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.
Yeah, as soon as you see all this order stuff...she's glucose unstable...and if I can't monitor her effectively, then I can't care for her. I would have said that I'd take her, but someone would have to take one-two of my currents....just the way it goes.
Eek! That patient should have definitely been in an ICU...in both hospitals (same system) I have worked in, insulin gtts always come to the ICU, regardless of hemodynamic stability....not only did you have to do hourly blood sugars and adjust the gtt accordingly (we also always need another RN verification on our electronic MAR when we adjust, dont know if you need that as well), but also infuse that 1L bolus and 3 units FFP, which means you will be in that room for quite a while....not fair (to both you and your patients). I would definitely write that up- the constant monitoring is too frequent if you have 4-5 other patients to care for...I am sorry this happened to you!
My one pet peeve about Insulin gtts is having to do q1hr glucose checks. I think its pointless. q2hr is enough. Why constantly chase the the blood sugar. In my ICU we never do q1hr, its always q2hr
My facility nearly always sticks insulin drips on the floors. This pt sounds like one they'd put on our med/surg units:no:, and they never adjust assignments accordingly.
After seeing so many of you state that insulin drip pts are sent to ICU at your facilities (I don't just mean this thread), I am really uncomfortable with my facility's practices.
I totally agree, this pt should be in the ICU!! By the time they are "hemodynamically unstable", it may be too late. As a traveler, I have been to several different hospitals, but the one constant so far is that all pts on an insulin drip go to the ICU, and even then, it's hard to monitor them as close as they need to be.
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
BSG of 500 and low BP? I'm curious if she wasn't in DKA again? If she's peeing out her fluid and dehydrating herself, that could explain her low BP (I see she needed a fluid bolus, big suprise...)
But yeah, ICU. Her cardiac status need to be monitored as well. Pts lose K+ w/ DKA (dehydration can make the K+ look falsely high or normal), she needs frequent lyte checks and she definitely needs to be on a tele monitor.
I don't think she necessarily needed to be in ICU, but definitely was too heavy if you already had five patients. I work in cardiac telemetry, and this is not an unusual type of patient for us to handle. But, I would certainly let my charge nurse know how busy this patient is, so that I would not have to take any admits.
Where I worked, if the ICU was full they would go into the medical ward, but they would call in an extra staff member to special that patient, if required. I would prefer to see a patient like that monitored closely, however. I would have refused to take the patient under those conditions.
Who did you voice your concerns to? Just curious. Bed control people don't care where they place as long as they have a bed. Did your charge not back you up. Next step would have been manager, then house supervisor then director. I don't play around when it comes to unstable pts. They may think you can handle it, but what about the other staff. Are they capable of handling that pt plus the others.
If it was me, I would have had the house doc come and evaluate the patient for transfer. I've done it many times when I worked on stepdown. We'd get patients that clearly needed to be in ICU but were sent to us and would crash within 2 hours of their arrival.
locolorenzo22, BSN, RN
2,396 Posts
Yeah, as soon as you see all this order stuff...she's glucose unstable...and if I can't monitor her effectively, then I can't care for her. I would have said that I'd take her, but someone would have to take one-two of my currents....just the way it goes.