Why does ICU want to refuse the patient all the time?

[mikeworksRN]

Okay I'm on a tele unit and the MD orders ICU. I notify the House and the manager of the Unit. Right away I get the manager wanting me to have the nurse call the doctor to see if she can put the patient somewhere else. Or she asks what are the VS, is the patient symptomatic, etc; which I would assume the MD had already decided upon or he wouldn't have ordered a transfer.

I'm just wondering, I'm not disrespecting. I want to know why ICU managers are reluctant to take a patient with an order to transfer to ICU.

[Altra, BSN, RN]

For the same reason they refuse to take critical patients from the ER ...

[classicdame, MSN, EdD]

no doubt the unit has a finite number of beds and a policy stating there has to be a specific number of nurses per patient. Therefore, if a patient is being placed there who could go elsewhere, then when the ER or OR needs an ICU bed, there may not be one. Also, another nurse may have to be called in to take care of a non-ICU acuity patient. ICU nurses are the most expensive kind of floor nurse, so the Director has to answer for that. There are other issues to consider, but these stand out the most for me.

[JustinTRN]

I’m an ICU nurse and this issue is usually always over staffing and money. We have doctors so eagerly to place a patient in the ICU at my facility that either the ICU or nurse manager always goes and evaluates. Maybe the the BP is low but is the patient’s baseline and does not need the acuity of an ICU when the ICU bed could be saved for an more acute admission.

Also, if we get patients from the floor we make the ED hold patients until we can complete the admission or transfer. If the floor patient takes up the ICU bed it could prevent us from admitting an ED patient if we do not have adequate staffing this making the ED hold the ICU admission all night which we hate.

At my facility if all staffing get’s absorbed, because of ratio laws, the entire unit of staff gets penalty pay. Meaning every single nurse in the unit gets an extra 2 hours of free pay just for not getting a break. One thing I’ve learned is these matters are almost always about the budget.

[MissBrahmsRN]

ICU nurses are the most expensive kind of floor nurse,

really?? in my hospital system you are paid per years of service & that's it, paid the same hourly for OR, ER, ICU, med-surg, OB, etc.

or do you mean because of the low RN-pt ratios??

[Corey Narry, MSN, RN, NP]

Do you work in a hospital that has an intensivist service? If that's the case, you may not be getting the whole story in this scenario. Typically, when a floor patient goes south all of a sudden and a need for ICU level of care becomes imminent, the attending physician contacts the ICU physician or intensivist who then assesses the patient himself/herself and makes the recommendation for ICU transfer. After that, bed management is called and the transfer is arranged with the ICU nurse manager. Whatever arrangements are needed to accommodate the patient transfer are made such as calling in another ICU nurse to work, changing ICU nursing assignments, or transferring a more stable patient out of the ICU to the floor. The intensivist in this case performs one of traditional roles as the ICU triage attending.

There are guidelines followed in triage in order to decide whether a patient really needs an ICU bed or not. Certain medical diagnoses warrants an ICU bed right away such as someone with an acute MI with complications, cardiogenic shock, life-threatening arrhythmias requiring close monitoring and interventions, hypertensive emergencies, aneurysmal dissections, respiratory failures requiring intubation and vent management, neurologic conditions with risk for airway compromise, massive GI bleeds, post-op patients who are at risk for hemodynamic instability, etc. With the absence of a diagnoses, other objective findings can be used as criteria for ICU admission such as vital signs (HR less than 40 and greater than 150 with symptoms, hypotension, tachypnea), respiratory distress, and abnormal labs with life threatening consequences. It's not always the case that the ICU just doesn't want the patient for no reason. ICU level of care is expensive and requires a lot of resources so it's always best to reserve admissions to those patients who actually require the service.

[cbc1147]

I find it the opposite in my hospital. We take some patients off the floors for ridiculous reasons. For example, a floor nurse gave a medication that made the patient hallucinate with no other problems, besides a hip fracture. He was in ICU for 1 hour, then it took another 6 hours to get him back to his original room up stairs. Guess what time it was? Yup shift change. We can never get patients to go upstairs to tele, ortho or med/surg floors, until about shift change. Its a big problem in our hospital, it is really a headache.

Maybe your facility has experienced the same situations and that's their response to combat it; albeit, not the right one.

[nurseprnRN, BSN, RN]

another factor is that there are some physicians who don't trust floors for one reason or another (the reasons can be good ones to ... oh, just bizarre), and figure their patients will get better care where the patient:nurse ratio is smaller. so the nursing department has implemented a policy that criteria must be met before transfer is accepted. it's really aimed at one physician or practice group as a behavior-modification tool, but it's applied to everyone.

[umcRN, BSN, RN]

really?? in my hospital system you are paid per years of service & that's it, paid the same hourly for OR, ER, ICU, med-surg, OB, etc.

or do you mean because of the low RN-pt ratios??

depends on where you are then. At my hospital the ICU nurses get a critical care differential, a few dollars more to the base pay if you work in an ICU

[kessadawn, BSN, RN]

I hear of this a lot, ICU doesn't want the patient, the floor doesn't want the patient, and I don't understand. At my hospital, we just admit, we don't raise a stink, none of us, not the floors, not my PICU, not the other ICUs, not ER. Patient goes where the doc wants. Maybe it's because we work in a pediatric hospital? Now I have had a kiddo come in and our intensivist decides the are much more stable than the outlying hospital originally presented, so they then go pretty quickly to the floor, but that's it. Is this a problem all of you are seeing?

[Altra, BSN, RN]

no doubt the unit has a finite number of beds and a policy stating there has to be a specific number of nurses per patient. Therefore, if a patient is being placed there who could go elsewhere, then when the ER or OR needs an ICU bed, there may not be one. Also, another nurse may have to be called in to take care of a non-ICU acuity patient. ICU nurses are the most expensive kind of floor nurse, so the Director has to answer for that. There are other issues to consider, but these stand out the most for me.

I believed this too, until I worked in the ICU ...

[MomRN0913]

It's not that someone doesn't "want" the patient. Acuity guidelines often aren't followed. We have doctors admit that they put their patients in our ICU because they "feel better" having them there.

The ICU has a certain ratio and a certain amount of nurses. If a patient codes, there is an ER or PACU admission, you need ot make sure your beds are being utilized efficiently. There are only so many nurses in the hospital that can take care of an ICU patient. We have had a case where a bed was taken for a patient on tele who simply needed a bolus.... then someone coded and was tubed on the floor and one of our nurses had to give up her 2 patients to go take care of that patient until a bed became available.

The manager is doing right by questioning the paitent's acuity I believe.