Reducing ED transfers from SNF

[HelenaHandbasket]

I am an external evaluator for several SNFs in CT.

I am seeing a disturbing trend in the numbers of patients the facilities are sending to the ED.

In most cases, the patient developed AMS and was sent to the ED. There they were dxd with UTI. Admitted and put on IV abts and IV fluids.

The buildings believe this is good nursing care if the patient is admitted. However, in fact, the hospitals feel a lack of confidence in the facility's ability to care for the patient if they are sending them out for a UTI.

When I worked on the floor (not too long ago!) if a patient developed AMS, I did a set of vitals, dipped their urine and checked a BG. If the urine was +, I would send for C&S, call the MD, report the vitals and results of the dip and get an order for a PO Abt to cover until the cultures came back. If the patient's mental status didn't improve within 24 hours, I'd reassess and send out as needed.

We have the ability to do IV abts, IV fluids, portable xray, IM Lasix, IM Haldol etc in our buildings. In my humble opinion there is a lot more they could be handling in the facility that they are referring to the ED.

How are you guys managing this kind of thing? Is this a QA issue? Our corporation is small and there is no one overseeing the DNS in each building. How does this lowly evaluator present this to the administrators/DNS without them feeling defensive?

[CoffeeRTC, BSN, RN]

Not true..we LTC nurses really could care less about what type of insurance the res has. Also, they would have to have a break in the skilling...most returns to the hosp are due to what the res is already being skilled for.

Yeah, years ago that might have worked.

[Norubit15, ASN, BSN, CNA, LPN, RN]

I totally understand your predicament. I believe that education of BOTH staff and families of the need for the reduction of transfers to the E.D. is key here. Nurses have been educated on the protocols (varies by facility of course) for providing the physician with the S/Sx of UTI and dehydration and have the ability to provide the treatment once ordered. The families and/or DPOA of the resident's do not always understand nor WANT to understand. I have witnessed discussions with family members where the bottom line was that they feel that their loved one would be better served in a hospital. They believe that the attention their loved one will receive is a better ratio than in the SNF. I believe it may amount to staffing at the SNF vs hospitals as their acuity is different.

So...if we can educate the staff and families with the understanding that we have the skills to take care of our residents in the same way (with the same training) as the hospital staff and pointing out that thousands of healthcare dollars would be saved in the process we can potentially turn this current pause in our facility operations around.

Of course, there will always be that one family that requests that their family go to hospital. Recently I had the opportunity to explain to a family that even if a hospital agreed to admit their loved one that hospitals too were under scrutiny for the criteria for an admission and that one day soon something such as a UTI with AMS or dehydration would no longer be a viable admission criteria. The family took pause and agreed to treatment within our facility.

So it may take "baby steps" but through education and perseverence I believe the situation will turn around.

On another note, most SNF's have a medical director that they can call if the PCP is unavailable no matter the time of day or night. If the "on call" physician is advising that all residents be sent out then perhaps they need to re-familiarize themselves with the facility's protocols. If the physician is completely informed of the symptoms my experience is that they will prescribe TX at the facility first and then reevaluate in 24-48 hours time unless otherwise notified. This allows time for labs and other diagnostics to be done on an outpatient basis for review as well.

[SuzieVN]

Not true..we LTC nurses really could care less about what type of insurance the res has. Also, they would have to have a break in the skilling...most returns to the hosp are due to what the res is already being skilled for.

Yeah, years ago that might have worked.

As an MDS Coordinator, it was fairly routine during management meetings to discuss who 'may need' to be sent out, to 'requalify' for skilled care, when the census dropped below the 'red line'. And the nurses NEED to know about insurance coverage- different payers have different pharmacies, ploicies, and etc- not knowing that is a good way to lose $ for the facility.

Other comments on this topic:

- Track what nurses send the most patients out. You may find a pattern, and the pattern may be that that nurse is one the providers do not trust to receive adequate reports from, so they order the patients 'evaluated'. Likewise, your detective work can show which nurse sends the FEWEST- you can then find out what she's doing right?

-One place I worked, the skilled unit was all agency nurses, different staff every day. The primary provider got sick of seeing her patients all crash on the weekends, from lack of continuity- so began the habit of sending a lot of people the ER on Friday evenings, knowing many would 'stick' (be admitted). She really thought she was doing good, and she was an excellent and compasionate advocate, but that habit got her fired from the SNF.