Would you send this patient to the unit?

[Birdy2]

Patient gets sent to me after getting report and learning that she was dehydrated with acute kidney injury. Vitals stable, but labs were a little off.

Ok so the patients slow but she's a&o. Within 30 minutes new labs came back. BUN 112, Cr 11.7, Ca 6.6, K 2.4, Na 109, C02 13. I had orders to give her NS @ 100, 40 PO K, and really nothing else. The K, Ca, and Na were low before, but not that bad. I think Na was 120 in the ED. The patient had been in the ED since 5pm. She came to me at 10:30 pm. No consults had been called in that the ED dr had ordered when he saw the patient. There was a renal and cardio. So at 11:30 when the patients labs are called to me Im calling and waking up someone when they don't even know the patient. I got orders to transfer the patient to the SICU, but I had to fight with the supervisor for that bed. I don't understand why that patient was ever sent to my floor.

I get that we were out of beds and not enough nurses, but the paitient could have started having seizures and died while I was helping one of my other 5 patients. It just worries me that they're sending people to our floor like this and then we end up having to transfer patients all night. I just wonder if this is normal and happening other places. Sure is scary.

[eukaryote]

Our floor also accepts these types of medical patients as our hospital doesn't have a step down. The floor I work on hyponatremia is often managed (SIADH, etc..) I admitted a patient this weekend with a Na+ of 113, K and low Mag...can't remember what it was. These patients have to be managed closely, but as long as they are otherwise stable and assigned to an experienced RN, I would not send to the unit.

[SierraBravo]

I work step down and we are 5:1...I actually admitted a patient the other night with a Na+ of 112 - we just put up the seizure pads and had fluids running - by the time we transferred him to med surge he was up to 130.

The K+ of 2.4 would be more concerning (to me anyway) - especially since they only gave 40 mEQ of PO replacement. In my hospital that would buy you at least 4 K+ riders.

A K of 2.4 is most definitely concerning, but there is no way I would be pumping in 4 runs of K on top of the 40meq that the patient got orally with a SCr of almost 12. Keep in mind, giving IV K can worsen the patient's SCr so you want to cautiously replete electrolytes in patients with renal failure. The 40meq of PO K was appropriate and I would have done a repeat CMP a couple of hours after that administration to recheck electrolytes. With renal failure, the patient's K will often times increase more than if you gave someone with a normal SCr that same amount of K. Typically, 10meq or 20meq will raise the serum K by 0.1 and 0.2, respectively, in a patient with normal renal function. However, I have seen a patient with a SCr close to this patient's SCr get 40meq of K and it bumped up her serum K by 0.9 (as opposed to the expected 0.4). Since the SCr is so high, they likely won't be producing much urine (if at all). Yes, you have to worry about arrythymias, but you also don't want to overshoot and then have to deal with a critically high K. This is why a renal consult should have been called immediately.

I would have also asked for a VBG or an ABG because the patient is clearly acidotic. Metabolic acidosis can cause electrolyte disturbances. So correcting the acidosis could also help correct some of the electrolyte abnormalities.

The other thing to consider is that you want to correct the sodium slowly so as to not cause any cerebral edema.

I also agree with the PP that said a repeat set of labs should have been drawn immediately as there could have been a problem with how they were drawn or a lab error. You don't want to go correcting a K of 2.4 if in fact is was actually 5.4.

This patient would have been appropriate for the floor only if the nurse taking him was very experienced. Otherwise, a step down unit would have been the right place for him since he would likely require frequent labs and electrolyte replacement as well as close monitoring.

[SierraBravo]

The BUN/Cr ratio suggests an intrarenal cause, such as nephrotoxic medications or a systemic illness.

Is the patient on diuretics, SSRIs, antibiotics, or receiving cancer chemotherapy (tumor lysis syndrome)?

Oh how I love that you said this! Unless the patient had poor skin turgor, dry mucous membranes, or other outward signs of dehydration, the BUN/SCr ratio most certainly suggests an intrarenal cause for the elevated BUN/SCr. The ratio for the patient was ~9:1 which does not necessarily suggest dehydration.

Incidentally, TLS would result in elevated K and uric acid.

[Anna Flaxis, BSN, RN]

Incidentally, TLS would result in elevated K and uric acid.

Yes, I thought TLS unlikely given the lytes- sounds more like someone with poor absorbtion/diarrhea/diuretic use or something of that sort. I could even imagine perhaps a person on diuretics who had an infection and was started on PO abx and then developed C-Diff, who either lives alone and so nobody noticed how sick they were getting, or maybe they are the caregiver for a frail/demented spouse, so their spouse wouldn't have noticed them getting sick, and they would have tried to keep going as long as they could because their spouse needed them.

But, that's just my imagination going wild- I could be WAY off. It's one of the reasons I love Emergency- we get to be detectives a lot of times.

[Birdy2]

You are all such great nurses and so smart. I hope one day I'll be able to come up with this stuff off the top of my head. I feel like I've forgotten so much. What I wouldn't give to be in school while I'm working. I knew so much more about disease processes when I reviewed every day. Now that I'm working there's just no time though.

Thanks for supporting my decision. I understand all rationales but I had other patients calling nonstop and there was no way to monitor the patient that closely. The ICU nurse completely agreed that I did the right thing. I just can't be believe how much I had to argue to get her a bed. I'm so sick of our ER slamming us. They had just gotten an IV before they brought her up. They had just hung fluids. No potassium given, no rechecks.i actually ordered the next set of labs that were drawn shortly after she arrived to my floor. That's ridiculous. One time my manager tried to keep a pt in the ER that they wanted to send us because her calcium was critical and they hadn't done anything by 2230 when the patient had been there since 1700. They called the supervisor and guess what...we still got the patient. Also, we used to be able to look patients up in the ER, but they locked us out since we were asking questions like why hasn't this/that been done. Guess they want to be able to lie. Happens all the time. That patient with the low sodium and other labs was actually ordered a monitor, but they didn't have one on her for hours. Then I get her with that potassium and when the doctor calls I can't even tell him what their rhythm is. Maybe I need to work ER so I can understand why so much of this is happening. It sure does get old

[Anna Flaxis, BSN, RN]

That ER sounds like a war zone. It sounds like a high volume, high acuity, understaffed ER. Maybe there is a lot of turnover because of low morale, and maybe they hire new grads or inexperienced ER nurses and throw them to the wolves instead of providing appropriate training and support. Maybe if you worked down there, you would gain an understanding, but at what cost to you personally and professionally? I'm really glad you're open to thinking about what it must be like for the staff down there, that their practice is so slip-shod. To me, it's not a sign of people who don't care- it's a sign that they are poorly staffed and poorly managed. This is what hospital administrators need to understand, is how poor ER staffing affects patient safety on the inpatient unit, not just in the ER. But typically, the ER is not the money maker for the hospital- they try to staff using the same matrix that one would use for an inpatient unit, but that doesn't work because ER flow is by its very nature unpredictable. Maintaining a minimal staffing level is dangerous- and you're seeing the results of that on your end.

Investing in the ER might not pay off in a fiducial sense, but in the sense of better outcomes for patients and improved staff satisfaction (meaning that people will stay and turnover will be decreased, resulting in better patient care) I cannot see the downside. Getting administrators to see it that way is a different story.

[blondenurse12, MSN, NP]

Personally, the first thing I thought of when I saw those labs was rhabomylosis. Obviously I don't have all the information but it seems suspicious. Hypokalemia and hyponatremia can cause rhabdo. Did this patient have a CPK or myoglobin drawn? If those things are markedly elevated, then the patient would absolutely need an ICU bed to initiate CRRT as soon as possible. Is she urinating at all? Not only that but you're in bit of a pickle trying to manage replacement of electrolytes on someone with serious renal dysfunction. It could go wrong quickly so I think you were definitely right getting her a transfer.

[michlynn, BSN, RN]

Happens everywhere. We get so many inappropriate patients that we either code or ship out within minutes/hours of admission.

[BrnEyedGirl, BSN, MSN, RN, APRN]

I don't know how it is done in other ED's, but in my ED I have absolutely no say in where the pt goes, neither does the ED doc. All of our admitting orders are completed by the admitting doc, any consults by the admitting doc. Once the adm it orders are in the computer the ED doc is really no longer involved unless the pt has a major change and needs intervention before I can get ahold of the admitting doc. I'm not saying this is the ideal way to do things, but it is what it is. I used to work on a tele floor and understand your frustration of getting a patient that required way more care than was available on a floor where each nurse had 10 patients! This problem is as old as time,...no one has enough resources, enough time or enough staff.

[eroc]

I don't know how it is done in other ED's, but in my ED I have absolutely no say in where the pt goes, neither does the ED doc. All of our admitting orders are completed by the admitting doc, any consults by the admitting doc. Once the adm it orders are in the computer the ED doc is really no longer involved unless the pt has a major change and needs intervention before I can get ahold of the admitting doc. I'm not saying this is the ideal way to do things, but it is what it is. I used to work on a tele floor and understand your frustration of getting a patient that required way more care than was available on a floor where each nurse had 10 patients! This problem is as old as time,...no one has enough resources, enough time or enough staff.

Yep, the admitting MD generally is the one to decide. It is out of the ED's hands once the patient is in admitted status….so talk to the MD that shows up on the floor.

Yep, step down pt. with the limited info posted. And it is absolutely a great idea for floor nurses to spend a week or two in the ED so that you can understand the stress levels are extremely high compared to the floor. Nothing like walking into a room expecting to come back and see your pt. and they are already gone upstairs.

[suanna]

ICU-No. A monitor is indicated for the K+ if for nothing else. I am amazed by the number of times a patient ends up in the ICU because they may be sick. If you are in acute care now-a-days, you are sick. It dosen't mean you need 1:1 or 2:1 care. Is the patient requiring a nurse to be at the bedside doing some intervention at least every few minutes to keep the patient stable? if not, ICU isn't required. When I graduated a med surg floor nurse on a cardiac tele floor would have 10 patinets, one on a vent, 2 on antiarrhythmic drips, 2 going for some proceedure in the morning. You would "turf off" 3 of your 10 to the LPN but still had to assess rhythm, lung sounds and any IV intervention- not to mention get and give report on them all. I'm not saying floor nursing is easy, but I am amazed at how often I get "Oh! we can't take that patient on a floor, they need ICU because...", despite the fact that the patient has perfectly stable VS and is showing no indication of a rapidly changing condition. Sure, they need timely intervention for the discovered anomalies, but that is what we were trained to provide in nursing school. Just be careful what you claim to be "unable to handle on the floor", the next thing you know the powers that be may decide the floor isn't able to handle enough stuff to make it an asset to the hospital, or since you can only take the least sick patients you are going to see a steadly increasing patient load. Personally, I'd rather take care of 6 patients that I have to keep careful track of a few problems each, rather that 12 patients with less to monitor, but with the same number of routine meds, daily care needs, teaching, charting, and dressing changes. It gets to the point where you are nearing ECF level nurse to patient ratio, but with patients with acute health care issues that you are responsible for managing. Stable patient with good VS but whacky lytes- just what I ordered for a good shift.

[jadelpn, LPN, EMT-B]

Well I'm not sure but I get confused trying to make sense of the labs. Sodium would be high if she were dehydrated which she was. And yes, potassium would be high with renal failure. Couldn't the BUN/Cr be a result of dehydration? I guess that would have been a good idea to do a redraw, but the lab tech doing it did a good job. I was actually in the room when she did it.

Sodium can be high in early dehydration, but can become low (which this lab result is) due to more extreme dehydration. Same with K. Additionally, the kidney injury could cause any of this stuff as well, complicated with the dehydration.

The BUN and Creatinine again I would think points to the kidney injury. And with such dysfunction of the kidneys, what one would "normally" see in labs is and can be majorly skewed.

The original labs in the ER could be vastly different when you redraw them some hours later, which you did, and those results showed that there were acute changes I would assume. So then you start talking about alternate levels of care.

Yes it does seem as if some shifts you spend transferring. But what the ED sees is not necessarily what it seen when on the unit.

And as a complete aside, if mangers took an active role in monitoring these kinds of trends, as opposed to survey results, it could help to ease a 10 patient load burden on nurses. And you don't know what is happening in the ED--if THEY each have a few acute traumas/codes--better for patient monitoring to be in a bed. Not suggesting this is ideal, however, if the business of healthcare actually cared about patient outcomes, this unease and frustration between units could cease.