Reducing ED transfers from SNF

heron, ASN, RN · Jun 10, 2011

I agree with everything except clysis. I have NEVER used or seen it used and I've been doing this since the 80's

When I worked at the Shattuck, we had a long term care unit that was rockin' ... I used to float there on occasion and worked the floor as agency. Many long term patients ... not a decub to be found. They used to keep a couple of their lols hydrated by starting a clysis and running in a liter of fluid over 12 hours every night. They used butterflies as subcutaneous needles. There are also special clysis sets (probably pretty expensive) that we used in hospice with tiny 3/8 inch needles that were 28 or 30 gauge that were pulled out after insertion, leaving a short catheter in place. I also wonder if pediatric angiocaths would work, too ... just so there's no indwelling needle. You can start one anywhere there's enough subcutaneous tissue to pinch up and infection/phlebitis/cellulitis issues are minimal. If you can give a subcu. injection you can start a clysis. (term is short for hypodermoclysis)

What you can't do via clysis is give most meds ... we've given opioids, haldol, ativan drip via clysis, but it's "off label". Especially, there are no abx that I know of that can be given subcu.

Herewith some links:

http://www.aafp.org/afp/2001/1101/p1575.html

http://www.annalsoflongtermcare.com/content/hypodermoclysis-maintaining-hydration-frail-older-adult

http://www.medscape.com/viewarticle/413369

Asystole RN · Jun 10, 2011

I have worked in several facilities where it was standard practice to ship to the ED for eval & treat for suspected UTIs/URIs that were suspected, esp if it was thought that IV ABTs were going to be needed.

This was not done because we did not know that the pt had a UTI/URI but because it was more cost effective. Those facilities of course were lower acuity facilities that negotiated lower prices, IV ABTs can seriously impact the bottom line and make a once profitable floor go in the red.

Depending upon the ABT (how many, which kind, how often), the frequency of IV starts, the types of lab work that may need to be accompanied with the UTI/URI, and the staff (IV nurses, RNs, of IV-LPNs) it can cost several hundred dollars a day to manage a patient's IV ABT therapy.

Sounds horrible to make the cost of care a concern but in reality even no-profits still have to pay the bills...

P.S.

In my current facility we utilize the iStat and Urysis and have a staff of IV nurses to manage IV ABT therapies, we are also a higher level Sub that negotiates a higher rate...

goodneighbor · Jun 10, 2011

This has been a very interesting discussion, and I appreciate the input from Cape Cod Mermaid who shared that she has to send an "Unplanned Discharge" form to Corporate that gives me another level of understanding of SNF management. I am thinking that, yes, it is good that we can get stat labs and have the E-box and all that, but in the real world I have had 45 pts and 2 CNAs and the real issue is nurse-to-patient ratio. When the acuity level goes up the nurse cannot safely treat and monitor all. Actually, it's tough on a quiet night. No longer are nursing homes filled with just Grandma or Grandpa who needs a little help in dressing-the patients are only somewhat stable (in a chronic way!) It might be more cost-effective to staff more nurses, do you think?, than to incur hospital expenses, but I am just dreaming. There is a proper I guess you call it scope of practice to hospitals and another to SNFs. Thank you, Heron, for the info on hypodermoclysis, which I've only seen done on a postpartum cat!

HelenaHandbasket · Jun 10, 2011

I suppose it also depends on what state you are in and your scope of practice. I don't have to get an order to dip stick a urine in a patient with AMS. If a patient is showing signs of hypoglycemia do you have to get an order to do a finger stick? :confused: A culture takes just as long to grow in the hospital as in the lab. 24 hours is 24 hours.

We can get stat labs done. The facilities don't LIKE to because there is an extra fee for stats, but it can be done. Our IV company can send someone out to do an IV start, again, more money, but possible to be done. More commonly in SNFs it seems clysis is coming back into favor as well. Once inserviced, any licensed nurse can start a clysis for hydration. Routine monitoring of labs would be sufficient.

As far as better, faster care. I'd have to disagree. A SNF pt with a UTI is last on the priority list in the ED.

Sgain, I understand there are concerns about staffing and handling acuity of patients. The cold facts are this...since the RUG IV rates have come out, it's painfully clear that facilities which take clinically complex patients will do better in the future. Those that have relied solely on "rehab" will suffer. The patient population in SNFs is changing and programing has to change to stay competitive.

Home care is stepping up their game and are able to do most of what has been exclusively a SNF market in the past.

Higher acuity may mean that corporations may actually have to hire more staff. I worked in a sub-acute rehab facility as a baylor supervisor 7p-7a. I had 75 patients in the building. I was a float supervisor. We had two nurses for 45 subacutes upstairs and one nurse for 30 subacutes downstairs plus 5 CNAs in the building. I did Heparin drips, CAPD, TPN. Hung SCADS of IV abts and IV hydration. I had hospice patients, ortho patients, CABG pts, stroke patients, trachs, you name it.

I'm trying to reflect to my corporation the changing climate of SNF care and emphasizing to them that we need to show we can actually take care of sick people. The days of $500/day walky talky knee replacements with no comorbidities is LONG over.

This is a great conversation. I appreciate it all. It's very helpful!!

HelenaHandbasket · Jun 10, 2011

Also, does anyone have an Unplanned Discharge Form they could share? Thanks!

CapeCodMermaid, RN · Jun 10, 2011

Our form is very basic...columns and rows:

Pt Name and Payor Source

Admission date and dx

MD who gave order to send

RN who assessed resident before sending

Symptoms res. was having

Interventions tried before sending

Hospital admission dx

southernbeegirl, BSN, RN · Jun 22, 2011

I am the RN supervisor on the weekends at my facility. I bust my butt not to send anyone out that is not emergent. I am not afraid to advocate for in facility treatment from an oncall doc that doesn't know my patients. but I've worked hard for the good reputation that I have with the on call docs/NP for no silly stuff.

If I may speak frankly, I think many of the orders to "send out" we receive could be stopped just by teaching the nurses how to call a doc, when to call a doc and teach them to critically think. When one of my nurses tells me someone needs to "go out", I listen to everything she says, then I walk thru the assessment with her and look at the patient myself. If I disagree, I tell her why, immediately. I make it a team decision that she and I are sending the patient out. Most of us have the advantage that we have worked together for years and years and know each other so well that we are a cohesive unit, but it took us awhile to get there.

On the other side, I've seen the RN's call an oncall doc for stuff i would never call about. "I just called to tell you ms. Smith fell and has a skin tear". "I got a culture back and their allready on the right antibiotic". I've seen them page a doc then leave the desk.

What I notice mostly is that if someone is getting sick for any reason, the nurse on the hall is so overwhelmed already that her first reaction is to "send them out". I feel it's my job to be that support person for her that says "don't worry, I'm here to help" and go at the patient as a team, or just do it for them because they are so overwhelmed. If they are the one that calls the doc, I see panic in their face if the doc says "IV" or "labs". Maybe if we had someone designated each shift to do those things? I know that when I am working, I am that person "unofficially". What I mean is if there is no RN, there is usually noone to start an IV. We have very few that will start an IV or draw a lab. In a way, it's a double edged sword. I start them because they can't, they can't because I do it for them. I think we should train all the nurses in a facility to draw IVs and labs. If they are confident at the skill, I think they would be more incline to call a doc and say "Ms. Smith looks dehydrated and has AMS change. Can I draw a CBC,BMP,UA and start an IV for fluids?". I haven't had a doc tell me no yet if I call with that request. my point is, I really think if we found a way to increase their confidence, it would save the company a 'buttload' (to quote my 13 yr old) of money.

Honestly, I don't understand corporate. I would think the cost to staff just one more nurse and one more CNA on each shift could help decrease the costs of an ED visit. but we all know they don't listen to us.

CoffeeRTC, BSN, RN · Jun 22, 2011

Gosh...we have a whole new P and P and system in place for this. I'm not sure what the name of it is SBAR? or something. There are algorithism and forms to fill out if there is a change in condition and basically tells you what do do and how to be a nurse. Most of us older nurses kinda resented the whole forms and what to dos, but it does have its benefits to keeping the resident in house for treatable things.

What holds us back alot of times is getting the necessary tests done in a timely manner....labs, xrays and meds delivered. On paper..they have a stat service, but in reality....stat is hours or the next day. What good is that?

SuesquatchRN, BSN, RN · Jun 22, 2011

Educate, educate, educate.

The new DNS at my last job (I just moved) instituted IV training for all staff. Very intense, very valuable, and it included which fluids to run for what. She ordered dial-a-flos and IV start sets, PICC and central line care kits, and INTERACT had already been implemented. There are wonderful sheets to guide the nurses through what to assess and what to say to the doctor. They will also be initiating clysis hydration.

I rarely sent anyone out unless they showed signs of sepsis - lowered BP and HR - and were obviously less stable than we could handle.

The other issue is staffing. Having an RN supe is wonderful if she isn't pulled to a med cart and floor assignment in addition to her managerial clinical duties..

goodneighbor · Jun 22, 2011

Southernbeegirl, you must be beloved by your team. You exemplify what an RN supervisor should be in that you guide, educate, and provide support to your nurse! You are writing about a true example of teamwork and nursing excellence. How important it is to have more than one RN in the building! As a new nurse I had accepted a position at a SNF and then realized I was the only RN with a DON who was available by phone (nights). I believe it is imperative to have adequate staff and precepting-or at least physical presence of experienced nurses (RNs). (If you're going into LTC find out your support team!) There are so many reasons that this is unacceptable--but the root cause is lack of adequate staff. I don't think there is really a "nursing shortage" but really a staffing shortage. If you have one patient with a hypertensive crisis that was really going on on the last shift and another with blood glucose over 400 and another with insufficient urinary output you cannot delegate assessments and still fill in all your MARS and do your trach care and unfortunately you're the only one that realizes how bad this is. This is why when you call for backup you are told to send them out. Your LVNs are overwhelmed also and your CNAs are changing bedsheets (if you are lucky) and are not certified to change colostomy bags. I think corporate thinks RNs are sitting at the desk waving a baton directing staff as in a symphony, while occasionally counting and recording NOC deliveries of meds, and that patients sleep all night. You learn to prioritize quickly, but the things that we think are important are not necessarily the things the family thinks are important. So, again, the root cause of ED transfers are not enough hands. I would love to see how a top notch SNF is supposed to work. I love the work and patients but the load is heavy. Perhaps there is a book (fantasy) of exemplary care. I suppose a private pay/ insurance facility would be better than a Medicaid only floor. This must be the reality shock they talk about. I would like to get past this! And get really good!

nola1202 · Jul 3, 2011

I am an external evaluator for several SNFs in CT.
I am seeing a disturbing trend in the numbers of patients the facilities are sending to the ED.
In most cases, the patient developed AMS and was sent to the ED. There they were dxd with UTI. Admitted and put on IV abts and IV fluids.
The buildings believe this is good nursing care if the patient is admitted. However, in fact, the hospitals feel a lack of confidence in the facility's ability to care for the patient if they are sending them out for a UTI.
When I worked on the floor (not too long ago!) if a patient developed AMS, I did a set of vitals, dipped their urine and checked a BG. If the urine was +, I would send for C&S, call the MD, report the vitals and results of the dip and get an order for a PO Abt to cover until the cultures came back. If the patient's mental status didn't improve within 24 hours, I'd reassess and send out as needed.
We have the ability to do IV abts, IV fluids, portable xray, IM Lasix, IM Haldol etc in our buildings. In my humble opinion there is a lot more they could be handling in the facility that they are referring to the ED.
How are you guys managing this kind of thing? Is this a QA issue? Our corporation is small and there is no one overseeing the DNS in each building. How does this lowly evaluator present this to the administrators/DNS without them feeling defensive?

just like you did here. just the facts, non-judgemental, what you normally do on a handout. Sounds like it would be a good inservice topic.l

DavidKarl · Mar 22, 2013

Don't forget the LTC folks that are sent out to be admitted (for 3 days, naturally) for an easily treatable UTI, or etc., in order to requalify for MED-A.