0540 86y/o F admitted to acute psych ward for Maj. Dep calls to desk, states "I just don't feel right". Skin warm, pink, dry. Vitals 132/80-98.3-86-24-89% RA. Lungs with crackles throughout. Alert and oriented x3.
0542: Covering doctor paged, orders to send to ER for evaluation recieved.
0543: ER notified, instructed to send pt down in "whatever's most comfortable" (stretcher, wheelchair, etc)
0544: Returned to pt's room to find a decreased LOC, VSS. Color pale. Turns heads and looks at you when you speak. (Here's where I got a bad feeling- we packaged her up in the cardiac chair and sent her to the ER). Made a stop at the nurse's station- I wanted O2 on her, but beceause we're a psych ward, we don't stock O2 supplies.
0545: CNA takes concious pt to ER. ER notified of pt's change in status.
0546: Resp. arrest called.
This pt's BNP was over 1800. She's now intubated in the ICU.
I, on the other hand, was berated by the Nurse Mgr. in the ER as well as the supervisor for not calling a code and following the patient to the ER. Our psych ward is 5-7 minutes away from the rest of the floors, and at night, it's only staffed with 1 RN and 1 CNA. If I'd left the floor, I could've been charged with abandonment. I felt it necessary to get this patient to the ER where she could get a higher level of care than I could provide with limited resources.
What do you all think? I'm a bit discouraged- I was told that I have "poor judgement" and I'll be spoken to by legal tomorrow.
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.
Impeccable diagnostic skills- Pt's ICU admission dx was left sided heart failure and flash pulmonary edema.
ER because the pt's physician was out of town and the covering doctor hadn't been around to evaluate her, so rather than giving an order, he wanted a physician to evaluate before treating.
Forget the lasix part. I just remembered, if you are on a psyche unit then your patients would'nt have IV's either. Your only option would be to get them down to the ER/ICU (No 02, no monitor, no IV, no drugs). Even if you
had called a code, what is the chance that they would have responded with
a crash cart?
Why would they put a 86 y.o. on the psyche floor for major depression? You would thinnk that she would be on the medical unit. There are a lot of things questionable about the scenerio but its definitely not you.
Well, apparently I am the only one approaching this situation from an ICU/ER nurse's point of view. I understand that you had limited supplies and limited support as far as staffing, resources, etc.... I think the part that really got me is that not only was the declining patient moved at all without first being stabilized, but was sent with a nursing assistant to the ER. Yes, you absolutely did the right thing by not leaving your other patients, but by sending a patient who was taking a turn for the worse off of the unit without a nurse puts your license in jeopardy just as much. I worked at a hospital where our psych unit was in a completely separate building, across a parking lot and up a hill. If there was ever a situation like this, the code team would have run across the parking lot and responded to the patient.....the patient would have never been wheeled across the parking lot to the ER, especially by an NA. I have never been to a hospital that does not have some form of a code team and/or fully stocked code carts on every inpatient unit. If this is truly the type of environment you are working in, then something needs to be done because it is placing your patients in danger and placing your license in jeopardy. Even if the patients in your unit must be medically cleared before coming in, it is still unheard of not to have backup emergency equipment available in an inpatient setting. I suggest you definitely talk to your nurse manager and/or supervisor about getting a fully stocked code cart in your unit ASAP in order to prevent something like this from happening again. Best of luck to you!
I spoke with her twice prior to the pt's arrival in the ER, and guess what? I charted it, too.
Should have, could have, and would have.
This could be picked apart over and over, but basically, I think she did the best she would with what she had.
No it may not be "by the book" but how many incidents that actually occur ARE these days?
Is it her fault there was no crash cart, no o2?
Yes we all agree that stabilizing the patient is first priority but she had nothing to work with, she did what she had to do.....I think she deserves a little credit, myself.
I'm not going to try to argue the point...however, please listen to your coworker about union representation during a reprimand.
I have not read through all of the replies. To protect my butt, I would also talk to an attorney in case the situation gets ugly. There is nothing like having an attorney in your corner when dealing with a hospital administration that, it seems, set you up to fail. JMHO.
Specializes in Geriatric Psych, Physicians office, OB,.
The psych unit where I work has oxygen supplies, but they are kept in our locked procedure room. Does your unit not do medical screenings before admission? New admits for our unit are usually sent through the ER for a medical clearance before admission. But we have to have an RN and a LPN on the night shift. What state do you work in? Sounds like to me you did the right thing. Why call a code on a conscious patient with stable vitals? I agree with most of the posters above.
I think you did the best thing you could've done under the circumstances. Maybe it would've been better to ask if the ER could send someone to pick her up, but I don't think time would've allowed. Overall, you showed quick thinking and reacted quickly to a patient deteriorating, so you have good skills.
As far as no equipment, that's a separate issue. I would have Admin get on that and fast.
This morning I spoke with legal, only to find out that this is the SECOND CODE that this has happened. When I got to my floor, the nonbrebreather I requested wasn't even there.
Anyways. The pt's only sat-ing mid 80's on a vent- so... who knows. But at any rate, I also got an apology from the Nurse Mgr in the ER for jumping down my throat- not needed, but appreciated.
As for the poster's question on whether our patient's our medically cleared-
well, they're supposed to be, but ti's been a huge problem by this woman who's running the program...she goes "fishing" for patients to fill beds, and then never informs medical of their admission...she doesn't work for the hospital, but rather an outside organization, so despite the staff's complaints, the hospital isn't easily able to just let her go. I know since I've been filling in there, we've had about 8 patients taken stat to the ER- one actually had a heart attack before anyone did anything, because she was "attention seeking" and everyone thought everyone else had alerted medical. *sigh*
Wow. It sounds like there are some serious issues at this hospital. It's a very unsafe work environment, and unless the powers that be intend to fix it, I'd be looking for another job.......:angryfire
Armchair quarterbacking is always easy to do, but it sounds like you did what you could do with the limited resources you had and the unbelievably quick decline that this patient had.
Wow. It sounds like there are some serious issues at this hospital. It's a very unsafe work environment, and unless the powers that be intend to fix it, I'd be looking for another job.......:angryfire
Armchair quarterbacking is always easy to do, but it sounds like you did what you could do with the limited resources you had and the unbelievably quick decline that this patient had.
that this has happened. When I got to my floor, the nonbrebreather I requested wasn't even there. 
cnolan
75 Posts
Impeccable diagnostic skills- Pt's ICU admission dx was left sided heart failure and flash pulmonary edema.
ER because the pt's physician was out of town and the covering doctor hadn't been around to evaluate her, so rather than giving an order, he wanted a physician to evaluate before treating.