Does your LTC get mad when you send patients do the ER?

Specialties Geriatric

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At the nursing meetings, we are told to always try to keep the skilled care medicare patient at the LTC by suggesting to the doctor that he order lab work, antibiotics etc etc etc instead of sending the patient to the ER. I don't know. If they don't want us to keep sending patients to the ER, then why do they keep allowing "medically unstable" patients to be admitted here all the time?

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Specializes in Rehab, LTC, Peds, Hospice.

Because they lose money. It's your license though. Basically if a Patient needs me in their room constantly or even very frequently due to an unstable condition and I can't care for them or my other patients adequately and safely - the best place is most likely the hospital who have the patient ratios to deliver the kind of care they need.

Some things can be managed at your facility. However, even though they can be done, 'stat' is within hours usually since you are most likely using an outside lab, outside mobile imaging service, etc. Also you need to take in consideration whether you have the meds you need if your pharmacy isn't on site or in your emergency med supply. Basically you need to assess whether your patient can tolerate waiting, waiting for care, meds and tests. In a hospital those needs can be met quicker. You are the patient advocate, you need to determine what is best for them, not the facility.

Also -just an aside, if a family member wants them at the hospital, I highly recommend you send them and tell the doctor that what they want. Even if you feel it's unnecessary. For should the situation worsen - you'd be to blame. Most doctors will send patients to the hospital if that's the family's wish.

Best of luck to you - it's hard place to be in the middle of those situations.

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If I doctor told me to send a resident to the ER and I tried to convince him to treat the resident here on the basis of financial motives, that would be unbelievably unethical.

Of course, it's not always in the best interest of the resident to ship them out. If they can be treated in the LTC, they should be. But I trust the physician to make that call. For me to try to "persuade" the physician to do one or the other is presumptuous. My job is to provide my assessment data and then follow the orders that ensue.

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Specializes in Rehab, LTC, Peds, Hospice.
If I doctor told me to send a resident to the ER and I tried to convince him to treat the resident here on the basis of financial motives, that would be unbelievably unethical.

Of course, it's not always in the best interest of the resident to ship them out. If they can be treated in the LTC, they should be. But I trust the physician to make that call. For me to try to "persuade" the physician to do one or the other is presumptuous. My job is to provide my assessment data and then follow the orders that ensue.

No offense Brandon, but as the patient advocate you can and should persuade the doctor if you feel strongly they should go to the hospital or whatever else you feel will benefit your patient. Doctors are human too, and even with all the information may make an error or fail to intervene.

They may still disagree - but you'll have the protection of having addressed whatever is at issue, also some doctors will educate you as to the reasons for their decisions - good opportunity to learn.

And be sure to document, document, document.

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Specializes in Rehab, LTC, Peds, Hospice.

I reread this - and realized I read your post wrong. Sorry - don't think what I said applies after all to your post. Oops!

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Are both of you in VA sounds like you work at my facility?

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After a week of not sending a patient out (he didn't look good at all ) On change of shift they found him unresponsive and had to call a code. Of course, it was swept under the rug that the nurses delayed treatment

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Because they lose money. It's your license though. Basically if a Patient needs me in their room constantly or even very frequently due to an unstable condition and I can't care for them or my other patients adequately and safely - the best place is most likely the hospital who have the patient ratios to deliver the kind of care they need.

Some things can be managed at your facility. However, even though they can be done, 'stat' is within hours usually since you are most likely using an outside lab, outside mobile imaging service, etc. Also you need to take in consideration whether you have the meds you need if your pharmacy isn't on site or in your emergency med supply. Basically you need to assess whether your patient can tolerate waiting, waiting for care, meds and tests. In a hospital those needs can be met quicker. You are the patient advocate, you need to determine what is best for them, not the facility.

Also -just an aside, if a family member wants them at the hospital, I highly recommend you send them and tell the doctor that what they want. Even if you feel it's unnecessary. For should the situation worsen - you'd be to blame. Most doctors will send patients to the hospital if that's the family's wish.

Best of luck to you - it's hard place to be in the middle of those situations.

Exactly. For the most part, a lot of what we send them back to the hospital for really could be managed in the facility IF we had all of the supplies and services. Yes, we can draw labs, start the IV, push drugs like lasix etc, but sometimes it is becoming more and more dificult to do this in facility. In an ideal world, we can get the stat labs done stat. If we had the fast turn around time that they promise (or even the service on the weekends or off hours) we can start treatment at the facility. Say we get the labs back and get new orders for meds....good luck getting them STAT thru the pharmacy (Omnicare....that was an entire other thread) STAT in our facility is 3 hrs from the order. We are real good about getting IVs started on our own but sometimes need IV team to come...that is another wait. XRAY services can be done STAT....again..a few hours.

I think it comes down to nursing judgement and using the protocols set up by your facility to prevent the frequent re admits. We always try to treat in facility first, but you need to know what you can and cannot do and the time restraints put in place by your vendors etc.

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I've worked in a rehab unit in LTC for over 2 years. They do not like sending patients to the hospital because they do loose money, a lot. As you may know, it becomes very stressful for admissions when census is low. A year ago, a pt. was sent to the ER during the 3-11 shift, and they returned to the facility at 0130. I was asked if the pt really came back at that time, or "could they have come back at 2330". The reason being is, if their head is on the bed by midnight, the facility gets paid, and that expensive increases if they had therapies. If not, that entire day with rehab charges, goes unpaid. Sad and unethical. Remember, when in doubt, send out !! This is not only to CYB, but the well being of the patient/resident.

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The goal for the (LTC) company I work for is to catch changes of condition *early* so they can be treated in the facililty.

It is incredibly stressful on both residents and their families to send them to the hospital, and better for all (resident/family/facililty staff/the bottom line) if we can avoid transfers. We have focused on teaching nursing staff how to recognize early symptoms of dx like UTI and pneumonia and how crucial it is for the nurse to act as soon as the beginnings of a problem are noticed. Although it has taken a lot of time

and training (we have more new grad nurses than most) we have been able to significantly reduce our rehospitalizations and ER visits. This also fosters better relationships with the local hospitals.

Money is always going to be an issue -- but we need to remember, that medicare money coming in is what allows us more staff and better pay.

New Medicare rules for LTC will be in effect soon -- which will levy hefty financial penalties on facilities whose resident are re-hospitalized for these "preventable" diagnosises (i.e. pneumonia and UTI). '

This also includes residents that return to the hospital any time within 30 days of their discharge from the LTC facility. If nothing else, this will force us to step up our recognition of emerging medical problems and turn discharge criteria/planning a notch -- again a win-win for our patients.

At the end of the day, preventing that re-hospitalization or er visit is universally what is best for the resident -- its not always all about the money......

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Yeah, pretty much. We have to call at the very least and get approval and I have had what you described, a very unstable patient who had family staying the entire time and I was called frequently into the room assessing and discussing care. I got nothing done and my entire shift was run around that one resident. I also wonder why I am getting these types of people admitted to our facility, we are not staffed for that type of care, but it has become frequent. I stayed after on my own time to do some charting the other day and discoverd that none of the Q shift charting or Careplans had been charted on in 2 days and I have no doubt that it was due to the new admits we had who kept us very busy. I ultimatly ended up sending that resident back to hospital but I got a lot of resistance and was told by Nurses who had been there longer, they are always hesitant to send anyone out.

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One thing that always confuses me in these discussions is when we say we send the resident out, as if it were our decision.

The nurse calls the doctor, gives him their assessment data, and the doctor decides whether to ship out or treat in place.

How can anyone be mad at nurses for the decision to send someone to the ER?

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