Sending res to hospital- did I make the right call?

[suzw]

So, I'm a brand new RN, with just over a month experience in my LTC/ rehab facility. I had 8 days of training (4 on each floor), which mostly consisted of working with a preceptor. So I know a lot was missed in my training, and I am trying to learn what I've missed, but it gets so overwhelming just trying to keep up. I have 25 patients when I'm on the LTC floor, and 20-22 when I work rehab.

Anyway, I usually work day shift but filled in for someone on evening shift Sunday night. The report I got on one resident was that he'd been SOB with insp and exp wheezes, and she had given him a neb treatment. I go to check on him and he is REALLY SOB and wheezing a lot, with resp 24-28. I give him another neb treatment and it doesn't improve. He is sounding like he is working hard to breathe. Check his temp and it's 101.9, so I page the MD on call. Told him all the symptoms and he immediately advises me to send him to the hospital.

I called transport, and the ambulance company decided his symptoms were too severe for routine transport and advise me to call 911. They actually refused to take him. So I call 911, they come, and the paramedic said he was concerned he may be septic (I never found out if he really was, but that was the concern).

So today in our nurse meeting, the new DNS says we need to call her FIRST when we are sending someone unless it's a dire emergency. She says she is disappointed I sent him because we could've handled it in house, and she could've convinced the doc not to send him. While it's apparently true I could've called for a stat mobile x-ray at 9pm (didn't know that), started an IV and had meds sent stat from the pharmacy, I don't know that treating him in house would've been the safest option. But as I said, I'm a brand new RN and there is a LOT I don't know. What would you do?

To be clear, I am not in trouble and she has not spoken to me personally or expressed dissatisfaction with my performance. Just disappointment at the revenue lost and inconvenience for the family. But did I make the right choice, or no? I hadn't been told we should page her before the doc, but for all I know, there could be a memo about it posted somewhere. It is easy to miss stuff in this place. Btw, the RCM said there was no policy about it that she knew of, but she is new too.

[suzw]

Oh, and BP was normal at 132/74, pulse was high at 100. he had pneumonia and is still in the hospital (2 days later).

[bugya90, ASN, BSN, LVN, RN]

I would've sent him. In LTC there is a lot you can do in house depending on policies, however there is a point where the hospital is the best place to be. With him being there two days already it really confirms you made the right choice. If he would've came back next day then it may have been different, but already admitted two days tells me the hospitalist was concerned and wanted him closely monitored and interventions readily available if needed, which may not have been possible in LTC with 20+ residents.

[chare]

...he had pneumonia and is still in the hospital (2 days later).

I think you answered your question, don't you?

[suzw]

LOL, yes I do think I made the right call, but it was just today in our meeting that she said he could've stayed in house and received IV abx, nebs, O2 and whatever else. But she didn't lay eyes on the patient. I did, and wouldn't have been comfortable caring for that level of acuity along with 20 other patients (one who was actively dying right across the hall). But then again, I'm new...

[suzw]

She says they are only keeping him in the hospital because the hospital wants the revenue. I'm not so sure, but don't know all the politics involved with sub-acute to hospital admissions.

[luvsltcrn]

With the hospitals being penalized financially for patients sent back to the hospital, this will become more and more common. We do the same thing at my facility. I am called before anyone goes to the hospital unless a true emergency. And believe me as a DON we don't like being called all day and all night but unfortunately it is what we have to do to try to minimize rehospitalizations as much as possible.

[CoffeeRTC, BSN, RN]

20 or so years in LTC and I would have sent him too. YES, we do have stat xray services and pharmacy and could start and IV BUT....how long would getting that in place take? In my facility it would be more than a few hours. With it being 9pm already the Xray probably wouldn't have been done and then read until the am. Pharmacy would take at least 3 hours (we have an ebox with some meds) and the IV might not be able to get inserted either.

I love the medics but get a chuckle with how they love to provide diagnosis within 5 minutes. The high temp and sob/ wheezing doesn't always equal sepsis.

[suzw]

Not to mention I was already totally overwhelmed with the dying patient and 10 diabetics, plus everyone else, and being new I wouldn't have know how to get all that going. I already didn't leave until 00:45, and my shift supposedly ends at 22:30. I don't think the DNS was planning to come in to get the IV in and order all the meds. And who is going to read the X-ray in the middle

of the night?

[MedicFireRN]

She says they are only keeping him in the hospital because the hospital wants the revenue. I'm not so sure, but don't know all the politics involved with sub-acute to hospital admissions.

I actually laughed out loud when I read this. As a medic with lots of experience on discharges to skilled nursing/rehab, I can tell you it's like pulling teeth in most place to get the hospital to KEEP patients that shouldn't be leaving. Gone are the days of keeping patients because of the revenue- once they are deemed stable, medicare/caid won't pay for them to stay inpatient. As soon as a doctor thinks they are close enough to stable to go, they're out the door. I have had to adamantly refuse patients because I knew that the place they were going couldn't handle their acuity. "Oh he's baseline febrile, they know about it" ....really? his temp is 103.9, he's pale and his pressure is borderline. Next day I find out that he got transferred back to ICU instead of getting discharged. This is not an uncommon occurrence.

BTW, You made the right call sending the res. Most places do try to handle things in house and that's when we get called 2 days later as the patient is actively circling the drain.

[suzw]

Thank you! As a new nurse, it means a lot to me to have experienced folks like yourselves telling me I did ok. :)

[suzw]

He's 81, by the way, with multiple comorbidities. Not someone who can easily tolerate a 102 fever.