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.
You absolutely made the right call, IMHO. First of all, the Dr. told you to send him and secondly, you couldn't provide the level of care he needed. Politics or not I would and will do the exact same thing.
Its a shame management wanted to let an elderly man struggle to breathe so they could save a buck.
It was the right call. You were the nurse there, you assessed him, not the DON. I understand what she was talking about, but unless she laid eyes on the resident, it was not her call to make.
A seriously good question (for your DON) is how long would all those other "in house" interventions have taken? Call for x-ray, waiting for x-ray to actually come, get stat antibiotics delivered from a pharmacy, insert IV and administer those antibiotics... X-ray report read??? That could all take a considerable amount of time, meanwhile your patient is short of breath and miserable. As soon as it progresses to respiratory distress, the hospital is choice. What were the oxygen sats?
I don't think the hospital is keeping the patient for revenue. Honestly, in my experience, patients are being discharged earlier and earlier so that more patients can accommodate their beds.
Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.
Your DON is going the way of management and financials, she is not thinking like a nurse. I work in a hospital and trust me, our Case Managers do not let patients just stay for revenue. They are pushing for discharges as soon as possible. You made the right call. A patient with a heart rate of 100, a temp over 100.3, and tachypnea would qualify for sepsis. And even if he could have been "handled" in house technically (which I disagree with), logically he could not. That patient is now staffed with a nurse ratio of about 1:5 while in the hospital. How on Earth could a nurse in LTC with 20 or more patients possibly have the time to adequately handle his illness?
My best advice when in doubt about a decision: Which course of action would you prefer to argue in front of the BON? That usually helps me determine the best route to take. And trust me that the BON does not care about the revenue stream at your facility.
The incomplete orientation you got is not your fault but it is the reason for this admission. How the devil were you supposed to know the facility could do IV abx?
It's hard to believe that no one told you to call DON before doc if it's so danged important to the facility. I wonder what else was left out of your training. Is there an O checklist? That policy should definitely be on it.
Not saying you did wrong. I would have done just what you did. I'm just angry at the O you got.
Day nurse should have given antipyretic and rechecked temp, at a minimum. How long had pt been febrile? coughing? appearing ill? SOB? wheezing?
Your DON is going the way of management and financials, she is not thinking like a nurse. I work in a hospital and trust me, our Case Managers do not let patients just stay for revenue. They are pushing for discharges as soon as possible. You made the right call. A patient with a heart rate of 100, a temp over 100.3, and tachypnea would qualify for sepsis. And even if he could have been "handled" in house technically (which I disagree with), logically he could not. That patient is now staffed with a nurse ratio of about 1:5 while in the hospital. How on Earth could a nurse in LTC with 20 or more patients possibly have the time to adequately handle his illness?
My best advice when in doubt about a decision: Which course of action would you prefer to argue in front of the BON? That usually helps me determine the best route to take. And trust me that the BON does not care about the revenue stream at your facility.
It was the right call. You were the nurse there, you assessed him, not the DON. I understand what she was talking about, but unless she laid eyes on the resident, it was not her call to make.
I have to disagree that it was not DON's call to make. If that's the policy, she could and should make the call. But OP was not oriented to this policy.
Abx could be started before CXR was done or read. Yes, lots of tension and work for OP, I agree. Right to keep pt at SNF? Who can say? If he should not improve or dies, wrong call. otherwise good, I guess. DON and Admin need to instruct their doctors to keep these pts in-house. That said, OP don't ever hesitate to call a doctor. I guess you jjust have to call your DON first. You'd still call doc for further orders.
I don't know what the 'RCM' is, but regardless, I think you did the right thing, considering that you didn't get enough training. I didn't either. My response to numerous questions or 'why didn't you do so-and-so' statements for months and months after I started was 'Nobody told me'. And the fact that he's still in the hospital 2 days later kind of shows you made the right decision too.
Korky, the DON is new to us (but experienced) so I don't think anyone really knew this policy. Two other nurses knew I was sending him and didn't mention calling the DON. As I said, I'm not in trouble, but her saying he should've been kept in house (in a all nurse meeting) made me feel like inside wrong, and I don't think it was wrong.
Also, I was the first to catch the fever. It has been checked by the CNA but I don't think she got it under his tongue because he was confused. Had to check it twice myself because my intuition was telling me he had a fever even though the first reading was 98.5 or something. I honestly think the day shift missed it.
Oh, and O2 sat was around 95, which is why I didn't start him on O2, though another nurse is saying I should have. Probably, but didn't know I could do that without an order, and doc didn't mention it.
Did I mention this was only my second evening shift and I got zero training for evening shift. Apparently some things are different from days but no one told me, even though I asked what is different about evening shift. Argh. I'll get this down though! I am determined to stay until I get good at it.
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...
Well the MD and the paramedic (who actually laid eyes on the res) disagreed with your DNS. They felt he needed to be sent. The first paramedic wasn't even comfortable using standard transport! That says something. If a quick ride in a transport van isn't adequate, then certainly the LTC facility is not. The res ALREADY had the nebs you have at your disposal which didn't work, so I'm not sure why she felt that would have been an option. I'm guessing there are no RRTs on staff in an LTC either, correct? Plus, you and I both know that getting meds sent "stat" from an outside pharmacy will not really arrive "stat."
Plus, what if you had called your DNS but she said not to send the res? You would have needed to go against her instructions, because this res needed to be admitted.
Hospitals don't do unnecessary admissions for revenue. They wouldn't get paid. Say I had a tubal ligation and wanted it reversed; the hospital wouldnt get a dime from my insurance because it's not a medically necessary and therefore not covered. They would have to get paid by me...but most LTC residents are mathematically unable to pay out of pocket for an unnecessary admission. I'm sure you've noticed with your required documentation that Medicare needs lots of ducks in a row to ensure reimbursement.
It wasn't even the transport van, but the ambulance company that refused to transport him (based on their algorithms of the symptoms I described to them)! It probably would've been fine, but they wanted 911 to take him because they have advanced airway capabilities and the ambulance company doesn't.
Next time I guess I will page her, and let her deal with the doc. I'm guessing the doc still would've chosen to send him. If not, I may have to have her or the doc come in and assess the patient themselves so it's not my license on the line if something bad happens.
Glycerine82, LPN
1 Article; 2,188 Posts
You absolutely made the right call, IMHO. First of all, the Dr. told you to send him and secondly, you couldn't provide the level of care he needed. Politics or not I would and will do the exact same thing.
Its a shame management wanted to let an elderly man struggle to breathe so they could save a buck.