Keep my patients out of the hospital!

cookie102 · Feb 1, 2009

It seems as though all of my patients are winding up in the hospital! I'm newer to home health, it's been about 5 months; I've been a nurse for over 4 years. I am case managing under supervision.
In the past two weeks, I've had one stroke recurrence, one perforated diverticulum (ok that wasn't anything I could have stopped and I caught it during a visit and called EMS appropriately), one CHF'er relapse, and one COPD'er just went back in, too. The CHF and COPD patients, for each one I was getting this feeling that all was not right, they were each just a little more tired, just a little decrease in appetite, no huge changes in vitals or general assessment. Just a feeling. For each of those patients I called the PCP during the last time I visited hoping for some orders, but I didn't know how to say, "Hey, this lady/gentleman just doesn't look so hot."
I am reminded of Charlie Brown in the Christmas special when he says, "Everything I touch gets ruined."
What is a good way to get the message to a phone nurse and from there to a PCP that you don't have a whole lot of change in your assessment other than increased fatigue and decreased appetite and you just have That Feeling that All Is Not Right?
Maybe I just need to accept that end stage CHF and COPD patients will visit the hospital?

sometimes what i have done is when i call the PCP with a situation that you are describing is i make them an appointment, hopefully within the next day or two....some patients you will never keep out of the hospital, what i try to use as a goal for those with the end-stage diseases is that ---i can't keep them out of the hospital but i will try and lengthen the time between hospitalizations,,,for example if they were in the hospital monthly perhaps i can extend that to every two months,,,go with your gut feeling, it usually is right.

christine_chapel · Feb 1, 2009

thank you cookie. the COPD gentleman, who I'd seen on Friday and who went in yesterday, had an appointment scheduled to see his pulmonologist on Monday!

I will try to shift my mindset to lengthening their times at home.

tencat · Feb 1, 2009

It's a fine line between home health appropriate and hospice appropriate. If they are going more often to the hospital, it might be time for hospice as the disease process appears to be getting worse. We certainly don't always keep them out of the hospital on hospice, but we try. I wouldn't take it as a failing on your part. COPD and CHF are conditions that are difficult to manage in the home setting, so sometimes we hit it, sometimes we miss it.

annaedRN, RN · Feb 1, 2009

Agree with tencat. Do what you can with teaching disease mgmt - diet, activity, weights, meds. Be an advocate to ensure that proper nebs, O2, or prednisone are in place to help maintain the little lung function that is left. I usually discuss hospice casually at first then if needed make MSW referral for hospice info. It is a very frustrating situation no matter what the outcome!

cmarn · Feb 2, 2009

I agree with the previous replies. When I first started HH, I was very hard on myself. I thought I should be able to do it all. Well, the bottom line is you do have to set goals for all patients but you may have one CHF pt that teaching daily wt, diet, etc WILL keep out of the hospital. Another CHF pt may be non-compliant or just sick enough that you cannot keep home. The goals do not have to be the same for each pt. To me, our goals have to be realistic. For example, the first pts goals could be that they stay out of hospital and increase knowledge of disease process. The second pts goal might be lengthend time at home or identifying exacerbation of CHF earlier to avoid lengthy hospitalizations. You get the idea. Our CHFers will be back and forth. Don't think you aren't doing a great job!