Today I had to transfer a patient back to the hospital and I'm not sure I did the right thing in advocating for the transfer...perhaps I still have new grad informationitis from studying so much to pass NCLEX. A brief HIPPA safe (I hope) background:
D arrived yesterday with a history of Afib, Heart valve replacement, and a Non STEMI MI during this latest hospitalization. In addition her Troponin levels were still critical and her PT/INR levels were no longer in therapeutic range. Early this morning the night nurse called the doctor because the patient was diaphoretic and her vitals were all elevated. In addition the patient c/o reflux and epigastric pain. The doctor ordered reflux medication which was given with a very small amount of relief.
I took over at 0630am. The patient continued to complain of epigastric pain increasing from a 5 at 0800 with morning meds (including Carafate) to a 10 at 1200pm after the second dose of Carafate which had not worked. Vitals were elevated (BP 137/87 when it is normally 100/60, HR 92-normally around 60, O2-93 on 2L NC-it was 97, and her MAP was 112). I called the doctor again because I felt those levels were serious and the patient showed distress. The doctor ordered the patient to be transported to the hospital for evaluation.
My questioning of my decision comes from the administrators wondering why I even called the doctor for what was in their minds "just reflux" because according to their paperwork the MI was in the distant past though when I admitted the patient last night the hospital said it was what she was being treated for and her Troponin was critically high.
Was I right to think because women often present with epigastric pain and "bad reflux" that evaluation was a safer option than assuming the patient was okay and it would go away with enough antacid?
NO you were not right. The patient had a recent MI, now presenting with pain, diaphoresis and vital sign changes.
You cannot assume this is reflux! You needed to perform a stat EKG and administer nitro SL. Of course the doctor needed to be notified, but just because the doctor and the night nurse THOUGHT it could be reflux, YOU need to start ruling out cardiac causes FIRST.
I am in a transitional/short-term rehab facility. We don't have Nitro or EKGs. Our crash cart is O2 and Suction...not much help at all. I thought heart attack immediately but was constrained until the patient failed to respond to the medication the MD ordered overnight. Once that failed he said to send her.
Ace of Hearts-No Nitro given by EMS but a 3 lead EKG done on site and vitals rechecked but the EMS convinced the patient to get transported since the 3 lead often doesn't show any problems even if they are present.
Glycerine-Scary thing is that the admin is an RN but hasn't done bedside in a long time. Her information did not show the recent MI so she was unsure why we were so concerned until I showed her the discharge sheet from the hospital when we got the patient which showed clearly the HX of heart problems.
I am in a transitional/short-term rehab facility. We don't have Nitro or EKGs. Our crash cart is O2 and Suction...not much help at all. I thought heart attack immediately but was constrained until the patient failed to respond to the medication the MD ordered overnight. Once that failed he said to send her.
Ace of Hearts-No Nitro given by EMS but a 3 lead EKG done on site and vitals rechecked but the EMS convinced the patient to get transported since the 3 lead often doesn't show any problems even if they are present.
Glycerine-Scary thing is that the admin is an RN but hasn't done bedside in a long time. Her information did not show the recent MI so she was unsure why we were so concerned until I showed her the discharge sheet from the hospital when we got the patient which showed clearly the HX of heart problems.
So..your facility admits patients,recovering from a NSTEMI..with no monitoring equipment available,and Nitro SL not available? Seems like you have bigger fish to fry..including your license.
You were NOT constrained.. if you suspected myocardial ischemia then call 911. STAT. Instead of dinking around with Dr. Dinkheads orders. Time is muscle.
You absolutely did the right thing, and I am suprised that given the hx of the patient they even questioned sending the pt to the hospital.
When I worked in ltc years ago, the census was so low at one point that they wanted us to call the DON at home before sending anyone to the hospital. How asinine.
OP: ( the first off the cuff wise guy responce I thought of was to just ask the administrators where they got their medical licenses)
But seriously folks I'm gonna pile on here with the rest of the crew and say beyond a doubt you absolutely positively did the right thing hands down.
A cardiologist once told me, I can see a patient, do all the tests in the world and give the patient a clean cardiac bill of health. But that doesn't mean that as soon as the patient walks out the door he won't have a big MI and fall over dead.
You can imagine, he said, the (hypothetical) difficulty so far of having to tell this to the widow when she asks, "but doctor, what happened?"
Keep up the good work. Have faith in your instincts and clinical ability and repeat after me: "no one dies on my watch" again and again and again...
And by the way, who would you image the administrators would rush to throw under the bus when the family starts asking "why did you kill mom?'
OP: ( the first off the cuff wise guy responce I thought of was to just ask the administrators where they got their medical licenses)
But seriously folks I'm gonna pile on here with the rest of the crew and say beyond a doubt you absolutely positively did the right thing hands down.
A cardiologist once told me, I can see a patient, do all the tests in the world and give the patient a clean cardiac bill of health. But that doesn't mean that as soon as the patient walks out the door he won't have a big MI and fall over dead.
You can imagine, he said, the (hypothetical) difficulty so far of having to tell this to the widow when she asks, "but doctor, what happened?"
Keep up the good work. Have faith in your instincts and clinical ability and repeat after me: "no one dies on my watch" again and again and again...
And by the way, who would you image the administrators would rush to throw under the bus when the family starts asking "why did you kill mom?'
The daughter did actually call me (we always have to call family during a transfer and I had to leave a message for her) and asked why I was sending mom back to the hospital she just got discharged from less than 24 hours earlier. Apparently I sound like I know what I'm talking about even though I didn't feel terribly confident but I told her my assessment and what had been going on and that it was the safest thing for us to do for her mom. She thanked me several times by the end of the phone call. But yes the administrators would likely fire me on the spot and tell the family to complain to the BON about me if the patient had died. I'm hoping to get out of this place as soon as I can...I was trying for a year but will be happy if I make it 6 months so I can hopefully find a better, safer (for my license) position.
So..your facility admits patients,recovering from a NSTEMI..with no monitoring equipment available,and Nitro SL not available? Seems like you have bigger fish to fry..including your license.
You were NOT constrained.. if you suspected myocardial ischemia then call 911. STAT. Instead of dinking around with Dr. Dinkheads orders. Time is muscle.
You were absolutely right in your judgement call. 10/10 epigastric pain is rarely going to simply be 'acid reflux'. I'd rather err on the side of caution...have her come back and they say she just has reflux rather than hold her there, in severe pain, and end up with a dead patient. You advocate for your patient, uphold and protect your license by making good calls like that.
Having your decision questioned by admin doesn't mean that you made an error in judgement. I agree with your assessment that the patient needed further evaluation. LTC administration is only interested in minimizing ED transfers for financial reasons. You have a solid rational for your decision, obtained a Dr.'s order and followed procedure which means that you don't need to worry any more about this event. Sometimes new nurses in LTC are a little too quick to transfer residents to the ED because they don't consider the larger picture and make use of all the resources at the facility level to meet the resident's needs first. However, I don't believe that you have made this mistake.
Especially with the pt's history, those symptoms are suspicious & nothing to fool around with. She needed to see a doctor & you saw that she did. The suits n heels have no idea what it's like taking care of & being responsible for pts. The only thing they can comprehend is $$.
So..your facility admits patients,recovering from a NSTEMI..with no monitoring equipment available,and Nitro SL not available? Seems like you have bigger fish to fry..including your license.
You do know this is ltc we are discussing right? Not LTAC. The majority of LTC short term residents are admitted for rehab after a hospital stay. Long term residents are essentially custodial care with some skilled services (med mgmt, sometimes wound care, tube feeds...). Either way, a 50 yo in the hospital for NSTEMI could be sent HOME in the same cardiac condition as, say, the 80yo who is sent to rehab because after being in the hospital they need PT and are unable to care for themselves. In other words their being in LTC is usually due to general deconditioning-they've been deemed safe for hospital discharge.
If they were able to toilet themselves and manage their own meds etc they would likely be headed home. Not too many private homes with "monitoring equipment." Nitro is a case by case prescription from the attending no different than if the pt is sent home. In an acute situation LTC would be expected to utilize EMS for nitro (if no existing script) and often for the 12 lead. That's fairly standard and not a danger to anyone's license.
The resident was not admitted to LTC due to their NSTEMI per se, they are there due to sequelae like generalized weakness, gait disturbance or possibly chronic CHF. They are there for rehab, not for cardiac monitoring. The only part of this that I would question is the use of a private transport company rather than 911 for a suspected MI-does the private company have paramedics and capability to give nitro etc?
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AvaRose
191 Posts
I am in a transitional/short-term rehab facility. We don't have Nitro or EKGs. Our crash cart is O2 and Suction...not much help at all. I thought heart attack immediately but was constrained until the patient failed to respond to the medication the MD ordered overnight. Once that failed he said to send her.
Ace of Hearts-No Nitro given by EMS but a 3 lead EKG done on site and vitals rechecked but the EMS convinced the patient to get transported since the 3 lead often doesn't show any problems even if they are present.
Glycerine-Scary thing is that the admin is an RN but hasn't done bedside in a long time. Her information did not show the recent MI so she was unsure why we were so concerned until I showed her the discharge sheet from the hospital when we got the patient which showed clearly the HX of heart problems.