"Don't Send Anyone Out!"

[TheCommuter]

I'm a newer LVN and employed as a weekend-double shift nurse at an upscale nursing home. My weekend RN supervisor has a happy-go-lucky, coolly unconcerned personality. He unrelentlessly picks on some nurses but tends to leave me alone.

He has made it crystal clear that we are to refrain from sending any resident to the hospital unless they are extremely ill. His reasoning is monetary: if a resident spends one week in the hospital being evaluated and treated, then the nursing home will lose one week's worth of money from that resident. Private-room residents pay $6,900 monthly and semi-private residents pay $4,600 monthly. This seems fishy and unethical to me. I usually will send a sick resident out because I want no person to die or worsen under my care. Any thoughts or comments on this issue?

[SilentfadesRPA]

Do you think that sending a gomer to an emergency department equals a higher level of care?

Remember the XIII Law: The delivery of medical care is to do as little as possible.

Please excuse my ignorance but what is a gomer? I am not aware of that word. Does that mean persons in LTF or nursing homes?

Thank you

Marc

[SaderNurse05, BSN, RN]

GOMER= Get Out Of My Emergency Room. I can't remember the name of the book, but basically as best as I can remember it was a term used for patients from nursing homes that were sent to ER and weren't going to get any better.

[fluffwad]

The other side of this argument is that some nurses send folks to the ER inappropriately.............sometimes because they didn't want to be bothered with dealing with the situation. A Skilled nursing facility should be able to deal with temps and low blood sugars. For example: sending someone out to sit in the ER all night for a 101 temp that could have been evaluated there is just thoughtless.

I work in a SNF. Sometimes it's the docs that send them out because they don't feel like being bothered with it.

[ktwlpn, LPN]

I would keep calling the physician whenever the resident's condition warranted...As for the "gomers" they deserve comfort and dignity....I work in LTC. We do not have on-site emergency services of any kind.Often we have to send the resident out to get a prompt x-ray or labs....A visit to the ED is still cheaper then a 3 or 5 day hospital admission because we waited a day for the Mobile Xray company and the resident's condition deteriorated...Usually the resident's families are the ones that push us towards aggressive treatment......Gomer-that frosts my cupcake- especially when you are talking about the LTC population...What age is the cut off? How old do I have to be before I am not "worth" anything? It does not usually refer to a patient that will "never get better" It usually means any pain in the butt patient....Frequent flyers,drug seekers,etc....The residents that I care for in LTC range from their mid 20's to 104- NO,they won't "get better" Things are usually pretty status quo...But they deserve CARE....

[Nascar nurse, ASN, RN]

I personally use my OWN common sense and go from there. There are times I explain to family and dr. that we can start an IV here - get lab here within an hour for a STAT lab, keep res. in familiar surroundings, etc.. when they are not to sick. Also have encouraged this when resident is a DNR and has a sudden severe CVA. Everyone (Dr and family)wants to hurry up and send them out.. for what.. a bunch of test that tell you what you already suspect and results that can't be changed on a 90 year old.

If some other time I can't be sure of .. example severe GI distress vs cardiac (but not crashing), I would go with usual protocol of sending them out if family/dr wants that.

If they are crashing and a full code - the heck with everyone. Calling 911 first and I'll deal with family and Dr. when resident is on the way out the door - rules be damned!

And of course there will always be the Dr. or family (or administration) that does not agree with you opinion of the situation. CYA and document everything!

[TheCommuter, BSN, RN]

Please excuse my ignorance but what is a gomer? I am not aware of that word. Does that mean persons in LTF or nursing homes?

I looked up the definition of g.o.m.e.r. tonight and, in my humble opinion, the meaning is quite heartless.

g.o.m.e.r. - Get Out of My Emergency Room. Term used to identify an elderly patient who is too sick to cure and refuses to die, causing the physician or nurse much wasted effort, time, and material for no good reason. Taken from _House of God_ by Samuel Shem. Also a derisive term for a nursing home patient so far gone with senility that that all he or she can do is sit in a chair or lie in a bed, be fed pureed food, defecate and gather bed sores.

http://www.pseudodictionary.com/G.O.M.E.R.

[achot chavi]

If the patient is under my care, I have the final call on whether to send them out to the hospital. Actually, I need an order from the doctor before sending someone out. This particular RN supervisor simply wants to be informed when we intend to send residents to the hospital with the hopes of persuading the nurses to change their minds and not send the resident out. I hope that made sense.

It is the doctor that calls the final shots.

Document ,Document, Document and do what you gotta do - tell your supervisor that you understand her/his preference but imagine how much money will be lost if the patient dies!!! At least you stand a chance that the patient will recover and be sent back to you to generate more moolah!!!

I hope you have a good relationship with the doctor so that if you feel that you cant handle something she/he will respect your request.

In our facility we have the opposite problem where the FAMILIES all beg us to take care of the problems and not send the patient to the ER where they may sit for hours and go crazy or die. So we try to hold on to 'em unless we really cant do anything!!

Last month a nurse felt something was off with a dementia patient and sent her to the ER- Thank G-d she did as her appendix was about to burst (it burst in pre-op and they cleaned her up) She is currently well and filling a bed by us thereby generating moolah for our facility!!!

[knockandhello]

GOMER= Get Out Of My Emergency Room. I can't remember the name of the book, but basically as best as I can remember it was a term used for patients from nursing homes that were sent to ER and weren't going to get any better.

The book is The House Of God. I remember reading it in the eighties.Quite funny.

[Marie_LPN, RN, LPN, RN]

g.o.m.e.r. - Get Out of My Emergency Room. Term used to identify an elderly patient who is too sick to cure and refuses to die, causing the physician or nurse much wasted effort, time, and material for no good reason.

Wow. The times i've heard GOMER was refering to the pt. that comes in, complains of this or that, yet refuses anything to be done, to which i ask why are you here then.

The above definition is why i will never use the term GOMER again. :angryfire

[leslie :-D]

first time reading this....

as a licensed professional, you have no duty to listen to your supervisor.

your assessment, your judgement, your decision (to pursue more aggressive intervention).

and i cannot emphasize enough, the necessity of thorough documentation; labs, conversations, orders, the whole 9 yds.

gomer my ass. :stone

leslie

[catlady, BSN, RN]

Hah. Ethical issues aside, the nursing supervisor isn't as hip on the economics as he thinks he is. A long-term resident whose stay is covered by Medicaid but has Medicare available will come back as a Med A resident after three qualifying nights in the hospital...which will dramatically increase the revenue to the facility for up to 100 days. Med A is the bread and butter of LTC.

[luvdaisy]

I work in home health and am constantly hearing from the "higher ups" how important it is to keep people from having to go to the ER... "it makes our outcomes and numbers look bad". Of course, our job as home health nurses is to keep people well at home so they dont have to be in the hospital, but it is almost impossible to keep people with heart and lung problems from exacerbating. If someone has a 5 pound weight gain in 24 hours and crackles in their lungs, then I am sorry but they are going to the ER for some IV lasix.