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.
Specializes in vascular, med surg, home health , rehab,.
ICU, how on earth can you safely take care of someone with that high of an acuity and 5 other pts? Even our PCU wouldn't take that pt as they are no better staffed than we are. Very risky for the patients & your nursing licence.
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.
My guess...they saw she was low, took her off all insulin, and sent her back into DKA and near DKA. Cause people don't realize type 1s get dka without insulin even if their bg was previously low.
ICU Patient. At a minimum, stepdown with tele monitoring. It's too much for a nurse to do an insulin drip +5 patients. As another poster said, her electrolytes had to be wonky.
Different hospitals have different criteria for ICU admission, depending on size, skill level of staff, availability of a step down unit, etc. etc. My current hospital, this pt would be in the intermediate care unit. Last 3 hospitals - ICU for certain.
Actually, I am changing my mind. She might have landed in ICU in my current hospital as well. Sounds like a sepsis picture over all, with DKA resulting. Too many problems for a Med-Surg unit with your assignment level for certain.
I agree with OP, did you write this up? Situations like this show need to clarify criteria for admission to ICU. I have worked in plenty of hospitals where MD had to be told 'sorry doc, this patient does not meet ICU criteria and is very stable, you may not admit this pt here'. The floor nurses could also tell the doc forget it, this is an ICU patient. Once you get the criteria clearly defined, it gives you a lot more power. Medical Directors (via charge nurse, nurse manager, director, chain of command channels) can be very powerful and helpful in this situation. Have had to call them a few times when someone is attempting an inappropriate admission. Eventually, the offending MD learned I would freely call Medical Director (and he would receive subsequent reprimands from Dept. of Medicine and hospital administration) and wouldn't attempt inappropriate admits if I was working,
lol!
Hospital administrators don't like this sort of thing to happen. They could be receiving different reimbursement in some situations. Some actually realize the liabilities involved and don't want anything bad to happen - to the patient, the staff, or the hospital as a result!
Bottom line, sit down with your nurse manager/chain of command and respectfully request clarification of admit to ICU criteria at your facility so you can be armed in the future. Know your hospital policies here.
Well after I got report from the previous nurse I went to the computer and looked up her labs, H&P, ect. Then I told my charge nurse who agreed that this pt need to be in ICU. So my charge nurse called the supervisor who said they'd go see the patient. Supervisor calls back and says she's too stable for ICU and of course my charge nurse just says okay thanks for checking. That certain charge nurse is such a pushover.
Then after the patient got there the MD that transferred her to us came to the floor. Apologized for the "mess." I told him I didn't understand why he didn't just transfer her to ICU and he said that he didn't think she was unstable and as long as we could regulate her sugars the patient would be okay. He thinks we "caught the UTI early." But yet he wrote a consult to urology for recurrent urosepsis.... hmm.. AND he hadn't even drawn blood cultures. I have 3 days off but when I go back thursday I will talk to my manager about it. I thought she was probably septic, her white count was up, she had >100,000 gram neg rods in her urine, Her pressure was on the low side, and her sugars were out of control. Sounds like sepsis to me. They tells us all the time and have little posters every where to watch for sepsis, catch it early, call a rapid response, get them in the unit... But yet no one listens to us... Its very frustrating!
And I was mad b/c the whole reason they transferred her to us was for an insulin drip. Which I never even started. At 1900 when I left her sugar was 93. And I didn't give her any insulin.
I do agree that patient should have be in ICU to have a one on one care basis because you still have 5 patients and it is very difficult for you to give a full time care for patient having an insulin drip
you're not wrong. This patient was a time and likely labor intensive patient with multiple issues that was obviously not a med-surg patient. A perfectly appropriate ICU admit. Unless they want someone else to take over your other patients, because you'd be in there with her your shift, as she is obviously the patient with the highest acuity and priorities. I'd fight that - and if nothing happened, your charge ought to take over that patient. IF that was refused, I'd go to the house sup - if that didn't work, call your manager. No way that is appropriate. Someone is pulling a fast one and dumping on your unit.
I agree this patient should be in the ICU. If you made your concerns known then you've done all that you could.
I've never heard of sub-q blood sugars? Finger stick or venipuncture blood sugars, sure. How are sub-q blood sugars done? I'm confused on that one.
sub q BS are done the same as finger sticks, I'm sure - different regions have different names for the same thing. Here, they call it chem bg's - I'm used to "chemsticks" personally....
ICU Patient. At a minimum, stepdown with tele monitoring. It's too much for a nurse to do an insulin drip +5 patients. As another poster said, her electrolytes had to be wonky.
you know, in the ER, it's not unusual to have your critical care patient (vented, even) and 4-5 other patients.... so you wind up focusing on your sickest and the others have to wait wait wait.... it is not the best of scenarios, to be sure. Other nurses need to have your back, esp the charge, to watch out for those others to ensure they don't crump. You can't do it alone and if they don't change your assignment, it's a team effort and you have to have help. Keep climbing higher in the chain of command to voice the concern - because you know if you don't and anything happens, you're the first one the finger would be pointed to...
Could you give an example of this technique? Sounds...useful.
emnicams
179 Posts
Q1hr accuchecks are an automatic transfer to ICU per my hospital's policy.