Transferring A Patient to Stepdown/ICU

[SwimNurseRun]

I am a new grad that has been on my own for almost two months now on a telemetry floor, with a 5:1 patient ratio on the day shift. Of course there are many things that I am learning every day, and I feel that I am getting the hang of the routine tasks of floor nursing... assessments, passing meds, checking orders, discharges, admissions, etc. I am not afraid to ask my coworkers when I have questions about how to do something, or asking them for a judgement call, but I'm a little embarrassed to admit I don't know the first thing when it comes to emergencies or codes.

I have yet to send a patient to the ICU, call a code, or call the rapid response team, but I am scared that I will not recognize the situations when a patient should be sent to a higher acuity floor. We have very sick patients at times, but what signs should be red flags to me that the patient needs the ICU? I understand increasing and weaning oxygen for O2 sats, but when is the line for intubation? I've had patients on 9L high flow satting in the mid-80s, and they don't claim to be short of breath at all!

Obviously I know that if I find a patient unconscious or without a pulse I would call for help, but what does the patient look like when he or she is "unstable" enough for stepdown?

Embarrassed to Ask,

SwimNurseRun

[RNsRWe, ASN, RN]

No need to be embarrassed, but frankly this is what you have a charge nurse for.

All you need to recognize are the signs/symptoms of a patient doing poorly, or a downturn in patient's status. Then go to your charge nurse (who had better be ALOT more experienced than you) for further guidance.

You won't be making any decision on whether your patient gets transferred; you're responsible for taking the problem further up the food chain (and in this case, it's to your charge nurse). If you feel your charge nurse is blowing you off and you REALLY think the problem needs more immediate attention, there's always a nursing supervisor above your charge.

[talaxandra]

Like RNsRWe said, it's not your call, so nobody will be relying on you to make that level of assessment on your patient. Where I work it's not the charge's call either - the unit can request their patietn be transferred, but ICU have the final say.

There was a lot of concern when emergency call were introduced at my hospital that ICU would be angry about being called for a non-emergency; as a result, several patients significantly deteriorated and/or had significant sequela that may have been avoided. ICU staff make it very clear that they'd rather be called for nothing than not called for soemthing, and I'm sure it's the same where you work. It can be embarrassing when a whole swarm of people arrive only to find your patient normotensive/well oxengated/well perfused etc, and I always feeling like saying "I swear, three mintes ago he was practically dead!" But they still do a proper review, and often initiate additional interventions.

There will sometimes be times when you're not sure whether or not to call for help - I've been nursing over twenty years in acute care and still occasionally get someone to eyeball a patient before deciding to call it. The important thing is to seek help if you're concerned, even if you haven't got anything concrete to pin your concern on. Know your Rapid Response parameters, and either call for one or get the person in charge to check on anyone you're worried about. And know that you're not the only neophyte to worry about making the wrong call :)

Good luck!

[classicdame, MSN, EdD]

you are over-worrying. The answers to those questions will come from the Rapid Response Team or Code Team.

Your best job is to REALLY know your patient so you can quickly determine a change in condition, then call for help. Low sats or "looking funny" suggest the Charge Nurse or RRT. Codes are when they are beyond the prevention stage and need to be turned back around.

[veronica butterfly, ADN, RN]

Be sure to use the resources around you, respiratory therapy, charge nurse, and your coworkers. If you are having a gut feeling that someone isn't doing well, have someone come and take a look at your pt. When I was a new nurse, I thought I had to know all this myself. It's much easier to pick up the phone and ask for help. Pharmacy is a great help for med questions too.

[Penelope_Pitstop, BSN, RN]

Sometimes you will find that your charge nurse isn't much of a help. A lot of times the people selected to charge are either good with staffing, conflict resolution, or have "leadership skills" but not the best bedside nursing judgement.

However, a lot of nurses who are NOT in charge are very helpful in these situations. You probably already know a few if you think about it. These are also the nurses who go out of their way to see if you need help, the ones who before they go to lunch come over and ask if you need anything, or at least ask if you've had lunch.

I was fortunate to have amazing charge nurses when I was a new grad. I called them CONSTANTLY. Oh my gosh, they were sick of me after a while, I'm sure! On my new floor, though, I've found that the charge nurses are better for staffing crises, NOT patient crises.

Oh, and guess what? I'm now one of those nurses the new grads seek out for help. But I wanted to let you know that it took me a while to get here!

[kayern]

Go with your gut..........what's the worst that can happen........you call an RRT or code on a patient that doesn't need it. Isn't it better to err on the side of safety. Additionally, listen to your patients, they can tell you lots.

Once you've had your first RRT/Code, you'll be fine. If you work in an institution that is worth anything, your peers, charge nurse and managers will be at your side helping you through.

Good Luck

[SwimNurseRun]

I am already finding the truth in that charge nurses range in leadership styles and strengths, haha. Still always a good resource, nonetheless.

But thanks for the reassurance, everyone! I agree that I just need to get that first code/RRT call under my belt and I will no longer be so worried about it! :)