. I have been on insulin drips and have always been put into ICU when I required one.

Woody:twocents:

[Dixielee, BSN, RN]

I agree this pt is a ticking bomb, and needs to be in ICU. She may not be hemodynamically "unstable" at present, but she bears very close observation and probably nearly constant attention to keep her from going down the tubes.

This is not in the patients best interest and it certainly is not safe staffing for the department.

[Elvish, BSN, DNP, RN, NP]

Have you written this up, Tiger?