Dumping on the ER?

Nurses General Nursing

Published

Hi guys. Little background I am a novice nurse working in LTC. Been a medic since I was 21 and was also a pct since I was 18 so I am not "stupid" but sometimes I feel that way when I send PTs out to ER.

tonight I sent a pt with hx of HTN, and a-fib and a newly fractured femur to the ER. My reason, her HR was more thready and irregular than usual and her BP was 160/110. I didn't want her to have a stroke.. She's got the a-fib, fracture and high BP risking her for blood clots and stroke. So although her family was against it I sent her out. The ER nurse in report said, if she has a hist of a-fib then the irreg heart beat isn't so much of a concern. I said yes but I am more worried about her BP and risk for clots. She is on warfarin for the fib but still, better safe than sorry. Or am I wrong?

i send out people because I do not have the resources at my facility do treat people as an ER would but I only send them for really abnormal or major things..

im just trying to get oter people's input to see if I did the right thing or if I am being over-caughtous and dumping on the ER?

Specializes in LTC, home health.

In this situation, I would have sent the patient out also. I am an LPN with 20 years of experience. I have worked in an ALF where I was the only nurse on campus for 3 buildings. I only had med associates and personal care aides working with me who had very little training. ALFs all want to take more complex patients, but they do not want to provide the staffing to care for these patients. LupieNurse, you should not have to work as the only nurse in that facility. It sounds extremely unsafe. I have gone back to a skilled nursing facility where I feel that I have the resources to care for my patients properly. I felt foolish at times working in ALF when sending patients out to the ER that probably didn't need to go there. However, I did not even have an RN on call. An LPN was in charge as the Director of Wellness. We were required to send out all falls if they hit their head, because we weren't even supposed to be doing neuro checks. I did not have the resources to properly care for someone who needed complex care. I don't think I will ever work in an ALF again unless staffing and conditions improve. It was very unsafe for those frail elderly residents.

Up Vote Up Vote ×

She came back and had a BP of 70/40. I started an Iv and sent her out.. This time I am not doubting myself im just in shock . She was only back for two hours! I saw that she was given IV furosemide.. Possibly drained too much? Pulse was weak rapid and fluttery- thready? I'm currently researching more on this disease process.

Up Vote Up Vote ×
Specializes in CIC, Geriatrics.

Yes, it might have been a little rash for an ER, however, you being a new nurse without an RN to guide you, no on-call that will call back leaves you to do the best you thought. Easy for experienced ER nurses to second guess when they are not in your shoes, and they don't really like our elderly sent to their ER. This is a prime example of nursing eating their own young. Really, you need to do whatever you think is best, it's called nursing judgment. If she had experienced a stroke and died, the family and ER nurses would have criticized you for not having done anything about a BP of 160/110. Sounds like you are receiving a patient in LTC that should still be in Acute, Also, you are being required by your administration to work outside of your scope of practice; LPN/LVNs do not have the education to do Nursing Assessments, where is your RN supervisor ???????? Or does an RN cost too much for "health care for profit" owners????? This is exactly the problem with making money on other's health care problems, no one thinks they have to pay for the correct staff to make these decisions. Please do not become discouraged, keep your chin up, and remember, haters gonna hate, and we need nurses who care more about the patients and residents than about what others may think You will continue to be a good nurse as long as you use what you have to care for others.

Up Vote Up Vote ×
Yes, it might have been a little rash for an ER, however, you being a new nurse without an RN to guide you, no on-call that will call back leaves you to do the best you thought. Easy for experienced ER nurses to second guess when they are not in your shoes, and they don't really like our elderly sent to their ER. This is a prime example of nursing eating their own young. Really, you need to do whatever you think is best, it's called nursing judgment. If she had experienced a stroke and died, the family and ER nurses would have criticized you for not having done anything about a BP of 160/110. Sounds like you are receiving a patient in LTC that should still be in Acute, Also, you are being required by your administration to work outside of your scope of practice; LPN/LVNs do not have the education to do Nursing Assessments, where is your RN supervisor ???????? Or does an RN cost too much for "health care for profit" owners????? This is exactly the problem with making money on other's health care problems, no one thinks they have to pay for the correct staff to make these decisions. Please do not become discouraged, keep your chin up, and remember, haters gonna hate, and we need nurses who care more about the patients and residents than about what others may think You will continue to be a good nurse as long as you use what you have to care for others.

I wonder what they are gonna do when I have my RN cause I'm going back to school for it.. They'll have to actually pay me more even though I'll be doing the same thing im doing now.. But I'll probably be gone by then lol. I'm trying to stick it out a year and then im out.. 50 patients with limited resources is too much even for an RN

Up Vote Up Vote ×
Specializes in ER.

No nurses at night? How does that work? What happens if there is an emergency?

At the end of the day, do what you do. ER will always question why you're sending them out. Don't worry. The nurse taking care of the patient probably isn't the one taking report.

The other day we had a patient who had a BP of 110/120 and then 150/110. We think the 110 was supposed to be 170/120. She was intubated ten minutes after getting here.

I think the only patient I truly was frustrated with was the DNR who arrived dead. Thanks. Instead of letting her die in peace she dies sometime between the ambulance and getting inside. My vitals of HR 0, bp 0/0, pulse ox 0% and respirations 0 were red. Chief complaint? I put down none since she wasn't complaining of anything.

Up Vote Up Vote ×
Specializes in ER, Trauma, Med-Surg/Tele, LTC.

I really don't understand the annoyance ER nurses have with receiving stable LTC patients because they think an LTC nurse overreacted. Stabler patients walk in through the door all the time. How is receiving a stable LTC patient any different than dealing with the back pain x 1 year that decided it was now an emergency at 1am? Because there's another nurse to talk down to instead of having to bite one's tongue at the walk-in lest we sacrifice those almighty customer service scores?

It's easy for ER nurses to say the patient is stable because we have access to monitors, labs, diagnostic imaging, feedback from colleagues, etc right there to back us up, while the LTC nurse pretty much only has a blood pressure cuff and his/her own intuition.

To the OP, keep doing what you're doing. It's always better to err on the side of caution than have poor patient outcomes because of thoughts about what others will think of you.

Up Vote Up Vote ×
Specializes in ER.

And it's a lot worse if we get a lot of unstable patients from one nursing home. Sometimes we sit there and ask what is going on.

Up Vote Up Vote ×
Specializes in ER, Trauma, Med-Surg/Tele, LTC.
And it's a lot worse if we get a lot of unstable patients from one nursing home. Sometimes we sit there and ask what is going on.

LTC nurses are under a lot of pressure from management not to send patients out due to the effect it has on billing. They always insist it can be managed in-house. I can't even tell you the number of times I've had to defend myself against management for sending a patient out when I worked in LTC.

Up Vote Up Vote ×
No nurses at night? How does that work? What happens if there is an emergency?

At the end of the day, do what you do. ER will always question why you're sending them out. Don't worry. The nurse taking care of the patient probably isn't the one taking report.

The other day we had a patient who had a BP of 110/120 and then 150/110. We think the 110 was supposed to be 170/120. She was intubated ten minutes after getting here.

I think the only patient I truly was frustrated with was the DNR who arrived dead. Thanks. Instead of letting her die in peace she dies sometime between the ambulance and getting inside. My vitals of HR 0, bp 0/0, pulse ox 0% and respirations 0 were red. Chief complaint? I put down none since she wasn't complaining of anything.

We have home care nurses on call at night for our subacute unit but not AL. Strangely this is not illegal here. And it's not illegal for me (an LPN) to run the whole building of 50 pt without an RN. I taught the night tech how to prep for ER transfers and she knows who is DNR and who's not.. I put little colored dots on all the charts which signifies code statuses and POLST. But I can only do so much when I'm not there at night :/

Up Vote Up Vote ×
Specializes in Dialysis.
I wonder what they are gonna do when I have my RN cause I'm going back to school for it.. They'll have to actually pay me more even though I'll be doing the same thing im doing now.. But I'll probably be gone by then lol. I'm trying to stick it out a year and then im out.. 50 patients with limited resources is too much even for an RN

Most ALs just say they don't have a position for RN in house and you're cut loose. Or such ridiculously low pay you will leave.

Up Vote Up Vote ×
LTC nurses are under a lot of pressure from management not to send patients out due to the effect it has on billing. They always insist it can be managed in-house. I can't even tell you the number of times I've had to defend myself against management for sending a patient out when I worked in LTC.

I'll tell you guys why I'm so cautious sometimes and although it may be an annoyance to other nurses I was sort of traumatized..

I was a new nurse for a few weeks. Had a pt with an undiagnosed aneurysm.. No signs or symptoms and nothing about it on the MD assessment. One night as I was about to leave the pt pressed the call bell.. I went in there thinking he just wanted some ant acid cause he had "stomach pain" all night. I walked in and asked if he was in pain. He said "I was but it went away an now I don't feel good."

As I was about to ask him his symptoms, he passed out and I caught him and lowered him to the ground as he started choking on his own blood. My patient in the next room had suction they weren't using anymore. I grabbed it and tried to plug it into his wall but my hands were shaking and slipping from the blood on them and i also didn't have gloves on when I caught him but didn't have time to care. Finally started suctioning him.. But it was too late and he was bleeding out. I screamed for help which I should have done before but I was so freaked out.

I the private aide down the hall ran into the room and called 911 from her cell phone. The guy ended up going out DOA.

After they left i was crying, covered in blood.. There was blood all over his bed, the floor, everywhere. There was blood in the room on the wall where I grabbed suction.

I'll never forget that and now whenever I get a gut feeling I can't ignore it. He had "stomach pain" that whole night and I had a bad feeling but no other recognizable symptoms or signs. BP was pretty high but the manager on duty who isn't a nurse kept saying he just needed an antacid.

I'll never ignore my instinct again!

Up Vote Up Vote ×
+ Add a Comment