My facility is going to a new mode of trying to care for hospital level patients.

Published

Its draining me so bad. I have noticed very clearly within the past few weeks doctors and NP's hesitance to send patients to the hospital, when before it was always a no-brainer. This is because they want to prevent re-hospitilazations likely to get more and better admissions. However, instead of staffing appropriately and having the resources, its business as usual. This means yesterday I had 2 unstable and sick patients who should be in the hospital, but are being treated in a LTC facility. I generally have 10 patients, but they are quite heavy with dressing changes, PICC's, etc. I'm starting to feel like I cant effectively care for patients because the staff and resources are non-existant. I spent about 40 minutes, if not longer trying to find a specimen cup and a straight cath for a UA/UC, because instead of going to the hospital, they want to treat in the facility. So a lab service not designed for unstable patients is being recruited to do important labs and they are snail slow. I have been so incredibly stressed and anxiety ridden and I really just need to vent. They want these difficult patients but not the staff or resources to effectively care for them and Im feeling like its very dangerous. My main inclination is to send to the hospital anyway but I fear retaliation.

Up Vote Up Vote ×
Specializes in Psych, Addictions, SOL (Student of Life).
Its draining me so bad. I have noticed very clearly within the past few weeks doctors and NP's hesitance to send patients to the hospital, when before it was always a no-brainer. This is because they want to prevent re-hospitilazations likely to get more and better admissions. However, instead of staffing appropriately and having the resources, its business as usual. This means yesterday I had 2 unstable and sick patients who should be in the hospital, but are being treated in a LTC facility. I generally have 10 patients, but they are quite heavy with dressing changes, PICC's, etc. I'm starting to feel like I cant effectively care for patients because the staff and resources are non-existant. I spent about 40 minutes, if not longer trying to find a specimen cup and a straight cath for a UA/UC, because instead of going to the hospital, they want to treat in the facility. So a lab service not designed for unstable patients is being recruited to do important labs and they are snail slow. I have been so incredibly stressed and anxiety ridden and I really just need to vent. They want these difficult patients but not the staff or resources to effectively care for them and Im feeling like its very dangerous. My main inclination is to send to the hospital anyway but I fear retaliation.

First of all I feel your pain. Medicare reduces reimbursement for readmissions within 90 days. Still there are many conditions that can be treated in house without transfer to the acute hospital as long as a correct diagnosis has been made. And we do catheterizations all the time. That is totally within the scope of practice for any nurse RN or LPN. It should not take you 40 minutes to find the supplies to perform this duty. WE are seeing more and more medically complex patients come through our doors because Medicare and other private insurance just will no pay for longer stays in the hospitals. We are also getting Short-stay patients directly from the ER some of which don't even fit our demographic such as a patient who was 20 something, Bright Alert oriented with excellent family support who could have gotten her treatments at home with home health which actually would have been more cost effective and comfortable for all concerned and freed up a bed in our facility for someone who really needed it. What irks me is when Medicare patients come in demanding private accommodations, unlimited visitors, and the pet pony to visit and we have to stand ready to pick up the horseshit. I don't mind sick people it's what I do and I do it well. What I dislike is needy, entitled patients and families that think everything should be free and right now. Alert, ambulatory, patients who can't wipe their own butts and are on the call light every 5 minutes. I sometimes want to tell them "Hang on a minute while I tell the lady down the hall to stop dying so I can help you."

Hppy

Up Vote Up Vote ×
Specializes in Emergency Medicine.

A UTI is a very treatable condition in an LTC and prevents an unnecessary trip to the ED- when done correct it takes 60 seconds or less to obtain a straight cath. What are you stressing out with about PICC pts? Easy blood draw and the dressing only needs to be changed every seven days. I think you may be stressing yourself out more than necessary. If you aren't happy, then move onto a slower paced job. We all have to take care of not appropriate pts for out area of care- like for me, a simple UTI sent in that could have been treated at LTC.

Up Vote Up Vote ×

You should be addressing the 40minute treasure hunt for the supplies with your boss. And if the (when) the staffing is poor, start letting the families know. Good luck.

Up Vote Up Vote ×
Specializes in ICU.

Up to ten acutely ill patients to one nurse, without the necessary supplies or resources is unsafe.

Your ace in the hole is to inform the family and let them go to the MD and admin to demand a higher level of care for their family member.

Not everyone wants to work with acutely ill and potentially unstablle patients along with the horrendous amount of documentation required in rehab and LTC.

You should really consider other employment if this type of nursing is outside of your experience and comfort level.

Up Vote Up Vote ×
Specializes in LTC,Hospice/palliative care,acute care.

In our LTC the lab comes once a day to pick up specimens,they will only come back if you place a stat order.It takes hours for the UA to come back,these residents can tank quickly.The docs don't just throw antibiotics at them any more so they can get septic and come pretty close to dying.The families do not understand what is driving this treatment plan.I understand attempting to treat in place (especially the very old and demented) but this situation seems like forcing palliative care on someone without their knowledge.

Up Vote Up Vote ×
Specializes in LTC.

So just a few points on how your situation is unfair, but not in the way you think. In the facility I work per Diem in:

All lab draw and UA supplies are centrally located, I don't have to hunt, just open a cabinet.

We have a dedicated wound and treatments nurse, I don't do ANY treatments, I pass meds and assess, that's my job. I get the wound nurse for dressings that I can't quickly and easily change.

My facility sends stat lab draws and UA UC to the local ED, they process for it. I send a CNA to the hospital with it. I get the results faxed as fast as I would in acute care. They call me to give me heads up if I need to get that fax asap.

I'm also encouraged to keep residents until I absolutely can't any longer. The difference is that I tell the doctor or NP when that is as I'm actually there. If I say hospital for eval, it's hospital for eval, I'm empowered and my judgement is trusted. Yours should be too.

If I think we are understaffed on my shift for acuity I'm empowered to call people in or have people stay over, often if the nurse I'm relieving feels this is the case, she's already taken care of it.

With all that I often feel I can't effectively care for residents because my ratio is 1 to 30ish (a few more a few less). 1/2 LTC, 1/2 rehab (aka "why aren't these people in a hospital"). I feel like I'm drowning some shifts. I feel ineffective and frustrated. I think that's the nature of LTC, not enough of the nurse to go around, even in a good facility where they are trying to give me everything that I need, short of MORE NURSES.

Up Vote Up Vote ×
Specializes in Allergy/ENT, Occ Health, LTC/Skilled.

I worked in a rehab that once was like this, it was awful. I was 1:25 ratio too. We took all kinds of people and we had a person that had hip surgery from a car accident but was also detoxing from some drug. We were NOT equipped to handle the severity of his withdrawal, I called 911 and he seized in the ambulance/vomited/very lethargic and the DON/administrator STILL gave me hell about sending him out. If he would have vomited when I wasn't in the room (which wasn't often with 25 patients) then he could have died. I refused to apologize for it and put my two weeks in the next day. They started taking vents/ PICC lines/etc etc, all things that are very dangerous to do with the ratio and staff we were equipped with.

I would start searching, it will only get worse.

Up Vote Up Vote ×
Specializes in Allergy/ENT, Occ Health, LTC/Skilled.
First of all I feel your pain. Medicare reduces reimbursement for readmissions within 90 days. Still there are many conditions that can be treated in house without transfer to the acute hospital as long as a correct diagnosis has been made. And we do catheterizations all the time. That is totally within the scope of practice for any nurse RN or LPN. It should not take you 40 minutes to find the supplies to perform this duty. WE are seeing more and more medically complex patients come through our doors because Medicare and other private insurance just will no pay for longer stays in the hospitals. We are also getting Short-stay patients directly from the ER some of which don't even fit our demographic such as a patient who was 20 something, Bright Alert oriented with excellent family support who could have gotten her treatments at home with home health which actually would have been more cost effective and comfortable for all concerned and freed up a bed in our facility for someone who really needed it. What irks me is when Medicare patients come in demanding private accommodations, unlimited visitors, and the pet pony to visit and we have to stand ready to pick up the horseshit. I don't mind sick people it's what I do and I do it well. What I dislike is needy, entitled patients and families that think everything should be free and right now. Alert, ambulatory, patients who can't wipe their own butts and are on the call light every 5 minutes. I sometimes want to tell them "Hang on a minute while I tell the lady down the hall to stop dying so I can help you."

Hppy

The needy patients/families in our rehab are SO bad right now. My job has 10 patients to every house so I am split between three buildings. I cannot always be over there doing every single little thing they think we should do. The ones that are A+O and can do for themselves are always the most lazy,. threatening to sue because we didn't get their medications to them exactly at 8 pm. Thankfully, I have a decent boss who tries to take as little as those families as possible but if they want in and our beds are empty, she has to take them. The families are worse than the residents, especially if they are in the medical field. If they want one on one care, they need to pay for it.

Up Vote Up Vote ×

Can you make a complaint to JACHO?

Up Vote Up Vote ×
Specializes in Psych, Addictions, SOL (Student of Life).
Can you make a complaint to JACHO?

Unfortunately

most LTCs are not under the purview of JACHO they usually fall under state or county Dept of health who are never on the side of staff.

Hppy

Up Vote Up Vote ×

It sounds as though your facility lacks organization. I worked in a similar facility, much time wasted searching for supplies, etc. I would say that if it is your opinion that your resident needs the hospital, but the doctor or NP disagrees, I would cover myself by notifying the DON (regardless of time of day or night) and I would advise the family of the resident's condition and how the doctor has decided to treat this (without criticizing doctor's orders). This would give the family (or DON) opportunity to override the doctor's decision. I would also talk to the resident, if he or she is cognitively able, to see what his/her wishes would be. If a resident or family state they prefer hospitalization, no doctor should argue with that.

Up Vote Up Vote ×
+ Join the Discussion