Question

Case 7

There has been a car accident and the driver if the car was brought to PRU. She has been stabilized in the emergency department; however, transferring her to another facility 40 miles to ICU away would not be appropriate in her health status for her injuries would not sustain life.

The patient has to be placed in ICU in the next 1-2 hours. The night supervisory gains composure and describes the status of patients occupying the 4 ICU beds.

Patient A- A 59 year old female, comatose, stroke victim who had been in ICU for 33 days; uncertain prognosis; retired, with no family

Patient B- 2- week old premature male, has Down's syndrome and has been in ICU since birth; hospital has brought a legal action to permit surgery to repair a duodenal atresia, a procedure the parents had not permitted; family in adjacent city.

Patient C- 35 year old male who underwent emergency appendectomy, developed severe wound infection and septicemia, source of infection is unknown; because of previous anaphylactic shock in reaction to antibiotics; requires ICU care; bachelor; aged mother in city.

Patient D- 13 year old female undergoing chemotherapy for leukemia with an experimental drug; has been in remission three times in the past; close monitoring of the experimental protocol and potential reaction to drug requires ICU care; family in city.
New Patient- 24 year old patient; college honor student in physics. scholarship winner; pregnant; engaged; no family known.

The supervisor ended the brief description by asking, "What should I do?"

You are the superviser and you have to make a decision. (continued on next page) - each question followed must be answered.

Describe your facility

Describe your staff

Explain any legal or ethical issues of the situation

Explain your management style/theory

Discuss cultural issues that the situation presents

Explain budgetary plans or concerns

Explain credentialing or accreditation issues the situation presents

Describe your response to the situation

Answer 1

1) Facility:

On receiving a crtical patient in emergency department who requires an ICU admission immediately, The doctor attending the patient informs the ICU incharge doctor on duty for an urgent consultation. After the examination by the ICU doctor, he is the one who decides if the case really needs an ICU bed or can be placed in an High Dependency Unit.

• If the patient is for ICU admission according to the ICU doctor, then he can allot a bed in ICU after discussing it with the charge nurse on duty in ICU.
• If there is no available bed in ICU for admission then a patient who is already present in ICU will be transfer to other department like HDU or Ward but under the supervision of ICU/HDU staff. The patient with minimal acquity or the one who is least critical is transfered.
• In case if all the patients in ICU is equally critical and none of them can be transfered, then the new patient will be manage in HDU or ward as per the availability of bed under closed supervision of a competent staff.
• If not this then the patient will remain in emergency department, with a competent staff care for patient untill any further arrangement for bed is made.

2) Staff:

The staff arrangement in emergency department is 6 staffs per shift. In ICU the staff to patient ratio is 1:2. In HDU the ratio is 2:4. and in wards its 5: 20. In case of non availability of beds when patient who requires a ICU /HDU bed, is transfered to ward, the patient will be taken care by an ICU /HDU staff. This staff will be pulled out from the unit who is on duty or may be an additional staff who is off duty and call for extra duty. If an on duty staff is taken from an ICU/HDU then a normal staff from the ward will be pulled out from the ward to ICU/HDU for help.

3) Legal and Ethical issues:

In many such cases, where a patient from ICU/HDU is transfered to other department, the relatives often give a negative response. Sometimes they donot authorise the transfer of their patient or may create a bias with the care providers on duty. According to their perspective, the patient in ICU is critical and can be transfered out once he/she becomes absolutely normal.

In certain cases, there is a bias within ourselves when we as a care provider, has to choose least critical patient from the group of critical patients. Though the patient being critically ill,has to be transfered out to other department because an another more critical case needs admission.

4) Management:

In arrangement of beds for admission, the doctor incharge on duty of both departments, Nurse incharges of both departments, Nursing supervisor, the technical director on duty, social worker and the GDA who is resposible to transfered is involved.

The management with the technical director as the head of the team, is resposible to arrange the bed in other outside hospitals in case of referrals. He is the one who would coordinate with the other hospital management and make necessary arrangements for proper and safe transport of patient. For critical ill patients, they are accompained by a doctor and a nursing staff. The social worker is required to communicate the need of transfering the patient to other department or hospital with their concerned family members and to explain their worries and concerns.

5) The cultural issues that concerns in this situation is presence of a pregnant female patient, other patients being female and a newborn. In our society, child and mother is consider to be given high priority in terms of love care and attention. This may influence the decision of the care provider in some condition.

6)Budgetary plans:

Since the new patient who is being brought to emergency department do not have any family known, therefore it becomes difficult for the management to make necessary decision regarding the treatment regimen. Lack of attendents with the patient will proke worries among institution management regarding the payment of cost of treatment.

7) Credentialing and accreditation issues:

Every institution has to appropriately accrediated with the concerned governing bodies. An accrediated organisation will have a framework and good knowledge about the policies and protocols that a healthcare organisation is permitted to do. Moreover this will also help them to deal legal issues.An accident case is a medicolegal case, in which legal formalities have to be completed. So proper staff credentialing and accreditation will help them to manage such MLC cases effectively.

8) Being a Nursing Supervisor,in the above stated list of patients admitted in ICU, the patient A i.e 59 yrs old comatosed female can be shifted to other department like a HDU or ward as per the availability of bed. This decision can be taken if consented by the doctor incharge of the patient. If not so, then the new female patient in emergency department, can be placed in HDU or other maternity ward with a single competent staff assigned to take care for the patient.