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?
The way I look at it, being on someone's sh*t list is a small price to pay for being able to live with yourself. You know you did the right thing. WTG, Marla!
You did good, kid. Like many of the other posters here, I think this dc planner was fighting DRG's,medicare/Medicaid payment, wanted to get rid of an already bad situation for the facility. After all, this was probably the most intensive patient in terms of manpower on your floor and possibly the whole place. Where it was PMS or a brain fart, she was unprofessional and you need to be prepared to fight a good case when she goes whinning to HN or some other administration flunky. Hope I have someone like you in my corner when I really need an advocate . Keep up the good work. :balloons:
Specializes in LTC, assisted living, med-surg, psych.
Thanks to all of you!! :kiss
Hoolahan made some good points about payment.......I've been a nursing-home admissions/discharge coordinator, so I know far more than the average floor nurse about Medicare/Medicaid, HMOs etc., and don't even get me started on managed care! :angryfire
I have a feeling that's one of the reasons this DC planner blew a gasket when I tossed the monkey wrench into the works; she and I have worked together in the past, and she knows that I know the business end of it. HOWEVER.......I still believe I did what was right, and everyone---including the nurse managers and the hospitalist---backed me up all the way. But even if they hadn't, I wouldn't have done anything differently; that patient was in what I deemed to be an unsafe situation, and I could NOT countenance that, let alone sign off on it and say, in essence, that I didn't give a rat's @$$ what happened to her once she was out the door.
Thanks again, everyone........it's always nice to hear from other people that one has done good! :)
Specializes in LTC, assisted living, med-surg, psych.
Oh, and BTW........you know how this patient became a paraplegic in the first place? She was dropped during a transport last fall, and ended up with a spinal cord injury.
You were absolutely in the right, and I know how stressful it is to be in the right, sometimes! you not only looked out for your pt, you know how to CYA.
Hopefully, your co-worker was just having a bout of temporary insanity.
Too bad if you're on her s@#$t list. Hang in there; You did the right thing. If the patient had been injured, guess who she would have pointed the finger at. She needs a reality check, on how a patient's safety is more important than her "power trip." Glad you documented well, as I'm sure she is whining to someone, and trying to make you look like the bad guy. Who's in charge around there anyway? Time for a meeting. Sorry if I sound harsh; I have no time and no patience for crap like that.
Specializes in LTC, assisted living, med-surg, psych.
Too bad if you're on her s@#$t list. Hang in there; You did the right thing. If the patient had been injured, guess who she would have pointed the finger at. She needs a reality check, on how a patient's safety is more important than her "power trip." Glad you documented well, as I'm sure she is whining to someone, and trying to make you look like the bad guy. Who's in charge around there anyway? Time for a meeting. Sorry if I sound harsh; I have no time and no patience for crap like that.
I'm happy to report that this incident has been resolved, and the DC planner involved has been kissing my back cheeks ever since........she's always asking my opinion on things now, being overtly friendly and helpful, and generally acting like that whole incident never happened. I wonder if it has something to do with the fact that 2 days after that patient went to the nursing home, she was back in the hospital (a different one, thank God) with respiratory failure and altered LOC?? :uhoh21:
Regardless, I would do the same thing again if necessary, and indeed another situation arose yesterday, this time involving a 49 YO man who'd just come out to the floor from ICU. He'd had a massive CVA, and his MRI that morning had shown expansion of brain swelling, with brain-stem compression progressing. He was doing some kind of weird tachy-brady thing on telemetry, and being a full code, he required almost one-to-one nursing because I had to do hourly neuro checks and the tele kept alarming because his heart rate would dip into the 30s whenever he fell asleep. The physician wasn't keen on taking him back to intensive care, but I pushed for it anyway because I just had a bad feeling about him. Call it instinct, call it superstition, but I felt that something awful was going to happen and I didn't want it to happen on my watch.....OR on my unit. Luckily, this MD trusts my judgment, and he agreed to transfer the patient back to ICU for closer observation, for which both I and the patient's family were immediately grateful.
I don't know what happened after that.......I transferred the pt. about an hour before shift change, and since I have the next 3 days off I won't find out how things went until Monday. I'm glad I pushed for the move, though.....the recent experience with the 42-year-old cardiomyopathy pt. who coded on us made me just that much more aware of all that can go wrong, and how quickly it can go wrong.
I would have insisted on riding along with the pt. to the NH if the planner would not back down on having the poor woman being transported in such a way. I have a reputation for being kind of easy to push around but I think even I would have put my foot down about that one.
I hope I have a nurse like you if I ever need to be hospitalized.
Chaya, ASN, RN
932 Posts
The way I look at it, being on someone's sh*t list is a small price to pay for being able to live with yourself. You know you did the right thing. WTG, Marla!