At what point do you send to the hospital?

  1. 0
    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
    Last edit by jamd11 on Jul 29, '13
  2. 30 Comments so far...

  3. 3
    I'm not sure of the structure of your facility, however, at mine, I would have been responsible for notifying the doctor and obtaining any orders. If I felt that the patient needed to be sent out, it would have been up to me to call the doc, notify him and family of change of condition, and explore/advocate options.

    The LPN's here charge their own floors, with the RN there as a back up. If I have any doubt, I get the floor RN, or more often than not, I call my DON or NM to come and help.
    elprup, NurseDirtyBird, and jamd11 like this.
  4. 0
    Thanks for the info!
    At the facility I am at (its probably different in canada mind you) the RN makes the final call (I'm a RPN which I think is equal to a LPN) to send to the hospital or contact the MD. I did phone the on-call acting doc and was basically told it was the RNs decision. I presented her with my assessments and what I thought was best for the patient and asked her to at least phone the MD for clarification but that didn't happen.
  5. 4
    In that case, I might follow up with my DON. I wouldn't do it in an accusatory tone. I would just want clarification and to know the rationale of why was the patient treated the way they were. You would also be able to express your feelings of not being heard or taken seriously by the RN.

    I can tell you, if that was my family member, upset would be a mild word for what I would be feeling.
  6. 1
    This whole situation stinks. Are you a RN because this is unacceptable. You have to follow the standards of nursing, remember from nursing school? ADPIE? This sounds like gross neglect to me.

    Even as a new nurse, you must advocate for your pts. You MUST call the dr for changes. If someone tells you not to, and you listen to them, you are exercising bad judgement. You are practicing under YOUR own license and you must protect it. What if this was your family member, would you be happy with your actions?
    mrsmamabear2002 likes this.
  7. 3
    Quote from jordynnmac
    Thanks for the info!
    At the facility I am at (its probably different in canada mind you) the RN makes the final call (I'm a RPN which I think is equal to a LPN) to send to the hospital or contact the MD. I did phone the on-call acting doc and was basically told it was the RNs decision. I presented her with my assessments and what I thought was best for the patient and asked her to at least phone the MD for clarification but that didn't happen.
    I had been in a similar situation at an LTC home in Canada as well, I called the family and asked for their wishes. Mind you, the pt was not a dnr. The RN had been unconcerned but I couldn't ignore the symptoms. Turns put the pt had indeed suffered from an ischemic stroke. I did receive a "talking to" for going over the RN's head but ultimately I did the right thing. I didn't stay long there and am happy in my current place of employment.
    canoehead, Esme12, and jamd11 like this.
  8. 2
    Quote from IsisC
    This whole situation stinks. Are you a RN because this is unacceptable. You have to follow the standards of nursing, remember from nursing school? ADPIE? This sounds like gross neglect to me.

    Even as a new nurse, you must advocate for your pts. You MUST call the dr for changes. If someone tells you not to, and you listen to them, you are exercising bad judgement. You are practicing under YOUR own license and you must protect it. What if this was your family member, would you be happy with your actions?
    Hi Isis. I'm not an RN and yes I remember my schooling. Had you read my entire post you'd see that I stated at the facility I work at in Canada the charge nurse who is ALWAYS the RN makes the final decision. I did what was required of me I told the RN my thoughts and I was completely undermined to the point I called the director of care who told me it is what it is and the RN makes the final call based off my information and assessments. I fulfilled my duties and documented everything including my opinion that the resident should have been transferred to the hospital or at least have the MD notified. I realize that policies are different in the states I was just looking for some general advice and not a lecture about how I was neglectful. I thank you for your opinion and I was not happy about the decisions made, hence why I was asking for advice. Unfortunately, I did all I could do and to answer your question I would be livid if it happened to my family member. I've only been at the facility for not even a month and I have to say I disagree with their policies and procedures and will be looking for employment elsewhere. I will also make sure to ask what their policy is in situations like this. Lesson learned.
    Nascar nurse and canoehead like this.
  9. 1
    Quote from IrishErin

    I had been in a similar situation at an LTC home in Canada as well, I called the family and asked for their wishes. Mind you, the pt was not a dnr. The RN had been unconcerned but I couldn't ignore the symptoms. Turns put the pt had indeed suffered from an ischemic stroke. I did receive a "talking to" for going over the RN's head but ultimately I did the right thing. I didn't stay long there and am happy in my current place of employment.
    Thanks for sharing. I wish now I went over the RN. But I can't turn back time . As I just posted above lesson learned ! I really dislike this policy, a previous Rpn was fired recently for going over the RN and sending a resident to the hospital. I was weary of this happening to me too. Thanks again for sharing !
    Esme12 likes this.
  10. 0
    Quote from IsisC
    This whole situation stinks. Are you a RN because this is unacceptable. You have to follow the standards of nursing, remember from nursing school? ADPIE? This sounds like gross neglect to me.

    Even as a new nurse, you must advocate for your pts. You MUST call the dr for changes. If someone tells you not to, and you listen to them, you are exercising bad judgement. You are practicing under YOUR own license and you must protect it. What if this was your family member, would you be happy with your actions?
    Yep.

    If the patient were to die and family sues its not the other nurse's license on the line, it's yours. I would've sent them out. If nothing was wrong they will come right back.
  11. 1
    Quote from chrisrn24

    Yep.

    If the patient were to die and family sues its not the other nurse's license on the line, it's yours. I would've sent them out. If nothing was wrong they will come right back.
    Not according to the policy at this institution it's states clearly that the RN is responsible for the final decision. I don't agree with it at all but it is what it is I called the doc to let her know and she told me exactly this " it's out of your hands the RN must make the decision to send". It's also in our employee handbook.
    canoehead likes this.


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