Discharge Flap

Tweety, BSN, RN · Aug 25, 2004

Yikes. Good thing you guys stood your grounds with this patient. Hard to believe this d/c planner is an RN. Down here, anyone who needs suctioning, or even has o2 nasal canula qualifies for an ambulance transport.

We had our d/c planner (non RN, although there are RN case managers about) plan a trached patient, with massive head injuries and decubes on a commercial flight with an RN to flie across country. He head rolled for that one. A few days later he left by air ambulance.

nursemary9, BSN, RN · Aug 25, 2004

HI

GOOD GOING!! You were working on behalf of that patient. I hope I would have done the same!! We are, after all, advocates for our patients!

Anyone who uses O2 or needs any amount of suctioning here must go in an ambulance and sometimes even needs to be accompanied by a nurse.

Mary Ann

allnurses Guide · Aug 25, 2004

Marla - good for you!! Patient Advocate of the Year medal coming up. :)

Thanks!!!

steph

missmercy · Aug 25, 2004

Good call!! I took care of a 700lb woman who was discharged home from the hospital to homecare because " she wouldn't fit in the hospital room bathrooms". She ended up falling -- took out (as in injured) the whole 5 person team of aides and nurses out taking care of her -- and the house supervisor wanted to know if her father (the patient's dad) could drive her in rather than send out all the personell necessary to transfer her via an ambulance. Needless to say, that supervisor was holding a placin in the unemployed line shortly thereafter.

She was on the floor!! It took eight EMS/vol. firefighters to get her loaded into the squad. She had to be carried on a door because the gurney wasn't going to be able to support her weight. Those factors alone necessitated the squad and the extra personel! How on earth was the poor driver supposed to get your patient into the house alone?! What on earth was that gal thinking?!

In her defense -- it may have been a PMS day, which may have followed a major altercation with DH about the finances and another with the children about what clothes to buy for school and the dog may have pooed on the floor that morning -- necessitating not only a spot carpet cleaning, but a change of shoes as well. Her McMuffin may have been scortched, the coffee cold and whe may have just been reamed out by the 3000 people she had just called trying to get a transport for this woman. HOWEVER -- no matter how much "excratory material collides with the oscillating ventalatory system" (BTW. LOVE THAT!!! THAT MAY BECOME A BUZZ PHRASE AT OUR HOUSE!!!)it is our responsibility to keep the best interests of the patient in the forefront and maintain a professional standard. Good judgement is a must whether the day is on it's way to Heck in a handbasket or not!!! Common sense is NOT optional equiptment and neither is common courtesy! You did the right thing!! Inspite of being bullied!!! GOOD FOR YOU!! Keep up the good work!~

redshiloh · Aug 25, 2004

Absolutely you did the right thing. I work on a spinal cord injury unit and we have been in this situation before: transport comes and there's inadequate personell and equipment to safely facilitate the transfer. We can't and don't allow it.

Guaranteeed if you HAD allowed the patient to leave like that and something had happened it woulda been YOUR hooha in a sling!

Lenap · Aug 25, 2004

You are an excellent patient advocate ! You did a right thing in this situation. What would have happened if the patient died or got injured during transport? We deal with a lot of trach patients and no matter where they are transfered or dc'd it's our policy to obtain a full 02 tank and portable suction machine and provide enough supplies for suction to last few days. This should be done everywhere. And of course when ordering ambulance for transport they should be informed what equipment should be on a board and what kind of patient will be transported. And no matter how fast we want to ship a patient out, this process should be well planned.Of course all of this is a discharge nurse's job. I guess we are lucky to have very experienced d/c RNs. Just wanted to say that you handled your situation well!

P_RN, ADN, RN · Aug 25, 2004

She was wrong. You worked in the best interest of your patient. I've sent many transporters away when I thought they couldn't handle a patient. Our discharge planners were social workers (MSW) not nurses though. I'm assuming that we might have carried a little more clout with them. Medicare still pays for ambulance when medically necessary-right?

hoolahan, ASN, RN · Aug 25, 2004

I can probably tell you what popped her cork...if the pt stayed in the hospital, and didn't meet criteria for payment, the insurance company denies the hospital payment for those days. It sucks, but they do. It happens so often, then the hospital goes through the expensive appeals process, and they always take it out on someone, not in management, probably the D/C planners.

I am NOT trying to excuse her behavior at all, just guessing at her frustration. She was clearly wrong, and indeed how would they have gotten her off the stretcher in the next place? The stretcher probably would've dropped off the ambulance, and she could have been injured, not to mention she should have have the necessary emegency equipment!

Another thing, the d/c planner probably had a smaller choice of ambulance co's if the pt was a managed care. (Some of) The HMO's pay crap, and use the cheapest bare-minimum companies for transport, so if the hospital used the EMS w 5 papramedics, that will be another cost the hospital has to eat, she is probably regurgitating just what the managed care person on the pre-auth line says to her..."They use this means of transport all the time..." yeah, well, she may well do so, but it doesn't mean it is acceptable or safe. Get the doctor to document all of this on the chart too.

I work in the quality dept of an HMO, and trust me I DO read your notes, and if the documentation is strong, if the hospital appealed these denials, we often overturn them if they can support their cause in the notes!! It is usualy doc notes that give more weight, but many times nurses notes do too.

Good for you for advocating for you pt marla!!

P_RN, ADN, RN · Aug 25, 2004

Good point Hoolahan (Nice to see you, too). With her being so disabled wouldn't Medicare be primary though? I know my Medicare is....much to my displeasure sometimes. You can tell it's been quite a while since I dealt w/ discharging patients from the hospital.

jnette, ASN, EMT-I · Aug 25, 2004

Marla - good for you!! Patient Advocate of the Year medal coming up. :)
Thanks!!!
steph

Steph said it, I ditto it !

Huge Kudos to YOU !!! :balloons:

explorer · Aug 26, 2004

Had a rather intense disagreement with one of our hospital's discharge planners yesterday, over a patient who was being transported to a nursing home about 25 minutes away. Without going into a bunch of boring details, I'll just say that this patient is over 400#, trach/02 dependent, and a paraplegic to boot; the 'transport' was an untrained driver with a van and a rickety stretcher I myself wouldn't have been comfortable on. No suction, no equipment in case she lost her airway during the trip.........nothing. Well, this pt. had been refused by every nursing home and transport company in the area, and I guess the DC planner had just about run herself ragged trying to get her out of the hospital and arranging transportation.
Trouble was, while six of us were trying to get this massively obese and totally dependent patient on this little gurney, she needed suctioning no fewer than 5 times, and was gurgly even after we stopped trying to hoss her around and got her back onto the bed. The respiratory therapist and I agreed that it was NOT safe to transport her under these conditions, and we approached the doctor, who strongly agreed with our assessment and asked us to have the DC planner arrange ambulance transport instead.
That was when the excretory material collided with the oscillating ventilatory system. The woman literally yelled in my ear, "This patient is transported like this out in the community all the time, no suction, no oxygen, and she goes on those little stretchers every time! Don't get in the way of this, Marla, I'm telling you!!"
Well, it was already a done deal.......all three of us, the RT, the hospitalist, and I had decided that it wasn't safe, and we'd sent the driver with his little rickety stretcher away. I think what pissed her off the most was having the MD back us up........otherwise, I'm still not sure what tripped her trigger. She kept insisting that this patient ALWAYS went places this way, and who was I to interfere when it was the only way we were going to get this woman out of the hospital to the only nursing home in the state that would take her?
Uh.....maybe it was because she wasn't in that room when six people tried to get the pt. positioned on the stretcher, and the pt. was choking on her own secretions and turning purple.......and I was? This DC planner is an RN, for heaven's sake.........did she want to be held responsible for it if the pt. lost her airway on the ride to the NH and had to be 'rescued' by someone who wasn't even trained in basic life support? I certainly didn't, and it wasn't even my patient.......I was the PRN nurse, covering for the pt's nurse while she was tending to another pt. But if I'm going to err, it's ALWAYS on the side of patient safety, and I don't care who gets their knickers in a twist.
I also decided right away to notify the unit manager of what had transpired and documented my rear end off in the meantime (minus the part when the DC planner popped her cork). If I was wrong---and I didn't believe I was---I wanted her to know ahead of time what I'd done, because this DC planner was madder than a wet cat and I knew she'd complain.
Even after the pt. had finally left---in the company of five strong paramedics who'd gotten her onto another narrow stretcher somehow---she couldn't resist getting in a few more digs: "See, she goes like this on those little stretchers all the time," "She hasn't needed to be suctioned since last night, why did she suddenly need it five times in ten minutes?" and so on. I finally said, "Look, all I could do was go on my judgment of the situation. I was in that room, you weren't, and you know what, I'd do the same thing all over again. All I can do is go on what I think is safe for the patient."
Now I'm sure I'm on her sh** list, but I hope at some point we can sit down and talk about it professionally.......sure would like to know what brought all that on. I've known and worked with this woman for years in different capacities, and there's always been a mutual respect and admiration....until yesterday. I'm sorry if I've made an enemy, but dang, if the same thing were to happen today, I wouldn't do it any differently, no matter what pressures were brought to bear. I'm NOT going to discharge someone into a situation I KNOW is unsafe........what kind of nurse would I be if I did that?
Thanks for letting me vent. :) I feel better now.

I think that you did the right thing!