What would you do?

[hoolahan, ASN, RN]

I got a call from the answering service tonight from a pt, "needs help with dressing changes for wounds." When I got the name, it didn't sound familiar.

I called the pt, it is 7:10pm here, she reports that she has been going to phila to a wound center for wound care, twice a week, and she is now wearing an una boot, which was put on Wednesday, and they are usually changed q 4 days, but she has a lot of drainage and a lot of pain with it, and she needs someone to come over and help her to change the dressing. She has no una boot supplies in the home, but she has other dressings we could make do with, she is just not able to do it herself.

I confirmed that she was not currently a pt, but has been in the past. She then repeats that she just needs someone to come over and change the dressings. NOW? I ask...nicely. Yes, she says. Now she told me in her first breath where she lived, and it is VERY close to my house. I asked if she had any relatives or family members who could assist her, she says no, but she did continuously refer to "we" in the course of conversation, maybe she meant her and her doctor? Anyway, I explained that I needed a doctor's order to start any care on her, because a nurse in NJ cannot practice w/o a MD rx. I also explained that we do not carry una boot supplies in stock, that usually pt's are sent home with supplies, and then we place a refill order from a med supply company. She was very sweet, and said she understood, etc.. I went inot a mini assessment, foot is slightly edemetous, but no more than usual, yes she keeps it elevated, foot is warm, no discoloration or change in appearance of foot. I asked why she is going all the way to Phila for care and asked is she had been to the wound care center in our town, she said the vascular surgeons and dermatolgists caring for her felt they could go no further with her care , so they referred her out there. (Do they realize how hard it is for these elderly folks??!!) Anyway, I asked her to clarify her pain, saying I was concerned, but she assured me that she has had the pain for quite some time, and she has been using percocet for it, so the pain was not new. All in all, it did not sound life-threatening enough to send her to the ER. Though I offered this as the most likely option if she felt the dressing had to come off tonight. She said she really didn't want to wait around in the ER for hours, d/t the pain, and I empathize, I do, but again I explianed I wished I could help her, but legally, blah blah blah. To make matters worse, she has a managed care plan so we need auth, and that is tough to get on the WE, let alone at 7pm!! She said she would call her doctor tonight, and I offered to have him call me tonight or in the am. Teachnicaly I am not supposed to call for the auth, looks self-serving for the agency, the referring party should obtain auth, ie the hospital or MD office, etc... I know for a fact we are the only HH agency which could accept this insur policy in our area, so if we can't help her tonight, no one can.

I feel like a $hit for not hopping over there to help her. I am so close, and I could go as a "friend" , but frankly, I have been burned by that in this same situation before. If it was a personal friend of mine, or did not come through the agency, I would go in a heartbeat, but, in this circumstance, I don't feel I can. Not only that, but I get calls from pt's like this, send out a nurse, and I can't tell you how many times someone has sworn there is no one to help them, only to find when we arrive, there are six people living in the home, most of them in the room with the nurse. Even though the lady was very sweet, I feel like 1) Why the he!! did this Phila doctor send her all the way home, knowing she "was alone" and not refer to HH? 2) Why did she wait til 7pm to call us if she knows the dressing needs to be changed on Sunday anyway?? Of course I didn't go there with the woman, b/c she really wasn't the one who should have thought of all these details, so made me wonder how does she get to Phila w/o help? Someone must be available to her, I KNOW her insurance co would not pay for transportation like that, trust me.

This is one of those times I hate to be in the decision-maker's seat. I feel so guilty, even though our agency has no obligation to this woman at this point. If you were me, what would you have done??

[Janet Barclay]

((Hoolahan))

I'd have done exactly as you did. You're a nurse, and you want to help, but this lady was trying to manipulate you into doing something that you are not comfortable doing. Presumably the lady got hold of you through the HH service that you work for. They had no business providing that information as the lady is not currently a client.

If I had a nickel for every family member of patients that asked me for ativan, tylenol, extra supplies etc, I could leave nursing a very wealthy lady. In those situations, we always have to refer to ER, walk-in clinics or what have you. I cannot prescribe meds without a liscence. No more can you assess and treat a wound on a lady that you have never seen before and have no real medical hx on.

You did exactly the right thing!

[hoolahan, ASN, RN]

Thanks Janet. I feel much better about it now. I never did get a call from her MD, I just hope she doesn't decide to wait until 7pm tonight to call me again.

IF you looked in the phone book and called my agency's # on off-hours, you will get an answering service, they are an outside company, so they put every call through, they have no way of knowing whether they are our pt or not. You wouldn't believe some of the calls I get, "I need someone to come over and clean up my grandmother, her diaper is soiled." And they aren't even our pt's! Very interesting fielding these calls!

[Louie18]

I learned very early on . . .

Should a compromising situation ever arise-ALWAYS, delegate UP.

[fiestynurse]

I like that Louie! I am going to have to remember that one. I think Hoolahan handled the situation quite well and I commend her for her professionalism!

[mustangsheba]

Hoolahan: In Oregon, we don't go into a patient's home without a doctor's order. That's bottom line. You don't even have to have second thoughts. No order, no treatment. If she thinks it's serious enough, SHE can make the decision to go to the ER. An Una boot starts out wet, so if she doesn't have fever or severely increased pain (and is not diabetic), it can wait until morning. In any scenario, you do nothing except explain her options. This isn't even something to dither about, Honey.

[hoolahan, ASN, RN]

Thanks again guys! I finally figured out why it bothered me so much, it is b/c she was sooo close to my home! I knew I could be there in 2 minutes and out of there in 15 if all I did was the dressing period. Otherwise, I think I would not have worried about it so much if she were 2 townships away. The bottom line is I have to be consistent, no matter where she lives, and folow protocol.

I puled her old chart today, she was under service until this past December, she lives with her husband, though it didn't mention his physical abilities in the chart, and she had a friend who helped her on the same street, and a son who lives about 10 minutes away, so that made me feel much better too. I tried to call her today, but no answer, maybe she was our or went to the hospital, but no calls tonight.

[Jenny P]

Margaret, as someone who has done home health in the past, I know you did the right thing, just as you know you did the right thing. You said the state of NJ requires authorization for you to visit. And you know as well as I do that if you would have gone there, you would have done a complete assessment and it would have taken a lot longer than 15 minutes to do so. Your license would have been in jeopardy. If her doctors felt the local wound clinics couldn't have done anything for her, the possibility of something happening while you were caring for her wound would be enormous-- and that's when your license would have been on the line. Even if she would have lived 2 doors down from you, (and even if she was someone you knew), it would not have been worth you risking your license by deviating from the standards of care that way.