Input requested...

[hoolahan]

This is a home care question, but I think any nurse can have a say in this question. Do you think it is appropriate to do blood cultures in the home if pt has high fever?

This is the situation. The client is very nasty and so is her dgtr. She had a mesh in her abd from a previous abd hernia repair, morbidly obese, and the mesh b/c infected, and had to be removed. She has a huge gaping wound in her abd, w a colostomy, a urostomy and a draining fistula to third ostomy bag. A nurse made a visit today, and the pt had a high fever, 102. She refused to go to the ER. Nurse called several docs. Surgeon on-call didn't know her, said call primary doc, pt refused to tell nurse who her primary was for some strange reason. Nurse called hospital to see who was listed as primary on hosp record, she calls the primary, that on-call referred her to the doc herself, said this is too much for me! Finally gets primary who tells nurse to get stat blood cultures. The nurse does not have these tubes or lab slip, she drives all the way back to office, finds out we don't have tubes for cultures. Sup says we can do them. Myself and another nurse said that is ridiculous! This nurse would have to drive to hospital get culture tubes, and drive back to house for second time that day, then drop specimen back to hospital. Two hours of time shot b/c pt didn't want to wait in waiting room. Nurse told her call 911. She refused, "can't deal with that." Finally, when sup found out we didn't even have the specimen tubes, she agreed that was a ridiculous waste of time. Nurse called doc and pt back, told pt go to er or we'd get labs tomorrow. She was warned of consequences.

Now, what do you think? Do you agree that that was ridiculous to expect that nurse to do that? If a pt is that ill, that a doc suspects sepsis, I am sorry, but they should be admited! I mean when was the last time you saw a pt come in for outpt blood cultures??!! I am just stunned that the nurse even considered it! I would have told doc and pt that I felt blood cultures are inappropriate in home care, unless for some reason the pt was being treated for a sepsis w IVAB in the home already. This was entirely not the case.

Your comments please.

[JMP]

Pt needs to go to hospital- NO IV ACCESS....so if you got the cultures and she is septic........ still needs to go to hospital. I would say, having done both home health and now ICU...YOU HAVE TO BE FIRM, tell them, not ask them and then see what happens. If the pt is still refusing, INFORM THEM OF WHAT THE CONSEQUENCES are....in fairly grafic terms if necessary.

[KRVRN, BSN, RN]

IVAB= IV antibiotics

[NRSKarenRN, BSN, RN]

Adding my 3 cents now.

Only nurses working in home care agencies with IV therapy routinely stock blood culture tubes in my 17 yr homecare experience. Just not enough call and certainly not STAT in most agencies. ( Done both)

Agree with Hoolahan, Cascadians and P-RN: This patient with open abd wd could have many reasons for temp, just not sepsis. R/O pneumonia--needs CXR. R/O absess: needs ultrasound, surgical probing etc.----NONE of these are readily done at home. Blood culture results not known for 24-48hrs.

Since known MRSA, open wd, possibility of contamination at home --if she refused notify primary caregiver, MD and supervisor. Document to CYA including informing pt/CG possibility of death from infection. I'd inquire re Tylenol with temp recheck in 3 hrs--call caregiver if still rising insist on calling 911; if return to normal then followup in AM visit.

Sometimes we cater to people too much to keepem at home ( Ive done it at times) but also understand patients have right to refuse. I've even written on a blank clinical note form

"Client with xyz problem, spoke with doctor who recomends hospitalization/ER visit. Client informed potential complications including death and declines ambulance/911 call. DR so&so informed along with Primary caregiver (list name and phone#).

I Signed, dated and got patient to sign-----done that if I suspect problem/hir on neck standing up and want to be relieved all responsibility. Since form is carboned, left one in the home admission folder. Let any lawyer try and sue me with that documentation.

[hoolahan, ASN, RN]

Thanks Karen and JMP. As for the pt, she was seen the next day, they did not go to the hospital Sat night, but when the nurse went back Sunday, she told me she insisted on 911'ing her to the hospital, and this time family consented. No official word yet on what they have determined as the cause of fever.

Mario, For a pt with MRSA; Most times if a pt has had a wound or pretty much any area infected with MRSA, they are usually also colonized with MRSA, that is, it can be found on the skin, or in nasal mucosa, but not in quantities large enough to indicate an infection, also would not have elevated white count, or other signs of active infection. Most healthcare workers, if you cultured their nasal mucosa would probably be positive for MRSA. So, the danger is in 1) cross contamination to other areas, ie, drainage from wound getting onto IV site, unlikely, but it could happen. or 2) cross contamination from pt to pt. It is not likely that I would be affected much by MRSA, or other family members unless they are immunosuppressed. The one type of MRSA issues I have seen in healthcare workers is some conjunctivitis when getting ventilator misted in the eye, or got a lougie in the eye, or when an aide once had very very dry and cracked skin on her hands, she got such a bad dermatitis, she had to go out on disability, and it wasn't clear if she could ever work as an aide again last I had heard. Of course most pt's in the hospital are already debilitated, so the greatest danger with MRSA is cross contam btw pt's. To prevent that, gowns, gloves, and/or masks and goggles, if respiratory infection or splash risk, are worn and pt usually isolated. Two pt's with the same strain of MRSA can be roomed together. In home care, for this particular pt, I would have worn a gown and gloves only, there was no danger of splashing with this pt. And I have to be careful of how I handle supplies in my bag, no going into the bag once the gloves are on!

Morbidly obese, well, I am not sure of the exact poundage that qualifies it, but in my mind, it is anyone who cannot be weighed on a normal hospital scale or sling scale in the hospital. It means that they are high risk for illnesses, or morbidity due to their excess weight. Usually folks this big have trouble even breathing due to weight pushing the diaphragm upwards and decreasing lung capacity. This diagnosis was on her chart, by the doc, not by me. It is OK to say this, but if I were you I wouldn't tell a pt they are morbidly obese! More of a medical term used between professionals. Like you would ask a pt to urinate, not to micturate or void. The later two might leave them wondering what language you speak. Or describing to a pt the purpose or the urine tube, rather than catheter (some know that one) or worse, when nurses tell pt not to worry about peeing the bed b/c they have a foley. Call me crazy, but if I wasn't a nurse, I would probably have no idea what a foley was!

[rncountry]

Hey Hotlips how are you?

When I read the original post my thought was--even if the nurse was willing to make the extra trips what good was actually done for the patient? I thought a couple things. Blood cultures take at least 48 hours, unless the prelim shows something quickly. I wondered did the patient have IV access, if sepsis was suspected then IVAB are indicated. Given this scenio than why would the nurse want to do something that ultimately is not going to likely benefit the patient given the setting and obstucles to caring for sepsis?

I'm doing wound nursing now, have on and off for 6-7 years now, so I also wondered given the wound and all that is going on there if the patient had a wound vac on? It sounded like she did not given drainage problems, though I would guess it would benefit her. Next, before blood cultures I would think a quanative culture of the wound would be something that should be done, it is very possible for active MRSA to be present. Note that often in my line of work. However to be sure a quanatative culture must be done, however given that it is something only the doc can do and something treated with IVAB also, so the patient can't adequately be treated at home.

I only briefly did any home care, when an agency I worked for did subcontracting with visiting nurses. I hated every minute of it, the pay was lousy and the day I had a patients husband threaten me I was done with it. Kudos to you for doing it.

[Shandy12]

Hi Hoolahan,

Read your posting with interest. Up here in Ontario, Canada, most nursing agencies forbid visiting nurses to transport specimens for the patients. If we have to draw bloods, or obtain other specs, the family is supposed to take the specs to the lab.

They don't want us involved in an accident and causing potential liability if the specimen contains some nasty contagious bug that is a risk to the general public.

Also, bear in mind that you did your best. You explained to the pt. the risks involved if she didn't get her blood cultured. After that, she has to take the responsiblity for her own care as long as she's mentally competent.

I'd chart like crazy and have the pt. sign a form that she understood the risks explained to her, and is still not willing to follow nursing and physicians' advice.

Lynda

[Jenny P]

I did County Health Nursing for 3 years back in the early 70's and after getting caught in a nasty situation of trying to transport a pt. into the clinic, my agency decided we could not transport specimens or patients (nothing considered to be contaminated); and we had a form to fill out similar to NrsKarenRNs' for pts. who refused to follow medical or nursing advice. It's a shame that this is a problem in this day and age; this should have been determined years ago by your agencies.

The other thing I wonder about here is whatever happened to the patients' right to refuse care? I would document like crazy to CYA, but doesn't the patient and family have the right to say NO?

[mario_ragucci]

Click - click - click

Hot lips pushes, and knocks over, many microbiology dominos that were set up and standing in Mario's brain. I read and re-read your post, and others dominos fall, as this very potential RN's brain congeals with a single post by a wonderful woman named Hoolahan. Big thank you.

[JMP]

Mario

IVAB stands for IV (intervenous) antibiotics. I don't think anyone addressed this question.

Glad things worked out Hoolahan.

[mario_ragucci]

JMP - thank you.

You should have never started something you couldn't finish. You have given me so much electric charge that now I am electric so now I am asking you not to try to touch me, because if you do touch me, you'll get shocked. Seriously. I was floating when I read your posts, and haven't touched the ground since.

:-) :-) kidding :-) :-) (zapp...crackle....BOOM) (lightning strikes the ground) (and the air smells so clean now)

[micro, RN]

Hoolihan,

Just a compliment to you.......couldn't do the home health nursing fulltime as you do for just the reasons you describe right here.........

In an answer to nasty client.......yes, some people are nasty.............in their habits, lifestyles, dressing and grooming and living environment.........just a matter of semantics.....but in nursing oh, my god.......do we all see our share, huh hoolihan.....

huganurse, p.rn and jay........great responses............like dishin about nursing.....since we do this more than live our other lives..............

hoolihan.....................keep on doing what you are doing........