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.
A doctor gave you an order to send him. To me, it sounds like he was in far too worse shape for you guys to handle in LTC.
At my facility we aren't even allowed to start IVs unless we're giving plain old fluids. No antibiotics or anything else allowed.
I would maybe speak with the doctor and ask him what his opinion on the matter was. I'm sure he would have still wanted him sent out. It sounds dangerous to always call an administrator before sending someone out. I know that my administrator has the ability to give an order TO SEND someone if the MD is unable to be reached. I know that my MD will have our back most of the time when we need to send someone. But for her to say "no, let's treat here"? I would be listening to the doctor and having the administrator call the doctor at that point.
Our pharmacy would take maybe 6 hours to get the med, if we even get it at all before next delivery. We don't have that many meds in house to play with. Yeah we can order a 'stat' Xray. The company we work with can arrive in 2 hours and we can get a read... well... who knows.
All in all I'm pretty sure a funeral would have been a bit more inconvenient for that family.
I wish I'd had all these talking points ready when she made that announcement. She made it sound like we could've started treating him right away, but I seriously doubt we had the right meds. Yes, we can give IV abx, but to do so without a doctor ever laying eyes on him, only a brand new nurse? I think I'm a good nurse, but o don't have nearly enough experience to handle that alone. Does not seem safe. If she ever says anything about it to me again, I am going to politely bring up all the points mentioned here. Thanks!
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.
^^^THIS^^^I've had POAs absolutely refuse a transfer so we attempted to intervene in house. My patient wasn't having breathing issues. The process can and usually does take several hours. If your patient went bad while waiting, I don't see 'my supervisor told me I cannot transfer him' (especially when she hasn't assessed him personally) being considered a valid reason for not sending this patient to the hospital the way he was presenting (and she sure as he'll isn't going to back you up either).
You did the right thing. I also don't believe the hospital is holding him for revenue. From what I've experienced, they are discharged ASAP.
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 disagree in part. What I was referring to is it wasn't the DON's call to make that this is an emergency or not, since she did not assess the resident. Having spent about 10 years as a DON, I do understand what she was trying to get across to the OP, but to question the OP and Dr. in meeting, citing a policy that several nurses had no knowledge of, is in fact wrong, especially since she had not set eyes on the resident.
Am I now playing Monday morning QB, probably, but I usually erred on the side of my nurses when it came to the residents. It is more prudent that way, unless I wanted to work 24/7.
Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
Good call. We used to say, "she in doubt, send 'em out".
The resident does meet SIRS criteria. This is a very serious problem because it has a very high mortality rate if not treated early--like ATB and lots of fluids within 1-3 hrs. A lactic acid and BUN need to be drawn to confirm the severity.
Considering the assessment and the patient load you described, I would have done the same as you. I've worked in LTC also, and I've felt the conflict between doing things that are patient-centered and safety-driven vs what's "financially ideal". It seems to be an ongoing dilemma, and I think it's present to some degree in all settings.
What I personally try to keep in mind is that, while I want to try to do what's best for my facility, my license is my own property and responsibility. The patient comes before the facility needs for these scenarios. If something happened to that resident, unfortunately culpability would have probably fallen on you. You saw a change in acuity and acted to give them more focused care. They were no longer medically stable in my opinion, and to me that means they're not LTC appropriate. An acute change in physiological status calls for an acute care consultation, in my book.
You used your judgment to advocate for the resident's best interests and also protected the quality of your practice. It's much easier to be a Monday morning quarterback and predict the medical course AFTER diagnosis is made. Out would have been hubris for you to just take those two components of temperature and wheezing, and decide it was pneumonia. She hadnt even assessed the patient at the time of the occurrence, so she doesnt have any legitimate basis to say what should have been done before a diagnosis was even made. Where I work, a fever past 101.4 with wheezing/SOB warrants full workup. Blood cultures, xray, CT, BMP, CBC, EKG, trop, and ABGs. It sounds weird and dangerous to me that she'd even want to talk the MD out of their decision to get further evaluation.
I mean, differential dx should be done. Even with a bedside CT, it's not definitive that just seeing infiltrates means only pneumonia. Is there a need to rule out cardiogenic, mechanical respiratory, or nephrological origins? Are they becoming alkalotic with that CO2 blow-off? There's a lot that could have been going on, and we nurses can't decide within our scope of practice that the problem just needs antibiotics, honestly, and you're right to want them moved to a higher level of care.
It seems more like a "preferred" thing for her, but honestly I feel safety should trump preference. Good for you for deciding to go with your gut and stand by your assessment.
I already agreed with sending out the above resident. but I used to see so many unwarrented hospital transfers that I can agree with calling a supervisor or DON before a send out esp if it is a newer nurse.
I've called drs before when I've had residents with a CHF flair up that might have needed a chest xray and increase in lasix or someome with COPD that might have needed nebs ordered. Doc right off the way is saying "send them to the ER" when it can just be a simple med change.
The patient comes first. You were absolutely right to send them if there was any doubt about your capability to handle the situation on your own. If things had gone bad, you would be the one held responsible for NOT sending them. I have dealt with this from both sides on days and nights. In LTC especially, you have to rely on your instincts and the other staff at hand. You will find that as a new nurse, the nurse aides who have been there a while will help you more than anyone if you treat them right.
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.
mander
60 Posts
A doctor gave you an order to send him. To me, it sounds like he was in far too worse shape for you guys to handle in LTC.
At my facility we aren't even allowed to start IVs unless we're giving plain old fluids. No antibiotics or anything else allowed.
I would maybe speak with the doctor and ask him what his opinion on the matter was. I'm sure he would have still wanted him sent out. It sounds dangerous to always call an administrator before sending someone out. I know that my administrator has the ability to give an order TO SEND someone if the MD is unable to be reached. I know that my MD will have our back most of the time when we need to send someone. But for her to say "no, let's treat here"? I would be listening to the doctor and having the administrator call the doctor at that point.
Our pharmacy would take maybe 6 hours to get the med, if we even get it at all before next delivery. We don't have that many meds in house to play with. Yeah we can order a 'stat' Xray. The company we work with can arrive in 2 hours and we can get a read... well... who knows.
All in all I'm pretty sure a funeral would have been a bit more inconvenient for that family.