An LTC Nurse POV: Why does it feel like Hospital ERs are bothered with Nursing Home reside

Phledd · Jul 16, 2016

I couldn't really guess what their reasoning was for sending him back so soon. Was this a one-time thing or a regular type of occurrence? Did the resident return with new cardiac orders? Maybe the doctor thought your SNF was capable of handling it? I just don't know....

I read a new LTC memoir this year that touched on this, but I don't think patient age was mentioned as a factor. The author attributed it more to healthcare workers (of all sorts) stigmatizing nursing home nurses. For example, sending patients to the ER just to get a problem resident out of their hair.

Regarding age...I went through that with my (active, lively) grandmother, but it was only a one-time thing in one ER. She had a horrible cough that wouldn't go away and things took a scary turn one night. The doctor said, "Well, you've lived a good life, haven't you?"

CoffeeRTC, BSN, RN · Jul 19, 2016

Wow.

A few things. Before you send a resident to the ER, if it is non emergent, make sure you are sending some information to them about the resident. Transfer sheet should cover the basics with a brief history of what is going on, baseline for ADLS, LOC, diagnosis list, etc. We also call to give a verbal report to the triage nurse. This is important especially if you cannot get the paperwork together fast enough. If you are giving them a good picture on what you suspect is going on and their baseline that helps tremendously. Let the ER know that you did xyz before sending them.

When EMS comes for pick up, give them the same report. Treat them like another part of the care team....they are. Sometimes we bounce ideas off of each other. (and take bets on who is right, lol)

When the ER calls to tell you they are sending the resident back...ask....hey, what were the results of XYZ labs? i need a copy please! If you send someome out for cardiac S/S...ask about the EKG, troponin levels, labs, chest etc.

i think that some ERs just get sick of getting residents that are dumped and sent blind (without report) and when they show up without family or with dementia, they might look for the quick fix and send them back thinking the drs in the LTC will deal with it in the morning.

downsouthlaff, LPN · Jul 20, 2016

Well I can tell you that at my facility we are required to send all pertinent paperwork, MARs, labs. I myself always try my best go give the hospital the best as far as baseline.

But what I can't comprehend is how can a Physician think that a SNF can handle an elevated Troponin level in a resident with no cardiac hx.

And the stereotype that LTC Nurses dump residents on ERs is crazy theory lol. When I send a resident out for eval it's usually a 45 minute ordeal that takes away from med pass time/shift time. Between doing a nurses note, notifieng R/Ps, gathering pertinent paperwork, calling the ambulance, calling report to hospital. This is a very lengthy ordeal at most nursing homes

Lev, MSN, RN, NP · Jul 20, 2016

We all know how hospital ERs are. You convince your hard headed mother to take a trip to the ER because she has some chest pain. So during the ER visit, CPK, Troponin check out okay. Other labs WNL. Maybe an elevated B/P but the doctor wants to admit for observation.
We all know that sometimes ERs are overused by some of us LTC Nurses. Most of us are guilty of it and some time or another. We are quick to send out for eval sometimes forgetting to check hx and PRN MAR. But we are nurses just being safe.
But after specific instances I just can't help but be a little appauled. A few weeks ago I was the LPN/Charge Nurse on a corridor with a very frail very elderly man. He had a new C/O chest pain and general lethargy. Manuel B/P of 152/98 (not baseline) T=100.2 R=24 P=120. 2:30am couldn't get ahold of PCP or N/P so of course use nursing judgement to send out to local ER for eval.
Get a call from the ER Nurse at about 4:30am saying that she was calling to give report. ER Nurse stated that doc was dx with UTI and wrote orders for Bactrim DS X7 days. Well as a Nurse I was a little suprised that this patient did not get admitted at least for observation with new chest pain, and whacked out V/S especially with no cardiac history but hey as an LTC Nurse I also kept in mind that UTIs can cause major havoc for the elderly. Res arrives back B/P has decreased a little bit still not the same old "Mr Jones" (not real name).
Next day our Ward Clerk happens to need current labs on this man so she calls the hospital and asks if as a courtesy she can obtain the labs they drew on him at the hospital for there records. When she received the labs via fax she was shocked. Critical elevated Troponin level and a few other labs that were not WNL. She immediately gives to DON and DON notified PCP. PCP is angry and appauled and immediately orders the resident go out to a larger cardiac hospital.
Resident admitted and hospital nurse reports to us some cardiac damage has occured but patient stable. My question how could this happen ? Do some emergency departments really stereotype older nursing home residents and look past some things they wouldn't on the general population because of there lack of a voice? Because they are a little more needy and demanding due to physical limitations?

This story doesn't sound typical. No ER that cares about lawsuits would send a patient with a significantly elevated troponin home to LTC. Keep in mind that some patients "leak" troponin, which means they have chronically high troponin from some other health condition. An elderly patient with chest pain would have troponins drawn every couple hours before they are discharged if the decision is made to send them back to LTC. In your situation, all the vital signs are due to the hyperdynamic state which is present with infection. If his vital signs were better and he was given IV fluids and antibiotics there is no reason to keep him for UTI if he can go back to LTC. The chest pain however.... Would be a reason to keep him.

downsouthlaff, LPN · Jul 20, 2016

Well let's hope this is not the typical behavior of Hospital ERs. Let's absolutely hope so. In the opinion of the residents PCP, he should have been admitted for the chest pain and elevated Troponin which was new and not baseline with no MI HX. And also C/O chest pain. I mean I'm a Nurse not a doctor but shouldn't an ER Physician think that should at the very least warrant a little more observation and dx testing ?

nursejoy1, ASN, RN · Jul 23, 2016

In my area, we have one ER that does things like this quite often. the others are much better. The "bad" ER, without fail sends our residents back with a diagnosis of one or more of the flowing- UTI, dehydration or impaction. No matter what we sent them for. once sent a lady out at 5 am for frank rectal bleeding. her Coumadin was already held per orders with an order to send out if increased bleeding occurred. It did. Quite a lot. Very thorough report given and at 10am, the day shift nurse called to check on her and they said she had all three. The nurse asked about the rectal bleeding and they said, "What rectal bleeding?" Another that fell and hit her right hip, transfer report written and verbal stated right hip pain after fall and order stated x ray right hip after fall. She received a chest x-ray and diagnosed with a chest contusion and sent back. Had to get an inhouse x ray the next day. Thankfully, she had no fracture.

kbrn2002, ADN, RN · Jul 27, 2016

In my area, we have one ER that does things like this quite often. the others are much better. The "bad" ER, without fail sends our residents back with a diagnosis of one or more of the flowing- UTI, dehydration or impaction. No matter what we sent them for. once sent a lady out at 5 am for frank rectal bleeding. her Coumadin was already held per orders with an order to send out if increased bleeding occurred. It did. Quite a lot. Very thorough report given and at 10am, the day shift nurse called to check on her and they said she had all three. The nurse asked about the rectal bleeding and they said, "What rectal bleeding?" Another that fell and hit her right hip, transfer report written and verbal stated right hip pain after fall and order stated x ray right hip after fall. She received a chest x-ray and diagnosed with a chest contusion and sent back. Had to get an inhouse x ray the next day. Thankfully, she had no fracture.

That kind of sounds like one of our local ER's. Unless a POA insists I never send anybody there. It doesn't seem to matter why we send someone there the diagnosis is ALWAYS UTI, pneumonia or both.

turningred15 · Jul 27, 2016

Perhaps if the patient was going to be in observation status and responsible for a large portion of the bill he/she decided not to stay. Obviously I don't know the background or decisional status of the patient but just a thought.

benegesserit · Aug 3, 2016

Oh, I could tell stories, but will resist, as my area is a little too small and identifiable. Basically everything everyone else here has mentioned, I've had a similar experience.

I've found that a lot of emergency staff are not particularly aware of the limitations of LTC, and therefore don't understand why we err on the side of caution. This is based both on conversation with people local to me and online. They see a facility that has doctors and nurses on staff and assume this means we have resources similar to a hospital, when we don't. It's a facility for people with complex needs, but who are overall stable. The local paramedics were shocked to learn our facility does not have an AED (I was shocked to learn this when I started, but they've been picking up residents from our facility for a decade!). ER nurses always seem surprised to learn we don't have a doctor (or lab, or an EKG, or radiology) in-house at all times. Yes, I can get all these in-house (though not all facilities can), but depending on the day of the week, it may be anywhere from several hours to days - not appropriate in a situation that seems emergent.

I've also seen ER staff (in this case, online - I've never heard these sentiments from anyone I've talked to in person) who hold the opinion that LTC residents inherently have no quality of life and should all be on comfort care. I suspect this attitude also leads to an underestimation of mental capacity. Yes, this resident has a diagnosis of dementia, but they're normally AOx2 and perfectly able to hold reasonable conversations, not unresponsive, so unresponsive represents a significant change from baseline.