Clinical Judgement Call...Not sure if I did the right thing

[AvaRose]

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?

[Glycerine82, LPN]

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.

In a SNF setting your choices are to send the pt. out in order to get the testing and treatment you mentioned above or to continue to monitor them and call the MD for new orders (nitro could have been ordered and given in my facility, not sure about OPs). Rarely do these types of facilities have EKG machines, nor could we do anything about an abnormal EKG aside from sending the pt. out.

That's why its so ludicrous that OPs admin had an issue with sending the PT to the ED.

[JWG223]

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?

What you did was with patient safety #1 in mind. You acted to the best of your ability, and did what a prudent person erring on the side of caution would do. Done deal.

[coolnurseclub, RN]

I'd have done the same. Let the ER Docs have that judgement call, reflux vs cardiac. I think your resident and family would agree

[That Guy, BSN, RN, EMT-B]

Did they get stents? Those assessments and vitals would warrant a quick look to check for restenosis in my hospital.

[marylou5]

If the patient made a U turn...you erred on the side of what you thought was in your patient's best interest.

If not your judgement/decision was sound.

My rationale is that you make the best decision on the symptoms present at the time....not your "expertise" to diagnose! Who cares what those who were not there think? My premise is that "you" had to be there. The longer you are around...the more experience you acquire... Wisdom comes with experience... if too many of your patients make a "U" turn....your judgement and/or inexperience may be at fault. No one on this site can answer this question for you....you were there...your call! You made it...live with it..that's your job.

[DebbieReynolds]

I agree with everyone else that she needed transferred. The patient has the right to be transferred. If you convince the patient they should be evaluated, management can't argue when you tell them it was the patients wishes to go to acute.

[RN_CHERIE83]

You made the right call - so, please stop questioning yourself for making a justified call. Her pain was clearly outside of normal re flux and I would gladly be happy to have you as my RN. :)

[OHNBJL]

You were absolutely correct in transferring her to the hospital. Don't let the administrator give you the 20/20 hindsight lecture. You assessed and made your decision on facts. Stick to it. As for Medicare guidelines and payments, they will drive you nuts. Don't let them influence your assessment and decision of a patients care. Great job.

[NurseDiane]

A non-STEMI MI during this latest hospitalization was "in the distant past" to the administrators?

Maybe the facility would be best served finding people that are familiar with clinical signs and symptoms of a cardiac event and how to handle it.

Your decision was right on the money. When questioned by administration, always stand your ground, explain the rationale for what you did and stick with it. This patient was unstable and needed to be evaluated in the hospital.

The administration's #1 focus is MONEY. Losing a cardiac rehab patient means a loss of $$$$$. That's why they didn't want the patient transferred to the hospital----because then they'd lose that bed to someone else who may not have the same kind of insurance that would reimburse at the same rate. The greed in healthcare makes me sick.

[edna317]

You were ABSOLUTELY right!!

[MunoRN, RN]

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...

It sounds like we're talking about an acute short term SNF, not LTC or LTAC.

[michelle.laree]

This probably isn't the best answer but the doctor is there for a reason. You were seeing things that were off and you called the doctor, as is appropriate. The doctor gave the order; the doctor sent the patient to the hospital!