is it just me, or has standard of care sunk?

  1. I'm sorry, but I'm not going to call a ER vs floor nurse thread. Even though I feel like I could.

    I had a patient admitted for a chest pain r/o ischemia. EKG looks ok, labs ok(WBCs a little high, but she admits to coughing up green stuff for 3 months, has empheysema). No home o2, denies pain currently, etc. I'm looking over the report when I notice that her bp has been going up at 2100, 2300 and 0015. no more VS. the highest at 0015? 215/102! (I figured it was a false high). they call up to see if bed's ready. "yeah, and are we doing anything for bp besides the 1 inch nitro paste?" nope. She gets up there and as I'm doing home meds, she mentions she hasn't taken her daily norvasc or lopressor yet. she's taken her lisinopril and her isosorbide. She told them downstairs.
    Ok, so I go out to double check meds/labs/etc. Didn't catch on the first glance when she got there, uhhhhh nobody called her cardiologist? Nobody did a set of enzymes? Nobody checked her pulse ox?
    ox is fine, her bp that I did was 198/98. Not great, but we'll deal.
    Called the medical, he states to give her a po bp pill, resume usual at 8am. STAT enzymes, they used the blood from ER, look ok. I called the cardiologist as nobody had called the consult, covering doc says, give her her usuals now, again at 8am, take off the nitro paste at 6 am. and we'll see. her doc will see her in am. due to pharmacy, get meds at 3am. By 5? 168/86. Just a bit better.
    am I the only one who thinks they should have done something for bp and run cardiac enzymes? the one time the complaint isn't taken seriously? we get people dying in the waiting room.

    Additionally, she is apparently homeless and does come into the ER off and on, but when a staff went down to get a suitcase she left, she heard the ER staff mention "hating her" and "that Fing B." why the hate? she was actually polite and informative for me.
    •  
  2. 18 Comments

  3. by   Sanuk
    How can they write admit dx of CP r/o ischemia and not do a cardiac workup in the ER? If that was the case, it would be a write-up at my facility and they would be asking questions about what the heck we are doing down in the ER. I've sent patients to the floor with BP's in the upper hundreds over teens, but they've been medicated and persistently high. Also, I don't care how much I might dislike a frequent flier, those nurses should know the walls have ears and things you say come back to bite you.

    Sorry you had to deal with all that and that your ER colleagues fell down on the job. It's not the case everywhere I promise.
  4. by   Isabelle49
    Unfortunately it is the mentality that believes those who do not have are not worth keeping. Very sad.
  5. by   ChristineN
    No one would be admitted to the floor at my hospital for chest pain unless a set of cardiac enzymes were sent in the ER. I find it hard to believe that someone didn't slack on the chest pain standard of care.
  6. by   imintrouble
    In defense of the ER, and I don't work ER, they frequently have the same pts, present several times a week with the same complaint.
    Apparently the ER is very familiar with this pt. Is it possible she had a complete cardiac workup the same day or the day before?
    It would have been nice if the ER had given the pt her scheduled BP meds. But the ER is not the doctors office or the clinic.
    It would have been nicer if the pt had taken them herself
    Last edit by imintrouble on Oct 17, '11
  7. by   emmanewgrad
    Beyond the point of being a frequent ED visitor, the standards of nursing and medical care should meet up with the pts chief complain. Very controversial medical situation.
  8. by   Medic2RN
    I'm curious - what was her chief complaint for coming to the ER? Was it originally chest pain?
    Regardless, I'm surprised that enzymes were not ordered in the ER - by the doctor or the nurses.
  9. by   Esme12
    Quote from locolorenzo22
    I'm sorry, but I'm not going to call a ER vs floor nurse thread. Even though I feel like I could.

    I had a patient admitted for a chest pain r/o ischemia. EKG looks ok, labs of(WBCs a little high, but she admits to coughing up green stuff for 3 months, has emphysema). No home o2, denies pain currently, etc. I'm looking over the report when I notice that her bf has been going up at 2100, 2300 and 0015. no more VS. the highest at 0015? 215/102! (I figured it was a false high). they call up to see if bed's ready. "yeah, and are we doing anything for bp besides the 1 inch nitropaste?" nope. She gets up there and as I'm doing home meds, she mentions she hasn't taken her daily norvasc or lopressor yet. she's taken her lisinopril and her isosorbide. She told them downstairs.
    Ok, so I go out to double check meds/labs/etc. Didn't catch on the first glance when she got there, ah nobody called her cardiologist? Nobody did a set of enzymes? Nobody checked her pulse ox?
    ox is fine, her bf that I did was 198/98. Not great, but we'll deal.
    Called the medical, he states to give her a po bf pill, resume usual at 8am. STAT enzymes, they used the blood from ER, look ok. I called the cardiologist as nobody had called the consult, covering doc says, give her her usuals now, again at 8am, take off the nitropaste at 6 am. and we'll see. her doc will see her in am. due to pharmacy, get meds at 3am. By 5? 168/86. Just a bit better.
    am I the only one who thinks they should have done something for bf and run cardiac enzymes? the one time the complaint isn't taken seriously? we get people dying in the waiting room.

    Additionally, she is apparently homeless and does come into the ER off and on, but when a staff went down to get a suitcase she left, she heard the ER staff mention "hating her" and "that Fing B." why the hate? she was actually polite and informative for me.
    First of all the ED comment was WAY out of line and the nurses who said that should be very happy I'm not their boss or night supervisor.....that kind of crp really makes me burn.

    Now to the visit and admit. I think care is slipping and I am fearful that this is only the beginning. With new regulations being enforced with medicare and medicaid, while warranted on one hand, we as nurses are going to be seeing this more and more often. When reimbursement is restricted by diagnosis and the patients failure to get better or have complications solely the hospitals responsibility that directly effect how the hospital gets paid.....as in they don't get paid at all if re-admitted with in x amount of time for same dx....we will begin seeing creative diagnoses and work ups so the hospitals can get paid. That coupled with the drive to do more with much less is going to effect care in a bad way. I just hope it doesn't get too bad before the pendulum swings back the other way.

    In the presence of productive cough with elevated WBC I would ask where the CXR and blood cultures are and why is there no antibiotics. But if she has been seen for that recently for the she can't technically be admitted for that if the facility wants to be paid.The ED will not usually treat other than the immediate issues. Restarting someone's home meds is not one of them (for the most part). and considering she hasn't taken any of her meds the lack of response and the elevation of the B/P is "with reasonable cause" so it is explained. I am concerned however the lack of an order for the lopressor IV as she needs the Beta blocker and hasn't gotten it for however long and can have refractory reactions from the stoppage of the beta blocker.

    I also take objection to her not receiving a full set of vitals upon admission to the ED regardless of how often the see her and now little they may change...that is Prue laziness and carelessness.....and that makes me mad too.. They may be busy and short handed and have many other sicker patients that are "supposed to be in the ED" but that doesn't mean they should treat her any less...and that makes me mad.

    I am concerned for their apparent lack of compassion for this little lady and their lack of concern for her just because she interfere with their day and important ED work by wasting their time. I find the behavior the most objectional of all. We have all had patients that we can't stand for one reason or another
  10. by   BrandybunsRN
    Quote from imintrouble
    In defense of the ER, and I don't work ER, they frequently have the same pts, present several times a week with the same complaint.
    Apparently the ER is very familiar with this pt. Is it possible she had a complete cardiac workup the same day or the day before?
    It would have been nice if the ER had given the pt her scheduled BP meds. But the ER is not the doctors office or the clinic.
    It would have been nicer if the pt had taken them herself

    Regardless of whether she had a work-up the day before, including enzymes, if she presents again the next day with CP she should be getting enzymes. If the physician feels strongly enough to actually admit her, the standard of care would be to have a complete cardaic work-up.... again... even if it was done days ago. (because we all know a patient can go from having angina with negtive trops one day to a MI with positive trops the very next day)
  11. by   imintrouble
    Quote from BrandybunsRN
    Regardless of whether she had a work-up the day before, including enzymes, if she presents again the next day with CP she should be getting enzymes. If the physician feels strongly enough to actually admit her, the standard of care would be to have a complete cardaic work-up.... again... even if it was done days ago. (because we all know a patient can go from having angina with negtive trops one day to a MI with positive trops the very next day)
    Is it reasonable to run cardiacs everyday for a pt who c/o chest pain everyday? How many times can they be negative before you say "The heart's not the problem" Is defensive medicine the only way to go? How long does the hospital do these tests with the results all negative?
  12. by   nursej22
    I can only speak for my facility, but it seems that the purpose/focus of care has shifted, as opposed to decrease in standards. I am guessing this is related to volumes, reimbursement, and staff experience and provider practice.
    When I first started patients in ED were diagnosed and had initial treatment started in ED and the admitting MD often didn't come in until after office hours or first thing in the am. This was back when GPs and internists were the admitting MDs, before hospitalists.
    ED seems more like a triage area--get an IV, may be some labs and an xray. Decide on dispo, wait for a bed. Treatment for their ailment often doesn't start until they get to the floor, unless its sepsis or a STEMI.
    ED RNs are discouraged from questioning or requesting tx. Their focus is get 'em in, get 'em out. I think this has led to many ED RNs not knowing what appropriate tx might be.
    Actual interchange between cardiac tele nurse and ED: "If the patient is admitted for pulmonary edema, then why has he had a liter of NS? Well, you're the cardiac nurse, you tell me."
    Another common exchange:"Has the r/o MI had aspirin? No, it wasn't ordered."
    And frankly, I don't care anymore, just bring them up so I can start their antihypertensive, heparin, antibiotic, analgesic, diuretic, whatever.
  13. by   Altra
    Quote from locolorenzo22
    i'm sorry, but i'm not going to call a er vs floor nurse thread. even though i feel like i could.

    i had a patient admitted for a chest pain r/o ischemia. ekg looks ok, labs ok(wbcs a little high, but she admits to coughing up green stuff for 3 months, has empheysema). no home o2, denies pain currently, etc. i'm looking over the report when i notice that her bp has been going up at 2100, 2300 and 0015. no more vs. the highest at 0015? 215/102! (i figured it was a false high). they call up to see if bed's ready. "yeah, and are we doing anything for bp besides the 1 inch nitro paste?" nope. she gets up there and as i'm doing home meds, she mentions she hasn't taken her daily norvasc or lopressor yet. she's taken her lisinopril and her isosorbide. she told them downstairs.

    at each of the 3 hospitals where i have worked in the er, we do not routinely start the admitted patient's regular home meds unless we are holding the patient for an inordinate amount of time.

    ok, so i go out to double check meds/labs/etc. didn't catch on the first glance when she got there, uhhhhh nobody called her cardiologist? nobody did a set of enzymes? nobody checked her pulse ox?

    if "nobody called her cardiologist" i'm assuming the patient was admitted to the medical service. is it the practice at your hospital that consulting physicians get called from the er?

    does the er at your hospital utilize point of care testing for cardiac enzymes? if so, is it possible that these were done, but for whatever reason the results are not crossing over with the rest of the patient's lab results? we've had that problem from time to time.

    if there is no documented spo2 reading in all of the er documentation that is certainly poor practice or just poor documentation.

    ox is fine, her bp that i did was 198/98. not great, but we'll deal.
    called the medical, he states to give her a po bp pill, resume usual at 8am. stat enzymes, they used the blood from er, look ok. i called the cardiologist as nobody had called the consult, covering doc says, give her her usuals now, again at 8am, take off the nitro paste at 6 am. and we'll see. her doc will see her in am. due to pharmacy, get meds at 3am. by 5? 168/86. just a bit better.
    am i the only one who thinks they should have done something for bp and run cardiac enzymes? the one time the complaint isn't taken seriously? we get people dying in the waiting room.

    additionally, she is apparently homeless and does come into the er off and on, but when a staff went down to get a suitcase she left, she heard the er staff mention "hating her" and "that fing b." why the hate? she was actually polite and informative for me.
    definitely an unprofessional comment. however, just as you have no doubt had those patients whose manner when interacting with you would lead you to believe that they just crawled out from underneath a rock ... become pleasant and well-mannered when speaking with the physician ... some people just do act very differently with different individuals, for whatever reason.
  14. by   canoehead
    Quote from imintrouble
    Is it reasonable to run cardiacs everyday for a pt who c/o chest pain everyday? How many times can they be negative before you say "The heart's not the problem" Is defensive medicine the only way to go? How long does the hospital do these tests with the results all negative?
    They can come in daily, or even several times a day, you still have to prove that THIS pain NOW won't kill them, per EMTALA. Most of the repeat chest painers have had some cardiac disease, and it would make sense if they had another infarct, eventually. So we have to make sure that today isn't the big one, then we can send them home.

    My most frequent flyer for chest pain eventually did die of a heart attack at home. He'd come in 2-3x weekly for three years for the same workup. Yes, he had come in the night before, and yes, all the labs were negative, and then he died.

close