Handling On Call

[CaringRN1234]

I want to hear from some other hospice nurses. We had an internal audit done awhile back and they brought up some on call items. Our administrator & social worker has begun to make alot of suggestions about nursing visits during on call (and neither of them are nurses, nor do they either have to take any call so they don't know what it is really like). They are saying that no matter why a patient calls on call that a visit needs to be made. I disagree. I have had many families call just to ask a question.

Please give me feedback from the group about your calls. Do you always make a visit or do you triage on the phone and handle via phone if you can. I think a visit should always be offered but sometimes families don't really want you to come out. Another example: maybe pt has elevated temp, we advise to give Tylenol then call back in 20 mins to check on pt. Pts fever has then gone down & pt is resting comfortably. Do you then make a visit or follow the next day & advise family to call if any other problems arise during the night? We cover a very large area (13 counties) with some pts living an hour away in rural areas.

It just seems like the nurses in our office are always having to stand up for our clinical judgements by non clinical people. A lot of times they make decisions about what they think should be done before even talking to us. What do you think about this situation? Do any of you find similiar situations in your offices?

[Rnmomajmj]

Our on call staff triage over the phone and offer to make a visit, most of the time they don't have to go out. It depends on the situation. Nurses seem to be second guessed at all times. We are short a DON at this time so we seem to have people trying to tell the nurses what to do. Our volunteer coordinator has been trying to act like the boss lately and has been trying to make decisions on admissions. We actually had a home patient call, doc agreed to an eval. The non-nursing staff decided that just because this patient appeared very ill she would be an appropriate admit. They became upset when another nurse and I started asking questions to try to clarify a few points. This patient lives 1 hour away from our office, we are short staffed on nurses, and all have more than our so called maximum amount of patients and they want a nurse to go out to do an admission when we don't even have all the medical records! Somedays it just isn't worth getting out of bed!!

[aimeee, BSN, RN]

We triage the calls too. Often a family just wants to clarify an issue or get a little reassurance that they are doing the right thing. In fact, in many cases a visit would be disruptive to them...like in the middle of the night when all the family wants is to make the patient comfortable again so they can all get back to sleep. Insisting on visits every time somebody calls can be counterproductive...some families won't call hen they really do need a little guidance just because they don't want to prompt a visit! Hospice care is a subtle art that depends on teamwork and trust. If there are indications that visits are not being done when they really need to be, its time for an analysis of what the indicators are for a visit. A blanket policy of call=visit is not an intelligent use of resources.

[curiousauntie]

When I started in hospice, I was doing on-call 7days on 7 days off. My biggest fear was that I would not know when I needed to actually go to the patients home or if the advice I gave over the phone was adequate. I got the jest of it pretty quickly. If I am not sure if a home visit is needed I offer to go to the patients home. If they are relieved that I am comming then I know I made the right decision. We use the "give him....and I will call back in a half an hour" tool. It seems to work well, and except for a couple of situations where the family members were a bit nuts anyway, I can say that I have not gone out to a home unnecessarily. If my gut says "maybe I should go" I do. And for the most part if the family seems OK with medicating or other interventions and are just asking for guidance, when you say that you will come out they answer "no, you don't need to, I just wanted to make sure I was doing the right thing." A lot of on call seems to be reassurance to the families.

Tell your non-clinical co-workers to stay with you for a couple of on-call shifts and see what you do...get awakened several times during the night, have to leave your home at the drop of a hat, or even make sense to someone on the other side of the phone with little or no sleep, sometimes for days in a row...and THEN go to work to do your regular shift the next day, and see of their attitude that "any call=visit" changes.

[uahrn915]

I work as a Clinical Director in a hospice in Alabama. Medicare/Medicaid are very clear when it comes to the on-call nurse. Have your non-clinical staff look at those regulations from your state's Medicaid website or PalmettoGBA so that what they are doing internally for on-call documentation is taking care of the questions that will come up in an audit. In our case, we update the log every morning. The on-call nurse from the previous night is expected to report any calls to the Clinical Director. Information is put into a call log showing who called, time nature of the call, if a visit was necessary and the outcome. Auditors get an overall picture of how the calls were handled and can then go to the chart to look for nurse's notes from that date. Auditors love it and are less likely to ding you if you are making their job easier.

As far as deciding if the pt needs a visit, RN's were drilled on triage during school and especially on the NCLEX. Tell your non-nursing leaders about the ABC's of triage... airway, breathing, circulation (and C is also for comfort in hospice care). You could add P for pain, but usually, if your case managers are taking real good care of their pt's, on call nurses shouldn't have pain issues. Sometimes the caregiver forgets to try giving btp meds before they make that call and when you follow-up the pt is fine. As mentioned before, if you hang up the phone and feel that patient will be OK, you have done the right thing. If you hang up the phone and second guess yourself for 30 minutes, call them back and re-assess the patient's status. If it is worse, go. If the CG says she is resting comfortably, get some sleep until the phone rings again. The next call may really need you there. (God seems to always keep that organized for me.) If you went on every call, you would be costing the company unnecessary money. You will take the whole day's reimbursement on an un-needed call. But most importantly, you remove yourself from getting to someone else that might REALLY need you.

Take the time to talk to the caregiver. Sometimes they just need reassurance that they are doing the right thing. Your calm soothing voice may be the only thing they needed. And as mentioned, always ask if they would like to have the nurse come out tonight, or would you like me to just let your case manager know the concerns in the morning. If they choose the latter, be sure to let the case manager know in the morning.

Jeff

[andre]

You could add P for pain, but usually, if your case managers are taking real good care of their pt's, on call nurses shouldn't have pain issues.

Jeff

I am going to respectfully disagree with that statement. Pain crises happen at all hours of the day and night. This is not a reflection on how well case managers are taking care of their patients.

Otherwise, I agree with the rest of your post!

Andrea