Long Term Care and dealing with EMS with an attitude

[sandyth]

I work in a LTC facility& had a pt with chest pain (crushing); Hx: A-fib, CHF, and multiple other heart problems; also 2 weeks post op Left hip fx. Pt wont ambulate blah blah...Anyway I call the MD after the Nitro doesnt relieve chest pain and he said to send her to ER for evaL AND TX. oKAY the EMS get there and say she is asymptomatic and medicare woulnt pay for transport (the EMS) had just been woke up)and proceeded to try and talk this woman into NOT going. I pressed the issue and finally they transported. Most of the EMS people are nice when they have to come but has anyone had this kind of problem with the EMS before?

[essarge]

I agree with the above posters who stated that, even though there is a DNR order, it does not mean that they do not receive treatment, and should be transported ASAP. Especially with the symptoms that the original poster stated.

On the other side of the coin, I have worked in an ER and seen many, many, LTC residents transported to the ER for "change in mental status" (they have alzheimer's, dimentia diagnosis anyway), presenting with no fever or any other physical symptoms. Sometimes it makes you wonder whether the staff at the LTC is just tired of taking care of these residents.

[medicrnohio, RN]

As a paramedic and a future nurse I thought I'd reply to this message. We can not refuse to transport a patient because of their insurance, at least not where I work and have worked. I always tell my patients, "I don't care if you have insurance or not. I do not work in billing. I am here to take care of you and get you to a hospital where they can care for you further."

As for DNRs, the laws vary by state as to what can be done for a patient by paramedics. In Ohio, we can not initiate ALS treatment. Meaning no IV's, no meds, no cardiac monitor. We can give oxygen, suction, and try to make the patients more comfortable. The one exception to giving meds is, if a patient is already on a medication, we can then give that medication. Once in the hospital they can often do more for a patient than I can as a paramedic. It's all about laws and protocols when it comes to DNR patients.

Michelle

[flashpoint]

From the EMS side of it...here, our nursing homes have a policy that they cannot call an ambulance without a doctor's order (unless there is an immediate life threat). So, we cannot refuse to transport a patient. There have been a few times I have assessed the patient and called medical control to see if we could treat at the NH and skip the transport. #1 patient with a nose bleed, nursing home staff was unable to stop bleeding. Patient was to go to hospital for packing and be transported back. Vital within normal limits. We had tha patient blow her nose HARD and then pinched it off for twnety minutes. Bleeding stopped, medical control gave orders not to transport. #2 patient fell and complained of hip pain. We transported to the hospital, where the patient jumped off the cot, walked down the hall to the soda machines and bought himself a Coke. X-rays were negative and the NH wanted the ambulance to transport back...we refused and the NH sent their van to pick the patient up...saved the patient about $400. #3 patient was to go to the hospital to have IV initiated by anesthesia because NH staff could not get one started (this patient had HORRIBLE veins!!!). One of the hospital's CRNAs is also a volunteer firefighter / EMT...he started the line there and we did not transport.

My biggest problem with going to the nursing homes is that once the ambulance shows up, all of the staff seems to congregate in that resident's room. There is no one to direct volunteers who show up later and no one out there to care for the reamining residents. I have walked into one of our nursing homes and seen 7 call lights flashing and three CNAs jsut standing in the room of the resident to be transported. I've also been told that the hospital knows why we are transporting so there is no reason to give me report, been told I cannot look at the papers in the transport packet, and had an O2 mask ripped out of my hand because the patient had COPD. Once the ambulance arrives, that patient is theirs and the ambulance protocols are the ones that need to be followed. Before I was a paramedic, I would have made the same arguments (about the O2 and things), but now that I know what I know...

[sandyth]

The EMS werent refusing to transport, just trying to talk her out of going. Like I said most EMS are as nice as can be, but these two just didnt want to transport, and by the way after reaching the hospital she was having a heart attack so I am glad I pressed the issue. After all of your replies at least I know i am not alone in this.

[ktwlpn, LPN]

Originally posted by essarge

On the other side of the coin, I have worked in an ER and seen many, many, LTC residents transported to the ER for "change in mental status" (they have alzheimer's, dimentia diagnosis anyway), presenting with no fever or any other physical symptoms. Sometimes it makes you wonder whether the staff at the LTC is just tired of taking care of these residents.

I doubt that the nursing home staff were "tired" of taking care of any of these residents-They were probably very attuned to their baselines and quickly able to pick up any slight change in their behavior that to an experienced geri nurse can signal a problem...Just because they have a dementia dx does not mean that they can not become delirious...UTI's often present this way-remember these residents can not tell us their sx-they depend upon us to pick up on any changes..And don't forget that these people do have family that frequently visit-if they insist "mother does not look right" they have the right to insist their loved one go out to be assessed in the ER..We are limited in LTC-we can not do stat labs or x-rays...Also-many,many elderly residents remain afebrile with raging UTI's...Geri nursing is a bit more challenging then you first thought,isn't it?

[Empress]

Let's say you were working EMS. You get called to a nursing home for altered mental status. You get there, go to the patient's room and quickly assess the patient. Nothing jumps up at you immediately with the ABCs, the patient is nonverbal and cannot answer questions. You find the nurse and ask him/her what's going. You're told "The patient has an altered mental status, here's the paperwork." You ask again what's going on, how is the altered mental status presenting, what's the patient's baseline mental status. The reply is "Dr So and So ordered it," and a shrug. You transport the patient, do a full assessment, and still nothing remarkable. You take the patient into the ER and give the ER RN your report, he/she asks why was the patient was transported, and you tell her what you were told by the nursing home RN. So the ER RN calls the LTC to find out, she's told it was from the off-going shift, still no answers. The ER doctor does a full work-up on this patient and nothing is found to be wrong with this person other than the pre-existing conditions.

Now do this 3-4 times a shift from different nursing facilities, and try to not start thinking about other possibilites about the nursing home staff.

[VivaLasViejas, ASN, RN]

I've worked in both LTC and hospitals, and I can see both points of view, but hey, let's not forget that the PATIENT is the focus of the debate here. Just because someone is old, demented, incontinent, non-verbal etc. does NOT mean that they don't deserve to be treated like human beings. They have pain, they have fear, and they have feelings that can be hurt by careless remarks from caregivers who seem to think that because they're "altered", they don't understand anything.

We can debate the value of life until hell freezes over, but I know one thing: you don't fail to treat someone unless their POLST or advanced directive says to do nothing---and even then, comfort measures must be provided. Everyone in the medical field knows that, and yet it seems the frail elderly are the least likely to receive proper care. LTC nurses overall are NOT in the habit of sending residents to the hospital because they're "tired" of caring for them. Not all hospital nurses hate caring for NH patients because of all the extra attention they require (incontinent care, close observation due to confusion etc.). And presumably, EMTs are in the business of taking care of ALL

citizens of the community. Yet, all branches of geriatric care are failing the elderly despite growing knowledge and understanding of the aging process. Maybe it's because old people are not glamorous, or because health care is still primarily concerned with saving lives, rather than helping people face the reality of decline and death. I don't know. But I do hope that will change as my generation enters its own "golden years". We've refused to grow old and be put out to pasture, and I imagine we won't go gently into that good night either. But the time to start treating the elderly with dignity and compassion is NOW.

Sorry for the lengthy rant, but this is a subject that's very near and dear to my heart. Thanks for reading it.:)

[ktwlpn, LPN]

Originally posted by mjlrn97

I've worked in both LTC and hospitals, and I can see both points of view, but hey, let's not forget that the PATIENT is the focus of the debate here. Just because someone is old, demented, incontinent, non-verbal etc. does NOT mean that they don't deserve to be treated like human beings. They have pain, they have fear, and they have feelings that can be hurt by careless remarks from caregivers who seem to think that because they're "altered", they don't understand anything.

We can debate the value of life until hell freezes over, but I know one thing: you don't fail to treat someone unless their POLST or advanced directive says to do nothing---and even then, comfort measures must be provided. Everyone in the medical field knows that, and yet it seems the frail elderly are the least likely to receive proper care. LTC nurses overall are NOT in the habit of sending residents to the hospital because they're "tired" of caring for them. Not all hospital nurses hate caring for NH patients because of all the extra attention they require (incontinent care, close observation due to confusion etc.). And presumably, EMTs are in the business of taking care of ALL

citizens of the community. Yet, all branches of geriatric care are failing the elderly despite growing knowledge and understanding of the aging process. Maybe it's because old people are not glamorous, or because health care is still primarily concerned with saving lives, rather than helping people face the reality of decline and death. I don't know. But I do hope that will change as my generation enters its own "golden years". We've refused to grow old and be put out to pasture, and I imagine we won't go gently into that good night either. But the time to start treating the elderly with dignity and compassion is NOW.

Sorry for the lengthy rant, but this is a subject that's very near and dear to my heart. Thanks for reading it.:)

Fantastic post mjl-I p\often feel as though I am beating my head against a brick wall....These people deserve an eval just as does anyone else that shows up at the ER,am I correct,Empress? How many times a day is your ER used as a clinic by frequent flyers? Are they more deserving of your time? I am guessing that the medical staff at the LTC really does know more about the patient then EMS or the ER staff...How often do these patients really get sent back with all systems normal? No UTI or dehydration? It is tough to eval an Altzheimer's patient but if it was YOUR mother and she was apparently in some kind of distress would'nt you want measures taken to help make her comfortable? I am betting that anyone would.....

[CoffeeRTC, BSN, RN]

I can't believe that they would refuse to transfer a pt to hosp. Ya never know with chest pain. Our EMS is the best and really takes care of our facility. (If you ask nicely they've been know to draw blood or start an IV on our difficult pts). As far as LTC sending people out just for the heck of it.... not on my shift. I try to discourage it.... just to much darned paper work, calls, etc.....

One more thought for the EMS folks, It might help to ask the LTC administration if you could do an inservice on what to say or do when transfering a res with your service. Like what info you need either verbally or on paper. I took EMT training in nursing school (and loved it) and learned a lot of how it was to be on the other side also learned how to give a pretty darned good report/ assessment of my res to the EMS.

[Empress]

I understand why many people use emergency rooms as "free clinics" since they have no where else to go for medical, but I do find it hard to understand why so many LTC patients are sent out to the ER for eval when they have a whole staff of medical trained professionals at their disposal. Other than a CT, the ER doesn't have anything more than what should be available at a LTC.

[CoffeeRTC, BSN, RN]

Not all LTC facilities are alike. I agree to a pt. We should be able to provide almost the same services that the ER would. At my facility the RNs are doing blood work (new for us, no retraining or inservices yet), our lab only picks up M-F until 3pm, Xray sevices are alittle better and might show up but not if ordered after 7pm, IVs we do have an IV team for help when needed, but as far as pharmacy services, don't hold your breath waiting! Like I said, not all facilities are staffed and equipt alike.

[ktwlpn, LPN]

Originally posted by michelle126

Not all LTC facilities are alike. I agree to a pt. We should be able to provide almost the same services that the ER would. At my facility the RNs are doing blood work (new for us, no retraining or inservices yet), our lab only picks up M-F until 3pm, Xray sevices are alittle better and might show up but not if ordered after 7pm, IVs we do have an IV team for help when needed, but as far as pharmacy services, don't hold your breath waiting! Like I said, not all facilities are staffed and equipt alike.

I agree-most LTC's in this area do not have in house radiology,lab or even an extensive pharmacy...That would be cost prohibitive.The docs make rounds once or twice a week-usually....So-the majority of the trained staff are aides.....The nurses are often responsible for 30 residents-comparing acute to long term care is apples to oranges.The most experienced nurses that come into LTC with the acute care attitude that they have seen and done it all are often in for a surprise.The residents are in their homes....The nursing staff faces the same limitations that a nurse in homecare does.....-I work in the county home...Any idea how much medicare re-imburses per day? Things are bad budget-wise in almost all of the nursing homes in this area....There are skilled care nursing homes with more services on site-they are few and far between around here...