Can I refuse an infant patient??

[knoelle30]

I am a home health nurse with 2 years experience in cardiac step down and 2 years in my current home health job. I take care of older people mostly geriatric. I have an admission scheduled this week for a 6 month old with a feeding tube. I'm absolutely freaking out. I've never done peds patients and definitely never done baby patients. I have zero training with kids and infants. I spoke directly with my boss in my interview and she said we never do pediatric patients. Now here two years later I've got one and I'm not okay. Do I have any right to refuse?? I feel like this is very obviously outside my level of training, but they don't seem to see a problem with it?? Peds is practically its own advanced practice in my opinion.

[CritterLover, BSN, RN]

Ethically you can refuse; however your employer can probably fire you for doing so. Will they? Maybe.

Are they offering you any education on pediatrics/pediatric gtubes? Mickey buttons are different than adult g tubes. Not hard, but different. After their first change in the clinic, parents are expected to change them out at home (ours do so every 3 months). They have parts, different extension, sometimes a farrell bag ... it is just different. TFs are also administered a little differently.

What will your role be? Are you just doing the admit or are you going to be following the child? Are they new parents? Why does the child have the g tube? Is there an oral aversion, some sort of structural problem that causes them to not be able to eat safely? Did they fail an MBS? Are they still trying to take PO or are they strictly fed by the gtube? Are there other medical issues? If the baby is just coming home at 6mo there are likely other medical issues.

So many questions ... not to freak you out but to help you figure out how to articulate your objections and educational needs if they end up pushing you to see the patient.

Parents will likely have many questions that you'll need to answer. They probably had thorough but quick education at the hospital (if the g tube was placed recently).

Sometimes companies get stuck with admitting a patient type that they don't usually care for due to insurance issues. Its tough. In that case, they need to find the best nurse for the job. As someone who used to be very intimidated by pediatric patients (but now works in a pediatric facility), I definitely feel your pain.

Talk with your manager, let them know why you object to taking the assignment. It *really* isn't as simple as applying what you know about adult gtubes to kids. This is especially true if there are other medical conditions that you'll need to assess as part of your admission. (If it is just the gtube a quick inservice might be all you need). If there is any other info I can give you let me know.

[brownbook]

Do you, or are you required to, have PALS?

[caliotter3]

Never heard of PALS being required in (routine) home care but that doesn’t mean it would not be useful. If OP does not want to work with this population, they can just refuse with a simple reason given, but be prepared for an argument from the employer. You can turn this into a learning opportunity if you can get the agency to commit to an experienced nurse to work with you for as long as necessary. Of course this would have to be with parent approval. The agency can’t use your RN status as a selling point in staffing this case since you have zero pediatric experience. You have to learn somewhere, somehow. BTW almost all home care is for children, draw your own conclusions. I can’t even remember the last time I was offered an adult case. It was years ago.

[knoelle30]

My role is teaching/training/developing a plan of care/ongoing visits and monitoring... All of my co-workers are freaking out about it, too. I can't answer this mother's questions or teach. I have no clue. My boss sent out an email saying someone has to do it. I'm literally looking for other jobs right now I'm so shaken about it. They've never offered an ounce of training. I'm definitely not PALS certified, either.

[CritterLover, BSN, RN]

9 minutes ago, knoelle30 said:

My role is teaching/training/developing a plan of care/ongoing visits and monitoring... All of my co-workers are freaking out about it, too. I can't answer this mother's questions or teach. I have no clue. My boss sent out an email saying someone has to do it. I'm literally looking for other jobs right now I'm so shaken about it. They've never offered an ounce of training. I'm definitely not PALS certified, either.

I wouldn't worry about PALS -- that isn't going to be helpful in the home since you won't have drugs/advanced airways available. Infant CPR is what you need.

At a minimum, they need to get you an inservice on how Mickey buttons work. Like I said above, it isn't hard but it is different. The company supplying the enteral supplies is a good resource. They likely gave the parents an inservice while they were in the hospital and should be able to come and do one for you and your coworkers. Your home care company owes you and your coworkers that. You'll also probably need an inservice on the pump as you might not be familiar with it. The parents should already have a basic understanding of those things -- g tube kids don't get sent home from the hospital until the parents can care for it at home. However, you'll want to be able to answer questions.

Beyond that, you'll be weighing the child with every visit, probably measuring length and head circumference weekly as well. Are they giving you an infant scale? That is pretty essential as tracking weight is huge and you can't use an adult scale. You'll do a basic assessment -- similar to a full on adult assessment plus fontanelles, diaper rash, g tube site, maybe reflexes. Are they voiding and stooling enough? Kids often get granulomas around their g tubes so that is something to watch out for. The surgery clinic will send home information as to how they want the g tube cared for. Sometimes they want it vented to a farrell bag for the first six months (longer if reflux is a huge issue); sometimes it is just if the kid had a Nissen with the g tube. That's a pain because it means the kid is always attached to the bag and some sort of pole/device to hang the bag on (though you can hang it on a stroller).

If there is no PO intake, generally they get a bolus feed every 3-4 hours over 30-60 min during the day and then a lower, continuous rate overnight (though not always). They rarely get fed at a continuous rate throughout the 24 hr period unless they are having trouble tolerating their feeds.

Outside of other medical issues the child might have, the care plan should focus on monitoring growth and how well the child is tolerating the feeds, monitoring the g tube site, and supporting the parents.

I hope that helps if you do end up having to do the visit.

["nursy", RN]

I got to the point where I refused all pediatrics, after several very uncomfortable experiences, not with the patients, always the parents. My personality is just not well suited to interacting with the parents. The agencies I worked for, however, were on a case by case basis. I got paid per visit, and each case was offered to me to accept or refuse.

If you can get out of it, I would, if the parents sense that you don't have any experience in what you are trying to teach them, they will not be happy.

[ruby_jane, BSN, RN]

OK so....

Is this a kid with failure to thrive or something otherwise relatively benign that requires just a g-tube?

If so - refresh your g-tube skills and you might enjoy it.

If not- then you're absolutely correct, pediatric home care is fraught with difficulties (many of them are produced by the parents). None of the difficulties are insurmountable but it may not be worth it for you.

[CritterLover, BSN, RN]

The more I think about this, I'm wondering why your agency was give the referral?

Are you in an area where there are plenty of home care agencies that take peds? Or are you in a rural area that doesn't have many options?

I think it if is the former, you and your coworkers can probably get away with banding together and refusing to admit the child. Do that now though so the referring hospital can find another agency. Even if it is an insurance issue, the insurance company should be able/willing to find a home care agency that has pediatric nurses.

If it is the latter .... well, my unpopular vote is that someone really does need to do it. It is tough to find nursing services for kids in rural communities. No matter how unsure you and your coworkers feel, having a nurse stop in a few times a week can really make a difference for some kids. Just know that you will likely have to rely heavily on the pediatrician's office as far as your assessment findings/what is normal/what isn't. Get the inservices from the enteral company, watch some you tube videos on how the pump works, and have your company get you some CEs on pediatric assessment.

If it is somewhere between the two and your agency wants to get into peds, then they need to hire and/or train some pediatric staff first.

[JKL33]

Agree with the above. If you are in an area with few options such that the most logical thing for this child is indeed to receive services from your agency that's one thing, but your employer needs to step up. If nothing else they could make some calls to see about an inservice (peds office, peds surg. office, unit from which the baby is being discharged....all of these places should have someone who can give a quick run-down) and then send some of you to get the information. If your employer just doesn't want to try to help with information, etc. then they just suck.

[Wuzzie]

3 hours ago, knoelle30 said:

My boss sent out an email saying someone has to do it.

Seems like a solid plan what could possibly go wrong??‍♀️?

[caliotter3]

Based on your reply after my previous post, you are not qualified for your position. They need to train you in the office, starting with pediatric assessment. A solid background of field experience would help you prepare for that role, but that is not what is going to happen here. You probably need to find another job if no one is willing to take you under their wing to teach you this job.