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Vent: Downgrading patient from ICU status

Posted

I'm a med/surg tele nurse by origin, but I also float in ER, ICU, as well as all of the floors.

One thing that irks me more than anything is being asked by management to call a physician and ask to "downgrade" a critical care status patient to a tele floor. Especially when the patient has just received admission orders for critical care. I understand the necessity of opening up unit beds when there are more patients than rooms and prioritizing, but this is how I feel.

1. If the doctor wants them on tele, they would have ordered admit to tele or transfer to tele.

2. If something happens to the patient when they are sent to the floor, then the doctor's going to be all mad at me because I called and asked.

3. There is no true step down or progressive care here so there is a huge difference between a 1:2 nurse-patient ratio and a 1:6 nurse-patient ratio.

4. Why can't management or especially the charge nurses, who have a better relationship with the docs, call instead of ol me, the float tele nurse who walks into a new shift and is pressured to call for downgrade orders?

OK that's my vent... And yes I have told management and charge nurses before I wasn't comfortable with doing this and they tell me, "Oh, just throw it off on administration making you call..." Yeah, well I still get chewed out, not administration.

Tait, MSN, RN

Specializes in Acute Care Cardiac, Education, Prof Practice. Has 14 years experience.

If they need beds open then it is the charge nurses responsibility, along with supervisors, to manage that, not someone there to help them when they are short. Does your home floor manager have any advice?

I am nust a med surg nurse but for requests like that , I just ignore them. If they want it done they can do it. How about you page the dr to speak with the person requeating it?

VICEDRN, BSN, RN

Specializes in ER. Has 5 years experience.

As an ER nurse, the arrogance of these people just stuns me. As though the MD just doesn't really want the patient on the unit or as though their own judgment is somehow more appropriate than the person writing the orders. The MDs I see at the teaching hospital are trained to specifically not respond to outside pressures on their choice of care for the patients and this is why. Its completely unreasonable to expect "borderline" ICU/tele patients to be moved to a 1:6 unit.

PediLove2147, BSN, RN

Specializes in Pediatric Cardiology. Has 7 years experience.

I agree. I don't work ER but if a patient is "borederline" they should be in the ICU if you don't have a step-down option. That is unsafe!

I agree with your vent and I hope that I have enough courage and insight to advocate for my patient in such a thoughtful and caring way if I'm ever in a similar situation!

CodeteamB

Specializes in Emergency. Has 5+ years experience.

The scenario you describe is unacceptable. Once a patient has been assigned a service and ordered to go to a specific unit it is the job of administration to find a bed for the patient, not to try and work around it. If they have a valid reason I downgrade the patient they had best be discussing it with the physician themselves.

It is absolutely not fair for a tele nurse who may have 5 patients to take a patient who meets ICU criteria, no matter how inconvenient it may be for bed placement.

Aurora77

Specializes in Med Surg. Has 4 years experience.

It is absolutely not fair for a tele nurse who may have 5 patients to take a patient who meets ICU criteria, no matter how inconvenient it may be for bed placement.

Not only is it unfair to the nurse (who will be blamed for any harm that may come to the patient due to improper placement), it's not fair to the patient. It's just asking for patients to be hurt or killed due to administrative negligence. You would think the legal department would be all over this. Of course, it may take a patient death and subsequent lawsuit for anything to be done.

Double-Helix, BSN, RN

Specializes in PICU, Sedation/Radiology, PACU. Has 10 years experience.

I agree. I work in a 19 bed PICU. Usually we have a census between 8 and 14. But one particular day we were very busy and literally every bed was filled. We got a call from the ER for a patient needing admission and we told them that we were full. Of course, the admin supervisor for that shift came straight to the unit. Again, we explained, "We have no open beds. We are full." His reply was, "Well, let's get some of these kids to the floor." Our charge nurse's reply was, "Okay, which child's care would you like to compromise to make room for another" The supervisor said, "Well, that's not what I'm saying." She replied, "That's exactly what you're saying. These kids need to be in the ICU. They aren't going anywhere." And they didn't.

Caffeine_IV

Specializes in LTC, med/surg, hospice. Has 7 years experience.

If they want to send critical care patients to the floor, they should send an ICU nurse along with them.

What does happen to patients needing an icu bed when none ate open? Do they just stay in the ER.

Downgrading the level of care to me is as bad as admitting a patient to general medical floor when they need telemetry just to "save" beds.

I've had to do this before (calling a physician to get the ok for a patient to get SD/Floor orders) BUT the patients are stable enough to go to the floor.... usually if no bed is available and ER needs to book then we simply say we have no available bed and that ER is going to have to manage the patient until one becomes available OR if we have someone who is stable enough to move out to the floor, then we go that route. ER/Admitting hates it but what can you do if there is no bed?

CodeteamB

Specializes in Emergency. Has 5+ years experience.

What does happen to patients needing an icu bed when none ate open? Do they just stay in the ER.

Yup. I have also had the ICU residents play LOC roulette with patients: "stop the propofol and if she bucks the tube we can probably extubate and sign off to medicine."

Um, yeah, fantastic! I'll just set up an alter and pray to all that's holy that we don't get a trauma or cardiac arrest rolling up in here that needs the ER bed. And this when the ICU isn't even full.

But that's a whole other thing.

rnlately

Specializes in LTC, Acute Care. Has 6 years experience.

If they want to send critical care patients to the floor, they should send an ICU nurse along with them.

What does happen to patients needing an icu bed when none ate open? Do they just stay in the ER.

Downgrading the level of care to me is as bad as admitting a patient to general medical floor when they need telemetry just to "save" beds.

We get this a lot where I work. I work tele/acute and we get a lot of unit patients before they are ready. Our ratio is also 1:6 and I usually keep my fingers crossed praying nothing serious happens to the unit patient. While I effectively try to manage my whole team. Dangerous situation.

Double-Helix, BSN, RN

Specializes in PICU, Sedation/Radiology, PACU. Has 10 years experience.

Our Peds floor doesn't even have monitors, so sending an ICU patient there, even with a nurse, really isn't a good option for us. The patient stays in the the ER (where they have monitors and are more prepared for an emergency) until we can admit to ICU.

ChristineN, BSN, RN

Specializes in Pediatric/Adolescent, Med-Surg.

I work ER and frequently when all of our ICU's are full we will be the "code bed" for the hospital, meaning if a floor pt coded they would come to us instead of going to ICU. We also occasionally board ICU pts.

When I worked med-surg I was also in the position where the ICU had sent a pt out too early and the pt had decompensated, but they did not have room and would not take her back. That was not a safe night

missej2002

Specializes in ER.

I have seen both sides of this working in an ED. The only time that ever asked a doctor to downgrade is if the pt is stable. I have seen so much insurance fraud that it is crazy, pt's being admitted med tele that does not need a tele; pt has not been on tele since in the ED and doc didn't even order an EKG, but the pt is admit with tele orders, how do you justify this fraud, and lets not forget the pt's admitted for observation, majority of these admits are fraud.

HouTx, BSN, MSN, EdD

Specializes in Critical Care, Education. Has 35 years experience.

In the US, every hospital that is accredited by the JC must have formal Admission & DC criteria for ICUs and other specialty care units (burn, Behav health, etc). Make sure you are familiar with those criteria. If it is not a 'disaster' situation and anyone is trying to DC a patient from ICU & that patient does not meet DC criteria - it will open up the potential for huge liability for the hospital & for the physician who OKs it.

Policies are your friend. If all else fails, just go all passive-aggressive and refuse to take actions that are not covered by hospital policy.

hodgieRN

Specializes in ER trauma, ICU - trauma, neuro surgical. Has 10 years experience.

I think it's a little different from this side. If there's a pt with multiple trauma and gtts vs the guy that's there because his hemoglobin is a low, well, one pt takes priority for the bed. I totally agree if there are open units beds, but docs will send pts to the unit so they won't get called at night for a tylenol order. They will send a pt to the unit and then ship them out first this in the morning (8 hrs later). The ER isn't supposed to be a holding area for unit pts. You can't let an ICU pt sit in ER for 8 hrs because some pt who is confused in restraints will be better monitored in an ICU bed. Where I work, I don't see pts being send out that are truly critical. But one doc in particular... I'll ask "Can we move this guy out. We aren't really doing anything." He tells us to keep the pt there so we can see to it that the pt gets physical therapy. Meanwhile, there's an ER pt that got ran over by a boat. We get bogus admissions too.