Reducing ED transfers from SNF - page 3

by HelenaHandbasket

3,790 Views | 26 Comments

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... Read More


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    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..
    IowaKaren and LTCangel like this.
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    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!
    DavidKarl and southernbeegirl like this.
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    Quote from HelenaHandbasket
    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
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    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.
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    Not true..we LTC nurses really could care less about what type of insurance the res has. Also, they would have to have a break in the skilling...most returns to the hosp are due to what the res is already being skilled for.

    Yeah, years ago that might have worked.
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    I totally understand your predicament. I believe that education of BOTH staff and families of the need for the reduction of transfers to the E.D. is key here. Nurses have been educated on the protocols (varies by facility of course) for providing the physician with the S/Sx of UTI and dehydration and have the ability to provide the treatment once ordered. The families and/or DPOA of the resident's do not always understand nor WANT to understand. I have witnessed discussions with family members where the bottom line was that they feel that their loved one would be better served in a hospital. They believe that the attention their loved one will receive is a better ratio than in the SNF. I believe it may amount to staffing at the SNF vs hospitals as their acuity is different.

    So...if we can educate the staff and families with the understanding that we have the skills to take care of our residents in the same way (with the same training) as the hospital staff and pointing out that thousands of healthcare dollars would be saved in the process we can potentially turn this current pause in our facility operations around.

    Of course, there will always be that one family that requests that their family go to hospital. Recently I had the opportunity to explain to a family that even if a hospital agreed to admit their loved one that hospitals too were under scrutiny for the criteria for an admission and that one day soon something such as a UTI with AMS or dehydration would no longer be a viable admission criteria. The family took pause and agreed to treatment within our facility.

    So it may take "baby steps" but through education and perseverence I believe the situation will turn around.

    On another note, most SNF's have a medical director that they can call if the PCP is unavailable no matter the time of day or night. If the "on call" physician is advising that all residents be sent out then perhaps they need to re-familiarize themselves with the facility's protocols. If the physician is completely informed of the symptoms my experience is that they will prescribe TX at the facility first and then reevaluate in 24-48 hours time unless otherwise notified. This allows time for labs and other diagnostics to be done on an outpatient basis for review as well.
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    Quote from michelle126
    Not true..we LTC nurses really could care less about what type of insurance the res has. Also, they would have to have a break in the skilling...most returns to the hosp are due to what the res is already being skilled for.

    Yeah, years ago that might have worked.
    As an MDS Coordinator, it was fairly routine during management meetings to discuss who 'may need' to be sent out, to 'requalify' for skilled care, when the census dropped below the 'red line'. And the nurses NEED to know about insurance coverage- different payers have different pharmacies, ploicies, and etc- not knowing that is a good way to lose $ for the facility.

    Other comments on this topic:

    - Track what nurses send the most patients out. You may find a pattern, and the pattern may be that that nurse is one the providers do not trust to receive adequate reports from, so they order the patients 'evaluated'. Likewise, your detective work can show which nurse sends the FEWEST- you can then find out what she's doing right?

    -One place I worked, the skilled unit was all agency nurses, different staff every day. The primary provider got sick of seeing her patients all crash on the weekends, from lack of continuity- so began the habit of sending a lot of people the ER on Friday evenings, knowing many would 'stick' (be admitted). She really thought she was doing good, and she was an excellent and compasionate advocate, but that habit got her fired from the SNF.


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