Needing Advise

Published

Specializes in Telemetry.

I am needing help with a problem at work.

I had a patient that was in the hosspital for 20+ days. The MD usually comes at night (which he did) We were expecting a discharge. After he came in he had wrote "D/C Home."

I went to the room to D/C patient and the patient stated "I am not going home tonight, the doctor said in the morning." (Approximately 2135 hrs) I immediately called the MD who stated VIA telephone order "Cancel D/C till AM." This order was written. (He apologized- He also admitted to this conversation.)

My supervisor (Charge Nurse) came in and asked the patient and she stated "I am going home tomorrow."

The next morning my supervisor demanded me to come in for an "urgent matter." I drove 50 miles (Without sleep)

She kept stating that "this is a business" and there was "no need to call the doctor."

Do you guys know any Standards of Care or National Care that I could bring up in the meeting this afternoon. I live in Louisiana. Thank You in advance!

Up Vote Up Vote ×
Specializes in MICU.

I'm confused as to what the issue is and why the supervisor needed to see you?

Up Vote Up Vote ×
Specializes in Telemetry.

She is basically bullying me (In General) Seems to take turns bullying people.

The day of the occurance I worked the PM sfift till 1830 and then I drove appromately 70 miles home. after receiving a call telling me to come back to work because there "Was an urgent matter that needed to be addessed.

Up Vote Up Vote ×
Specializes in Emergency Room, Trauma ICU.

What was the urgent matter? I'm very unclear on what the problem is here.

Up Vote Up Vote ×

Could be that the facility finds it is no longer getting payment for patient and wants them out the door. It's complex, but actually simple once you understand how things work.

Insurance/Medicare, predetermine for just about any possible dx what the course of tx will be and how a patient should progress which gives them a formula on how long they will pay for a hospital or SNF stay for that patient. Of course things change/develop that might alter that course, but for the most part it's the "law" as far as patient planing in light of income goes for the facility.

The goal is to treat the patient and get them out the door before payment for that dx ends. Any screw up or delay by the facility will not be paid for, and the facility has to eat it = $loss. Now having said that, there are a lot of smoke and mirror things going on too. The patient is not to know that the facility wants them out, out, out!!! Usually the patient is informed of a discharge date anticipated but not guaranteed so they can look ahead and know it is coming. If the patient says that they do not feel they are ready for d/c but there is no clinical data supporting a NEED to keep that patient in the facility, if planned well, the actual d/c projected date told patient has been padded with a little leeway. This is so the hospital doesn't get dinged in the patient satisfaction department. This is why you have Case Managers... they know when to open the trap door and get that patient out! So if Case Managed well, you the patient are told, Hey if all goes as expected we'll have you home by Wed. But the actual trap door opens on Thurs or Fri. Out means home or into someone elses hands eg Home Health or if need be rehab LTC. This is also why you see very sick patients d/c out to SNF that really need to remain even in ICU sometimes! Simply, nobody is going to pay for your inpatient stay anymore, and frankly, they know you don't have the cash...

Patient care is not the concern anymore, it's only given as long as insurance/Medicare will pay.

So this manager might not have liked anyone messing with the discharge date, and is deciding it's all your fault. The MD doesn't care if he is not an employee of the hospital, so he'll go ahead and give the patient a few more hours for his numbers in the patient satisfaction surveys...

Up Vote Up Vote ×
Specializes in MICU.

I understand how insurance pays for acute care as I've been working in an LTACH the last two years. I still don't understand what the issue with the nurse is. Sounds like the problem lies with the doctor and case management, if that is really what this was about. I feel like I'm missing part of the story..

Up Vote Up Vote ×

I really get my fill of this crap. We had a nurse in our SICU recently receive a write up for failing a core measure. A patient was ordered to have a foley out a certain date after surgery. That day, the patient went down hill and was basically a hypotensive trainwreck all day. In the chaos, the nurse didn't think to get an order to keep the foley in. Fail. Write up.

Wouldn't it be nice if we could just take care of people? I realize it the whole system is flawed, not a single hospital. It is a business afterall and that is why we get paid. But, it still irritates me when supervisors come down on nurses for stupid stuff like that.

Up Vote Up Vote ×

I am very confused by the details, but reading between the lines it sounds like the OP is being called on the carpet for delaying the discharge until the next day.

To the OP, my opinion here is of limited value, but I think you did the right thing by calling the physician and I'm sorry that you are getting the blame for the mix up.

Up Vote Up Vote ×
Specializes in Med/Surg, Academics.

As I understand the issue, the supervisor is upset that the nurse didn't discharge the patient that night per the original written order for financial reasons. The OP is also upset that she got called in for "an urgent matter" that was simply a face-to-face tongue-lashing. The Op is also asking for standards of care pertaining to appropriate discharge times given the fact that the discharge order was written at 2130.Does that about sum it up, OP? In my opinion, if the supe is going to have a talk with you, he/she should also talk to the doc. If the facility is losing money for too-long stays, the people actually responsible for monitoring and ordering d/c are the ones to address the problem to. Yes, nurses need to be aware of these things in order to plan for them, but to be singled out for responsibility? No.

Up Vote Up Vote ×
Specializes in Med/Surg, Academics.
My supervisor (Charge Nurse) came in and asked the patient and she stated "I am going home tomorrow."
When was this done? Before or after you received the order to d/c in the am? Also, when did she say to you, "This is a business" and " there is no need to call the doctor"?
Up Vote Up Vote ×
Specializes in ICU.

Wait you're talking about this happening at 2130 but then you say you worked til 1830? I'm so confused.

And then driving 70 miles, or 50 miles?? Please add more info, this story is inconsistent and apparently lacking in some key details. Why are you in trouble?

Up Vote Up Vote ×
Specializes in Telemetry.

Basically, the DR told me to hold the Discharge. I wrote an order saying that. Unit director got angry because of LOS.(Length of Stay). I got called in at noon the next day and was told by my unit director that I needed to come in ASAP. So I drove 70 miles to the hospial to have a meeting with her. She stated that I should have never clarified with the doctor and that there was not a reason to.

Up Vote Up Vote ×
+ Join the Discussion