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.

[JesusKeepMe]

You know how we do if we feel a pt isn't getting the care they need despite use advocating for them, we documenr the crap out of that situation. Most times as nurses, documenting is all we can do after going to the ends of the earth for out pts.

I'm not sure how the pt you mentioned could get on hospice, but it seems that he/she surw as heck needs to be on hospice like yesterday.

[KelRN215, BSN, RN]

Who facilitates transfers like this at your hospital? At my hospital, when it came to discharge, doctors did nothing but write the actual order. Our Case Management department would have blocked the discharge. Did the SNF know all the details before the patient was transferred? I can't imagine any of the facilities we used to send patients to accepting a patient in this condition.

[Lev, MSN, RN, NP]

I admitted a patient at the end of the shift. She seemed bad and clearly not ready to be transferred to my floor (Med-surg stepdown with high nurse to patient ratio). She was wheezing on admission and just had that "bad look." Next day, I had her and she is sweating profusely. Take her temperature and draw her labs. Surprise! Temperature spike and elevated WBCs (up 10k from yesterday). Since she was a post op hip, Ortho came to examine the incision site, which was draining, and said it's not otho related. Chest x-ray - changed from day of admission. Possible pneumonia. Not only that, but she has a UTI as well. I come back two days later. The night shift nurse coming off is crying from the load back there. I heard the day shift nurse yesterday was crying as well. "She has no bowel sounds, her abdomen is distended. I gave her laxatives the entire night and two enemas and nothing! I was on the phone with Dr. ____ at 2 am. She keeps coughing up brown stuff and it looks like bile" CT showed post operative ilius. So UTI from Foley and postoperative pneumonia and ilius. This patient does not belong on our floor. Dr. Shows up at 8:30.

Me: "Dr ____ when is Ms. *Smith* being transferred?"

Dr: "What? She's being transferred" (He thought some emergency had happened)

Me: "Well, not yet...She isn't appropriate for our floor. The nurse to patient ratios does not allow us to take care of a patient like her. The nurses are in her room all day and don't have time to see their other patients." He thought I was joking.

Me: "I'm not joking; I'm perfectly serious. She doesn't belong here.

He transferred her!!

Two days later he said. "You were right..that patient is a mess. With the pneumonia and the ilius and she developed C-diff on top of everything"

She was on the surgical unit for 5 days. Now she is back with us and doing so so much better.

Unfortunately, this is a scenario that repeats itself over and over again. Usually they aren't transferred though.

[Yuppers21]

OP - report this incidence to case management, risk management, the bean counters up in accounting or whoever. I assure you, someone will care that your hospital is not getting reinbursed for the second admission. Good luck, what a sad position to be in.

[VivaLasViejas, ASN, RN]

Hospitals' treating patients like hot potatoes does nothing for the SNF's image, either. I do some QA work for my facility and we do our level best to prevent hospital readmissions, but sometimes they come to us in such precarious shape that we wind up sending them back before we get our own readmission paperwork done. This does NO ONE any good, least of all the poor patient.