My Day At the Hospital....

[roser13]

My brother has been inpatient for 3 days for a perirectal abscess with surgical debridement. Dressing changes are quite challenging, requiring an entire kerlix packed wet to dry, plus outer dry dressing. Dressing change required after every BM.Hospital is an hour away from my home. I received a call from my brother, telling me that surgeon was discharging him to home today. No longer medically necessary to keep him inpatient. Home Health was being arranged.

Husband and I set out for hour's drive, arrive @ 1:00. Social worker is in the room, states that she's "arranging the home health agency" for dressing changes. We sit patiently, visiting with my brother, waiting for arrangements to be finalized. Brother is going to stay with 80-year-old parents, on the assumption that medical needs/dressing changes will be taken care of primarily by home health nurse, plus myself. After 2 hours, we put on the call light and ask RN how things are going.

She immediately says "well, I don't think discharge tonight is a reasonable goal. The insurance company is balking at paying for home health nurse since the patient can walk, talk and feed himself." Well, yes, he can do all of those things, but he CANNOT change his perirectal packed dressing. Nor can his 80-year-old parents. I mention that today is Friday, and to my knowledge, not much can be accomplished with insurance companies on Saturday or Sunday. Nurse assures me that oh yes, we will get this accomplished tomorrow if not tonight

Another 2-hour wait. I'm preoccupied with being a PATIENT patient advociate. At the end of the 2 hours (6:00), I go to the nurse's station. Politely ask the RN: "has there been any progress?""Oh no," she says. "You guys might as well go home."Apparently, social worker has gone home, insurance company closed down an hour before, yet no one as said word one to us. Seething inside, trying to keep my cool so as not to make my brother feel bad.So.....insurance company would rather pay for 1-2 extra inpatient days' stay, rather than a home health nurse? And the nursing staff? knowing we were sitting there from out of town, waiting for discharge, and they can't even update us on the progress/lack thereof?

And no, the RN was not running around like crazy, tending to other patients. There were a total of 6 patients on the floor, with 3 RN's (I counted on one of our numerous walks around the unit).Suppose that my brother didn't have a nurse for a sister? Suppose he allowed himself to be discharged to his elderly parents' home without a plan for dressing changes because he didn't know any better (and he is not an unintelligent person - just not experienced in the medical field).I hate hospitals and I hate insurance companies. I just don't know which I hate most.

[roser13, ASN, RN]

Frankly, I think 5-7 days in LTC would have been the more appropriate discharge....

Agreed. But because he is a walkie talkie it was not an option. There was no place in the decision-making process for an individualized care plan that took into account the severity of his wound and its unfortunate location.

[rita359]

Best case scenerio, some insurance representative available 24/7 like hosptial patients they serve but you know that won't happen. Working on discharge on Friday is frequently fraught with these dangers. Its the nature of the beast.

[KelRN215, BSN, RN]

My brother has been inpatient for 3 days for a perirectal abscess with surgical debridement. Dressing changes are quite challenging, requiring an entire kerlix packed wet to dry, plus outer dry dressing. Dressing change required after every BM.Hospital is an hour away from my home. I received a call from my brother, telling me that surgeon was discharging him to home today. No longer medically necessary to keep him inpatient. Home Health was being arranged.

Husband and I set out for hour's drive, arrive @ 1:00. Social worker is in the room, states that she's "arranging the home health agency" for dressing changes. We sit patiently, visiting with my brother, waiting for arrangements to be finalized. Brother is going to stay with 80-year-old parents, on the assumption that medical needs/dressing changes will be taken care of primarily by home health nurse, plus myself. After 2 hours, we put on the call light and ask RN how things are going.

She immediately says "well, I don't think discharge tonight is a reasonable goal. The insurance company is balking at paying for home health nurse since the patient can walk, talk and feed himself." Well, yes, he can do all of those things, but he CANNOT change his perirectal packed dressing. Nor can his 80-year-old parents. I mention that today is Friday, and to my knowledge, not much can be accomplished with insurance companies on Saturday or Sunday. Nurse assures me that oh yes, we will get this accomplished tomorrow if not tonight

Another 2-hour wait. I'm preoccupied with being a PATIENT patient advociate. At the end of the 2 hours (6:00), I go to the nurse's station. Politely ask the RN: "has there been any progress?""Oh no," she says. "You guys might as well go home."Apparently, social worker has gone home, insurance company closed down an hour before, yet no one as said word one to us. Seething inside, trying to keep my cool so as not to make my brother feel bad.So.....insurance company would rather pay for 1-2 extra inpatient days' stay, rather than a home health nurse? And the nursing staff? knowing we were sitting there from out of town, waiting for discharge, and they can't even update us on the progress/lack thereof?

And no, the RN was not running around like crazy, tending to other patients. There were a total of 6 patients on the floor, with 3 RN's (I counted on one of our numerous walks around the unit).Suppose that my brother didn't have a nurse for a sister? Suppose he allowed himself to be discharged to his elderly parents' home without a plan for dressing changes because he didn't know any better (and he is not an unintelligent person - just not experienced in the medical field).I hate hospitals and I hate insurance companies. I just don't know which I hate most.

This is an example of why inpatient case managers should be NURSES. Why wasn't a referral to VNA made on the day of admission? They knew he was going to go home with complicated dressing changes, the referral should have been made immediately and then the ball could have been rolling with the insurance authorization. Although if dressing changes need to be completed with every BM, that may not even be the ideal situation for him. He'll have a nurse come in once a day to assess the wound and change the dressing but there's no guarantee it won't need to be changed another 3 times that day and what happens then? He certainly won't qualify for Private Duty nursing just for dressing changes and I can't imagine any VNA would agree to be "on call" for dressing changes multiple times/day. And insurance companies generally don't like to pay for home health- I had to fight with one the other day for a child with leukemia who needs to get her chemo at home.

Before I left the hospital, I had a similar situatiion with the surgery team. 9 am on a Monday morning, they come in and tell my patient, "you're going home today." Now, mind you, this patient was a teenager with a PICC line in place who needed to be discharged on IV antibiotics. Case Management had only become aware of the need to even make a referral to VNA on the weekend (when they're only in house until 12pm) and the patient had neither a supply company nor a VNA in place. The mother hadn't been available so PICC line teaching hadn't been done. Not to mention the child was in state custody! In my experience, surgeons have no concern for the whole picture and just want to be done with their patients as soon as they deem fit.