Preventing return to hospital transfers

Blackcat99 · Oct 30, 2013

At our facility, management gets mad at you if you send someone to the hospital. So nurses avoid it if possible by suggesting that the doctor order stat labs and start IV's instead.

CapeCodMermaid, RN · Oct 31, 2013

We use all the Interact III tools, I developed a risk assessment tool which we use within the first 24 hours after admission to try to determine what may send the person back, and we have a readmission tracking committee in which we review all unplanned transfers to the hospital to determine if we think it was a valid transfer. We started last year....averaged 25 transfers to the hospital of which we thought 19-20 could have been prevented. Last month we sent 15 people to the hospital and thought 14 of them HAD to go. It's a process. All the interact tools are available on their website for free.

Nascar nurse, ASN, RN · Oct 31, 2013

At our facility, management gets mad at you if you send someone to the hospital. So nurses avoid it if possible by suggesting that the doctor order stat labs and start IV's instead.

You probably need a better understanding of everything involved. Why isn't it best for the resident that they stay in their own home with the caretakers they are used to? How many residents have you readmitted with a Foley catheter, new haldol orders, reports of restraints in the hospital, increased confusion and new pressure ulcers that they didn't have when they left....all to treat a UTI that could have been resolved in their home. Why as a skilled LTC nurse can we not predict when we've got a CHF resident going bad again & actually do something about it before they are in actual distress.

We talk out of both sides of our mouth. On one hand we get our feathers ruffled when hospital nurses make us feel inferior because we are "just LTC nurses" but then we refuse to take charge of our residents & act like the skilled nurse we are suppose to be. You shouldn't be doing this so management doesn't get mad but because it's the right thing to do.

(Now with all that said, there are acute & unpredictable changes that occur that requires a hospital transfer - I'm not new at this & I'm passing on the lecture from someone before it starts).

Blackcat99 · Oct 31, 2013

I was always taught "When in doubt, send them out.". I know they were "watching" one of our sick residents. I checked her out and felt she was having some kind of serious cardiac problem. When I sent the patient out my manager got mad at me. She said "We had things under control. You didn't need to send her out". She was in the hospital for 10 days. When she returned I read her ER report. The report said she was having a "heart attack". Now what would have happened if I had not sent her out and she died? The manager would have probably said "What is your problem? Couldn't you see that she needed to be shipped to the hospital?

Blackcat99 · Oct 31, 2013

At my facility, they always say we don't need to send people to the hospital because we can get everything stat here that we need. However, nothing is here on site. They talk about having stat lab available, stat x-ray available and stat pharmacy services available. It's a lie!!! I don't call having to wait 10-12 hours or more being considered "stat". No one actually arrives stat so why are we pretending that stat services are actually available?

LaRN · Oct 31, 2013

I think that avoiding hospitalization when possible is a very good thing, however, in the wrong hands, (and there are many) this could be a serious disadvantage to the patient.

I wouldn't want to be very ill and the decision on whether or not I get the proper care was somehow hinged on the deciding facility getting fined if the powers that be determined it was an avoidable hospitalization

Blackcat, everything you say is true about most of the facilities I've been in. really makes me grrrr when someone admonishes your decisions that they would have probably made themselves. or worse yet, helped you make that decision.

LadyFree28, BSN, LPN, RN · Oct 31, 2013

I have sent people out for good reasons; some I didn't need to...due to a good assessment. :yes:

We do get STAT x-rays, EKGs, dopplers, etc.

One needed a STAT Doppler, received one, found a DVT and was sent out; another pt was admitted and it was discovered that there was lymphoma; I sent the pt out due to the new onset symptoms and my assessment; one of my residents had a new onset bradycardia, got an EKG, new onset with no other changes; kept assessing apical HR; got labs, found out UTI...if the resident was to be sent out without being treated in house, it would've done the resident more harm than good.

Yesterday, I had to give a good rationale of why a resident was having repeated "liquid loose stool" I started looking at trends, and this resident had alternating days with soft stool; I reviewed his orders and it specifically stated to hold his senna if the was an "increase", and he has a history of constipation; there was a suggestion to get stool culture, etc; however, the resident didn't need it; no one held his senna after being told that he had loose stool; the resident has Alzheimer's and depression, and did even said he didn't say anything when the nurses were giving him the senna after having loose stool. We have protocols on loose stool, and because of utilizing lab work, we could tell whether he needed the RIGHT intervention.

In my opinion, good assessment skills, and a good grasp on nursing knowledge (including looking at the little things and seeing the big picture while balancing time management and prioritization skills in a period of time) usually trumps everything else in LTC; most of the time, in house treatment when done the RIGHT way, most residents will not need to be sent out, and the appropriate ones will. :yes:

Nascar nurse, ASN, RN · Oct 31, 2013

I was always taught "When in doubt, send them out.". I know they were "watching" one of our sick residents. I checked her out and felt she was having some kind of serious cardiac problem. When I sent the patient out my manager got mad at me. She said "We had things under control. You didn't need to send her out". She was in the hospital for 10 days. When she returned I read her ER report. The report said she was having a "heart attack". Now what would have happened if I had not sent her out and she died? The manager would have probably said "What is your problem? Couldn't you see that she needed to be shipped to the hospital?

But who taught you "when in doubt, send them out"? In the case you describe above, they did need sent out but for everyone of those there is usually 2-3 more that didn't need to go. Makes me think of a nurse that sent a resident out at 1am because she felt a soft lump in the residents abd. This resident was sleeping & asymptomatic but forced out of bed & across town to get diagnosised with the same hernia she'd had for years. Family & Dr. Not thrilled & made us look like complete idiots.

LaRN · Nov 10, 2013

If the patient is treated in the nursing home instead of the hospital, better hope everything goes well, otherwise the state will cite them for failing to provide the pt with the proper care, proper assessment, etc.

hospitals are set to manage medical problems...everything is in house.. when meds are ordered or changed, there's little or no delay....same thing with labs, xrays, etc...its routine for them. whereas in the nursing home, everything is generally outsourced, no routine, which equals increased time to get needed care.

the nursing home has to be sure they're qualified to manage whatever patient medical problems they decide to take on.

CapeCodMermaid, RN · Nov 11, 2013

The state won't cite you if you provide care. Not everything has a good outcome. People die in the hospital all the time.

LaRN · Nov 11, 2013

CapeCodMermaid that makes sense, but most state rules don't make sense, such as 29292 regulations on pt's rights and individuality, including that the facility provide a home-like environment, but yet if a patient has any personal care items in a shared bathroom, thats a deficiency.

"dying is sometimes unavoidable, unless it happens in a nursing home"