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?
Quote from CapeCodMermaid
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:
Last edit by heron on Jun 9, '11
: Reason: clarity, addition of links for further info