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?
Specializes in Pedi; Geriatrics; office; Pedi home care..
The old adage "Better Safe, Than Sorry" comes to my mind.
Unless the administrator is a nurse; he/she does not need to be questioning what you did. You assessed your patient. You notified the doctor. He/She made the decision to transfer back to the hospital; after you notified him of the patients symptoms and admitting diagnosis.
I say Good For You! You did what you are trained to do: 1) Assess; 2) Contact the doctor & report what your assessment showed; 3) you followed the doctors orders.
Thank you everyone :) As I said before, I will see on Tuesday if she is back with us or if she was deemed too unstable for rehab. This is the part of the process that will take me the most time to learn...making clinical judgements and using the all so important critical thinking skills they drilled into us during school. All of my previous jobs were the type where you weren't meant to think for yourself so this is pretty different.
Thank you everyone :) As I said before, I will see on Tuesday if she is back with us or if she was deemed too unstable for rehab. This is the part of the process that will take me the most time to learn...making clinical judgements and using the all so important critical thinking skills they drilled into us during school. All of my previous jobs were the type where you weren't meant to think for yourself so this is pretty different.
You did the right thing, as many have already stated.
Always remember - it's easy to look at an event in hindsight. We don't have that luxury, though. We are expected to determine if a fall caused a fracture without any X Ray. We are supposed to know if someone is having a cardiac event without benefit of even an EKG - even if we could all be expert at reading them. ALWAYS err on the side of caution. ALWAYS.
I can empathize with the bean counters, too. A facility does, after all, have to turn a profit to stay in business. A nurse is not focused on the money side of things (and the nurse should not be focused on that, certainly not to the exclusion of giving correct nursing care). Still, someone has to count those beans or patients will have nowhere to convalesce, nurses will be out of work, have nowhere to be angelic. :)
You did the right thing for the patient by calling his physician. If you had done nothing and the patient suffered from an untoward event, you would never forgive yourself. Administrators are often neither physicians, clinicians or nurses. Who are they to tell you how to do your job. They are only worried about getting paid, as frequent readmissions negatively impact their medicare scores and payment.
She had all the signs that she was physiologically in deep trouble. You absolutely have to go with your gut and send the patient out. I had 2 such instances in the first 3 months after grad and I sent both out. From mgmt I got " this is their home and they shouldnt be sent out".
Fact of the matter is that the home wont get paid for the bed while pt is in hospital. They are worrying about their lost revenue.
One of them turned out to be just at the onset of a middle cetebral artery stroke. The other was pneumonia. The pt had a pretty high fever and the education nurse was telling me to give him Tylenol to bring down the fever to make him more comfortable before I sent him out. Now I am all for patient comfort but it is even more important for the doc in the E.D. to have a true pic so he can make the right diagnosis. With a decreased temp due to my intervention with Tylenol he woulddnt have all the info. So my answer to the nurse educator was "No, they have to see him as he is". I sent him out without the Tylenol. They kept him for 10 days. Just follow your gut. Rather that than the patient die because they had a care system that was asleep at the switch and laser focused on not losing the $$ for the daily room rental.
Why is a patient with critical troponins being discharged from the hospital to go to rehab????
There's not really any reason not to by itself since troponins can remain elevated (critical) for up to 2 weeks after a cardiac ischemic event has already fully resolved.
The pt had a pretty high fever and the education nurse was telling me to give him Tylenol to bring down the fever to make him more comfortable before I sent him out. Now I am all for patient comfort but it is even more important for the doc in the E.D. to have a true pic so he can make the right diagnosis. With a decreased temp due to my intervention with Tylenol he woulddnt have all the info. So my answer to the nurse educator was "No, they have to see him as he is". I sent him out without the Tylenol. They kept him for 10 days.
So sad you can't give APAP and also trust the ED doc to see that their temp was post-APAP.
Allgood2016, LPN, LVN
51 Posts
The old adage "Better Safe, Than Sorry" comes to my mind.
Unless the administrator is a nurse; he/she does not need to be questioning what you did. You assessed your patient. You notified the doctor. He/She made the decision to transfer back to the hospital; after you notified him of the patients symptoms and admitting diagnosis.
I say Good For You! You did what you are trained to do: 1) Assess; 2) Contact the doctor & report what your assessment showed; 3) you followed the doctors orders.