Reducing ED transfers from SNF

psu_213, BSN, RN · Jun 9, 2011

As an ED nurse, I totally agree with you. When I was an aide, I worked in a SNF, and I know there are some excellent nurses working in LTC. I don't necessarily hold (what I think is) unnecessary ED tranfers against the nurses. For example, an A&Ox3 pt has an acutely AMS. Most likely a UTI (also, possibly dehydration, etc.). RN calls the doctor. Given the 'sue happy' environment in which we live, why would the doctor NOT want the pt sent for a ED evaluation, rather than have them sit in the SNF with an evolving stroke. Pretty unlikely that stroke is the dx., but the MD has to practice defensive medicine.

One other example that I encounted: SNF called in that they were sending in a hypoxic pt to our ED. Found with low sats. When the pt arrives, the paperwork with him says that the pt was found outside, smoking, and had taken his supplemental O2 off. Pt was being sent back to the SNF. I called the SNF to tell the nurse that the pt was coming back, and that his only problems were that he was a lifelong smoker that took his O2 off too often. Nurse says to me, "yeah, well my concern is that his hypoxia is caused by anxiety...maybe your doc could write him a presciption for ativan." Luckly, over the phone he could not see me roll my eyes. :uhoh3: So I mention this to our doc and he replies "and my concern is that they now wasted thousands of dollars on an ambulace trip and an ED evaluation for nothing." (oh, and no ativan script)

I apologize, this was more of a rant than an answer, but considering ED overcrowding, I hope that you get some good suggestions to prevent unnecessary visity.

Chin up · Jun 9, 2011

The way you present this...put it in dollars and cents. They will hear you, just have your facts straight. But agreed, this is a huge problem and I am sure they understand this, but don't know how to rectify. You can put suggestions with your assessment. A large corporation I worked for a few years ago, began SBAR training and the numbers went down dramatically. Peace!

HelenaHandbasket · Jun 9, 2011

Thanks for the replies!

I agree about the "defensive medicine" comment. This is why I always know what I want when I call the Dr.

If we can prove that we practiced prudent medicine ie, we assessed AMS and found UTI, txd it and AMS did not resolve, we further assessed and then sent the patient out who in addition to having a UTI had an evolving stroke, I think we've been effective. :)

I just went to the InteractII site and downloaded bunches of their forms! Excellent resource. I'm not sure if they are tracking ED transfers in the facilities or even who would be doing that. I'll have to find out.

They complain about falling below bed hold and I counter that with "keep the patients in your building!". :yeah:

Chin up · Jun 9, 2011

I have spoken with facility doctors about sending residents to the ER so quickly and all state, they don't like to, it is not in the residents best interest, and it has huge cost. But, they don't have confidence with treating by phone, due to lack of accurate and complete reporting by the nursing staff. I can't tell you how many times I have heard this. Staff training has to become a priority, to keep these residents in the facility where they belong. Why I am a huge advocate of SBAR in LTC. I have seen with my own eyes, the difference it has made. It gives the nurse confidence and eventually becomes second nature. But facilities need to do their part, and train, not assuming all nurses know how to think things through and then report their findings to a doctor. Peace!

goodneighbor · Jun 9, 2011

When a pt has AMS and any other S&S, particularly on Noc, you have to call the physician to advise. At night, you get the on-call who frequently is an intern whose safest bet is to "send them out". So now you have a Dr's order to ED. Also anything reported at night usually results in a "send them" order. As an RN you can suggest/request labs, fluids, Abt, etc. but you run the risk of being accused of "practising medicine" by administration. The order to ED originates with the DR or on-call most of the time, not necessarily the RN. Also the ADON is usually an LVN/LPN and not able to make clinical judgments but able to make administrative judgments. The DON is beholden to the Corporation that is deciding in fear of litigation. I have seen pts sent out to change a Foley catheter, and usually the reason is a SNFs "policy" to change out the cath once a month. Nursing home policies do not always follow CDC guidelines or best practices but vigorously enforce their own guidelines. So, in short, the reason for ED visits is physician-led or corporation-led, I believe. Does anyone have any opinions on this?

fallinnstyle · Jun 9, 2011

As a longtime LTC nurse, I would rather err on the side of 'defensive medicine' than 'would you please tell the court why this resident became septic and died and never got transferred to a higher acute care in time to save her?'

I actually understand where you are coming from, but I do not think I have ever worked a LTC facility where I had ability to 'dip stick urine'. Even if I suspect UTI, I have to call the MD, get the order, collect urine, wait for lab to pick up in the AM, wait till afternoon for results, call MD with results for a script hopefully (many want to wait for C&S to come back before initiating tx), oh,,,then once I have the script, fax to pharmacy and wait for evening/noc med delivery to initial dose.

As you can see, sometimes its not that LTC nurses are unwilling to care for UTI pts, its just that sometimes we feel they will get better and faster assessment and treatment initiation at the ED than we can provide. The way I see it, yes it will cost more, but you get a UA at ED, get results immediately, get a script, start tx and resident is immediately on their way to better health.

Same thing with dehydration. Just coz a LTC has supplies to initiate IVs, doesnt mean that we can. Some nurses havent started an IV since nursing school. Also, we can not monitor electrolytes (same lab issue with UTI, have to get outside lab to come draw and wait for results. No such thing as STAT labs). Anyways, they go to ED, draw labs, bag of IVF started, lytes monitored, fluids adjusted accordingly,,,,etc etc.....

Resident comes back,,,,happy as a clam......with much better looking and smelling pee.....

That is my experience with LTC. We want to provide the best, fastest and most efficient care,,,,but we simply do not have the supplies and access needed. In the end,,,it seems better for the resident to go to ED.

One more thing,,,,,most of the time in off hours when a different MD/NP is on call and is not familiar with the residents, the most likely thing they will say is 'send to ED for further eval and tx'. Defensive medicine at its best. and I don't blame them one bit. There simply isn't much information that you can give a 'blind' practitioner over the phone to risk his license on not sending a resident out..

Sorry this ended up as a novel...

casi, ASN, RN · Jun 9, 2011

As someone said above LTC may have the ability to do these things, but a lot of times getting the labs drawn, sent to the lab, results back, and somebody to start an IV and get IV abx from the pharmacy can take days.

In this matter of days the resident continues to decline. Imagine being the nurse with 30-50 patients trying to deal with someone acutely ill and declining with everything else.

CapeCodMermaid, RN · Jun 9, 2011

Every week I have to send the 'unplanned discharge' report to corporate. One of the things on the report is "what interventions did/have you tried before sending the resident out?" That box used to be blank. Now we try as best we can to keep our residents with us. Every study has shown that residents, especially long term ones, do better in a familiar environment. There are many aspects to this problem: one nurse to 30 or 40 residents. Honestly, even the best nurse doesn't really have time to thoroughly assess a resident who is going bad. The covering docs are covering their behinds. The docs don't realize that we can do IVs, stat labs, and have a huge EKit with many choices of antibiotics. Then there are the families. I, as the DNS, can spend the time talking to them and asking "What can they do at the hospital we can't do here?" They can put someone on a ventilator and give IV lasix or IV solumedrol but other than that.......

We all need to get better at 'catching' changes before they become too bad. Our residents are getting sicker and sicker and we need to be able to care for them in the facility. Those facilities with protocols and means to care for sicker patients will be the ones which thrive. When Medicare is going to take 20% of a payment back if the resident is readmitted to the hospital after 7 days at the SNF, that hospital will send its patients to facilities that can handle sick people.

We signed up for INTERACT which is a study trying to keep residents in the nursing home, but frankly, we're all too busy to take the on line classes.

I've asked the new doc to do teaching and training in assessment skills. I've told the local hospital and most of the covering docs what we can and can not do. In the end it boils down to training, resources, and staffing.

psu_213, BSN, RN · Jun 9, 2011

I don't mean this as a criticism of any person, their post, or thier facility...

But, it seems much most efficient to have supplies to be able to "dip" a urine (it is not difficult at all to do!). If if is negative, then a trip the ED is warrented. If positive, get an order for antibiotics. At the LTC facility where I worked, there was an 'ER box' with a supply of 1 or 2 doses of common antibiotics and other medications. I can never remember a resident being sent out of the facility in the middle of the night because a medication was not availiable to or could not quickly make it to the facility. Also, have the nurses trained (or re-trained) in IV starts. Where I worked, it happened often enough that nurses should not fall out of practice.

Two comments along with this:

1. I know the next response is going to be "why don't we just install a CT scanner and OR suite while we are at it." I'm just trying to post solutions to the problem brought up by the OP. Yes, we could always take it "one step further" to the point of ridiculousness, but these are a fairly quick help to this one problem.

2. I don't want nursing/health care only driven by money. However, with each "unnecessary" trip to the ED by ambulance (whether a LTC resident with a UTI or a middle aged person with a sore throat--yes, it happens all too often) it effects each person fincially, whether through higher prices for insurance or less money in nurses' paychecks.

Finally, for the comment that if the doc on call takes a call at night, they will play it safe and send the resident out...I only work days in the ED, and we seem to get plenty of LTC residents with UTIs.

heron, ASN, RN · Jun 10, 2011

We seem to have missed the point made above about how a single nurse is supposed to work up, treat and monitor adequately a dehydrated resident with a uti which, as we all know, can move quickly to urosepsis ... when s/he is responsible for 40 or 50+ residents with maybe 2 CNA's on night shift.

Standing orders reviewed and signed by the attending MD on admission, emergency stock of the most commonly used abx, ivf and other supplies can help with the logistics if the facility policy is written carefully. IV's can be avoided if the resident is started on po abx and hydration is given with a clysis - much easier to start and maintain than an iv.

I have to wonder, though, about nurses making a differential diagnosis with phone consult with MDs ... risk management might be tricky. You would have to be very careful in defining when in-house initiation of treatment is and is not appropriate.

You gotta remember Murphy's Law ... if badness can happen, it eventually will. In hospice I've taken care of many, many elders whose final illness started with a uti ... usually already progressed to sepsis when they were seen in the ED. Whether the infections were silent until all h**l broke loose or the staff were just too rushed to see the early signs is unclear.

There's a reason these folks are called "fragile".

Great question!!! Would love to see what you come up with.

CapeCodMermaid, RN · Jun 10, 2011

We seem to have missed the point made above about how a single nurse is supposed to work up, treat and monitor adequately a dehydrated resident with a uti which, as we all know, can move quickly to urosepsis ... when s/he is responsible for 40 or 50+ residents with maybe 2 CNA's on night shift.
Standing orders reviewed and signed by the attending MD on admission, emergency stock of the most commonly used abx, ivf and other supplies can help with the logistics if the facility policy is written carefully. IV's can be avoided if the resident is started on po abx and hydration is given with a clysis - much easier to start and maintain than an iv.
I have to wonder, though, about nurses making a differential diagnosis with phone consult with MDs ... risk management might be tricky. You would have to be very careful in defining when in-house initiation of treatment is and is not appropriate.
You gotta remember Murphy's Law ... if badness can happen, it eventually will. In hospice I've taken care of many, many elders whose final illness started with a uti ... usually already progressed to sepsis when they were seen in the ED. Whether the infections were silent until all h**l broke loose or the staff were just too rushed to see the early signs is unclear.
There's a reason these folks are called "fragile".
Great question!!! Would love to see what you come up with.

I agree with everything except clysis. I have NEVER used or seen it used and I've been doing this since the 80's