What Would You Do?

WVUturtle514 · Feb 23, 2006

I'm not trying to upset the apple cart here, but I have a couple of comments. Crash carts are generally dispersed throughout every hospital, including areas that are not directly related to patient care (i.e., cafeterias, etc...). Surely there is a crash cart on your psych unit that contains an oxygen tank and O2 supplies (which this patient obviously needed). Even though this patient was supposed to be sent to the ER, there was an obvious emergent change in patient status, at which point (seeing as how you were the only RN and had no backup) a code should have been called immediately. A patient does not have to be in cardiac arrest in order for a nurse to call a code. At every hospital I have worked at, a respiratory arrest is also considered a code. Once the code had been called, you would have had backup very soon, including nurses, MDs and respiratory therapy. I don't believe that under ANY circumstances, should this patient have been sent ANYWHERE until she was stabilized, especially not without an RN present. If the patient's status had not changed before you sent her off the floor that would have been a different story, but the fact that you witnessed and documented an acute change in LOC and VS and still sent the patient off the unit with an unlicensed personnel, is unacceptable and I do not believe that it was using critical thinking skills at all. I'm really not trying to be rude or mean here, but I completely understand why you got reamed a new one by the nurse manager. Anytime there is an emergent change in patient status, you should never just "send the patient off" without first being evaluated by a physician. It doesn't matter if the patient was supposed to go to the ER or not, you're darn lucky that the patient actually made it to the ER before they truly did code (cardiac and respiratory arrest). Hope I'm not being too harsh....just my two cents. Best of luck to you!

cnolan · Feb 23, 2006

Thanks for all your comments- greatly appreciated. My hospital staff 28 people on night shift- we had a total of 35 patients in the hospital last night when the incident occured. Our Code Team response time is roughly 7 minutes (and about 8 or 9 to the psych unit, due to location), and the only in-house physician is our ER doctor. We do have a crash cart- but with minimal supplies to code patients, as they're deemed medically clear before coming. I had a full O2 tank...but no O2 delivery devices to be found. (ER aware, I was told to "make out an incident report".

Perhaps I should've called for assistance, but in the split seconds I had, I felt it more prudent that she get to a higher level of care, as her VS were stable (see first entry). The only change in her was a pastier color and a decreased LOC.

This afternoon I was called by a coworker who had heard the story- she encouraged me to speak with our union rep r/t the administration not being allowed to reprimand an employee without a union rep present (I, on the other hand, am not into making waves...so, I don't know). Anyways. I'm on my way in now- I'll let you all know what happens.

Town & Country · Feb 23, 2006

Anytime there is an emergent change in patient status, you should never just "send the patient off" without first being evaluated by a physician.

Completely disagree, the nurse did what she should've done, keeping her there on the psyche unit waiting for more personnel would have endangered her further; she needed transfer to the ER.

If I was her, I would not back down.

LilPeanut, MSN, RN, NP · Feb 23, 2006

I'm a nursing student and PCA - and so I'm approaching it from that perspective.

In my hospital, non-licensed personnel are not allowed to transport unstable pts. I think calling a code and getting emergency supplies ready would have been prudent. What if the pt. had gone into resp. arrest on the way to the ER? Get the pt. into a bed, call for help and prepare for an acute problem.

Town & Country · Feb 23, 2006

getting emergency supplies ready would have been prudent.

What emergency supplies, she didn't even have o2 to put on her........!

WVUturtle514 · Feb 23, 2006

Completely disagree, the nurse did what she should've done, keeping her there on the psyche unit waiting for more personnel would have endangered her further; she needed transfer to the ER.

100% absurd. While I understand that this is a small hospital with limited personnel and only one MD, I cannot believe that you think that sending a patient (who is going down the drain) on a 7-9 minute trip to the ER with a nursing assistant is not considered endangering the patient. First of all, we should start with basic life support (taught in nursing school and any BLS class) which is A-airway, B-breathing, C-circulation. This patient had a decreased LOC, was initially 89% on RA with crackles (which shows that the patient did indeed have co-morbidities, even if they were undiagnosed) and whose skin is pale. Obviously, this patient is either not oxygenating or not ventilating, in which case A for airway takes priority. I completely agree that this patient needed a higher level of care at this point, but to send the patient off the floor with a nursing assistant!!! Are you kidding me? I worked in a level 1 trauma center ER and every single patient who came in with a change in LOC immediately got put on a monitor. And in any hospital I've been in, patients on monitors are NEVER to be transported by unlicensed personnel only....they must always be accompanied by a nurse or MD. Instead, open that crash cart and pull out an O2 mask, because I'm pretty sure that any hospital (whether on a psych unit or not) is going to have basic airway supplies in all of their crash carts (once again, A for airway comes first). What if the patient would have crashed on the way to the ER? While I completely respect the job of a nursing assistant, they are not nurses and they are not trained or licensed to assess patients and stage interventions. This patient, "conscious" or not, was unstable and should not have been moved under any circumstances, let alone by someone who is unlicensed. I just don't understand how you think that sending the patient off the floor with an NA is safer than keeping the patient on the floor and administering O2 and basic support until further help arrived. And on another note, "if" the crash cart that was available did not contain O2 supplies (which I cannot fathom), it still would have been more prudent to send the NA hauling a$$ to another unit to get O2 supplies rather than sending the patient on a 7-9 minute gurney ride unattended by an RN. I'm very sorry if I am coming across as rude here, I promise I am not trying to do so. You went to nursing school for a reason, you have BLS (and ACLS perhaps) for a reason, don't be afraid to use your common sense. In the ABC's it seems that T-for transporting the patient to another unit, would come almost dead last. Getting the patient to the ER isn't going to be very helpful if the patient is already dead when they get there b/c they coded on the way and the NA didn't know what to do or have any help.

clee1 · Feb 23, 2006

100% absurd. While I understand that this is a small hospital with limited personnel and only one MD, I cannot believe that you think that sending a patient (who is going down the drain) on a 7-9 minute trip to the ER with a nursing assistant is not considered endangering the patient. First of all, we should start with basic life support (taught in nursing school and any BLS class) which is A-airway, B-breathing, C-circulation. This patient had a decreased LOC, was initially 89% on RA with crackles (which shows that the patient did indeed have co-morbidities, even if they were undiagnosed) and whose skin is pale. Obviously, this patient is either not oxygenating or not ventilating, in which case A for airway takes priority. I completely agree that this patient needed a higher level of care at this point, but to send the patient off the floor with a nursing assistant!!! Are you kidding me? I worked in a level 1 trauma center ER and every single patient who came in with a change in LOC immediately got put on a monitor. And in any hospital I've been in, patients on monitors are NEVER to be transported by unlicensed personnel only....they must always be accompanied by a nurse or MD. Instead, open that crash cart and pull out an O2 mask, because I'm pretty sure that any hospital (whether on a psych unit or not) is going to have basic airway supplies in all of their crash carts (once again, A for airway comes first). What if the patient would have crashed on the way to the ER? While I completely respect the job of a nursing assistant, they are not nurses and they are not trained or licensed to assess patients and stage interventions. This patient, "conscious" or not, was unstable and should not have been moved under any circumstances, let alone by someone who is unlicensed. I just don't understand how you think that sending the patient off the floor with an NA is safer than keeping the patient on the floor and administering O2 and basic support until further help arrived. And on another note, "if" the crash cart that was available did not contain O2 supplies (which I cannot fathom), it still would have been more prudent to send the NA hauling a$$ to another unit to get O2 supplies rather than sending the patient on a 7-9 minute gurney ride unattended by an RN. I'm very sorry if I am coming across as rude here, I promise I am not trying to do so. You went to nursing school for a reason, you have BLS (and ACLS perhaps) for a reason, don't be afraid to use your common sense. In the ABC's it seems that T-for transporting the patient to another unit, would come almost dead last. Getting the patient to the ER isn't going to be very helpful if the patient is already dead when they get there b/c they coded on the way and the NA didn't know what to do or have any help.
Please reread the entire thread; including the statement of no crash cart, no O2 delivery apparatus, the only licensed person in the unit, etc. etc.
If the pt had stayed where he/she was, he/she would likely have died. Calling a code would not have appreciably increased the chances of survival (d/t response time for help, lack of supplies, etc.) Calling EMS to come for the pt and take them around to the ER was an option; however, we can all see now that the pt likely would have expired prior to their arrival anyway. The only viable option was to send the pt to a higher level of care poste haste; by the quickest means available, without compromising the rest of the pts in your care.
Hindsight is 20/20, or so they say. I'll tell you that it is not so clear-cut when you are making life-or-death decisions in real-time with very limited options.

cnolan · Feb 23, 2006

Please reread the entire thread; including the statement of no crash cart, no O2 delivery apparatus, the only licensed person in the unit, etc. etc.
If the pt had stayed where he/she was, he/she would likely have died. Calling a code would not have appreciably increased the chances of survival (d/t response time for help, lack of supplies, etc.) Calling EMS to come for the pt and take them around to the ER was an option; however, we can all see now that the pt likely would have expired prior to their arrival anyway. The only viable option was to send the pt to a higher level of care poste haste; by the quickest means available, without compromising the rest of the pts in your care.
Hindsight is 20/20, or so they say. I'll tell you that it is not so clear-cut when you are making life-or-death decisions in real-time with very limited options.
Thank you Clee- I was starting to feel completely incompetant after hearing "Don't be afraid to use your common sense".

clee1 · Feb 23, 2006

Thank you Clee- I was starting to feel completely incompetant after hearing "Don't be afraid to use your common sense".
Anytime cnolan....
I am only an LPN student now, but I was an EMT-I a long time ago. I have had to make the choice, numerous times, between a mad scramble to the ER, or pulling into a parking lot to try to save a code.
I've been there: riding an EMS unit (not my own) w/o defibrilator, cardiac meds, wrong sized O2 mask/cannulae, etc. etc.; trying to decide what to do with a pt going sour.
ALWAYS use your best judgement. Take all options into account and do what you think is best. As for your supervisory team, if they want to make the tough calls, then they should be there to make them on the spot; not coming back on you (to cover their own assets, IMO) after the fact for doing the best that you could under crappy circumstances.

leslie :-D · Feb 23, 2006

was the pt. in question, on the psyche unit for a few days as she deteriorated from clear lungs (on admission) to crackles throughout, a few days later? did no one notice this decline, a change in ms, rr 24?

leslie

The Sphynx · Feb 23, 2006

I got 4 questions:

1) Why did'nt the physician order lasix?

2) Where was the house supervisor?

3) Why the ER and not the ICU?

4) Why don't they have a crash cart?

Intersting. ....Interesting. Sounds like there are bigger issues here?

Psyche units are not treated the same as medical units. Never mind that some psyche issues are biological in nature (like bipolar illness). There is a disconnnect there within the system.

Anything that fast sounds left ventricular to me (could possibly be new also)

I don't see what your options were. You made the call and you did'nt have support available. I'm not approaching this from an ER or the ICU perspective for reasons of discussions.

cnolan · Feb 23, 2006

was the pt. in question, on the psyche unit for a few days as she deteriorated from clear lungs (on admission) to crackles throughout, a few days later? did no one notice this decline, a change in ms, rr 24?
leslie

I myself had assessed her 5 hours prior when I came on my shift, her lungs were clear, RR 18, A&O x3. Two days prior nursing staff had documented pitting edema in her feet.

Even now...I STILL cannot get over how quickly things transpired.

Coming on to my shift tonight, I spoke with the psych unit NM who had spoken with the ER's...who offered sincere apologies- she "wasn't aware" of the conditions up here...which is ridiculous, because I spoke with her twice prior to the pt's arrival in the ER, and guess what? I charted it, too.