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.

[SHURN]

well, the admit I got tonight is a good example. I get in report that the pt is on a NRB, HGB 7, ? GI bleed. Was med surg, but pulmonary wanted ICU. No prob, It sounds warranted. So I get the pt. He is on 6 L NC, sats 100%, BP 120/60, HR NSR. A/O. I call the primary for a few things and ask (not rudely or in a presumptuous manner BTW) why this pt is ICU. I know the pulmonologist and totally trust him, but just curious what I am missing. Turns out he got a call from our bed management that they felt the pt needed ICU and a pulm consult. Well apparently bed management never talked to the ED nurse and the ED RN did not question this decision. So now, we have med surg orders again and yet another transfer for this poor man who has been sitting in ED all day.

Obviously this is a problem on many levels, but inappropriate admissions are an issue when we have only 2 open ICU beds at that point.

[OkieeRN]

I am not a PICU nurse but a PACU nurse. I work at a teaching hospital so many times the doc writing the orders is a resident. Many times residents tend to overreact in where to place the pt. Because the pt will be watched so closely in PICU they like sending them there. I see the need for the PICU to question the transfers. At least at my facility.

[Deb123j]

I have been on both sides. A floor nurse for 3 1/2 yrs and in ICU for 1/2 year.

I had a patient with some mild issues, called the hospitalist and he demanded I send the patient to the ICU. I can't remember specifics, but this was totally unnecessary! I spoke with my charge nurse, who spoke with the administrative officer, who spoke with the doctor. He still wanted to patient to go to the ICU. *I believe this was the last open ICU bed in a very large hospital* The administrative officer wanted me to give it another try with the doctor, so when he called me with a question I asked, "Do you REALLY want me to send this patient to our only ICU bed for xyz problems???" He recanted, the patient stayed and was fine.

I agree with the comment from somebody else that stated that some docs just don't trust floor nurses and think the patient will get better care in ICU.

　

　

　

[blondy2061h, MSN, RN]

We have some doctors who are very eager to send patients to ICU, which is obnoxious because I work on a unit with a 1:3 nurse:patient ratio, with full cardiac monitoring capabilities, where we're allowed to give pressors. An NP wrote orders to transfer a patient with a bp of 80/40 to ICU, when fluid boluses hadn't been attempted yet, but less pressors.

[umcRN, BSN, RN]

I work in a children's hospital. Children cannot go to the floor if they need more than 3L high flow nasal cannula, so sometimes there are otherwise stable kiddos who just take a long time to wean, sitting around in those ICU beds. I also worked in the NICU, mind you a children's hospital NICU so all our babies came in from elsewhere and we would take kiddos up to 3mos...sometimes older if the picu was full, and our docs would NEVER send a baby to the floor once they were nearing discharge, even though there are plenty of babies on the floors as well, once in our nicu thats where they would stay until discharge. And i'm not talking finicky preemies but the full term two mo old who comes in respiratory failure, gets better and is just poking his way through a bottle, stays until its time to go, however if he had presented to the er with mild cold symptoms, he would have been admitted to the floor

[meandragonbrett]

Coming from the perspective of a critical care supervisor who oversees 70 ICU beds on shift......

Beds are a valuable resource in the facility and must be used appropriately. We use a "Triage" type system to determine and sort through the ICU bed requests. We have certain physicians who are notorious for admitting their patients to the unit because they know the unit nurses won't call them in the middle of the night over things.

Our critical care areas have admission criteria and one of the criteria MUST be met for admission to one of the ICUs. It's not always an issue of "The ICU doesn't want the patient" The time and resources of the ICU are valuable and very expensive on the hospital budget and we have to use those resources for patients who are appropriate to be admitted to critical care. You'd be amazed at some of the ICU bed requests we receive. It's generally the repeat offenders that do this.

[hiddencatRN, 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??

Even if the base pay is the same, the ratios make them more expensive.

[cherrybreeze, ADN, RN]

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.

Bolding is mine: Maybe I'm in the minority, but I've never worked with a doc who transferred a patient whose low BP was their BASELINE BP. Pretty obvious that that isn't a concern?

What bugs me is, getting an order to transfer to ICU and have to fight and fight with the nursing supervisor about it. As if they know more than the doc, etc. A lot of times they have no CLUE, where we, as the floor nurse, have spent all day with the patient and KNOW they need to move. Doc has been called several times, been in to see patient, and ALSO knows they need to move. I don't think you can have "set" criteria that MUST be met. Patients aren't always going to fit in neat little categories. It doesn't mean they don't need to be moved.

[Tait, MSN, RN]

I had a patient sinking into a hole with flash pulmonary edema, am shift change. I got orders from the am doc to transfer her to ICU. I called to get a bed and was given the third degree by the RRT. Supervisor did the same thing. After about thirty minutes the family came up and made her a DNR because they had "discussed" with the night MD that they didn't want extraordinary measures when he originally wanted to send her to ICU. (Though no one bothered to make her a DNR at that time)

I called the sup back to let them know I didn't need the bed anymore and was greeted with "oh well I am glad I was dragging my feet on that one anyway."

I think the most frustrating part of the whole transfer situation is the attitude that 1.) We don't know what we are doing. 2.) We are somehow responsible for the docs choice. 3.) Our patients aren't important enough to be transferred.

I understand it is a rock and hard spot. I get it. Just wish we didn't have to take it out on each other.

Tait

[MissBrahmsRN]

oops wrong thread