Patient clearly not ready to be discharged. . .is discharged. Vent.

[AlphaPig]

This is sort of a ranty long post. . .just a warning :)

A few weeks ago, I was floated to an "overflow unit" (in other words, a lonely little floor with no real staff or support or manager just sort of shoved in a deep dark crevasse of the hospital) and I had a pretty sick patient. Tons of co-morbidities (DM, CHF, pnuemonia, AMS, hx of cva and about a million more I don't remember). From a SNF. Oh and on contact for EVERYTHING, like things I had never even heard of and had to look up. Picc line, peg tube, foley, oxygen NC.

Anyway, so I go in to assess her and turn her (by myself, because on this floor there was no CNA, no charge nurse, no unit secretary - NOTHING, just me and one other nurse. Thank god I only had 4 patients that day because it was primary care, baby!) So I assess her and her lungs sound awful, like she is freaking drowning. O2 sat is 99 on 2L so that is ok. She had had a thoracentesis the day before and they had taken off 1,500cc. Upon further search in her records, she had had a previos thoracentesis 5 days prior where they had removed 1,700cc. She needed to cough but couldn't do it.

More than that going on, but you get the picture.

So. . .the primary comes in and discharges her back to the SNF! I was shocked, I ventured a "Do you think she is ready? Did you listen to her lungs?? Did you see her labs???" and he just shot me a dirty look and said, "we aren't doing anything for her here, she can go back." and I said, "has pulmonary signed off?" and the MD wasn't happy about that and stalked off. THEN, he returned a few minutes later and rattled off all of his reasons for sending her back to SNF and ended with "she will be back, probably next week, she will be back for sure" and I said, "well then WHY ARE WE DISCHARGING HER??"

THEN, I took it upon myself to call the pulmonologist to say, "um, the primary is discharging this patient" and the pulm said "WHAT?!!? I was going to order a follow up chest xray tomorrow and this patient needs aggressive RT therapy that they don't have at the SNF!" so I was relieved and thought maybe the pulm could stop the discharge. ..nope! He sighed and was like "well, if he discharged her, that's his issue" and I was like "NO! please, call him! tell him you want to keep her here!" Nope. No, he just signed off. I even called the primary back and told him what the pulm had said - Nope.

So. . .off the patient goes back to the SNF. I felt so so so bad.

AND. . .the next week I come back after about 4 days off and the patient's name was still on my list and. . .there she was. . .back after only 2 days at the SNF. . .and this time in the ICU.

I hate things like this. I told my nurse manager and she just shrugged her shoulders and was like "well, the patient is very sick"

UGH UGH UGH!!!!

THEN MY NURSE MANAGER HAS THE AUDACITY TO TELL ME I HAVE A SPECIAL VIP PATIENT COMING TO ROOM XXX AND THE FAMILY MIGHT MAKE A BIG $$$ DONATION AND TO TREAT PATIENT EXTRA WELL. . .

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

How do any of us survive this job?

(I am going to make a separate post about this lil VIP patient)

Thanks for listening! sometimes I just need to "talk" to others who get it.

[UnbrokenRN09, BSN]

OMG. That is horrible! I'm assuming this patient has no family and didn't have the mental capacity to voice what she wanted. It sounds like the attending just didn't want to deal with her. It's sad when helpless people like this have no one to stand up for them except their nurse! I just don't see his logic here....a readmission is far more costly for a hospital than an extended stay. Especially with how strict Medicare is becoming on what they will or will not pay for.

Well, sounds like you did everything you could to prevent the discharge. The attending sounds like an @$$ and the pulmonologist obviously has no balls and is just as heartless. Since your nurse manager wouldn't do anything, is there someone higher, like a director or chief nurse officer you can report this to? I would think most hospitals would absolutely not want Dr's like this....that's just a law suit waiting to happen!

[CrossCountryRN2008]

Insurance may have driven the discharge. Case managers and MDs talk to the insurance or he could have been more worried about answering to them when he kept her longer.

[imintrouble, BSN, RN]

Some of our pts are so sick they could be inpts in a hospital forever. As it is, we have a few that are admitted at least once a month. Sometimes every other week. Some people are just not going to get better. Or their "better" provides no quality of life.

I think the docs acknowledge futile care, long before the rest of us do.

[HouTx, BSN, MSN, EdD]

I know that it's no comfort to the patient - or probably to the OP - but that hospital will receive ZERO $ for a 2-day readmission. There are significant financial penalties for inappropriate discharges. My advice? Get to know the facility's case managers. They are an excellent resource in cases like the one described by the OP.

[SaoirseRN]

Some of our pts are so sick they could be inpts in a hospital forever. As it is we have a few that are admitted at least once a month. Sometimes every other week. Some people are just not going to get better. Or their "better" provides no quality of life. I think the docs acknowledge futile care, long before the rest of us do.[/quote']

However, then they need to clarify the direction of care because the revolving door of admit, discharge, re-admit is hardly improving quality of life.

[imintrouble, BSN, RN]

However, then they need to clarify the direction of care because the revolving door of admit, discharge, re-admit is hardly improving quality of life.

I agree with you, but pts and family frequently want "everything done" when it comes to code status. Doctors talk to them. Nurses talk to them. They consider "giving up" as failure.

What other options do doctors have? When the pt's best condition is still not good enough to go home, and they refuse to become a DNR.

You can't live in a hospital. Or can you?

[cardiacfreak, ADN]

I know that it's no comfort to the patient - or probably to the OP - but that hospital will receive ZERO $ for a 2-day readmission. There are significant financial penalties for inappropriate discharges. My advice? Get to know the facility's case managers. They are an excellent resource in cases like the one described by the OP.

I agree, ZERO pay, and betcha the pt needed another thoracentesis done too. That was one costly discharge!

[Nascar nurse, ASN, RN]

As a SNF DON, I had a frequent flyer readmit one day where the EMT's wouldn't even take her out of the rig until I went out to accept. One look at the patient & I told them to shut the door & take her right back. (The patient was on a vent within 2 hours of her return).

[edmia, BSN, RN]

This is sort of a ranty long post. . .just a warning :) A few weeks ago I was floated to an "overflow unit" (in other words, a lonely little floor with no real staff or support or manager just sort of shoved in a deep dark crevasse of the hospital) and I had a pretty sick patient. Tons of co-morbidities (DM, CHF, pnuemonia, AMS, hx of cva and about a million more I don't remember). From a SNF. Oh and on contact for EVERYTHING, like things I had never even heard of and had to look up. Picc line, peg tube, foley, oxygen NC. Anyway, so I go in to assess her and turn her (by myself, because on this floor there was no CNA, no charge nurse, no unit secretary - NOTHING, just me and one other nurse. Thank god I only had 4 patients that day because it was primary care, baby!) So I assess her and her lungs sound awful, like she is freaking drowning. O2 sat is 99 on 2L so that is ok. She had had a thoracentesis the day before and they had taken off 1,500cc. Upon further search in her records, she had had a previos thoracentesis 5 days prior where they had removed 1,700cc. She needed to cough but couldn't do it. More than that going on, but you get the picture. So. . .the primary comes in and discharges her back to the SNF! I was shocked, I ventured a "Do you think she is ready? Did you listen to her lungs?? Did you see her labs???" and he just shot me a dirty look and said, "we aren't doing anything for her here, she can go back." and I said, "has pulmonary signed off?" and the MD wasn't happy about that and stalked off. THEN, he returned a few minutes later and rattled off all of his reasons for sending her back to SNF and ended with "she will be back, probably next week, she will be back for sure" and I said, "well then WHY ARE WE DISCHARGING HER??" THEN, I took it upon myself to call the pulmonologist to say, "um, the primary is discharging this patient" and the pulm said "WHAT?!!? I was going to order a follow up chest xray tomorrow and this patient needs aggressive RT therapy that they don't have at the SNF!" so I was relieved and thought maybe the pulm could stop the discharge. ..nope! He sighed and was like "well, if he discharged her, that's his issue" and I was like "NO! please, call him! tell him you want to keep her here!" Nope. No, he just signed off. I even called the primary back and told him what the pulm had said - Nope. So. . .off the patient goes back to the SNF. I felt so so so bad. AND. . .the next week I come back after about 4 days off and the patient's name was still on my list and. . .there she was. . .back after only 2 days at the SNF. . .and this time in the ICU. I hate things like this. I told my nurse manager and she just shrugged her shoulders and was like "well, the patient is very sick" UGH UGH UGH!!!! THEN MY NURSE MANAGER HAS THE AUDACITY TO TELL ME I HAVE A SPECIAL VIP PATIENT COMING TO ROOM XXX AND THE FAMILY MIGHT MAKE A BIG $$$ DONATION AND TO TREAT PATIENT EXTRA WELL. . . !!!!!!!!!!!!!!!!!!!!!!!!!!!!! How do any of us survive this job? (I am going to make a separate post about this lil VIP patient) Thanks for listening! sometimes I just need to "talk" to others who get it.[/quote']

That is so sad for her. In reality, with refractory pleural effusions like that and co morbidities up the wazoo, she's probably hospice eligible. Someone isn't having goals of care talks with this patient or her family if she's not capable of decision making. In my book, that's negligent care. But we're just nurses, right? What do we know?

You tried to do the right thing and everyone just washed their hands of her. Sad indeed. Sorry you had to deal with that frustration.

Sent from my iPhone using allnurses.com

[morte, LPN, LVN]

Oh! Me thinks ya got one good EMT there!

As a SNF DON, I had a frequent flyer readmit one day where the EMT's wouldn't even take her out of the rig until I went out to accept. One look at the patient & I told them to shut the door & take her right back. (The patient was on a vent with in 2 hours of her return).

[Been there,done that, ASN, RN]

You did a good job, trying to talk to LOUSY DOCTOR. In the future, look him straight in the eye and TELL him.. I do not feel it is in the patient's best interest to discharge her. She needs blah blah blah. Be firm and specific.LOUSY DOCTOR may cave.

The patient suffers from pleural effusions that require intermittent drainage. LOUSY DOCTOR can only see that part of the patient's issues and expects her to return every 5 days or so .. he gets his fee.. so why not ?

Your facility does not have a strong utilization management team that should be looking at LOUSY DOCTOR.Re-admissions are the major focus in Medicare reimbursement . utilization management and LOUSY DOCTOR should know this.

(@ crosscountry) As an insurance nurse , I can assure you this was not insurance driven... but LOUSY DOCTOR driven.