Do you feel like your acute rehab floor gets patients who have absolutely, positively NO business being in intensive inpatient rehab? It seems like more and more of our admisssions are just hot messes who end up going acute and leaving us in a day or two because they aren't good candidates for 3 hours of therapy a day. Some are very sick and just need more time to stabilize before coming to us (of course, people just don't get the time they need in the hospitals anymore before being kicked out) but some are just not good candidates.
For example: 99 yr old lady with extensive cardiac hx who fell and broke hip. First day in rehab, 1 hr of therapy left her in bed on O2 unable to wake up to eat or anything. MD came and said "oh, she's just old" No **** sherlock, maybe she should just go home with an aide to enjoy her final days. 2nd day, she couldn't do all of the therapy. When family asked about maybe doing 'light' therapy in the bed, MD said "if she can't stand the therapy, she needs to go to a nursing home" which scared the family so they shut up. 3rd day, I walk in and pt looks like c r a p - ran full cardiac workup which was negative, but it was apparent something wasn't right with pt. The MDs came and made some med changes, but again just said "she's old" I put her on hold from therapy and kept a close eye on her. In the afternoon, she had acute neuro changes (slurred speech, change in pupils) so we took her to a stat CT and sure enough, she had a big bleed. Pt went to ICU then hospice then passed a week later.
Why was she put in rehab in the first place? 99 years old? Cardiac hx? Why not just go home with her aide (family had $$$ - pt had a private aide) and enjoy her last days/months/years?
I was her nurse on day 2 and 3 - wish I could have done more. I feel like I did everything I could - called the MDs, got testing done, talked with the family, comforted the patient. I know it was her time, but I feel like the therapy killed her.
Last edit by dianah on May 6, '12
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May 5, '12
The same thing occurs in our acute rehab. I am a weekender, but it seems I've transported someone off our unit every for 4 of the past 5 weeks because their condition went dangerously south during the shift. As with everything healthcare, it's about the money: their Medicare payments in their previous setting had been exhausted, but they have another three-weeks of benefits available for rehab. After I shipped one patient to another facility after she had been trending downward for three shifts, I was told we should have kept her a few more hours because "we don't receive any payment unless the transferred patient is on our floor for at least three days."
To make the problem worse, our ratios are rising to alarming levels. Where a 6-1 ratio used to be the norm, I was told last week by a manager that "you can handle 11-patients if needed." I informed her I could "task" on 11-patients, but it wouldn't be safe.
I'm disappointed. The unique situation that is rehab should be a nurse's dream job. Too bad it's turning into a nurse's hell!
May 5, '12
11 patients!?!? On acute rehab? That is ridiculously unsafe - our CNAs don't even have that many. We usually have 6 patients with 7 being the max I have ever had. The days i have 5 patients are the best.
Yup - all about the $$$. I didn't know that about medicare payt (I don't pay attention to the insurance stuff - it all gives me a headache).
We have been shipping off SO many patients recently - at least one a shift. I swear, soon they will be sending them over straight from ICU still vented on multiple drips. . .come on! Get up! We have to get you dressed and ready for PT at 8AM! What? You're in a coma? No excuses! Get your ted hose on!
May 6, '12
THese stories would make me laugh if I didn't cry first. It is, indeed, all about the reimbursement. I've seen folks who should have been put on hospice "encouraged" to use up their skilled time first. What is the benefit to the patient in that scenario? And why am I even stupid enough to ask that question?
May 7, '12
Seems like some sort of multidisciplinary "team" approach would have mitigated some of her distress (and yours). I'm not a rehab nurse, so I'm probably speaking out of turn, but almost all patients benefit from an organized plan. An hour of therapy--that's a lot for that patient. It could have been decided ahead of time to limit her therapy to 15minutes, providing O2 during the treatment--any number of things.
If I were you, I'd be ready to chew nails. Or a doc, whichever I found 1st. If they have a Mortality/Morbidity conference, she should be presented, and you might ask to be present.
As for the 11-1 staffing ratio, words totally fail me.
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