For other ED nurses out there, I don't mean any offense with this post. I'd rather vent here than take it out on someone who isn't even involved. I may have just bumped into a nurse with an awful day or something.
So I'm still in a LTC/SNF dealing with my patients at night we were overstaffed so we actually had a reduced patient load for once 29 instead of 38 to 40. I was so happy so I could catch up on paperwork. However about an hour and a half before my shift ends I have two patients acting up. Using ABC's I had to prioritize what patients had to be attended to first.
One is a patient with respiratory issues with audible crackles when breathing that basically with lower level of consciousness and lethargy. Pulse ox was 82 and even with the rebreather it did not improve so I arranged to get the patient sent out. I gave report to one of the ED nurses and she asked me what the blood sugar was. I said I didn't take a blood sugar because it didn't occur to me since the patient had audible crackles and a non improving pulse ox. She proceeds to go off on me: "It's standard procedure! Are you new or something? We'll be waiting for the patient"
The second one was complaining of chills and had a temp of 101.5, so I gave him the existing order of tylenol for fever orally and told him to call me if he feels worse. An hour later I took his temp and it went up to 103 so I paged the doctor. The doctor asked how his wound packing drainage looked like, I come to see the patient and I see the patient is in the bathroom looking as if trying to vomit. I tell the doctor about the new onset of nausea and attempted vomiting. Doctor orders to be sent to the ER. I have to call yet again to the ED for report. Sadly it's the same charge nurse I explain the situation and this time she decides to blast me again: "What is it with you people? Don't you understand oral tylenol won't work in older patients. Next time do a suppository first before calling, not even worth sending him at this point." *I explain the doctor ordered the patient being sent out* "You should have still done the suppository, still does not change things. You nursing home nurses are something else."
Seriously, I've been working for less than a year and these are the first two patients I ever had to send out. Was I in the wrong in my actions? I wanted to lash out at the nurse for being an ass but I was seriously too busy trying to help my patients out. Giving a suppository to a patient who is alert and oriented as well as able to swallow pills did not occur to me anyway.
If my patients don't get admitted, I'll be happy to take the writeup from administration for wasting time waking up doctors, clocking out 15 minutes late, and ******* of the ED at the affiliated hospital. I thought I made the right choice sending them out. But to be put down by another nurse, I can see why a lot of my classmates have switched careers already.
This is an example of a nurse in one discipline of practice (ER) thinking she is much better skilled and qualified than another discipline of practice (LTCF/SNF). You all took the same NCLEX or LPN version of NCLEX (I don't know what this is called) to be licensed to practice. You have to use your nursing judgement. I am a Home Health RN (BSN). Many hospital nurses "look down" on others as somehow their experience or practice is far superior. You did your job, you don't have to take flack from someone because they are having a bad day or because they feel superior. Tell her to have a good day, and let her deal with her own insecurities.
Specializes in Certified Med/Surg tele, and other stuff.
OP, you say the person was the charge nurse? Is that correct? Like I said before, (and stand by it), keep it conversation short and sweet with her. I mentioned SBAR because it's to the point with no rambling and hopefully you can get off the phone quickly. If she cops an attitude, (which I mentioned SBAR would not cure that, only lessen the time spent with her) that you then simply talk over her, tell her the pt will be transported in XYZ minutes, tell her to have a nice day and hang up.
Then...get back on the phone and call the nursing supervisor.
This is an example of a nurse in one discipline of practice (ER) thinking she is much better skilled and qualified than another discipline of practice (LTCF/SNF). You all took the same NCLEX or LPN version of NCLEX (I don't know what this is called) to be licensed to practice. You have to use your nursing judgement. I am a Home Health RN (BSN). Many hospital nurses "look down" on others as somehow their experience or practice is far superior. You did your job, you don't have to take flack from someone because they are having a bad day or because they feel superior. Tell her to have a good day, and let her deal with her own insecurities.
If it means anything, I've often thought the opposite about home health nurses- you're out there on your own! Wow. But, back to the topic at hand...I try to look at every opportunity as a learning experience for the next time. Check the blood sugar? Yeah, great- I'll remember that for next time. PO APAP not effective? I'd have to see some literature that supports that one. Put on full confidence armor and warm up my SBAR skills before calling the ER (or L&D, for that matter)- learned that one a loooong time ago. I work phone triage, so when I send a patient to the ER from home, I kind of warn them the same thing. "Make sure you tell them exactly what you just told me, and I'll call them now to let them know you're on your way."
Specializes in LTC, assisted living, med-surg, psych.
Having worked both acute and LTC, I know how both the OP and the ER nurse felt. I wish that LTC nurses weren't looked down upon by acute-care nurses; even I, as a nurse/administrator, occasionally get an earful from a frustrated ER nurse. It's part of the job, and I don't take it personally; everybody has a bad day once in a while.
But having been on the other side, I can relate to every acute-care nurse who absolutely dreads getting a nursing-home resident with AMS. There's a really good reason for this. LTC patients are almost universally undone by the hospitalization---they become confused and lose all semblance of normality. They're often incontinent, combative, agitated, and/or difficult to understand. They climb out of bed and fall. They scream and yell and disturb their roommates. They may have to be hand-fed. And they are anything but cooperative patients because they can't understand what's being done to them.
These patients are a nightmare both in the ER and on a general med/surg floor. Thus, nobody really appreciates it when the nursing home staff send a resident to the hospital for something that can, and probably should, have been dealt with at the home, e.g. fecal disimpaction. However, it should NEVER be a reason to be rude and condescending to the NH nurse on the phone.......we all have a job to do.
First, I'm sorry that the RN at the ER treated you that way. It was undeservered.
Second, and forgive me if this sounds wrong, however I am a new LPN, still looking for a job...
As a Paramedic, I always thought it was silly and a waste of the Nurses time to be calling the ER when transfering a patient since I would be calling the ER enroute as well. By reading through the posts, I'm finding that this is a common occurrence. Is it due to facility policy, or a need to due a Nurse to Nurse handoff? I know that I seem dense on this, however there are some things that just aren't taught in school.
Specializes in Med/Surge, Psych, LTC, Home Health.
I gave report to one of the ED nurses and she asked me what the blood sugar was. I said I didn't take a blood sugar because it didn't occur to me since the patient had audible crackles and a non improving pulse ox. She proceeds to go off on me: "It's standard procedure! Are you new or something? We'll be waiting for the patient"
The second one was complaining of chills and had a temp of 101.5, so I gave him the existing order of tylenol for fever orally and told him to call me if he feels worse. An hour later I took his temp and it went up to 103 so I paged the doctor. The doctor asked how his wound packing drainage looked like, I come to see the patient and I see the patient is in the bathroom looking as if trying to vomit. I tell the doctor about the new onset of nausea and attempted vomiting. Doctor orders to be sent to the ER. I have to call yet again to the ED for report. Sadly it's the same charge nurse I explain the situation and this time she decides to blast me again: "What is it with you people? Don't you understand oral tylenol won't work in older patients. Next time do a suppository first before calling, not even worth sending him at this point." *I explain the doctor ordered the patient being sent out* "You should have still done the suppository, still does not change things. You nursing home nurses are something else."
Woooooooowwww.... amazing. In eight years of nursing, I'VE never heard anything about
not being able to give elderly patients, oral tylenol. And if the patient possibly has a serious infection, why shouldn't they be sent out?
As far as the first resident... I wouldn't have taken a blood sugar either if the patient wasn't diabetic? Even if they were, what does that have to do with crackles and a pulse ox of 82? Okay, well, after reading a few of the other replies, I guess it IS a good idea to get one.
I would so report that nurse. She was way out of line. I'm in agreement that just because she's having a bad day, that's no excuse to be so rude.
The nurse was incredibly rude to you and it wasn't appropriate.
On the other hand, since I actively work in an ER, I would offer the following insight: we get so many nursing home transfers that are NON-EMERGENT and totally a part of the patient's overall state of health AND as noted by another poster, are only made worse by a transfer, that its hard not to become inpatient.
I agree with the assessment that giving a good report would also help. A lot of times when we recieve report, its sloppy, indicates that the "nurse" on the other end of the phone has no idea why the patient is being transferred (hiding behind your MD who should be admitting to the floor his/her own patients is NOT the right answer) and doesnt actually explain what you expect the ER to do. Conversely, its suggests that you do not understand what the ER might do for your patient.
We recently took in a patient with a fever from a nursing home. Guess what? We do nothing for that except given tylenol (yup, I saw what you said) and send the patient out if labs and x-ray are negative. Labs and x-rays are non-urgent and could have been done in an outpatient setting. Would you bring your 2 year old in just because he or she suddenly has 101.5 fever? No. You wouldn't.
Its become a dumping ground for nursing home patients that the MD doesn't want to actually admit to the floor and for nurses that feel overwhelmed, understaffed and frankly, underqualified at what they do (sorry, just sayin' that SNF is a tough world and isn't for just any warm body out there). I am sorry you bore the brunt of that.
Usually, I just smile and listen and move on with my life. There is nothing I can do if they are sending the patient out.
It is not "hiding behind the md" if the MD wants the patient sent out. I do not work in skilled nursing, but I would call it more CYA on the snfs behalf.They do not staff to wait and see and you can't take the chance of waiting overnight if the patient can't breathe like the OP mentioned. I used to work in dialysis and a lot of times the MD would send the patient to the ER knowing they can't do much for the patient but mostly to cover his butt. Frustrating? Yes for all involved. But if they do not send em out and something happens, guess who gets sued?
And for the record, I would not take my 2 year old in for a fever, but then again, my 2 year old won't sue me if something goes array.
I talked to my mom as she is a seasoned nurse about the situation and told me: "Your intentions were right so do not feel bad, you probably should have done the blood sugar. I have to get you out of that place, I'm scared if you finally get the hospital job you might forget some basics."
I do fear though my skills are degrading in that place.
And for the record, I would not take my 2 year old in for a fever, but then again, my 2 year old won't sue me if something goes array.
Awe - you beat me to it. That is exactly what I was thinking. I also won't get a survey citation for failure to follow MD orders (you know I had to notify the MD of the change in condition because failure to do so is a different survey citation too).
Just another thing to bring up. I agree with the ER nurses that the resident would do best if left in their facility. I've been doing this for many years and I get it - I truly do, BUT some Drs want them sent out to cover their own a$$ and there is NO changing their mind.
It is not "hiding behind the md" if the MD wants the patient sent out. I do not work in skilled nursing, but I would call it more CYA on the snfs behalf.They do not staff to wait and see and you can't take the chance of waiting overnight if the patient can't breathe like the OP mentioned. I used to work in dialysis and a lot of times the MD would send the patient to the ER knowing they can't do much for the patient but mostly to cover his butt. Frustrating? Yes for all involved. But if they do not send em out and something happens, guess who gets sued?
And for the record, I would not take my 2 year old in for a fever, but then again, my 2 year old won't sue me if something goes array.
Its our job as nurses to make sure the patients are getting appropriate care and to advocate for the patients. If you do not know or do not understand the logic behind the transfer, you shouldn't bother calling report because you can not offer any insight, just information out of context. If we followed your line of reasoning, we would be cocktail waitresses handing out pills and medications without stopping to check WHY the patient is getting this. Waitressing doesn't require a license. Mistakes happen and people who aren't present don't always think clearly. It is our job to shed light on it for the MD.
And for the record, the staffing at the SNF is not my fault either and not my problem. The law allows for these folks to be dumped on us because you aren't staffed for it and I can't wait till that changes. As for the lawsuit, I am not dignifying that with a response. Defensive medicine and nursing are not in the best interest of the patient, the system or society and have no place in decision making. I consider those practitioners who think like that to be sadly misinformed (I was a paralegal for five years) and not confident in their skills.
Will add: I specifically refer to the fever. As for the low O2 sat, I don't know the hx there but I am a little suspicious that this problem was either avoidable or a part of a bigger picture for the patient that with a little prevention (nebs, lasix, who knows?) could have been avoided but I was assuming OP had already tried coughing, all medications available, and that the patient looked distressed.
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RachRN66
18 Posts
This is an example of a nurse in one discipline of practice (ER) thinking she is much better skilled and qualified than another discipline of practice (LTCF/SNF). You all took the same NCLEX or LPN version of NCLEX (I don't know what this is called) to be licensed to practice. You have to use your nursing judgement. I am a Home Health RN (BSN). Many hospital nurses "look down" on others as somehow their experience or practice is far superior. You did your job, you don't have to take flack from someone because they are having a bad day or because they feel superior. Tell her to have a good day, and let her deal with her own insecurities.