Need advice please

[sweetie01]

I am a Case Manager in Bed Management.

When patients come in for admission we often do not have a bed available immediately. Patients often wait an hour or more for a bed. If 3 patient are waiting on the only available bed, we determine who gets it first, based on diagnosis, orders, assessment. Our Manager expects us to assess the patients. She has even provided us with a BP cuff, thermometer, and pulse ox.

We have been told that we are NOT a treatment area & we can't treat patients. We have been told that if a patient is in distress, we need to get them to a bed immediately ( if appropriate) or send to ER. The problem is that when we do send symptomatic patients to the ER, our manager does not support us. Also, none of us are trained in triage. We have explained our concerns to the manager with no results.

What is my liability in this situation? Is this triage? Am I worried about nothing? Any advice would be appreciated. Sweetie01

[leslie :-D]

what does your manager suggest if a pt is symptomatic yet doesn't support the pt being transported to the er?

just make sure you document any/all interventions with detailed responses from your mgr.

are you a nurse? if so, can you get a doctor involved?

leslie

[gypsyatheart]

I am curious also, are you an RN, as only RN's should be assessing pt's independently and then deciding the best course of action...I mean that is triage. How can you do case/bed management if you can't triage? Sorry, I'm a bit confused?

[sweetie01]

Thank you for the replies. Let me try to clarify. I am an RN. I guess I'm feeling uncomfortable because I have not done patient care in years and neither have any of the other Case Managers. None of us has been trained in triage. We were hired into positions that did not require patient care and now we seem to be doing triage.

Sometimes our manager supports us sending a patient to the ER and sometimes she doesn't. She usually disagrees when she does not feel the pt was not acute enough to go to the ER. The problem is that she will not clarify what we are supposed to do with patients that have stable VS and pulse ox 97% that are complaining about SOB, all of a sudden doubling over with abd pain, etc... She disagrees that they should go to ER, but yet she tells us if pts are in distress they need to go to ER. She may not consider that distress, but I do. I was always taught you treat the patient if they have complaints. If i were on the floor, I would call the doctor and let him know what was going on and let the doctor decide what to do. I could call the doctor in this situation, but I can't treat. I don't feel comfortable having someoe sit in the office that is symptomatic, wheter it be objective or subjective on the patients part.

We don't have any policies or procedures or protocols to guide us at all. I keep explaining how imporatant it is to at least have policies and protocols to follow, but she doesn't think we need any.

I have many concerns about this. #1- none of us has done pt care in a long time. #2- none of us are trained in triage #3- we have no policies or protocols to guide us. Am I just being paranoid because I haven't done pt care in a long time? I feel at the very least we should have protocols. She doesn't think this is triage. Any advice, even if to tell me to relax would be appreciated.

Sweetie 01

[Antikigirl, ASN, RN]

One, I think you should take a look at your states Standards Of Nursing Practice. In mine (Oregon) if you fail to act based on your nursing assessment of a patient you are in deep trouble! Also, not being a Patient Advocate can get you into deep water as well. So take a look at your states rules...those can come in handy when you get into trouble spots.

Two, I have been in this situation many times. Working in assisted living, no one wanted to send patients out to the ED, yet our facility had little we could do for patients that had acute conditions that either may need, or need more invasive action than just giving meds or taking VS.

What I did was to call their MD...if it was a recent surgery or what not I would contact the surgeon (make your best judgement) or typically I would call their PCP. Even if it took getting the MD on call! I asked their advice on the matter and DOCUMENTED it fully...and did a telephone order for it to make sure whatever implementations I was to do could not be under debate. (always document whom you spoke to, at what time..sometimes I even documented how long it took to reach the MD because if time is a factor and I wound up sending someone in in the mean time...that is rationalized in my documentation, what was said, what I did after, and all of my assessment data before/during/after..which is cruitial!).

Hope that helps...whenever I got into a situation where I didn't feel comfortable with a patients health and well being by my assessments, I always called the MD! :)

[Jolie, BSN]

Do you, as the bed controller, have access to a chart to document your assessments, contact with other members of the healthcare team, interventions, or evaluations of patients who remain in your department while waiting for a bed?

It sounds like you definitely need a way to document your findings and actions in order to protect yourself legally.

[BKRN]

I work on a MED/SURG floor, sometimes our direct admits would have to wait a few hours for a bed, room to be cleaned, etc. We would often have admitting call us and ask that someone please come down and wait with the patient as they were having chest pain, abd pain, even had one that was "hard to wake up"! We would tell admitting that they needed to send the patient to the ER to be stabalized before coming to the floor. To the OP I would definately send these patients to the ER as their situation may have changed. So instead of a MED/SURG bed they may need to go to tele, ICU, etc. And if your Nurse manager does not back you, than perhaps she could come and assess the patient to decide their level of care.

One, I think you should take a look at your states Standards Of Nursing Practice. In mine (Oregon) if you fail to act based on your nursing assessment of a patient you are in deep trouble! Also, not being a Patient Advocate can get you into deep water as well. So take a look at your states rules...those can come in handy when you get into trouble spots.

Two, I have been in this situation many times. Working in assisted living, no one wanted to send patients out to the ED, yet our facility had little we could do for patients that had acute conditions that either may need, or need more invasive action than just giving meds or taking VS.

What I did was to call their MD...if it was a recent surgery or what not I would contact the surgeon (make your best judgement) or typically I would call their PCP. Even if it took getting the MD on call! I asked their advice on the matter and DOCUMENTED it fully...and did a telephone order for it to make sure whatever implementations I was to do could not be under debate. (always document whom you spoke to, at what time..sometimes I even documented how long it took to reach the MD because if time is a factor and I wound up sending someone in in the mean time...that is rationalized in my documentation, what was said, what I did after, and all of my assessment data before/during/after..which is cruitial!).

Hope that helps...whenever I got into a situation where I didn't feel comfortable with a patients health and well being by my assessments, I always called the MD! :)

[sweetie01]

Thank you everyone! We do not have access to the chart, but we do have a log that we document on. It has notes on all the patients that come through the admitting office on that date. We do document all of our interventions and calls here.

It sounds like I should call the doctor on some of the less obviously acute patients if I have concerns first before I send to ther ER. I will just have to make it clear that I can't treat the patient, just watch them to make sure they don't get worse. If their in obvious distress, I'll still assess them and document, but I will just send them to the ER.

I'll keep nagging my Managers for policies and/or protocols for what we are doing. I'm still not sure how we were hired to do case management, but are now assessing and triaging pt's. That's healthcare, be flexibe or move on I guess.

I also talked to someone on the Board of Nursing at length today and gave examples of pt's I'd sent to the ER and why. She told me that I was doing what was right for the patient and to give myself a break. This made me feel better.

One problem I also have is that I determine the patient needs to go to ER and triage tells them to sign-in, but you have 8 patients in front of you. Of course the patient doesn't want to sign in and wants to go back to the admitting office. It does no good when I explain that I can't treat and that the ER can get you back immediately and theres a doctor there if you need help. I can't force the patient to sign in, so I have to take them back to admitting. This scares me, but I guess all I can do is monitor to make sure they don't get worse and call the doctor, making sure to document everything. An example is a pt in admitting with dx of angioedema, no sob, resp and VSS, no obvious swelling, but complaining of difficulty swallowing. Didn't feel comfortable leaving in admitting until the patient got into resp distress. Triage told him he had a bunch of people in front of him, so he wouldn't sign in. I stood with him in the ER going round and round about why he needed to be in the ER, until a bed was ready. The triage nurse was no help. My manager actually agreed with me on this one when we discussed if after the fact.