Vent: Downgrading patient from ICU status

[ukjenn231]

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]

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?

[anotherone, BSN, RN]

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]

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]

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!

[Bruce_Wayne, ASN, RN]

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]

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]

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]

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]

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.

[AuNaturelle]

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]

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.