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Discussion in 'Emergency Medicine' started by willlynilly, Dec 26, 2008.
refused by our MICU. pH 6.95, HCO3:3, glu 600
as long as you documented this, you did your job. Really it should get sent to the QA board. We've all sent a lot softer things to the ICU.
That is crazy, even if its someone who comes in all the time..
How was that "refused" by the MICU? I presume the MICU attending personally came to the ER to evaluate this patient to determine he didn't meet MICU criteria?
We had automatic MICU admission criteria where I trained. This was created because residents often inappropriately played the role of gatekeeper. A pH <7.2 was a slam dunk admission irregardless of cause.
The admissions that weren't in the automatic admission criteria were evaluated by a resident. They talked to a fellow, and if the fellow decided it needed ICU admission, then fine. If the fellow decided it didn't need ICU admission and the ER attending thought it did, then the ICU ATTENDING had to personally come to the ER and evaluate the patient. Pretty much guaranteed an ICU admission because most wouldn't do that at 2 am.
it was an... interesting day today. first this patient came in (seen by the other resident), somehow, the MICU attg came down and said "let's give him a couple of hours and see if his gap closes to less then 26. if it's over 26, then we'll take him).... the initial gap was 33. after three hours of working on him, his HCO3 went up to 6 but his gap "closed" to 22 because his chloride was like 112 or something like that. so the MICU attg refused the admission because he was heading in the right direction. unbelievable. he was in the dept for 7 hours... when he should have been gone within a hour.
i had a patient in the next room when all this was going down, a guy in full blow DT's, who i have about 200 mg of valium, giving him 20 mg every 10 minutes, to finally get him sedated, and they initially refused him. but later recanted and decided to take him. crazy.
Both highly inappropriate, neither of which would fly if they were brought up for review. Work avoidance is dangerous. So is downplaying of how sick DKA patients can get, since they "see it all time".
When I was a resident (I don't think they still do it this way) we had a real problem with the ICU teams. The issue was disposition. Here's how is dysfunctioned:
If a patient was on the floor and admitted to a gen med team and they crumped they went to the ICU. When they were better down the line they could be dumped back on the original team.
If a patient was admitted directly to the ICU there was no gen med team to dump them back on so they stayed on the ICU service for their weeks of inpatient silliness.
Consequently the ICU teams had a huge incentive to block and get the patients admitted to floor teams even if they then immediatley crumped and had to go to the unit. Really bad perverse incentive.
Amusingly once while on a gen med team (only one month of gen med wards in my residency thank God) the ICU started trying to dump a patient back on us. No one on my service had ever heard of the patient. Turned out that they had been sent to the ICU 8 weeks before and no one who was rotating then was still around. But we were indeed "Gen Med team 4" or whatever so for the purpose of "continuity of care" we had to take the patient back.
I sincerely wish that the 'public' read posts like these. When I tell my friends and family about the crazyness that goes on, and how dangerous a lot of this is for patient care, they are absolutely shocked and amazed - and yet things like this are a regular, every day occurance. Not sure what public outrage would do, but some kind of reform has to come down the pipe... this is just a terrible way to run a system.
Public outrage would be addressed by the Joint Commission and/or CMS. Be careful what you wish for.
I agree that systems like the above should be fixed, but I assume the root of the problem is more a lack of competent leadership at the institutions, and it may be hard to fix that with public pressure.
I'd like to provide an IM perspective here, because I take issue with the presumption that refusing a patient like this in the MICU is due to "work avoidance." At Duke we only have 16 MICU beds and it's a totally closed unit. We quite often have 14-15 ventilated patients in various states of critical illness, many of whom are sick transplant patients or neutropenic cancer patients. In order to take someone with DKA we typically have to literally move a patient. Sometimes this is possible...the least sick patient can sometimes go to the SICU, neuro ICU, or CCU if they have a bed, but the MICU team would no longer manage them, and sometimes that affects quality of care just due to different levels of familiarity with the types of conditions treated in these different units. As such, the MICU residents and fellow will sometimes refuse to accept DKA patients even with a pH below 7.2, or 7.0, if we think it would be unsafe to transfer anyone out of the unit to make a bed for that person. Granted, if the patient with DKA is sicker than our least sick patient, we'll do everything we can to make the transfer, but this is usually not true. Clearly, this is NOT work avoidance. If anything, it makes more work for us to do what we think is the right thing, but from our perspective it has nothing to do with the length of time a patient is in the ED. Refusal to admit a patient is typically not about avoiding work, and it's unfair to assume this. In fact, more time in the ED for a patient like this is what we feel to be the best thing for the patient, but sometimes it means a 4-8hr stay down there, unfortunately.
Our medicine floors are practically step-down units in many senses...they'll run insulin drips and the like, so we can actually manage DKA quite well in most settings on the floor. So we'll often request that the patient in the ED be given a few more hours of fluids and the insulin drip in the ED to make sure they're headed in the right direction before the patient comes to the wards. This makes good sense, I think, if we don't have room in the ICU but we also don't want someone potentially unstable going to the floor. Frankly, the ED is much better equipped to provide both levels of care and transition between the two, whereas the floor staff would be grossly unprepared for an unstable patient. I agree, it's not optimal, but given how sick patients are these days and the growing bed shortage, this is what we're forced to do for the time being. With ever-increasing waiting room times though, I can certainly understand your frustration about patients being kept in the ED for this long. I'm just not sure what a safe alternative would be.
Has anyone else experienced this dilemma? Does this change your perspective on keeping these patients in the ED for longer periods of time? I'm curious to hear your thoughts.
I accept your assertion that this is not always about work avoidance. However in my ER I only have 22 beds. They're usually all full as is the hallway, the other hallway that's full of chairs, the fast track and the waiting room. I will usually have 3 to 5 EMS crews trying to offload patients to God knows where and 4 more inbound. That doesn't even address the helicopters. So I'm not real keen on keeping a patient who clearly needs to be admitted in the ER for a few more hours.
It changes my perspective. I should be training at a major university hospital with floor nursing that can handle drips. I swear a sliding scale is too much to manage for some of our floor nurses. Where I'm at, any drip (insulin, heparin, labetalol, etc) ARE ICU criteria. Sad.
Few ED's are well staffed enough to deliver ICU level care when running at anything near peak capacity. I can put in the lines and write the orders to deliver goal-directed therapy, but at a 1-4 or 1-5 nurse/patient ratio that doesn't mean it's going to happen. When the census is low we can approximate ICU level care, but the census is almost never low. In other words, what docB said.
When I was at Duke, the MICU was like this: 8 pulmonary rocks, 4 pulmonary pre/post transplant failures, and 4 garden variety sick MICU players (like you'd expect them to be). Duke pulmonary/critical care is pulmonarily legendarily strong, and with due cause. Critical care, though, not so much. What I was used to, concerning critical care players, was the sickest patients coming in, and those that were differentially better going out (and continuous revolving beds). I didn't see that; in my month, 7 patients were there when I got there, stayed there, and were there when I left.
And one thing that DID happen (which maybe doesn't anymore) was, although the MICU was a closed unit, the MICU house staff and attendings would also manage patients in other, open units (neuro ICU and CCU, mostly, with SICU and CVICU not so much). In fact, the CCU was always willing (since the CCU was fellow-run, vs resident-run for the first go-round for unit admissions) to take MICU overflows, and not even involve the MICU team (unless the pt had a pulmonary issue going on).
Perhaps the most telling was a Pulm/CCM attending where I am now, who was fellow-trained at Duke when I was a resident, who said one day about the difference, "They're not as sick, in general, but things happen here."
docb makes an excellent point. Tying up beds in an ED is unacceptable. There are way too many patients in the waiting room to tie up a bed, and while we may make the one person needing an ICU admission better, we may make 2 patients septic by delaying their evaluation and thus tying up even more resources.
The ED does not do well in providing long-term care. Patients with serious medical conditions are better off in an ICU where a nurse has only two patients. An ED nurse may have four or five patients, and instead of getting a new admission each shift, may go through a new patient every hour with each new patient requiring an assessment, labs, IV, etc.
Delaying ICU care because the ICU is full is completely unacceptable. It sounds as if Duke's ICU needs to be expanded (drastically). Where I trained, we had a 24 bed MICU, a 10 bed MICU north, plus admitted patients on the MICU service who were physically in the CTICU, SICU, CCU, and TICU.
Its a lovely can of worms our health care system sits in.
Regarding the op: Although I agree with all the above said in terms of delays, I trained where our ICU was almost always stuffed full. Minimal step down. And they moved the 'icu rocks' out. People rarely stayed more than 2 weeks in the ICU. They had miserable 'staffing' issues as well.
The most important question is not what the patients labs were, but what did the patient *look* like. I would accept a 'screened out' DKA'er who is sitting up and talking to me, looking pretty peachy (not the labs, the patient) and get one of my crumping septic patients up to the unit first.
In essence, everyone but dermatolgists are getting kind of hosed in medicine right now: short staffing, tiny spaces, not enough nurses. Doesn't mean we shouldn't try fix things, but when you look at general 'systems theory', just fixing a small part doesn't really do anything. You have to fix the system: more nurses, more staffing, etc etc, for everyone.
This has definitely changed now, but it indeed used to be the way that you mentioned, and it was probably quite unsafe (too many sick patients being managed on different floors by not enough residents). They're all closed units now except for the cardiothoracic ICU, and it's rare that patients are managed down there by the MICU team since those beds are always needed for post-op care. The MICU team only manages patients in the MICU now. Other units can get a MICU consult, but this doesn't happen all that often and they still manage their own patients. As someone mentioned, we do indeed have an absurd shortage of MICU beds. There's a massive hospital addition in the works now that will hopefully greatly expand our ICU capacity. But I'd venture that this isn't a problem at all unique to Duke...it seems as if ICU beds are in short supply at many places, especially when criteria to get into the unit are more lax (such as requiring an insulin drip).
Regarding others' comments, I agree that it's not optimal to be providing longer-term care in the ED, but I also maintain that ED nurses are better trained and equipped to deal with those patients who are in the "limbo" stage between being stable for the floor or clearly in need of ICU care. This is one of the great strengths of the ED, and is an extension of triage, one might argue.
This dilemma comes up all the time for us, and can sometimes become rather difficult to navigate without upsetting our ED colleagues. I remember a recent situation whereby an ED patient was placed on 100% facemask in the setting of pneumonia with tachypnea and hypoxia, and the MICU was called for admission. But there was no blood gas drawn, and the patient's sat was 98% on the facemask. He looked great, and when the unit team requested a gas his pO2 came back at over 200! As it turns out, the guy was easily weanable down to 4L NC, and didn't need ICU-level care, yet we were being asked to use our last remaining bed for this patient because someone wanted him out of the ED as quickly as possible. With how busy the waiting room can get, I'd probably feel the same way, but it's important to understand the medicine perspective too. From our perspective, taking into consideration the limited resource that are ICU beds, a patient like this is best served by staying in the ED for an extra 30 mins to an hour to wean the O2 and make sure they're stable enough for the floor. The same is arguably often true with DKA patients.
And that's the key...stability. Knowing for sure that a patient requires admission isn't necessarily the end of the story in terms of ED care. If they're not stable enough for the floor but are not sick enough to warrant a critical care bed, which is by definition a scarce resource, then more work sometimes needs to be done or more time taken to stabilize the patient. I agree it's not ideal and increases waiting room time, but it would be worse to ship the patient to the ICU, take up a bed needed for a different patient who later codes on the floor, and then force a second handoff of care, first from ED --> ICU and then from ICU --> a medicine team on the floor, thereby further increasing the risk of errors and miscommunications.
Not trying to be confrontational, I just think it's important for us all to better understand both perspectives, which will enable us to better devise and implement solutions to the problem of hospital and ED overcrowding, and more smooth, efficient transitions in care from waiting room --> triage --> ED --> the wards.
this is a very interesting topic.
We frequently run into this problem at our hospital too, however........
I feel DKA is a little bit of an interesting thing though.
DKA seems to almost ALWAYS be directly discharged from the ICU the next morning. They get their insulin drip, bunch of fluids, their gap closes in 6-10 hours, they get their lantus and they go home.
This is literally how fast DKA can turn around. So, frequently i understand why ICU doesn't want to take DKA'ers because they so frequently turn around and they often "look" great (ie patient eating, watching tv, stable vitals), but their labs look awful.
So, I can understand the IM/critical care guys perspective.
Even the guys with pH (which I never check) that is super low, give 'em their fluids and insulin and it goes aways pretty readily.
Problem at my place is that they WILL NOT do insulin drips on the floor so they HAVE to go to the ICU. This is a system issue and will hopefully change in the future.
So, many times the lab criteria are met for DKA, but the patients look sooo well.
I don't know how sick the guy looked with a ph of 6.9, but my guess is that his pH didn't stay that low for long after being resuscitated.
A PaO2 of 200 isn't very normal for being on a NRB. Under 300 you're suspecting acute lung injury. Around 200, you're approaching ARDS (without knowing anything else about the patient.) This isn't taking into account respiratory distress, hypoventilation, or concern for sepsis. Depending on the patient, I may advocate for ICU or stepdown care, despite his ability to "wean to a nasal cannula."
I'm not suggesting that pts can't change or that we don't need to learn to deal with a scarce resource, but I'm just reminding you not to live and die by a blood gas.
Sorry Mike, but I have to disagree. A PaO2/FiO2 ratio less than 300 (or 200) suggests lung pathology. In order to diagnose ALI/ARDS you have to meet 3 criteria:
1) P/F ratio less than 300 (200 for ARDS)
2) Bilateral Pulmonary Infiltrates
3) No evidence of elevated Left Atrial Pressures
this was classically done w/ Swans--now done with Echo
Reminds me of a place I'm working now where I had an intubated patient turned down by the ICU. Went to the CCU.
I assume you had improved that pH significantly by the time of refusal?
Um, how are you disagreeing?
#1 a PaO2 of 200 is not good on a NRB
#2 Refer to the "without knowing anything else about the patient" comment
#3 I know the other criteria for ARDS, I am sorry I didn't type them out.
I would also refer to the general sentiment of my post... don't live and die by a blood gas (similar to the "But the PCO2 is 40!" argument when a person is profoundly tachypneic and looks like crap.)
Yup. where I was used to be like this. If there was a drip, they had to go to the unit. I *hated* wasting space in the ICU on well looking patients just because of thier labs or insulin drip. I would often get very agressive with IVF and keep them for a few hours to 'close' the gap and get them on a floor. I would much rather have that bed available for a septic aortic stenosis hypotensive APE patient.
Perhaps I misunderstood. It sounded like you were saying a PaO2 less than 200=ARDS. My point is that it is the ratio between PaO2 and FiO2 that is the number. My apologies if I misread what you wrote...
I agree that clinical gestalt is much more important than an ABG. Heck, we intubate without looking at ABGs, much to the chagrin of our medicine colleagues. ABGs, to me, are rarely useful except to see the base deficit/excess, in asthma, and in an already intubated patient. Otherwise, they rarely help me...
Where I did residency, DKA only went to the ICU if they got intubated, or had another serious complication (MI, CVA, Sepsis). If it was simple medication non-compliance (most cases), they were treated and then discharged from the ED regardless of initial labs, pH, etc. Sometimes DKA'ers would be on insulin gtt's in the ED for 12-14 hours before being bridged....
while i see your point, it actually changes in private practice.
as a resident, you're only responsibility is to the icu. your thought is throughput of the patients into and out of the icu. the goal is less in, and more out in order to "diurese" the unit.
as an attending, the patient becomes your responsibility. so, whether or not the patient goes to the unit, the patient is still yours to deal with. so, you get the patient to where they need to go- in this case, whatever unit can handle an insulin drip.
i've been an attending for 6 months now, and if docb called me up and wanted me to admit to the unit, i'd come down and make my own determination of where the patient needs to go. many times i downgrade, sometimes i upgrade. it all just depends on my feel. here in vegas, that patient would have to go to the unit, as no other floor can handle insulin drips, afaik.
what would make the most sense in this case would be for the micu attending to talk with the ed attending, and then have the general im attending/team called. unfortunately, it often doesn't work like that. clearly the patient should not be promptly discharged and needs medical attention/treatment. the issue becomes where does that take place, and for how long.