Advice to the LTC nurse...

[southernbeegirl]

Hi guys! I have worked in LTC for 16 yrs. I have listened to ER nurses, EMTs, paramedics talk about "nursing home" nurses. I have worked hard to develop a good working relationship with the on call docs that my facility uses, the local EMS and ER depts. I'm always trying to improve my communication skills with them. I also would like to help the nurses improve their phone skills to relay what is pertinent to the situation. (I am the nursing manager).

I don't mean this thread to turn into a nursing home nurse bashing but I won't get my feelings hurt by fellow nurses expressing their frustrations with us.

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

[xtxrn, ASN, RN]

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.

It has a whole lot more to do with state and federal reimbursement than it does anyone in the local facility. When a facility has to make due with 70 bucks a day per resident for nursing pay, dietary, housekeeping, maintenance, reception, laundry, utilities, food costs, etc, there's not much for "extra" staff... some facilities are better than others at utilizing what they do get paid. But the local management don't make the rules for staffing- they're told how much they will get for nursing staff, and they have to figure out how to allocate it. :)

[Roy Fokker, BSN, RN]

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 hear ya. It's a common complaint as well with a lot of primary care docs who deal with the general populace too. I even had a rant about it a while back...

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.

I totally agree! For the record, I don't partake in the 'eye roll at nursing home nurses' etc.

Like I said before - I don't work LTC. I sincerely doubt I'd be able to work LTC.

Trying to communicate AMS for an Alzheimer's pt or post-CVA pt is extremely difficult

Yes. I suppose as an ED nurse all I'm trying to work on is figuring out what Mr. Smith's baseline status is.

I mean, asking "is he AOx3" is a dumb question! Yes, he's "confused" but "how much more confused"? Yep, you're right that sometimes it's hard to quantify these things - but it does help if we hear something along the lines of: "Mr. Smith is usually talkative. He answers questions. He's confused about time and place - last noted, he thought he was in Okinawa with the Marines in 1975. But usually he's pretty good with daily needs. He walks with a walker, he's able to tell us when he's in pain, he's not that sharp with his continence, which is why he has a diaper. He can be combative at times but gentle redirection seems to work..." etc.

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.

Sometimes, the problem lies with the ED too. I know of more than one charge nurse (the ones responsible for transfer calls) who literally don't care and it's up to the staff RNs to play catch up...

I had more in my head, but thats all I could get out before forgetting.

You need to up your dose of Aricept dude...

Just kiddin'!

Just some pet peeves from both sides. Sorry if this is lengthy, but I just found this site and love posting here :clpty:

Glad to have you here on allnurses!

Nothing wrong with the length of your post... just wish you could remember the other stuff you wanted posted and post it too!! :)

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.

I hear ya. And it makes me mad ... I wonder how many "policy makers" be their government or private - would want to live as such???

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)

Yep, mistakes happen at both ends.

Most of my 'altered mental status' nursing home patients end up having a UTI. I say most, because some of 'em end up having sepsis from a raging UTI. Or from pneumonia/aspiration (cc: short of breath).

I believe the crux of the 'misdiagnosis' issue rests with poor communication (mis-communication?) between facilities. From LTC to ER and vice-versa...

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.

And what as an ER nurse I'd absolutely love is for one of y'all who DO know the pt. to give me report in definite terms. "Pt. was fine last night when he went to bed. One of our aides found him throwing up around 2 pm today" Vs "we don't know when the vomiting started."

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.

You won't find any arguments from we with regards to LTC staffing. My clinical rotation alone convinced me that it was preposterous!

cheers,

[VICEDRN, BSN, RN]

1. Please do not return patients to us so that we can discontinue the iv nobody discontinued. Grab some tape and gauze and have at it.

Please don't send me a febrile patient that is 100.4. That's not a fever in our hospital and we won't treat it.

2. Please do not sound near tears when I send her back to you with no treatment. We don't treat temps of 100.4.

3. people have limitations. We are all trying not to be snarky but you have Tylenol on your mar so we are, rather understandably, annoyed.

4. Please do not dump your violent alzhiemers patient on us and be surprised when I call from triage to ask what's different since her baseline includes a hx of interpersonal violence.When you have no answer for me, again, expect snarky responses. It is as you say, a busy place and we don't want to be dumped on.

5. please do not send patients without report in groups of threes.

6. Please do not be surprised if people look at you funny and you work at a facility that has 40 beds but 3 of your residents are dying from sepsis in our icu. Word gets around. Same is true for stinky, filthy patients covered in bed sores.

7. Please do not omit relevant information for whatever reason you are inclined to do so. This includes not telling us patient has tb or that these blisters have tested positive for mrsa.

8. Please tell us what is different today. If patient has hx of asthma and is now short of breath, we won't know what to do.

9. Please try to convince md that we do not need anymore patients. He can admit to floor or tx there.

10. Back pain that is chronic and you forgot to get refill or pharmacy is out is not a reason to send patient to er and yeah, I bet folks get snarky then too.

11. Please pick up the phone when we call. Please.

I know there are some good facilities out there but I know there are one that are notorious

[notqueenb]

A good report tells us what the current complaint is. As others have said: what is normal for this pt & what is different today. A brief medical history is good, including vaccinations & a legible list of current medications. Also helpful if SNF contacts family, at least with those pts where family is likely to come to ER to be with pt. It seems like I usually get either not enough info ("pt not himself today") or too much (10 handwritten pages of hx, meds, etc.). We try to return pt to SNF with typed DC instructions & prescriptions. What info do SNF nurses wish we sent to them after ED visit?

[LilgirlRN, ADN, RN]

I would suggest putting together a form that details a report so that you don't leave anything out...

Pts Name

Age

Drs name

Nurse name

Facility's name

phone number where you are calling report from (not the main number cause lots of times I have no idea what room the patient came from)

Is this patient a DNR?

Cheif Complaint and what you have observed and/or done to help this patient

Vtal signs

Medical diagnosis list major ones

Any recent surgeries?

Any recent abnormal labs?

Does the pt have an IV?

Any relevant meds... pt is usually alert and oriented but after the patient had Trazadone 50 mg he's obtunded.

what patient is like normally.. can they ambulate, a&ox3?

Did you call the family?

Have you called the ambulance yet?

ETA?

Please send a copy of the MAR

It sounds like a lot of work I know but once you get used to filling this thing out its less time consuming because you can just look at your sheet and talk. Or you can just fax us the sheet and if we have any questions we can call you directly because I have your entire name not just Susan and I have the phone number of your unit!

[psu_213, BSN, RN]

Getting the right paper work from LTC can be thin line to walk. The other day I got a pt from a SNF (legitimate visit to the ED, ended up being admitted). Anyway, the pt came with approx 50 pages of paper from a tough to read (poor copy) of the MAR, a copy of their entire POA paperwork, a copy of ALL there demographic info (I never realized there could be approx 15 pages of this), and buried in all this was a copy of the pt's POLST. Paperwork is important though. I've also gotten pt's that were sent with only a copy of their facesheet. Point is, it is a somewhat 'delilcate' balance on how much paperwork to send.

[Heart 2 serve]

As a LTC nurse, when I read alot of the post with anger towards the LTCs from the ER or EMS staff, I have to agree with them. I can't get over some of the stories I have heard.

As you know, the insurance companies, medicare etc are cutting back on hospital readmits and won't pay for them. Our company has instituted an big program for this. At first I was a bit inusulted that we have a book to consult with s/s and algorithism that tell us how to be nurses. (srlsy...it is very basic and includes nursing measures and what to ask the docs for when we call. It even tells us when to call the doc)

I can see how this can be very beneficial for the newer nurses or even those that don't have a clue.

We also now have a (I kid you not) 3 or 4 page transfer sheet and it really does go over everything that the ER or EMS need to know.

As a side note...getting the Flu or Pnumo info is sometimes a challenge for me when we get young or frequent short stay residents. I will now look into getting this infor more readily available (It could already be on the transfer sheet)

Do you have a specific author you would suggest for the s/s and algorithism book?

[Dixielee, BSN, RN]

I agree the previous few posters. I'm not interested in a long history of the patient on the report. I do like the list that was given a few posts ago. If it is in a checklist type form, organized and easy to fill out and read, it benefits everyone. When I get a packet of 50 copied pages of various types of information I don't even bother to look at it.

My biggest pet peeve is LTC sending a dying DNR to the ER. We get this a lot! It seems like they don't want to have to deal with the paperwork, family, etc. that comes with it. As far a other patients being sent, I see that as a judgement call from the LTC who know the patients baseline.

What I want in report is:

Name and title of person calling me, name and contact number of facility (we get a lot of patients with loads of papers but they don't say how we can get this patient back to the LTC. If there are 6 halls and several areas, give me the contact number of the person I need to speak with if I have questions once the patient arrives.

Quick medical hx, not all of the ICD9 diagnosis. And why they are coming to ER You can say 69 year old female, hx CVA 2010, still with right sided weakness, ambulates slowly with walker. Non insulin dependent diabetic, takes metformin, BP controlled with meds. Tripped and fell on the way to the bathroom, laceration to forehead, bleeding controlled with dressing, no loss of consciousness, patient not on blood thinners. Awake, alert and oriented.

Allergies? Contact physician? Last tetorifice shot? Readable med list to be sent, family contact person and have they been notified? These can be on main transfer sheet, just don't make me dig through papers to find them.

Last labs and x-rays IF relevant to this visit, send only if recent enough to be useful

Yes, baseline LOC and general ability to take care of basic needs, like toileting, feeding, pushing the call light, etc. You know your patient better than anyone, we are just trying to get a basic picture of this patient so we will know if there are any changes.

I appreciate the OP for asking this, and I give big KUDOS to our LTC staff. You have a horribly demanding job and I appreciate it. My dad spent the last year of his life in LTC after a CVA and I was amazed at the constant flow of activity and how much you guys actually can get done. It is no easy job, and I'm thankful you are there.

While you know your patient very well, just bear in mind the ER staff is seeing them for the first time, so just pare down all you can into a concise bit of information that will help us get your patient to the point where they can come back safely to you.

[DixieRedHead, ASN, RN]

I'm not an ED nurse but I'm gonna chime in with a request...

Please always document on the send-out sheets or paperwork when the last flu/pneumo vax was given. We floor nurses have to know for core measures, and it's easier all around if it gets done that way. Last BM and accurate mobility/neuro baseline is nice too.

Obviously that won't be able to be done in all situations, but it sure is nice when it does happen.

It wouldn't hurt if the LTC got the immunization documentation from the hospital where these are given without having to devote an hour's worth of phone calls to medical records.

I don't generally send anyone to the hospital unless it's an "emergency" and I don't think when the last BM would even register on my scale of importance if it were not a GI event.

And exactly where are we supposed to include this " accurate" information about mobility status, and neuro baseline so that it will get to floor nurse?

I have been both an ER nurse and now LTC ADON. We rarely get any report from our local hospital at all. Just a discharge summary and medication reconcilliation sheet. The rest is for us to figure out.

[Lunah, MSN, RN]

For those of you who are ENA members, there is this:

http://www.ena.org/IQSIP/Safety/Patient/Pages/SaferHandoff.aspx

They're guidelines for safer handoff between LTC-type facilities and EDs. Might be a good thing to use to establish better relations/reports with local facilities, especially those that are often troublesome. I provided this stuff to my NM and suggested she visit local facilities to establish contact, and that she also bring cookies. (Food always draws people in, does it not?? LOL.) Don't know if she ever did it, but she thought it was a great idea.

[SaraO'Hara]

Advice from a SNF nurse, to my fellow SNF-ers: Name, admitting DX, history. Why you are transferring today. Any care (first aid, meds, oxygen, etc) given prior to transfer. Current VS and blood glucose (if diabetic). Any really outstanding skin issues. Your call-back number.

Send copies of: History/Physical, recent progress and nurses' notes, labs, MARS.

This is what I've gleaned over many SNF to ER transfers (in my whole 3yrs experience, I know ). An example of what NOT to do was furnished nicely by a nurse at a LTC (not my usual facility - I filled in for one shift there).

The pt was there for rehab, post bilateral tibial fractures. History of A-fib, HTN, mild COPD. Complaining of nausea, SOB, denies chest pain. Vitals yada yada. 02 running at 3L. Duoneb already given. Persistent wheezes, BUL.

Co-nurse called report while I copied records. "Hi, this is Bubbles at Dreamland Care Center... we're sending you a lady... she's a little nauseated... something going on in her upper lobes, not sure about that... anyway she's coming by ambulance..."

The poor ER nurse's ire was audible from my seat. Lo siento, guys

[brillohead, ADN, RN]

Co-nurse called report while I copied records. "Hi this is Bubbles at Dreamland Care Center... we're sending you a lady... she's a little nauseated... something going on in her upper lobes, not sure about that... anyway she's coming by ambulance..."[/quote']

Wow, I'm only a nursing student, and even *I* know that this is completely pathetic!!!!

(and totally LOLing at "Bubbles" for the pseudonym!)