Patients who want to be admitted for minor things

[Emergent]

We had a patient the other day whose ankle was still hurting after a minor accident the day before. He has already been seen, the splint that was put on bothered him so he removed it. History of previous ankle problems. Our most generous doc was on, he first prescribed percs. Pt refused, he said dilaudid that he got the day before worked the best. He got IM dilauded. He got another x-ray, no fracture. Somewhere along the way, I mentioned about discharge. He said that, oh no, he didn't see how he could manage at home, he expected to be admitted. Middle class, retired guy, by the way, in his 60s, brought in by family member who lives a few blocks away.

He insisted, then, that IV dilaudid is the only thing that would kill his pain. He got an IV, got several doses of dilaudid. Sent family member home saying that he would likely be admitted. I spoke to him of the fact that he doesn't meet criteria, he argued and whined. Doc came and reiterated. He argued and whined. Finally he demanded to speak to administration (3 AM in morning) Nursing Supervisor sent in, 15 minute session with her.

Finally got him out the door, I was amazed! I cooed and sympathized all the way to the lobby where he waited for his BIL. Was so happy to be rid of the unrealistic pest.

Would love to hear your stories!

[sharpeimom]

This thread made me remember when I was in college and threw up in a corn chip bag to avoid making a huge mess at a frat party!

[Gabby-RN]

Where I work older adults (55+) with sprains or fractures could be held in the ED or admitted for observation while they await placement at a skilled rehab if they cannot safely care for themselves at home. If the patient lives alone and has a fractured wrist or a sprained ankle or they live in a 2 story home or have stairs to get in to the house it would not be safe for them to go home alone. Especially at 3am when its dark and they are tired and a little loopy from narcotics. Having family nearby makes no difference (as far as what services they can get) if the patient is usually independent. The family is not obligated to care for the patient, it is a bonus if they are willing of course but not a requirement, at least in my state.

What if the patient lives in a 2-story condo where the bathroom or bedroom is on the 2nd floor and they fall trying to get there. Anytime someone sounds afraid to go home or worried about how they will care for themselves after an injury I always page social services or case management. They know if the patient will meet rehab criteria or maybe VNA. It covers my behind and the doctors if something were to happen that we consulted someone, it usually makes the patient feel better, and if it turns out they are not eligible for any assistance, they are mad at that person and not you. (Lol jk)

Maybe this guy just wanted dilaudid, who knows but better safe than sorry. He probably did not need inpatient hospital services but maybe he met criteria for a visiting nurse or some physical therapy. A couple of days of inactivity can be pretty detrimental to an older adult especially if they aren't eating or drinking like they should because they can't get around.

[poppycat, ADN, BSN]

I live in a 2 story condo with the only bathroom upstairs & the kitchen downstairs. I'm over 55 & my husband is gone from 7:30 a.m. to 5 p.m. for work. In the past 6 months I've had both knees replaced & no one ever said "let's keep poppycat in the hospital longer because she'll be home alone all day". I had to figure out how I was going to manage all day every day with no one there to help me because I have no family nearby & my friends all work, too.

Being 55+ & living alone is not, in my opinion, a reason to be admitted for minor ailments.

[Gabby-RN]

I live in a 2 story condo with the only bathroom upstairs & the kitchen downstairs. I'm over 55 & my husband is gone from 7:30 a.m. to 5 p.m. for work. In the past 6 months I've had both knees replaced & no one ever said "let's keep poppycat in the hospital longer because she'll be home alone all day". I had to figure out how I was going to manage all day every day with no one there to help me because I have no family nearby & my friends all work, too.

Being 55+ & living alone is not, in my opinion, a reason to be admitted for minor ailments.

I am not saying people should be admitted to the hospital for sprains. I said that where I work older patients that do not feel comfortable going home due to an injury are often held in the ED while placement at a Rehab is arranged or VNA services. It is great that you feel comfortable going home and caring for yourself but other do not. If insurance will pay for rehab or skilled nursing services why not offer it to people if it makes them feel better about going home and continuing to maintain their independence? I have worked at rehab facilities and done VNA, taken care of knee replacements at both.

[twinkerrs]

I guess my psych nurse is coming out but I have to think about his place in erikson with the two failed marriages etc. so I guess I have to agree with llg in that this guy probably needs some help with his psychosocial needs. The iv dilaudid is very concerning but being an older adult he may have aches and pains elsewhere that it helped also.

[sharpeimom]

Being 55+ & living alone is not, in my opinion, a reason to be admitted for minor ailments.

I agree but only to a point with the above statement.

Are we talking about my husband's 56 year old niece who has had both knees replaced due to being in a severe car accident or are we discussing my mom's twin sister who just turned 93 and has had both of her knees replaced TWICE? She wore the first two replacements out!

The niece has MS plus two middle-sized kids plus a husband who's overseas in the Army. She can manage just fine with her kids there, but not quite a safely without them. My auntie will never ever think of herself a being old. OLD is for little ol' ladies, for heaven's sake! But she's so much like my mom was. She moved to a lovely retirement center three years ago, which was appropriate, but still travels wherever and whenever and with whomever she wants (or goes alone) and ha absolutely no intention of changing!

I would have different standards for each one. I don't think people neatly categorize sometimes.

[Emergent, RN]

If everyone without a great support system, and a relatively minor health problem, is admitted to the hospital, the taxpayers and insurance payers will soon go broke. We cannot, as a nation, afford to pay for every little need that someone might have.

Specifically, in the case of the fellow I mentioned, he did have a support system, plus he had plenty of financial resources. After being told that he did not meet admit criteria, he proceeded to beg to be admitted and he would pay out of pocket! The doctor suggested that he would get more bang for his buck by checking into a nice hotel.

The fellow was anxious because his sister and her husband (who live 4 blocks away) were going out of town to help their daughter with her new baby. All I could think was that I was glad he wasn't MY brother who lives 4 blocks away from me!

[Ruby Vee, BSN]

I live in a 2 story condo with the only bathroom upstairs & the kitchen downstairs. I'm over 55 & my husband is gone from 7:30 a.m. to 5 p.m. for work. In the past 6 months I've had both knees replaced & no one ever said "let's keep poppycat in the hospital longer because she'll be home alone all day". I had to figure out how I was going to manage all day every day with no one there to help me because I have no family nearby & my friends all work, too.

Being 55+ & living alone is not, in my opinion, a reason to be admitted for minor ailments.

I'm over 55, and my husband, who is over 60, also works. I live in a three story townhouse. Kitchen on the middle floor, bedroom and bathroom upstairs and back door (to let the dog out) downstairs. I, too have had both knees replaced in the past six months. Both times, I was discharged early with a cane and instructions on how to use it to go up and down the stairs. It wasn't fun, but I managed.

Unless you're paying cash out of your own pocket, being over 55 and living alone is not a reason to be admitted for a minor ailment. And how many of us can afford THAT?

[Ruby Vee, BSN]

I am not saying people should be admitted to the hospital for sprains. I said that where I work older patients that do not feel comfortable going home due to an injury are often held in the ED while placement at a Rehab is arranged or VNA services. It is great that you feel comfortable going home and caring for yourself but other do not. If insurance will pay for rehab or skilled nursing services why not offer it to people if it makes them feel better about going home and continuing to maintain their independence? I have worked at rehab facilities and done VNA, taken care of knee replacements at both.

Using services frivolously drives up health care costs for everyone. If someone is uncomfortable going home and caring for himself but still able to do so, he should do so. Rehab and VNA services cost money. Of course if he can afford to pay for those services in their entirety out of his own pocket, he should go for it. Making people "feel better about going home" doesn't justify spending money on services they don't actually NEED.

[systoly]

i do not nor have i ever worked in a civilian ER,

but it occurs to me that the F/U (and it was a F/U) should have been

with any Dr. office, but certainly not with the ER

and the primary C/O pain of known origin does not constitute admission

or even a trip to the ER in my (untrained, but common sense) opinion

[Gabby-RN]

Using services frivolously drives up health care costs for everyone. If someone is uncomfortable going home and caring for himself but still able to do so, he should do so. Rehab and VNA services cost money. Of course if he can afford to pay for those services in their entirety out of his own pocket, he should go for it. Making people "feel better about going home" doesn't justify spending money on services they don't actually NEED.

I shouldn't have worded it "making people feel better about going home". It is about improving patient outcomes. A week of VNA services is far less expensive than the subsequent trip to the ED and hospitalization which could occur. I am not saying EVERY older adult should receive or be offered frivolous services but patients that want the services and are screened by case management or social services and found to be eligible for services, should receive services. Preventative care is not a new thing. It does cost money but far less money than the alternative. I really believe that rehab and VNA services are a method to offering a type of preventative care because the hope is that you are preventing further injury or decline.

http://healthworkscollective.com/ecaring/121911/er-visits-and-elderly-why-are-costs-so-high

http://www.medscape.com/viewarticle/812718_4

http://www.elderbranch.com/blog/older-adults-emergency-room/

[thelema13]

I once admitted a woman with a dx of morbid obesity.