Making sure a patient is medically cleared

elkpark · Jul 16, 2013

Everywhere I've ever worked, that has been the physician's responsibility/role. If I heard anything in the nurse-to-nurse report that really concerned me, I would follow up on it, but, in my experience, at that point, the physician has already agreed to accept the client based on the information provided by the referring physician.

Umberlee · Jul 16, 2013

We don't have doc-to-docs, it's the nurse's responsibility to accept the patient. I guess it never crossed my mind that that wouldn't be standard in most places (other places I've worked have had less physician involvement so nurse-to-nurse was always the standard). The docs don't even do anything initially with the patient from what I can tell except give verbal or written orders for start-up medications and restrictions, and of course any emergency medication if the patient is unstable. I'm still brand new and haven't actually had to do any admissions on my own yet but clearing someone medically without actually being able to see them first and only going off of what info is available in the chart is something that I'm kind of worried about.

elkpark · Jul 17, 2013

How can you admit clients without an admitting physician's orders? I've been in psych nursing almost 30 years, in five states, and have never heard of such a thing. Sounds to me like you're being asked to practice outside of scope. I would refuse to take that kind of responsibility, and find another job if it really came down to it. It would be interesting to know what your state BON and medical board would think of this arrangement.

Umberlee · Jul 17, 2013

We have the physician sign off on admitting orders, but that's after the nurse has given the go-ahead to accept the patient. From what I've seen, the process is something like this: admissions gets the referral, scopes the situation out to see if we have the room and the staff, requests paperwork from the hospital to see what the nurse may need to review before we agree to take the patient. Then admissions consults the nurse, nursing goes over the paperwork and has half an hour from the time we're told about the referral to do the nurse-to-nurse. The patient has not been accepted at this point. If everything looks and sounds okay, then we give the go ahead for the patient to come over. During the admission process the nurse determines what orders will need to be obtained from the physician for admission--restrictions, meds, etc. and solicits the orders from the doc at the time of admission, but not before. So we do get physician orders, but not until we've already committed to taking the patient.

elkpark · Jul 17, 2013

Wow. I would not be willing to work in a facility that used that model. I would not be willing to take responsibility for making those kind of decisions. I've never heard of any place where a physician did not make the decision(s) about admitting people. Your physician(s) may be signing off on the orders after the fact, but I guarantee you that, if something went terribly wrong, you would get left holding the bag and the physician would refuse to take any responsibility.

Orca, ADN, ASN, RN · Jul 17, 2013

I worked in a freestanding mental health facility (geropsych unit) in which treatment staff on call screened patients for admission. This led to the only patient I have ever had die in my care. It was a Sunday morning, an agency CNA and me for eight patients. One was a new admission who had come in on night shift (I was 7-3) from a small town hospital about 90 miles away. When I did my morning rounds, the fact that he was on four liters of O2 told me that the admitting diagnosis of depression wasn't his primary problem. He went into cardiac and respiratory arrest while I was setting up my AM meds.

After this we had a chat with our treatment staff about the questions they were asking when deciding to take someone. We came up with a few basics:

1. Are there any tubes or lines running into or out of the patient?

2. Is the patient on continuous oxygen?

3. Is the patient ambulatory?

4. Can the patient communicate?

The answers to all four questions regarding the patient in question were the exact opposite of what we should be looking for. By the time I assessed him, he was on the verge of being comatose.

Normally our intake staff would have assessed the patient in person before requesting physician approval for admission. In this case, because of the distance involved they accepted him sight unseen because they didn't ask the right questions. The patient had told the people in the rural hospital "I don't want to go on living like this." Given his long list of medical problems, I would be of a similar opinion if it were me. In their infinite wisdom, hospital staff interpreted this as suicidal ideation and contacted our intake staff for possible mental health admission.

We also encouraged intake staff to get more specific information regarding what was being called suicidal ideation - especially when the call came from a competing hospital with a mental health unit. Sometimes ER staff from other hospitals would call us to see if we had beds available - a sure sign of a pending dump. I developed the habit of telling them that they needed to talk to our intake staff about that, after which I would promptly call said intake staff and alert them of the attempted dump. In most cases the patient didn't have insurance, had a wad of medical problems they didn't want to deal with, or was such a management problem that they didn't want him/her admitted to their own unit.

New Angel · Jul 18, 2013

Our facility also mandates a MD to MD consult & discussion before accepting a Pt. that is to be medically cleared. But on my night shift, I myself do a great deal of the chart review & recommending to the MD on-call {very small facility, we use an out od town on call doc for night MD orders}. If I am not comfortable admitting a pt., I don't. I consult with admin before allowing a pt. that could possibly be unstable medically into our facility. I have had the xperience of an ER attempting to send someone over who was medically cleared for psychiatric admission, but had not even a CMP/CBC/UA performed...The list of 4 questions Orca wrote above are perfect.

I always ask the other Nurse:

-Lines/Tubings/Catheters removed?

-Is the pt. ambulatory? {meaning, can you as a nurse get them out of your facility without an elevator in the event of a fire}

CBC/CMP/EKG/UA/UTOX/Blood Alcohol levels

-Yes, chest xray post intubation.

-Any and all ED/Medsurg/ICU reports

-Sleep apnea machines? Wheel chair? or other assistive devices you may need for the pt. on your unit.

-Seizure recently? how is it being controlled now?

-What meds were given?

-Up to the minute Emergency department summary reports/ nurses notes/ MD notes.

I got a pt. once that the sending hospital considered to be "ambulatory" because they could self transfer from their wheel chair, however, they were not able to go down the stairs in the event of an evacuation {no ramps here}. {Our unit is on the 3rd floor}, and we didn't have the staffing to carry her out as well as manage our other pt.'s in a given emergency. I was lucky not to have a fire evacuation that night, but I was certainly mildly anxious about having someone on my unit that would be difficult to remove in the event of an emergency.

Also: my favorite training tip: When in doubt, send them out.....anytime you are concerned that your psych pt. is decompensating into emergent or acute medical issues, call 911 and send them out to be medically cleared. Its your license on the line, and I do agree with the other poster that it could wind up being your own liability, not the doc's, if you accept & admit a pt. that is not stable and something goes wrong.

gcupid · Jul 19, 2013

Everywhere I've ever worked, that has been the physician's responsibility/role. If I heard anything in the nurse-to-nurse report that really concerned me, I would follow up on it, but, in my experience, at that point, the physician has already agreed to accept the client based on the information provided by the referring physician.

"On the record" it is the responsibility of the physician to determine acceptance. But "off the record", what do u think really takes place? I'm familiar with the process of marketers (non-medical by the way) and nurse liaison's fishing for patients during business hours and when night shift arrived bc administration is sleep and hospital nurses are eager to get rid of psych patients and make room for other ill patients, it was the charge nurse screening paperwork sent by other facilities to see if patients were possible candidates for admission.

If it met "facility guidelines" under the authority of the medical/psych director, which probably was the only document that deemed the nurse screening tool powerful enough to permit acceptance to the facility with out illegal ramifications, the patient could be accepted and orders were initiated after calling the doctor to tell him/her that "we" the facility accepted the patient.

gcupid · Jul 19, 2013

Are there any specific questions you ask or things you check to make sure a patient is medically cleared before coming in? We had a patient who had been mechanically ventilated after a suicide attempt and came in with what was eventually determined to be postventilatory pneumonia. We had to try and treat it in-house without the ability to do chest xrays, cultures, etc. That was a very dodgy situation so I'm thinking in post-vent patients I should ask for a chest x-ray prior to admission. Anyone else have any pointers or situations that have shaped your "nurse to nurse"/medical clearance? I am the kind of person who always thinks, "Oh sure, we can handle that" and I don't want to set myself up for disaster. Thanks!

You will learn quickly. Make sure that the facility faxes over more than just a face sheet (Lol!). I need to be a consultant:sarcastic:

1. Every facility should have a patient population that is targeted and is eager to accept. Find out who are these individuals.

2. When reviewing paperwork make sure most recent labs, X-ray, & MAR reports are present and base your inspect your assessment off of the main diagnosis as well as the patient's past medical/surgery/psych history. The MAR (medication administration record) acts as a tool that gives clues. You may have a patient that has been taking lortabs, macrobid, metformin, Lipitor, & metoprolol. You need to ask yourself "why" when evaluating the MAR. The pt's history most of the time should coincide with the MAR, if it doesn't.... Ask the nurse in report, why?

From the example of meds listed, this patient could "possibly" have DIabetes, high blood pressure, hyperlipidemia, some type of present infection or prophylactic antibiotic, and chronic/acute pain due to some reason. Everything needs to line up.

Something's you will have no control over & there is only so much that can be revealed from paperwork & report. Just make sure you document to protect yourself.

Ex: reported concerns to doctor "&"charge nurse/director of nursing that patient may need follow up chest x ray/additional labs/culture to determine if conditioning is worsening and/or med is effective bc patient has vital signs, physical assessment reveals,(i. e., neuro status/behavioral change, cloudy urine noted, frequency, bruising, etc) and document doctors response (no new orders, dr stated that blah, blah).

Hope this helps....

macfar28 · Jul 21, 2013

We have an assessment dept within our free standing center (staffed with a nurse or a counselor) that receives calls about admits and also an ACT counselor in the ED (just within our health system locations) who refers. The counselor or nurse then runs the patient by the physician for admit. I've never found that appropriate. Counselors are valuable but in terms of screening patients medically, it seems unsafe. I think our admins keep it this way however because sadly, counselors are cheaper. We definitely have those referring sources as well as counselors within our system who conveniently leave out info because let's face it, the patien has to be placed somewhere and it's on that referring source to find that place. Frustrating to say the least. Our docs sometimes give admit orders when the pt is accepted but sometimes not. Lots of room for improvement.

elkpark · Jul 22, 2013

"On the record" it is the responsibility of the physician to determine acceptance. But "off the record", what do u think really takes place? I'm familiar with the process of marketers (non-medical by the way) and nurse liaison's fishing for patients during business hours and when night shift arrived bc administration is sleep and hospital nurses are eager to get rid of psych patients and make room for other ill patients, it was the charge nurse screening paperwork sent by other facilities to see if patients were possible candidates for admission.
If it met "facility guidelines" under the authority of the medical/psych director, which probably was the only document that deemed the nurse screening tool powerful enough to permit acceptance to the facility with out illegal ramifications, the patient could be accepted and orders were initiated after calling the doctor to tell him/her that "we" the facility accepted the patient.

Well, "off the record," as I've already said, in 30 years of psychiatric nursing in five different states, I've never worked anywhere where anyone other than a unit physician (or NP with admitting privileges) made the decision to accept an admission, so there are plenty of facilities that follow that practice. I'm surprised to hear there are places that use a different model. I would not be willing to work for one.

If anything ever goes seriously wrong, the physicians and the hospital will hang the nurses (or whatever other non-physician/NP/PA providers were involved in the decision to admit) out to dry. If people here are comfortable living with that, fine; that's their choice to make. I wouldn't be.