Vent thread... when to send a pt out - page 3

by pppp87 7,052 Views | 29 Comments

I've been at an LTC facility for 3 months now. One thing is clear at my facility: take caution before sending residents out to the hospital. I was always taught as far as LTC goes, especially as a newer nurse, "when in doubt,... Read More


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    WoW pppp that's nuts!
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    Yep Mappers!! With the hospitals keeping patient's for less and less time. They come to us with a very high acuity alot of the time. I mean a procedure that used to land a patient in the hospital for let's say a week. Now they are being discharged from the hospital in 2-3 days. Too sick to go home we get them **shakes head**
    mappers likes this.
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    Quote from psu_213
    Huh?? On AN there are all sorts of things for which nurses think they can lose their license. Well, practicing medicine without a medical license is something for which you can actually lose your license. Chart your attempts to try to contact the doctor--be specific: when you called, how you tried to reach him/her (answering service, cell phone, etc.). But don't just give a med and look for an order later. If it is a bad outcome, there is a good chance the doctor and your DON will hang you out in the wind.
    Yep.. I haven't given anything to date without an order here but it is what is expected in an emergency here, especially at night when the doctor is almost always not readily available. During the day, IV's have been started, D5, fluids, neb's etc have been given w/o an order. We should really have a Dr oncall here..
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    Quote from psu_213
    did you call ahead to give report to the ER? I realize that it sounds like this person was somewhat familiar to this ER, but it is always helpful to hear the the facility when they send a resident in--why are they coming? How are they different from their baseline? What interventions did you perform before they left? Etc. As I said, if you did not call it does not excuse the ER nurse, but, speaking from experience, it can be helpful to get that call.
    ALWAYS call the receiving facility when you send a patient ANYWHERE. (in any setting...this includes ER nurses sending patients back)
    I am an old ER nurse, and it chapped my hide when I didn't get a call when patients came from any another medical facility.

    I teach nursing, and hammer this point home to my students. It's just plain rude not to call, and bad outcomes will happen when we don't share clinical (and any other pertinent) info.

    A lack of communication is the worst thing we can do for our patients!

    And send as much paperwork as you think is appropriate (H&P, MAR, nurses' notes, face sheet)

    And seeing that your pt ended up in the ICU, you made the correct call to send, period.
    Last edit by hogan4736 on Nov 29, '12
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    Ah, yes, albuterol is right for urosepsis, the old treat urosepsis via the lungs approach. Why not?

    I think you should quietly, anonymously report the DON to the powers that be. She sounds realistic but dangerous. Does she have a longstanding relationship with the evasive, elusive, rarely available doctor, who then writes whatever orders are necessary to cover what's already been done?

    She is practicing medicine without a license, she is implicitly diagnosing, she is wanting her staff to do likewise - all so the doctor can sleep through the night or keep seeing patients at the office or keep bringing his business to this nursing home. Maybe it's the facility owner who doesn't want to pay for a doctor who is willing to work. What a damned mess! And it's not uncommon.

    Whatever the reason, do not get into this very bad habit of practicing outside of the law. You worked hard for your license and you will lose it if you do what this DON wants you to do. And no one, not the doctor, not the owner, not the DON, no one will back you up if anything goes wrong.

    Be sure to document explicitly when you call a doctor - write the phone # you used in the chart. Write what you did when you couldn't reach the doc.

    How much trouble are you in for sending someone out without an order?

    The ER nurse is a real trip! Never mind her, but do call and give report in the future.
    LTCNS, pppp87, nu rn, and 1 other like this.
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    You did great and you did your best. Sometimes we think we should do more but the mere fact that you act quickly is something to be proud about.
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    Well, since being sent to the ER is a doctor's order, I don't see how any DON could get mad at *nursing* staff for too many ER admits. All we do is provide the doctor with our assessment and he decides on the course of action. If a doctor says the pt needs to go to the ER, what right does a nurse have to question it?

    With that said, I *do* think we should treat as much as we can in-house. Not because of $$$ issues (which I couldn't care less about) but because a trip to the ER is very traumatic for our elderly residents. And, I'm sorry, but hospital staff can be very rough and uncaring toward our residents. It's obvious many of them look down their nose at LTC residents.

    As for the 'sepsis' thing I agree that in, in theory, we can give some IV ABX, fluids and Tylenol as good as any hospital floor. BUT asking a floor nurse who already has FORTY other residents to also be responsible for someone acutely ill is an insane burden. It's undoable.
    LTCNS, catlvr, pppp87, and 1 other like this.
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    How is that her baseline if she was admitted with urosepsis?

    If a resident is stable then by all means keep them in the facility and get an order for IV abx. But your resident to me doesn't sound too stable and you did the right thing by sending her out.

    Lets say you kept her and she went even further south.. people would be saying "why didn't you send her out...". You never want that to be the case so .. better safe then sorry.
  9. 1
    Quote from pppp87
    The evening charge called the hospital this evening and found out the pt was admitted to the ICU. My DON is still brushing it off and saying that everyone here probably has urosepsis and that's something that could be treated here... I was offered a job at a PCU in a teaching facility so hopefully I can move on and get a better nursing foundation there...
    Um..no. Many residents can have a UTI or bacteremia, but not urosepsis. Yikes!

    ICU....you picked up on this person right in time...good job!
    LTCNS likes this.
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    When i was a new nurse working in a LTC i had a patient that was in resp distress. no matter what neb tx and o2 i adminstered he pulse ox and ease of breathing never got better. The doctor on call was very rude and ordered more neb tx. I knew something was not right. I called the family and told them that the doctor did not want to send her to the ED but i felt something was extremely wrong. I sent the lady to the ED. A few hours later the nurse from the ED called and told me that she doesnt normally call but she wanted to tell me the patient had a PE. Had i not sent her to the ED she would have died. Thank goodness i iused my assessment skills and gut instinct.


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