Frustrating day in home care!

[SWRN84]

Today I saw a patient for an extra visit. She had been to the ER on Monday for exac of COPD. She sounded so much better on the phone today, but when I got there, her pulse was 134-140, irregular, obviously in A fib. Her physician is leaving the practice, but the kicker is, she has never really seen her physician....she sees the nurse practitioner in the office. He is NOT leaving the practice, and will be working with another physician. So....anyway...she was having chest pain...rated at 3, not sharp, non-radiating, but obviously symptomatic with the high heart rate. I called to report it to the office where NP works. His nurse called me back. Apparently the NP was upset because our agency had sent orders back to the office for the physician to sign, as we cannot accept orders signed from NP. This is nothing new for him. Anyway....he says "if she doesn't think I'm good enough to sign her orders, then she can just figure it out herself and do what she thinks she needs to do." I was SO mad! I told the nurse on the phone that I thought that was so unprofessional for him to act that way. It's not MY fault the rules are the rules. I didn't make them up. It is so aggravating to me when patients are put on the back burner because of someone's ego or someone's bad day. In the end the patient refused to go get evaluated in the ER anyway. She's totally lucid, and totally refused. I instructed her on calling EMS and when she should do it, etc, as far as symptoms go. She was agreeable to doing that if she "got worse." We went through everything possible re A fib. I called her back this afternoon....chest pain is gone, she is feeling better, she has a dose of Verapamil to take this hs, so I'm hoping she will convert back to sinus rhythm. I am having a nurse go see her tomorrow to check up on her. She also called and has an appt with the physician who will take over in the practice. So she can get her PCP changed, and continue to see this NP. I was just so frustrated with this NP I couldn't stand it! Now all I will do is worry about this patient tonight until I talk with the nurse tomorrow. But...what can you do when a patient refuses to be evaluated? Not a whole lot I guess....it's their choice and their decision, but it sure is a frustrating situation all around. Just needed to vent a bit.

[DutchgirlRN, ASN, RN]

As long as you've documented her refusal to be evaluated in the ER or at a physicians office then you're in the clear. We can take orders from a NP but the orders are always signed by the doctor. I think that NP needs an attitude adjustment. You did fine.

[Traveler]

It is very frustrating to deal with egos when there are patients right in front of you in distress. It certainly is not the time nor the place to air problems. The patient needs to be the focus. The NP was aggravated because the orders were not sent to him/her. Perhaps it's because they would then not be able to bill for POC oversight or just because they know the patient and were actually interested in the POC. NP's are actually allowed to sign POC's and bill Medicare for POC oversight, they are not allowed to order hh. Perhaps your case manager needs to call this MD office and make sure that your agency is made aware when this NP is the primary. That way you can be sure to put the collaberating doc as the ordering MD and the NP as the primary with their UPIN on the OASIS.