Ummmm..are they ALLOWED to do that?

[NurseJacqui]

OK, I have worked in about 5-6 different ERS, both as staff and agency an I have never experienced this. Right now I am doing a contract in a dinky little community non-teaching hospital. The ER is understaffed and bursting at seams because they admit everyone who rolls in the freaking door. Well the other night nursing supervisor called to say that she was sending the ER a patient from med surg with a positive troponin because ICU was full. Ummm can they do that? We only had 4 nurses first of all(no secretary, no tech), with almost every bed full most of them in a holding pattern. And the patient was going to be MINE. I already had 7 patients, ALL of them holds. Its like I am not even an ER nurse anymore. But can they do that....just turf pts from the floors BACK down to ER, especially when WE are already overwhelmed? The ER nurses say it is done all the time and when they threatned to complain they were told by supervisor that " Go ahead and when we get shut down we will all be out of a job" So there are 12 ICU beds with 6 nurses and 30 ER beds, with 4 nurses? How is that fair?

[ERERER]

you cannot transfer a patient to another facility if you have the ability to care for them. this does not mean bedspace, it means specialties (burns, neuro, etc). i've been doing this a long time. you would never find a physician to accept an established pt just due to "bed problems". THAT would be an emtala violation. Emtala addresses inappropriate transfers, started out as an "anti-dumping" legislation to prevent sending self-pays to other facilities. For example: we send out all our OB's because we do not offer, or have OB physicians on staff. This would be even if the entire hospital was empty. the closest facility that offers OB and has bed space is obligated to take the pt, insurance or not. THAT is emtala in a nutshell. Someone above said it "emtala ends when the pt leaves the ER". It does not cover in house patients at all. If the powers to be think that the pt would be safest in the ER, then that's where they go, like it or not. The patient still has their admitting orders, physicians, etc the same. The only way the ER doc gets involved is if the pt codes. Which would be the same if the patient was upstairs.

[grammyr]

As a supervisor in a small rural hospital, I do what is best for the patient. If it means physically putting them in the ED then so be it. If a patient on the floor goes bad and ICU is full, to the ED they will go, not because the nurses on the floor are not capable of taking care of the patient, but because if that patient is going south I need a crash cart, drugs,etc handy and the ED is the next best place. if there is no space in ICU. This would be a short term solution until a space in ICU could be made available or the patient gets transferred to a tertiary care hospital.

[hogan4736, BSN, RN]

you cannot transfer a patient to another facility if you have the ability to care for them. this does not mean bedspace, it means specialties (burns, neuro, etc). i've been doing this a long time. you would never find a physician to accept an established pt just due to "bed problems". THAT would be an emtala violation. Emtala addresses inappropriate transfers, started out as an "anti-dumping" legislation to prevent sending self-pays to other facilities. ..

you most certainly can transfer d/t lack of bedspace...if you have documented overcapacity...even the big city hospitals to it...

you can also transfer d/t equipment failure (i.e. vents)

we are a small hospital, and we have 3 vents...one was on a pt, the other two failed...I transferred the pt...

[hogan4736, BSN, RN]

As a supervisor in a small rural hospital, I do what is best for the patient. If it means physically putting them in the ED then so be it. If a patient on the floor goes bad and ICU is full, to the ED they will go, not because the nurses on the floor are not capable of taking care of the patient, but because if that patient is going south I need a crash cart, drugs,etc handy and the ED is the next best place. if there is no space in ICU. This would be a short term solution until a space in ICU could be made available or the patient gets transferred to a tertiary care hospital.

I am also a house sup in a small rural hospital, and you are doing the wrong thing by placing the pt in the ER...do your tele floor and PACU not have crash carts, and do you not have ACLS??

No OR/PACU call?

no ICU director/clin coordinator to come in?

[UM Review RN, ASN, RN]

This is a common misconception...

If you are an RN without ACLS, you CAN push the same meds as an ACLS RN...

your hospital may have a policy that trumps this, but an RN is an RN is an RN

You're right; hospital policy does trump this. And IMHO, it should. No one without the proper training or equipment should be pushing certain meds.

I could probably also be floated over to OB or Pedes, but frankly, it'd be quite dangerous for the patients for me to do that.

[hogan4736, BSN, RN]

I respectfully disagree (See Braselow Tape)

In a code situation, with several ACLS RNs around (I am in a small hospital - I am okay w/ ANY RN pushing epi), there is plenty of help...

Things I have given once (IV) in 12 years (IN THE BIG CITY EDs):

Pitocin (in an emergent situation...we need OBLS!!!!)

Colchisine

Vasopressin

Aramine (didn't have ACLS current for this one...a RARE vasopressor-WOW)

levophed

NEVER given:

TPA

Ampho

Streptokinase

Nobody killed yet...

If you don't know, look it up...if it's crazy, ask...

One exception:Chemo...I need the class

Let's get real...There are 2 reasons EVERYONE passes ACLS and PALS these days (hospital RNs only...does NOT include medics and CC transport RNs):

1) How many codes has an RN run (alone) in the hospital?

2) mean instructors (the old school ACLS ones) suck - intimidation is not conducive to learning

[UM Review RN, ASN, RN]

I respectfully disagree...

In a code situation, with several ACLS RNs around (I am in a small hospital - I am okay w/ ANY RN pushing epi), there is plenty of help...

Things I have given once (IV) in 12 years (IN THE ED):

Pitocin (in an emergent situation...we need OBLS!!!!)

Colchisine

Vasopressin

Aramine (didn't have ACLS current for this one...a RARE vasopressor-WOW)

levophed

NEVER given:

TPA

Ampho

Streptokinase

Nobody killed yet...

If you don'y know, look it up...if it's crazy, ask...

I guess I'm overtired, but I thought we were talking about putting an AMI patient on a Med-Surg unit? Where that patient might need things like Nitro gtt, Integrilin, things like that, because I was under the impression that this particular patient was originally to be turfed to the CCU.

So based on the usual Med-Surg nurse's patient load as well as the lack of tele monitoring available, I would think that a patient with those needs would be too labor-intensive and need care that was more specialized than the average MS unit could deliver.

Our hospital designates certain meds for certain units--for instance, Progressive Care can run Integrilin, Cardiac Stepdown can give IV labetolol or Versed, but the nurses do have to be tele-certified for our hospital in order to give a lot of the common cardiac drugs.

I prefer it that way because the staffing ratios are such that if a patient needs extra monitoring, those units are equipped and staffed to do so.

To get back on-topic, our hospital's policy also does not allow a patient to return to ER once the patient has left. We have had a couple of instances where a patient was on our Tele unit being bagged until we could get an ICU bed, but the ICU nurse came down to us, so we could take care of the rest of our patients.

Hope that clarified things, hogan. Have a good evening.

[grammyr]

I am also a house sup in a small rural hospital, and you are doing the wrong thing by placing the pt in the ER...do your tele floor and PACU not have crash carts, and do you not have ACLS??

No OR/PACU call?

no ICU director/clin coordinator to come in?

I do have crash carts on every unit. Our tele unit is also our med surg unit. PACU is a one bed recovery room that I wouldn't stay in with a critical patient alone due to its physical location. The decision to move a patient to the ED is a short term move to make room in ICU. For me, its a do what ya gotta do at the time kinda things. I am certainly not going to put the patient on a stretcher in a hallway. The ICU director is very good about coming in when needed, OR/PACU is a totally different matter.

[CrunchRN, ADN, RN]

I think the issue is NOT that they moved the pt to the ER, but that they did not relieve the ER nurse of part of her patient load so that she could safely care for a patient that needed intensive care level of nursing. How could she do that with 7 patients?

[hogan4736, BSN, RN]

I see what you mean Angie...

I would not want my MS nurse titrating dopamine...

What I am referring to is, in a code situation, ANY nurse can push epi, regardless of ACLS standing...

[NurseyPoo, RN]

Unfortunately this happens a lot... We have been full and the ER has had to endure patient's like this for us...There was a patient who was actually in a hold in the ER for over 24 hours a few weeks ago for the ICU that I work in... It is a reality that I hate see but...it is what it is. I would rather the patient be in the ER then on a floor without monitors, but I agree with a few of you regarding the relief. The supervisor should have relived the nurse getting this patient of at least 2 patients. One of the reasons I left floor nursing was because of the patient loads. Having 7 or more patients consistently! It is a horrible feeling to have such a responsibility and then to get a patient who is dealing with a heart condition...OUCH! The stress is awful for a nurse not to mention the poor patients and their families who have to see the nurse under such stressful conditions. It makes us look bad, no matter how you try and keep it together the stress always shows on your face. Especially to an anxious patient and family.

[withasmilelpn]

Really, nursing everywhere needs to be staffed based on acuity. I'm just a LTC nurse but they keep putting tons of skilled patients on my floors with rehab needs and PICCs etc.. because there is no room on rehab. I've worked rehab and I like it but the reason why you carry such heavy loads in LTC is because they are not supposed to require huge amounts of time to care for. Patient care suffers period. They need to listen when we say this is not safe. We are not being lazy! We are advocating for our patients!