DKA, pH 7.2

[southerndoc]

So, DKA'er, bicarb of 8, pH of 7.2.

Admit to ICU or not?

I was going to send her to the stepdown unit, but there were no stepdown beds. So she went to the ICU.

Yesterday I was discussing the case with a famous attending (who happens to be an endocrinologist -- one of the early guys of emergency medicine). Anyhow, he said he never admits DKA'ers to the unit unless their pH is <7.

Is this common practice? Maybe I've been working with ultraconservative attendings. I'm not comfortable sending a patient to the floor with an insulin drip, and I don't have 12-16 hours in the ED (nor the nursing power) to bring their DKA under control in order to discharge or send to the floor.

So, what's your policy?

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[USCDiver]

Many floors won't accept a patient with an insulin drip. Could be different on different floors, but I've run into similar restrictions when trying to admit or transfer a patient on other types of drips. Rationale is that an insulin drip often requires q1h FSBS and adjustments and floor nurses can't provide that level of care with the patient ratios they are forced to practice under.

 

[12R34Y]

I think a floor could handle a DKA with pH 7.2 without too much problem, but all of the insulin drips are required to go to the ICU at my school's hospital for all the reasons that USCdiver stated........no floor nurse can possibly keep track of a patient that requires such close monitoring as 1 hour FSBS.

later

 

[MollyMalone]

On my stepdown floor (I'm a nurse), we take insulin drips and most DKA's get sent to us and not to the unit. I didn't realize that we're unusual!

 

[DrQuinn]

I think if the BMP is normalizing while in the ED, you could send them to the floor. stepdown would be ideal, i think. at tampa general, i think the nurses have 3 patients each, ICU is 2 patients each. i hate to tie up an ICU bed with someone who is going to be discharged in the afternoon anyways, and as long as their K is ok and they don't bottom out, i don't see why not step down always. but our stepdown unit is basically the "vegetable garden" with all the people on trachs who will just never ever be able ot go to the floor.

Q

 

[docB]

This is a great thread so students and residents can see how much care, and particularly, level of care are determined by hospital policy more than medical necessity.

In my hospitals anyone who carries the diagnosis of DKA will have to go to the unit. The floors and the intermediate unit (analogous to everyone's step down unit) won't do q 1 hr glucoses and they won't take an insulin gtt. In fact in our hospitals the intermediates won't even take a pt on a titratable nitro gtt. They'll only take them if the gtt is set and not titratable. Go figure.

I agree that many DKAs could go to lower level of care and I manage many of them without gtts but like I said, hospital policy.

 

[USCDiver]

On my stepdown floor (I'm a nurse), we take insulin drips and most DKA's get sent to us and not to the unit. I didn't realize that we're unusual!

I think you are misunderstanding. We are saying that most DKA's go to the Unit or step down unit. My comment was that General Medical Floors often won't accept drips or anything that requires q1h anything. I think the step-down unit is the ideal place for a DKA, of course in our ED we don't get to tell anyone where to send their patients. The admitting MD makes that decision.

 

[Jeff698]

at tampa general, i think the nurses have 3 patients each, ICU is 2 patients each.

Out of curiosity, what is the typical RN-patient ratio in your ED?

Take care,
Jeff

 

[docB]

Typical ER nurse/pt ratio everywhere I've been is 1/4.

 

[MollyMalone]

I think you are misunderstanding. We are saying that most DKA's go to the Unit or step down unit. My comment was that General Medical Floors often won't accept drips or anything that requires q1h anything. I think the step-down unit is the ideal place for a DKA, of course in our ED we don't get to tell anyone where to send their patients. The admitting MD makes that decision.

I don't think I was misunderstanding; there are two posts on this thread which state that, at that person's hospital, all insulin drips are required to go to the ICU, period.

 

[EMIMG]

A nurse to pt ratio of 1:4 is quite good at many places. We were lucky if we had that in our "obs unit" where i trained at as a resident and that was where the pts were "more stable".

IN terms of DKA most places I have experienced require pts with drips to go to a unit or a stepdown. In terms of the gas, I don't really see if there is much in the way of utility of drawing gasses on a lot of the pts. I typically will not give bicarb to pts and I find that gasses may be overdrawn. In fact, one of my favorite things to be asked my medicine residents after I intubate a pt is "what was the gas?" I tell them I will get one in half an hour to adjust the vent and they say they like them to see how bad the pt was when they came in. My typical response is they were bad enough to be intubated.

Going back to step-down units, during residency one of our SICU docs mentioned that the only good thing about our step-down unit was it was close to the hospital.

 

[AJM]

In fact, one of my favorite things to be asked my medicine residents after I intubate a pt is "what was the gas?" I tell them I will get one in half an hour to adjust the vent and they say they like them to see how bad the pt was when they came in. My typical response is they were bad enough to be intubated.

I really don't like that kind of attitude towards critically ill patients. You may not realize it in the ED because you don't have to deal with intubated patients after they get to the ICU, but it really helps in the future management of these patients to know what the mechanism of respiratory failure was before they were intubated. For example, there's a difference in management of a patient who was intubated for hypercapnic respiratory failure as opposed to one who was tubed for pure hypoxemia. Once you tube a patient, you will no longer be able to objectively tell why they needed to be tubed in the first place. Sure, it doesn't help you directly in the ED because you've already decided the patient needs a tube, but it will make life much easier for your colleagues who will be managing them in the units, and will improve patient care.

Our ED used to not gas patients at all, but they've now started at least gassing the ones they are about to intubate (unless, of course, it's a truly emergent intubation) -- it's so nice to finally see an ABG done at presentation! And it's not just to "see how bad their gas was", but it helps us to piece together what's been going on with the patient.

Now to get back on topic. As far as the DKA business -- most of our DKA's are handled on the floor. The nurses hate it, because the nursing ratio at best is 1:4, and can get up to 1:6. The only times these guys go to the unit is if they are more complicated than the typical management. I have rotated at a community hospital, though, that requires that all DKA patients on an insulin gtt have to go to the ICU.... makes the ICU rotation there really easy, because the patients in the unit are a lot less sick on average.

 

[DrQuinn]

Out of curiosity, what is the typical RN-patient ratio in your ED?

Take care,
Jeff

depends. we have two "critical areas" in the ED (Major Trauma and Major Med) that are 1:2, nurse has to be an RN, and is often TNCC and ACLS. other intermediate care areas that are 1:3-4, RNs.. Two other non critical areas are 1:4, mix of LPNs and RN.

Q

 

[southerndoc]

A nurse to pt ratio of 1:4 is quite good at many places. We were lucky if we had that in our "obs unit" where i trained at as a resident and that was where the pts were "more stable".

IN terms of DKA most places I have experienced require pts with drips to go to a unit or a stepdown. In terms of the gas, I don't really see if there is much in the way of utility of drawing gasses on a lot of the pts. I typically will not give bicarb to pts and I find that gasses may be overdrawn. In fact, one of my favorite things to be asked my medicine residents after I intubate a pt is "what was the gas?" I tell them I will get one in half an hour to adjust the vent and they say they like them to see how bad the pt was when they came in. My typical response is they were bad enough to be intubated.

Going back to step-down units, during residency one of our SICU docs mentioned that the only good thing about our step-down unit was it was close to the hospital.

I only got the ABG because of her bicarb (8). With a normal bicarb, I generally do not draw ABG's.

As mentioned earlier, all the stepdown beds were taken. I didn't want to send her to the ICU, but with a nurseatient ratio of 1:6/7 on the floors, it makes things dangerous to send someone on a drip to the floor. Her q1h FSBS's should turn into q5h and with bad luck, will probably be found with a FSBS of 15.

I also had a similar situation of sending someone who overdosed on Oxycontin to the unit because the stepdown beds were full. I couldn't send the guy to the floor. At 3 mg/hr, he was breathing fine. Drop his naloxone down to 2/hr and his sat drops to 85% with a RR of 8.

 

[roja]

What is this step down unit you speak of?

Here, if its a drip = unit. thus we try to get DKA's off an insulin drip in the ED if possible. Usually is as we have no icu beds and by the time they are screened etc we have closed the gap, etc.

Our patients can only get to the step down through the unit.... never happens

 

[anonymousEM]

hmmm...today our ED was 1:8 with each of the RNs in the major medical area with at least 1 unit player...besides the 4 unit players assigned to the Resus RN. It seems we end up trying to aggressively treat and close the gap on our DKAers giving even a few extra hours til consult as it ultimately moves pt flow in the ED better...I rarely see a DKA make it out of the ED to the unit as they're never sick enough to get the 1 open bed MICU can spare--they just board in the ED until they are downgradeable. It doesn't seem right that our ED RNs should have to pick up the slack for the whole rest of the hospital but when we end up holding, an RN can have a couple of unstable MICU pts as well as new ED workups vs upstairs where the MICU RNs never have >2 pts and usually they are stabilized as it often takes a couple of shifts (or days) for them to go up in the first place.

But it makes us pros at ICU mgt. And hospital politics. The joys of overcrowding!

 

[Jeff698]

It doesn't seem right that our ED RNs should have to pick up the slack for the whole rest of the hospital but when we end up holding, an RN can have a couple of unstable MICU pts as well as new ED workups vs upstairs where the MICU RNs never have >2 pts and usually they are stabilized as it often takes a couple of shifts (or days) for them to go up in the first place.

Yup. And thus the point of my original question. You're right. It somehow just doesn't make sense.

Take care,
Jeff

 

[roja]

Out of curiosity, what is the typical RN-patient ratio in your ED?

Take care,
Jeff

Busy night? (assuming nurses don't take thier union break) it is 2 nurses per 20-25 pts.


Yes, that would be a 1/10 ratio... regardless of number of emergent, etc.