Advice to the LTC nurse...

Anne36, LPN · Jun 28, 2011

I was just curious, even if the LTC nurse gives you a baseline for this patient will you really acknowlege or use it when assessing your patient? Mabye Im wrong, but I am sensing a lack of respect for the LTC nurse judgement and abilities.

psu_213, BSN, RN · Jun 28, 2011

I answer as an ED nurse...in general, I don't have a problem with any particular pt being sent to the ED for eval/tx. The issue is some pts that are sent to us at very busy times. Two examples:

1. Pt sent in for low sats. Turns out the pt took his supplemental O2 off an went outside to smoke. No one tried to put his O2 back on before sending him to the ED. The nurse then calls to tell us, "My concern is he's anxious, could you send him back with a prescription for ativan?"

2. Pt comes in AMS with low sats. When medics got to the facility, pt was coughing up small amounts of her tube feed...the tube feed was still running....while the pt was lying flat in bed. Family comes in and directs all the anger (and a lot of it) at us (the ED staff) because she had dried tubefeed around her mouth and her tube won't flush...again. Sorry, interventions to save her life took precidence over cleaning the tube feed. Admitted with a dx of aspiration PNA.

Part of this just happens. When talking with the LTC nurse, the ED nurse is expressing negative energy (sometimes very rudely). This energy is mostly directed at the doc who sent the pt in, but the LTC is on the phone so they are the one that takes the brunt of the anger. Both the ED and LTC are busy (usually in different ways) and that can lead to some unpleasant exchanges between the nurses.

psu_213, BSN, RN · Jun 28, 2011

I was just curious, even if the LTC nurse gives you a baseline for this patient will you really acknowlege or use it when assessing your patient? Mabye Im wrong, but I am sensing a lack of respect for the LTC nurse judgement and abilities.

I questions the nursing judgment/abilities of a few (definitely the minority) of LTC nurses. Also a few ED nurses. And a few m/s nurses. In every facility there is nurses I'd trust with my life if I was a pt there...there are also some at every facility that I would not at all want to be 'my' nurse. I think in every 'type' of nursing there is some great some not so great. In fact, that is the way it goes in just about every walk of life.

southernbeegirl, BSN, RN · Jun 29, 2011

I totally agree with yall about getting poor report or patients being sent out for ridiculous reasons. I guess what I'm hoping with this thread is to maybe open up a dialog and get some advice I can use with my nurses. thanks for all the replies!

beckd · Jun 29, 2011

I hate getting a pt into the ED with abdominal pain and then find out that they have not had a BM in 5 days. Fabulous.

NeoPediRN · Jun 29, 2011

Hi southern. I'm not an ED nurse yet but did work as an ED tech for 15 months. Our hospital was right down the street from a high acuity LTAC. One of the biggest things that bothered me is that they would arrive in a deplorable state. Dirty FILTHY gowns, smelling like they hadn't had a bed bath in days, old food under folds of their breasts, Foley catheters caked with excretions or reaking of a UTI. It was a wayyy too common occurrence. I actually applied and worked at that hospital as a tech after seeing it so often to try to understand why they looked so awful coming in. It was pretty typical - overworked and understaffed. Sad. But I did always try give a full bed bath because of that experience, and if the patient had to go out acutely and there was time I would put a fresh gown on and make sure they looked and smelled presentable. I do realize that not every LTC/LTAC center operates like the scenario I described above. :)

Fngrpntsnotasin · Jun 29, 2011

Some times we have no other choice but to send to ER. I get ERs are a busy, busy place, but when one of our residents falls at noc and hits their head and the like they are going to have to go. We also are required to send flu and pneumo vacc paperwork. When I call report into the ER I ask for the charge nurse, introduce myself and where I work, let them know we are sending our resident, give them name age,m/f, why we are sending, current relevent dx, baseline for res and any devations from, residents MD, let them know we are sending their mar,tar, info sheet that contains residents full list of dx, birthdate, RP information, current labs, current vacc information, most recent vs, Po2, BS, order to send to ER. I also ask what other info they need or would like right then over the phone. I get the name and title of who I am speaking to and tell them thanks and hang up. What else would be helpful info to give during a telephone report?

emtb2rn, BSN, RN, EMT-B · Jun 29, 2011

The above is how we have coached our local ltc's to give report. Works very well when done. Of course, we often get pt's without any notice.

My pet peeves are:

when the mar isn't sent, just the med order sheets. We have no way of knowing what meds have been given without calling and having to walk through the mar.

ams without detail on baseline. Ummmm, how can i tell if this is abnomal?

Roy Fokker, BSN, RN · Jun 30, 2011

I don't mean this thread to turn into a nursing home nurse bashing

I genuinely hope it doesn't. While it's no secret that plenty of ED nurses (including me

) and EMS face frustration with LTC staff - I'm always inclined to give 'em the benefit of doubt. I've never worked LTC and from the stories I hear through the grapevine ... YIKES! :eek:

Do you have any advice for those of us in LTC?

Advice? Not from me.

Requests? Why yes indeed! :)

1. The already touched upon topic of altered mental status patients. Yes, we'd love to know what the baseline is: Can they talk? Can they walk? How good is memory? How advanced is dementia/alzheimers? Are they incontinent of urine/stool? Do they have any family we can reach?

2. This is probably going to sound quite rude, but I don't mean to. Honest!

When we call and ask "when was the resident sent here for altered mental status last observed normal or near normal mentation?" - in variably the response we get is "I don't know". I understand that nurses are few and residents are many. But surely someone can tell me "well, Mr. XYZ was acting his usual self until last Saturday. He started talking to someone who wasn't in the room then!". Or something of that accord.

Yes, I may be looking for an "exact symptom time" (stroke, tPA, you know the drill) - but I'd be greatful for any information that tells me "when was the last time pt. was seen at baseline". Two hours ago? Yesterday? The day before? Gotta gimme something - I ain't the one who sent the resident to the ER for evaluation!

So please, dig through the charts if you have to - I'll hold on phone patiently! :)

3. The 'right chart' on the 'right patient'. :eek: I totally understand that mistakes happen, screw ups are part of human nature (especially when stressed out). But this should be resolved by the third fax for the pertinent details, yes? The only reason I bring this up is because each time we're informed of incorrect demographics - we have to toss out the blood/urine samples we've collected so far [wrong patient/specimen, yes?] There's only so many veins we can stick a sick patient for blood work.

Other than that - ignore the callous remarks about LTC nurses.

I could never do the job y'all do!

cheers,

PunkBenRN · Aug 20, 2011

I worked in LTC for 2 years prior my hospital job, so I think I can offer insight on both sides.

To ER nurses: Please understand that LTC is a very over-regulated business. There are watchdog groups, family, insurance companies, and regulatory committees that all have to put in their two cents about everything. Subsequently, there are A LOT of rules to follow, and we are practically walking on glass at all times. We don't get a pat on the back for getting something right, but when we are wrong we are pounced on in all directions. Seriously.

If we send someone to the ER (unless they are actively arresting or stroking out), we HAVE already called the doctor, and it was the doctor that sent them in for evaluation. Some doctors have no respect or trust for LTC nurses, and every call will be "Send in for evaluation". We are just as frustrated as you to send someone in with UTI symptoms or Low Na symptoms when we are just seeking the OK to draw a lab.

I know some LTC nurses are, well, a little numb. So are some nurses in the hospital. So are some nurses in the ER. You will find great nurses and terrible nurses in LTC, please don't judge by the weakest link.

We see our patients five days a week all year long. We know these people inside and out. We know when something is wrong, even if we don't know what it is. Trying to communicate AMS for an Alzheimer's pt or post-CVA pt is extremely difficult (unless it is obvious change in LOC). When you are trying to get me off the phone as soon as possible, its difficult to communicate details about change in status. When you give a snarky response like "Are you sure they aren't tired?" or "They have alzheimer's, of course they are confused", it dwindles what little confidence we may have had calling with report and we are not as forth-going with information at that point. You just closed all hope of an accurate communication line. Even if we can't put into words, we know that SOMETHING is wrong - take us at our word.

For LTC Nurses:

If someone is diabetic, check their glucose before calling. Hell, check it if something, ANYTHING, is wrong. If someone is COPD or hypoxic, check the O2 Sat. And for God's sake, verify the accuracy of the 02 sat by manually checking the radial pulse and compare with the pulse that the pulse oximeter gives you - if there is a discrepancy and the pt is not symptomatic of hypoxia, consider getting new equipment. If the pt hasn't voided in 8 hours, ask all the LNAs before making the call to the MD - it is possible that someone forgot to chart.

When you call for report, be ready to give report. What is the problem right now? What have you tried? Has it happened before, and what worked last time? What were their vitals/labs recently? Whats changed? If you don't know what is important in report, that's ok - have the chart in front of you, and the nurse will help you find what they need.

Before you call the doctor, is this something that can't wait until the MD comes by for rounds (in a day, week, or whenever they come)? If unsure, ask the doctor you have on the phone. I guess where I'm going with this is only send them to the Emergency Room for Emergencies.

If they are agitated, have they eaten? Have they gone to the bathroom recently? Are they tired? Are they in pain?

If someone is suddenly lethargic, is it 3 AM? Its okay for someone who is 102 years old to be tired at 0730....

I had more in my head, but thats all I could get out before forgetting. Just some pet peeves from both sides. Sorry if this is lengthy, but I just found this site and love posting here :clpty:

Finallydidit · Aug 23, 2011

Okay as a nurse in a LTC facility, I have to respond to this post.

I work wkend baylor 7a-11p, my facility has 120 residents, and a staff of 1 RN, 4 LPNs and 8 CNAs, (however, with it being wkends, there are always call outs and the norm is 6 CNAs. I honestly can't recall when the last time we have been fully staffed for a full wkend... With that being said the LPNs are responsible for 30 Residents each, and the CNAs 20 Residents each.

Company policy is that each resident be changed, turned, cleaned, etc Q2/hrs. That gives the CNA 6 minutes per resident per 2 hours.

Keep in mind that in addition to the changing, turning, and cleaning, the CNAs also have take their residents to dining room, pass and set up meal trays, and feed the majority of their 20 residents. Also 1 of the CNAs has to stay in the main dining room during meal times, and another has to go to the "restorative" dining room and assist the "at risk" residents, this leaves 4 CNAs on the floor passing the trays and feeding residents.

In addition to the above the CNAs also have to pass ice, hydration, and snacks to their 20 residents. and if they are medicare, they also have to get a full set of vitals q8/hrs.

Please keep in mind that this is the wkend and Activities are abundant throughout the day and evenings, with church services both afternoons and evenings on Saturdays, and even an additional one thrown in on Sunday mornings right after breakfast. Yes.. 3 church services on Sunday. PLUS... we get all the FAMILY visits. Did I mention that company policy also states that we can not interrupt our residents during "activities" or "family visits" to do any care for them? It is considered a violation of their rights.

So if Ms Jones who is alert and oriented to name, demented and incontinent, decides to go to the dining room for breakfast, visit with family and stay there until the afternoon church service is over there is absolutely nothing that anyone can do about it. Now a good family member will bring her back and ask that she be changed, but that is not usually the case, as that cuts into their weekly 1 hour visit.

If Mr. Jones decides that he doesn't want to take a bath for a week...... He has a RIGHT TO REFUSE. We can send him to "behavioral" after a couple weeks of refusing, but they will send him back..... and the process starts again.

I could go on forever, but I think you all get the idea.... We at LTC facilities, KNOW that most of the residents are going to have a UTI, they wear briefs all day, and no they don't get changed as often as they should, with state guidelines on adequate staffing being what they are it is IMPOSSIBLE to change all the residents every 2 hours. WE CAN CHECK FOR UTIs at the facility... That is NOT what we are sending them to you for. We are sending the to you because WE KNOW THAT SOMETHING IS WRONG but can't diagnose it. Just because they are 92 doesn't mean for you to check their urine, and send them back to us, only to have them returned to you the next day throwing up blood due to a GI bleed. (happens all the time)

There truly are good LTC nurses and we try to get them to you ASAP, because we do know them so well, and we do know if something isn't right but we can't exactly put our finger on it or we know and can't do anything about it.

I honestly believe that "most" LTC try to be the absolute best that they can do with the staff that they have. The expectations, rules, regulations that are placed on the staff of these places are mind boggling and I often say the only way to make them better is for every one to set a date and just up and quit and open the eyes of the powers that be but we love our residents and that is the only reason most of us work under such conditions.

xtxrn, ASN, RN · Sep 1, 2011

I answer as an ED nurse...in general, I don't have a problem with any particular pt being sent to the ED for eval/tx. The issue is some pts that are sent to us at very busy times. Two examples:
1. Pt sent in for low sats. Turns out the pt took his supplemental O2 off an went outside to smoke. No one tried to put his O2 back on before sending him to the ED. The nurse then calls to tell us, "My concern is he's anxious, could you send him back with a prescription for ativan?"
2. Pt comes in AMS with low sats. When medics got to the facility, pt was coughing up small amounts of her tube feed...the tube feed was still running....while the pt was lying flat in bed. Family comes in and directs all the anger (and a lot of it) at us (the ED staff) because she had dried tubefeed around her mouth and her tube won't flush...again. Sorry, interventions to save her life took precidence over cleaning the tube feed. Admitted with a dx of aspiration PNA.
Part of this just happens. When talking with the LTC nurse, the ED nurse is expressing negative energy (sometimes very rudely). This energy is mostly directed at the doc who sent the pt in, but the LTC is on the phone so they are the one that takes the brunt of the anger. Both the ED and LTC are busy (usually in different ways) and that can lead to some unpleasant exchanges between the nurses.

The Ativan issue is a huge no-no for LTCs....there has to be a valid dx by the PCP or psychiatrist with the accepted ICD-9 code to go with it, or the state health dept can ding the facility for overuse of psychotropics.....whoever sends someone in for that needs a shoe upside the head :) Medicare does not pay for benzos outpatient at all. Reason is irrelevant.

The tube feeder flat in bed coughing formula is another huge problem for the facility- and could be using the ED to diagnose it, to cover their butt, since it wasn't diagnosed at the LTC....a technicality that helps avoid sentinel events at the LTC that could drag the state in (and sometimes should :eek: ). I love LTCs- if they're good- but some are scary places...sometimes the nurses want to get out of them really badly, but won't leave "their people"- seen many refuse promotions at the good and bad places, because they are so committed to their folks- they're the ones who can tell you if the patient has a mole on the lateral surface of any given toe :up: And the CNAs use their own money to buy hair 'decorations' for their ladies, and aftershave for their guys. :)

I've worked LTC a lot in the past. Most LTC nurses are good- and know their residents extremely well. But, like any specialty, there will be those that graduated bottom of the class, and peaked there

I'm no longer working, but a suggestion would be to send a copy of the most current MDS- as long as the info is still current. It has the ADLs, mental status (usually by nursing and social workers), medical diagnoses, etc (though the MDS 3.0 is coming out soon, and who knows what they've done to it this time - lol..... those who never fill them out must be the ones making them up ) At the facilities I worked at, we had to send a face sheet, minimal transfer sheet- that had minimal ADL info, allergies, etc; POAH info, advanced directives (and especially any out of hospital Adv Dirs for EMS), med and treatment sheets (including PRNs)- those also had the last flu/pneum shots on them, and any other pertinent info...and call report. If it was a really lousy situation, I might not get as much xeroxed- but with the verbal report, I'd ask for the ED fax number, and generally get it to you before the patient got to the ED.

The MARs are supposed to have a diagnosis for EVERY medication.

I've always wanted to have a packet of info at LTCs on the chart ready to go in an emergency- that wasn't filled out DURING the emergency- but keeping it updated would be a nightmare, and could cause more harm than good.

I've had more problems w/EMS (and I respect those folks a lot, in general)- one genius told a little lady (on the floor, hip externally rotated, leg shortened, and yelling in pain) he'd get her up and see if she could walk.... and he got VERY snarky about my asking him to not do that. He got her up. Said since he'd been called, he'd assess :uhoh3: (yeah, that's great buddy- why not step on the hip while she's still on the floor to assess pain :down: )

It's true that LTC nurses don't have the acute stuff going on every day- but a lot of them comb over the info when the patient returns, and learn a lot so they know in the future what they may be dealing with. They want to do the best they can for their residents. :) Many DO have acute experience. And they've had some strange stuff come back from the hospital, so they can be a bit leery about sending their folks out- one guy was sent out w/pneumonia, and came back with a Foley-with no corresponding dx- a big problem with LTC- Foleys are not allowed without an accepted dx (now THAT is some deep pulmonary toileting ).