Unstable Patients on MedSurg

Nurse Beth, MSN · Oct 31, 2017

Dear Nurse Beth,

I work on a medical floor. We have a 7:1patient nurse ratio. The acuity levels are very high at times with transfers from ICU. We have no continuous monitors.

I am stressed to the 9s at times over unsafe situations for pts that are still by my definition "unstable". Management. always has a Monday morning quarterback excuse to justify the incident reports and death rates on our floor. Usually telling me that there was a consensus among the MDs that pt was ok on our floor. At what point should a nurse who is a staunch pt. advocate speak out and to who?

Dear Unsafe Patient Care and Staunch Advocate,

That is such a bad problem and a good question, my friend. It's exactly what I see- high acuity and unstable patients on a MedSurg floor.

I work in California, so at least the patients have some protection under ratios- five patients. I can't imagine having seven patients.

Examples

Here are just a few all too common examples:

Patient transferred up from ED or ICU and condition doesn't match hand-off report
Patient on "remote tele" and goes into uncontrolled afib, requiring intervention
Patient with early signs of sepsis remains on MedSurg
Workload too high- hourly fingersticks, inappropriate drips or meds requiring frequent vital signs, close observation (chemo infusions)
Post-op continuous bladder irrigations requiring hourly I&O
High patient turnover- patient transferred/admitted to floor only to be discharged during the same shift

Put Responsibility on the Provider

When you assess that your patient is unstable, call the provider and be persistent.

"The heartrate is 112 at rest, the white count is 18,500/mm3, and the lactic acid is 5. Would you like your patient transferred to a higher level of care?"

If you meet resistance:

"How often would you like the vitals signs checked? and "Please give parameters for when heart rate, blood pressure and SP02 should be called"

Your intention is to write these as an order.

It's one thing for a doctor to say "They can stay on MedSurg"

It's another for a doctor to say "Don't call me for an SP02

Use Resources

Utilize your Rapid Response Team and enlist your charge nurse when your patient is unstable.

If you are tasked with hanging blood, taking frequent vitals, passing meds all at the same time, ask your charge nurse for assistance in prioritizing. It should be clear you cannot do all these things safely at once.

Your manager is not standing up for safe patient care and there is undoubtedly pressure on her/him to maintain the status quo. Ask your manager if there is an acuity tool used to determine patient placement.