At what point do you send to the hospital?

MedChica · Jul 30, 2013

Hello!
I'm a new nurse in LTC and I would like some clarification from experienced nurses.
My question is at what point would you make a call to send a LTC patient to the hospital?
I'm asking this question because recently a patient who is normally independent started to present S&S of a stroke- favouring one side, drooping extremities and facial expressions to the left. Febrile at 38.9 (sorry I'm in Canada I think that equates to 102), BP 205/109. Patient's baseline BP normally ranges from 90/50-100/60. They went from being able to speak coherently to basically babbling on about nothing.
I notified the charge nurse who basically shrugged their shoulders and told me to get the personal support workers to put them to bed. The patient is a DNR with measures to send to hospital. This infuriated me as the change in health status was so severe. I could be over reacting as this nurse has more experience and has dealt with this before, but I just felt this patient should have been sent to the hospital.
In the past few days the patient went from walking to a complete hoyer lift and unable to do much of anything and to my knowledge the doctor hasn't been notified of the change in health status.
I know in LTC this is a slippery slope but I was just surprised and I am very new and inexperienced at what point you make the call to send a LTC patient tot he hospital?
I know each situation is very different and it depends on their DNR status, etc. Just looking for a bit of advice!
Thank-you in advance :)

She should've sent that resident out. Just because the pt's DNR doesn't mean that you don't respond to their emergencies, especially when there are orders with a send out option.

Maybe the RN just had that whole 'been there; done that/the new nurse is just overreacting' type thought process? That sounds right.

Is she always like this when there's a problem?

She still should've checked him out herself. We have a resident who has heart attacks 12 times an hour, to hear them tell it. LOL Everyday, he has 20 strokes. "NUUURRSE!", he screams. However, we/I check it out. I sigh, roll our eyes and still perform vitals/assessment. I talk to him and settle him down. He forgets about his stroke. That old 'song and dance'. I tell him to use the call-light if he has any issues. 20 minutes later, he will do just that.

Yet, you check the pt regardless. There may come a time when that little man is not just crying wolf.

I read that you called the doctor? Good.

... and the doctor told you that it was 'up to ya'll'? Yeah - that sounds about right. LOL Too much responsibility and liability.

I'm a new nurse (1 year in august) as well and I've never had a more experienced nurse fail to treat or totally blow off a pt with those s/s, so I can't offer much advise. Once the decision was made to monitor the resident and the CN went on break. After much thought, I noted the deteriorating condition, thought we lacked the resources to treat or improve and sent the resident out.

The CN came back. I told her. She didn't get mad. She just wanted to understand my rationale. Good call vs Bad call. Only time, she's ever disapproved was when a resident was impacted. The other newer PRN nurse asked me what to do. I told her that we'd probably do 'large volume soap-sud enemas' and attempt to 'manually dig that poop up outta there when it comes within reach, I guess...'

Well, I guess she asked the CN the same but mentioned 'sending them out'. Our new CN is about 72 years old. Deeply experienced and military trained (a retired Col). ICU, Med Surg, Psych, ER...she has a psych degree, too. We're new nurses on the floor so, of course, we all think she's a walking go-to encyclopedia for all things nursing-related.

To her, 'it's embarrassing' for a nursing home to send a resident out for impaction. I think I agree because as I've come to understand, it's nothing that the nursing home can't fix. Honestly, I don't know how that resident got impacted in the first place. She has healthy BMs every day. One of the senior nurses who used to work here would bomb her halls out every other week or so...because you can't believe the ADLs, some of these residents aren't self-aware and the CNAs don't always tell you when the resident's having bowel troubles. I've begun to wonder if I should do this practice.

Anyway, why would a charge get mad if it were totally necessary? Situation like that shouldn't turn into a ******* contest. "No - I'M the CN and my say goes!" Yeah - they're the charge but that's your resident, too. You're in 'charge' of their care, too.

I can absolutely understand a new nurse being too unsure or afraid to go over anyone's head and send the resident out, though. Just make sure that you chart everything. CYA!

IrishErin · Jul 31, 2013

The doctor should definitely be informed of the change in her health status! How has her BP been since? Has her swallowing status been reassessed? She may need a change in diet too.

My thought exactly! If she was never formally treated for the stroke, what will they do for the change in patients status now?

BrandonLPN, LPN · Jul 31, 2013

I charted what was expected of me. I'm not sure how it is in the USA, but we chart everything that happened including dialogue had with anyone present. So I charted in the progress note the dialogue that I had with the charge nurse and the DOC. I probably didn't write in my "opinion" I don't have it directly in front of me but in there is my documentation of the dialogue with all parties. If you don't chart it , it didn't happen. As a previous poster stated, nursing in different countries varies... expectations, responsibilities, schooling, the dreaded policy, and so on. Now I know I could have done things differently, that I am sure of, it was an exceptional learning of what NOT to do next time. I will never let a policy get in the way again- that is if I feel it is threatening to the patient safety. I'm also in no way trying to be ungrateful, spiteful or rude because of the previous comments that I was neglectful or being irresponsible. I am happy people are taking the time to read my situation and give their input.

I apologoze if my post (the one about not documenting your opinion) came across as overly critical or harsh. Didn't mean it that way.

When sentinal events like this happen, you can't be too careful in your documentation. Only chart the facts and do not document any more information than you have to. I would never, ever, chart that a RN specifically said that the pt doesn't need to be sent out. (not saying you did) Just document that the RN was informed of the change in condition and leave it at that. A lawyer would have a field day with a documented nurses note that stated a RN said not to send a res outor said "just put him to bed".

This is a hot button issue with me, because so many nurses I work with are so terrible at this sort of thing. One nurse actually wrote in the nurses notes that she assured a resident's wife that an investigation was pending on said resident's injury. I've also seen nurses document in the nurses notes that an incident report has been filled out.

If/when such documentation goes to court, nurses notes like this are more or less an admission of guilt on the part of the facility!

imintrouble, BSN, RN · Jul 31, 2013

I haven't working in LTC for awhile. When I did, I called the MD when a resident's condition required medical attention. Unquestionably, what you describe should have been called to a doc.

It's not the nurse's decision to transfer or not to transfer. It's the MDs.

It's the nurse's job to report a change in condition to the pt/res doctor.

The doctor then decides what kind of intervention is required. That may or may not include an order to transfer to the ER for eval.

Blackcat99 · Oct 20, 2013

I was always taught "When in doubt, send them out." However, at my LTC they get mad when you send anyone out to the ER. They say 'Oh you should have told the doctor to leave her here and we could give her IV fluids here. I got scolded for sending out someone who according to the ER report was having a "heart attack". We are suppose to call the DON before we send anyone to the hospital. I don't do it that way. I wait until after the paramedics have taken the resident out and then I call the DON.

Blueberry36 · Oct 26, 2013

I absolutely hate when physicians use the, "If you feel like it's necessary to send his/her out, go ahead and send them out." statement. Did anyone call the family and ask there opinion. At my facility when sending someone out is questionable, that is something we can do. A lot of families won't want the resident sent out. In that case if family is POA and it is in reporting that's justifying the decision to keep the resident. Like someone already mentioned although I think the resident should have been sent out, is it likely it would have changed the outcome that much?

NurseGuyBri · Nov 19, 2013

I give my LPN's the full ability to circumvent the RN. It is a fail-safe. I also REQUIRE the RN to explain why they are making their decision to the LPN. We are co-workers and a team, not parent/child.

For the OP, my first instinct would be to call the MD and while on the phone, look up the BP and vitals for last 3 days or so, read the notes, and find out if there was a med change or maybe they missed a medication. I would expect the nurses to use SBAR or info gathering to give the practitioner a full picture and request to send to ER. One symptom is usually not enough to go to ER for me, but 2 or more is. If it was just high BP and a little listlessness, i'd ask for a one time hydralazine. If it was high BP and babbling, BYE BYE BYE! To the ER you go.

I always want 2 nurses assessing, but if either thinks the patient needs to go out, out they go, as long as they can explain why. "They're just different today" is not enough, that is a sign of a need for education on assessment skills.