We had a patient the other day whose ankle was still hurting after a minor accident the day before. He has already been seen, the splint that was put on bothered him so he removed it. History of previous ankle problems. Our most generous doc was on, he first prescribed percs. Pt refused, he said dilaudid that he got the day before worked the best. He got IM dilauded. He got another x-ray, no fracture. Somewhere along the way, I mentioned about discharge. He said that, oh no, he didn't see how he could manage at home, he expected to be admitted. Middle class, retired guy, by the way, in his 60s, brought in by family member who lives a few blocks away.
He insisted, then, that IV dilaudid is the only thing that would kill his pain. He got an IV, got several doses of dilaudid. Sent family member home saying that he would likely be admitted. I spoke to him of the fact that he doesn't meet criteria, he argued and whined. Doc came and reiterated. He argued and whined. Finally he demanded to speak to administration (3 AM in morning) Nursing Supervisor sent in, 15 minute session with her.
Finally got him out the door, I was amazed! I cooed and sympathized all the way to the lobby where he waited for his BIL. Was so happy to be rid of the unrealistic pest.
When I worked on the floor, I received a pt with a dx of "not feeling too well." On assessment, it turns out....he had no specific issues, just did not feel like going home not feeling well.
Where I work older adults (55+) with sprains or fractures could be held in the ED or admitted for observation while they await placement at a skilled rehab if they cannot safely care for themselves at home. If the patient lives alone and has a fractured wrist or a sprained ankle or they live in a 2 story home or have stairs to get in to the house it would not be safe for them to go home alone. Especially at 3am when its dark and they are tired and a little loopy from narcotics. Having family nearby makes no difference (as far as what services they can get) if the patient is usually independent. The family is not obligated to care for the patient, it is a bonus if they are willing of course but not a requirement, at least in my state.
What if the patient lives in a 2-story condo where the bathroom or bedroom is on the 2nd floor and they fall trying to get there. Anytime someone sounds afraid to go home or worried about how they will care for themselves after an injury I always page social services or case management. They know if the patient will meet rehab criteria or maybe VNA. It covers my behind and the doctors if something were to happen that we consulted someone, it usually makes the patient feel better, and if it turns out they are not eligible for any assistance, they are mad at that person and not you. (Lol jk)
Maybe this guy just wanted dilaudid, who knows but better safe than sorry. He probably did not need inpatient hospital services but maybe he met criteria for a visiting nurse or some physical therapy. A couple of days of inactivity can be pretty detrimental to an older adult especially if they aren't eating or drinking like they should because they can't get around.
The problem is the guy didn't have a fracture, he had some ankle pain . If everybody with a pain is able to be admitted there wouldn't be enough rooms or staff to care for those who are truly injured or I'll.
A sprain is definitely not something a patient should be admitted to the hospital for. I just meant offering for a visiting nurse to check on him once or twice if his insurance allowed. I should have worded my post better initially. At the hospital I work, we sometimes hold off on discharging a patient home temporarily in order to allow for case management to arrange for services at home or through a rehab facility either as an outpatient or inpatient.
The hospital has someone from case management and social services around the clock so it really is not a hassle to have them consult when a patient seems nervous or hesitant about going home - more like "Hey Sally can you see if this patient qualifies for any follow up services. He is really nervous about going home with this ankle sprain and the pain. He is saying he wants to be admitted". Maybe the patient wont qualify for a visiting nurse and doesn't meet criteria for outpatient rehab but he can be put on the list for the follow up nurse to call and check in on him. Sometimes people are told they qualify for a visiting nurse and they decline or when ask if they would like a call from the follow up nurse, they say no thank you and you document what you offered the patient and move on. I am sure this whole process started as a way to improve patient satisfaction scores or something but from what I have seen it really does make a difference.
The hospital has a somewhat similar grant program for ED patients that have certain respiratory conditions and can not afford their meds. Social services can provide them with up to $200 worth of medications for these conditions for 3 months and set them up with an appointment at a clinic to see if there are more affordable medication alternatives. They also offer to assist with helping those not insured with getting insured. I have no idea how long this grant program will last but it has definitely helped cut down on some of our frequent fliers that were coming in for asthma exacerbations because they ran out of meds and could not afford to refill them so maybe they will make it permanent.
Spin off: why do I become so annoyed when someone has a simple lac with simple sutures and I tell them to f/u with a doctor, a walk in clinic, a free clinic ect to have the sutures removed and they tell me 'oh, I'll come back here in 7 days to have em removed'.
Same goes for the peep who demand to be admitted for minor things. That are of course 10/10 pain and they are debilitated lol
The psych nurse in me is just shocked then when he found out he was being discharged he didnt say he wasnt safe to go home, that he felt like harming himself, etc. Many of the patients we get are there originally for a minor ailment and when its time to go...
Where I work in an inner city hospital we have patients who were admitted for things like altered mental status or chest pain observation well they have now been Inpatient without insurance for 3 months They are perfectly fine to go but they have no where to go No assisted living or acute short term care will take them but the Dr's won't send them home alone... It's a huge drain on beds and staff to care for them when they are here only waiting for placement
psu_213, BSN, RN
3,878 Posts
When I worked on the floor, I received a pt with a dx of "not feeling too well." On assessment, it turns out....he had no specific issues, just did not feel like going home not feeling well.