Dumping on the ER?

Unfixable · Jan 30, 2016

Seeing her BP was elevated and it normally is not that high, it probably is a CHF exacerbation. 80% of patients with a history of afib also have CHF because with afib the atrial chambers of your heart don't actually beat, they just quiver, you actually lose 30% of your ejection fraction. So let's say normally your EF is great at 70%, if you go into Afib you lose 30% of your EF, which will make your EF only 40%. An EF of 40% or less is considered to be severely impaired and warrant a diagnosis of CHF. Her BNP isn't THAT elevated, I've definitely seen worse and most places if it's higher than 36,000, that's what the lab value will read "greater than 36,000". People who come in with BNP's that are that high have likely had CHF for 10 years or more. I have yet to see a patient with no history of CHF whatsoever come into the hospital with a BNP greater than 10,000. NSTEMI is a term that encompasses all conditions that can cause cardiac injury without EKG changes. I have seen patients come in with a CHF exacerbation with elevated troponins. I have seen patients with pneumonia have elevated troponins. I have seen GI bleed patients come in with a Hgb of 4.0 have elevated troponins. Why does this happen? Because pts with pneumonia or pulmonary edema have fluid in their lungs, therefore gas exchange isn't optimal. In fact none of your organs are being oxygenated adequately, your fingers aren't being oxygenated adequately that's why when you put the pulse ox on their finger it reads 82% instead of 98%. But 75% of the oxygen you breathe is used by your heart, so if your ability to breathe is impaired, and your heart isn't getting the oxygen it needs, it will cause a myocardial injury AKA NSTEMI. Oxygen is carried in the blood by hemoglobin, if you have no hemoglobin, your blood doesn't have the ability to carry oxygen to your heart, NSTEMI. I've taken care of patients who have come back from the cath lab and the cardiologist would say "she has takotsubo cardiomyopathy" AKA "broken heart syndrome". Where stress causes you to have an NSTEMI. Kudos to you for trusting your gut with this patient! LTC you need good assessment skills because that and a blood pressure cuff are all you have!

%D#2 · Jan 30, 2016

Seeing her BP was elevated and it normally is not that high, it probably is a CHF exacerbation. 80% of patients with a history of afib also have CHF because with afib the atrial chambers of your heart don't actually beat, they just quiver, you actually lose 30% of your ejection fraction. So let's say normally your EF is great at 70%, if you go into Afib you lose 30% of your EF, which will make your EF only 40%. An EF of 40% or less is considered to be severely impaired and warrant a diagnosis of CHF. Her BNP isn't THAT elevated, I've definitely seen worse and most places if it's higher than 36,000, that's what the lab value will read "greater than 36,000". People who come in with BNP's that are that high have likely had CHF for 10 years or more. I have yet to see a patient with no history of CHF whatsoever come into the hospital with a BNP greater than 10,000. NSTEMI is a term that encompasses all conditions that can cause cardiac injury without EKG changes. I have seen patients come in with a CHF exacerbation with elevated troponins. I have seen patients with pneumonia have elevated troponins. Why does this happen? Because pts with pneumonia or pulmonary edema have fluid in their lungs, therefore gas exchange isn't optimal. In fact none of your organs are being oxygenated adequately, your fingers aren't being oxygenated adequately that's why when you put the pulse ox on their finger it reads 82% instead of 98%. But 75% of the oxygen you breathe is used by your heart, so if your ability to breathe is impaired, and your heart isn't getting the oxygen it needs, it will cause a myocardial injury AKA NSTEMI. I've taken care of patients who have come back from the cath lab and the cardiologist would say "she has takotsubo cardiomyopathy" AKA "broken heart syndrome". Where stress causes you to have an NSTEMI. Kudos to you for trusting your gut with this patient! LTC you need good assessment skills because that and a blood pressure cuff are all you have!

Thank you for all the info. Every poster on here has been very insightful. She has no hx of chf so this is new. She is still in the hospital so I have only gotten bits of report and I will know more when she comes back but I am assuming this is the start of a chf dx and possibly worsening of her already dx conditions. So my priorities as I read from someone else will be assessment of pain and breathing, and preventing infection and atelectasis and other lung issues. I read her pt inr and it's not in normal range she needs more Coumadin so if I don't get an rx im gonna request a higher dose and weekly checks as this doc has bi weekly checks ordered. Gonna do daily weights too. I'm gonna request they send her back with an incentive spirometer because we don't have those. Thank you everyone. My patient would thank you all as well if she could.

NurseSpeedy, ADN, LPN, RN · Jan 30, 2016

Totally terrifying. The fact that there is only a tech at night is unbelievable.

Unfortunately, I think this happens a lot. I worked for an ALF (large company) that had over 100 ALF beds and over 20 memory care beds. The marketing people would give tours during the day and say, "that's so and so, she's one of our nurses. We have a nurse available 24/7 for our residents needs"...This was a shady way to sell the "nurse available 24/7" bit. There was a nurse onsite sometimes for 12 hours a day. If resident needed a nurse outside of this time frame, the care staff (med tech or resident care associate(not a CNA)) would call the Nursing Director for the facility which was an LPN. The only RN was the regional nursing director and if she was onsite then there was a major problem at the facility. Good directors answer their phones 24/7...we didn't always have a good director. However, when they are not onsite and live over an hour away it is hard to know what is going on with the resident without health care personnel with the resident to assess what is going on and rely the information to the director over the phone. One day I had influenza A and was not able to go in to work (not able to walk but also not willing to infect the whole building with the virus either). There was no nurse there that day since they couldn't find someone from a nearby facility willing to pick up the shift. These residents deserve so much more than what these companies are providing them and they are paying top dollar for these services that have been misrepresented to them when they signed their lease.

I think the OP did the right thing, except for the family not agreeing with the transfer. Where I worked, the medics would not transfer the patient if the POA was refusing. Therefore, when it was something that I knew they needed to go to the ER for, I would calmly explain what was going on and why I disagreed with not going. Most of them eventually allowed the transfer. Most of them were glad that they did, especially the one that had been having TIAs a few months earlier because this time it was a CVA.

In ALFs there are very limited resources for us to use and based on the facilities credentials (many don't have it for skilled nursing), we aren't even allowed to do anything skilled-I'll use the pulse ox as an example-we were not allowed to check it (but PT had one when they were there!). I would call the doctor if it was something that I thought we could treat in-house such as an elevated BP. Most of the patient's doctors were very good about calling us back, there was only one that I had problems with.

If my gut was telling me that something was an emergency I have learned to trust it. I worked in a hospital for several years and it has usually been right. Better to be cautious than not.

%D#2 · Jan 30, 2016

Unfortunately, I think this happens a lot. I worked for an ALF (large company) that had over 100 ALF beds and over 20 memory care beds. The marketing people would give tours during the day and say, "that's so and so, she's one of our nurses. We have a nurse available 24/7 for our residents needs"...This was a shady way to sell the "nurse available 24/7" bit. There was a nurse onsite sometimes for 12 hours a day. If resident needed a nurse outside of this time frame, the care staff (med tech or resident care associate(not a CNA)) would call the Nursing Director for the facility which was an LPN. The only RN was the regional nursing director and if she was onsite then there was a major problem at the facility. Good directors answer their phones 24/7...we didn't always have a good director. However, when they are not onsite and live over an hour away it is hard to know what is going on with the resident without health care personnel with the resident to assess what is going on and rely the information to the director over the phone. One day I had influenza A and was not able to go in to work (not able to walk but also not willing to infect the whole building with the virus either). There was no nurse there that day since they couldn't find someone from a nearby facility willing to pick up the shift. These residents deserve so much more than what these companies are providing them and they are paying top dollar for these services that have been misrepresented to them when they signed their lease.
I think the OP did the right thing, except for the family not agreeing with the transfer. Where I worked, the medics would not transfer the patient if the POA was refusing. Therefore, when it was something that I knew they needed to go to the ER for, I would calmly explain what was going on and why I disagreed with not going. Most of them eventually allowed the transfer. Most of them were glad that they did, especially the one that had been having TIAs a few months earlier because this time it was a CVA.
In ALFs there are very limited resources for us to use and based on the facilities credentials (many don't have it for skilled nursing), we aren't even allowed to do anything skilled-I'll use the pulse ox as an example-we were not allowed to check it (but PT had one when they were there!). I would call the doctor if it was something that I thought we could treat in-house such as an elevated BP. Most of the patient's doctors were very good about calling us back, there was only one that I had problems with.
If my gut was telling me that something was an emergency I have learned to trust it. I worked in a hospital for several years and it has usually been right. Better to be cautious than not.

We have a very small ten bed subacute unit.. And that's where I get all my skill experience. I really would rather work somewhere with not as many limited resources honestly and am applying for more jobs. I actually am considering a doctor's office over this because at least if there is an emergency the doc is like, there! Lol.

I take patients 02 in AL all the time and I just don't chart it. I just do it to get a better assessment done and I communicate it to the doc but do not write it anywhere.

wolf9653 · Jan 30, 2016

So far a LTC is concerned, a hip FX is an emergency. We are only designed/staffed/ supplied/ for stable patients.

wolf9653 · Jan 30, 2016

You know, I'm sorry, I read that as her hip fractured at that moment, and needed treatment. I don't think I'd have sent her out myself. I would have called the doc and asked if he wanted me to give clonidine. Based on my experience, every place is different.

ED Nurse, RN · Jan 30, 2016

Thank you for all the info. Every poster on here has been very insightful. She has no hx of chf so this is new. She is still in the hospital so I have only gotten bits of report and I will know more when she comes back but I am assuming this is the start of a chf dx and possibly worsening of her already dx conditions. So my priorities as I read from someone else will be assessment of pain and breathing, and preventing infection and atelectasis and other lung issues. I read her pt inr and it's not in normal range she needs more Coumadin so if I don't get an rx im gonna request a higher dose and weekly checks as this doc has bi weekly checks ordered. Gonna do daily weights too. I'm gonna request they send her back with an incentive spirometer because we don't have those. Thank you everyone. My patient would thank you all as well if she could.

Her INR is less than 2? Biweekly checks are completely appropriate if a pt is stable on a certain dose of Coumadin.

Mellah430 · Jan 30, 2016

Great Job OP!!

Lev, MSN, RN, NP · Jan 31, 2016

To me this sounds like a CHF exacerbation/volume overload hence the elevated BP (especially diastolic BP), elevated BNP (which is diagnostic of volume overload/CHF even at 600), and troponin leak. It may not be an NSTEMI. CHF and afib can cause troponin leak which can reach levels of a mild NSTEMI.

I suppose CHF can exacerbate existing afib (i.e. making is more irregular) since the ventricles become even less efficient. The thready pulse doesn't really fit with volume overload - bounding pulses are textbook, however with chronic afib anything is possible.

**canoehead, BSN, RN** · Jan 31, 2016

We wouldn't have done anything for her in our ER, but I get why you wanted to send her out. You should have access to a doctor, or RN even, to run these issues by them. Calling an ER RN will get you the "don't send her" information, but you don't know that person, or their priorities. It's a shame you are put in that position, it's a shame the patient had to endure a transfer, but if you can't contact your doc or supervisor, you have to err on the side of safety.

You saw something was off, and you were right...excellent instincts!!!

ED Nurse, RN · Jan 31, 2016

I just noticed you are/were a paramedic- the paramedics I know have very advanced assessment skills and a wide scope of practice that encompasses a large area of acute medicine. Paramedics are trained to easily prioritize and triage pt issues and the level of care they will require. I'm unsure of why you seem

so hesitant as an LPN- like I said, the paramedics I know have a way bigger scope than LPN's.

TriciaJ, RN · Jan 31, 2016

So one by one the things you described weren't enough to warrent sending her, but you added everything together and knew something just wasn't right. Err on the side of safety and it paid off for you!

I'm with JBudd. When in doubt, send her out. People with more expertise than you might say there was no point sending her, but you have to deal with your own level of expertise and the resources you have at hand. I've sent soft calls to the ER and had them sent back without much intervention. But I'd still rather have people mad at me than have someone die and it be all my fault.

If my employer wants the expertise of an experienced critical care nurse, they need to hire one.