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.
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.
Concern for sepsis was right on. This pt had 3 SIRS criteria elevated temp, HR >90, and RR >20, and suspicion for infection. So I give props to the medics on this one.
Glad the pt got sent out. Your director sounds a bit crazy OP. The hospital would rather send him back if your facility can treat than keep him.
LTC administrators want to treat everything in house, but sometimes you CAN"T. YOU made the right call. You may have saved this man's life. If the man had died in house they would have blamed you for failure to rescue.
Specializes in LTC, assisted living, med-surg, psych.
I would, and indeed have, sent residents out with similar issues. One of my DONs had a rule that we nurses were to call her before calling the doctor, and I always did but ultimately it was MY decision to call the doc and send someone out. And believe me, hospitals do not like to admit frail elderly people, especially those from a nursing home, unless it's totally necessary...most of the time the ER barely looks at them before sending them back to the facility. Your resident was VERY sick or he wouldn't have been admitted. Good call.
I would, and indeed have, sent residents out with similar issues. One of my DONs had a rule that we nurses were to call her before calling the doctor, and I always did but ultimately it was MY decision to call the doc and send someone out. And believe me, hospitals do not like to admit frail elderly people, especially those from a nursing home, unless it's totally necessary...most of the time the ER barely looks at them before sending them back to the facility. Your resident was VERY sick or he wouldn't have been admitted. Good call.
We definitely need something stronger than "like" in some instances
From vintagemother's link, the patient met three criteria for SIRS when only two are needed. temp > 101F, RRs > 20/min, and HR > 90.
Working as a tech in a hospital has also showed me that hospitals are really in the business of flipping beds as quickly as possible. They wouldn't have kept them for... now three days without due cause.
I hope I'm as good of a new nurse as you are when I'm finally a nurse.
Oh yeah, forgot to mention code status, but it was that was the first thing I checked. He is full code, with all interventions.
Not for anything - but even if he were a DNR that doesn't mean you leave him in house and let him die of sepsis. DNR does not mean "do not hospitalize" or "comfort measures only"
Yes I would have sent the resident out too. Especially after speaking to MD. Write up and document a telephone order from the doc indicating resident is to be sent to hospital. As far as change of condition, my facility poliy is to let the "on call RN" aware as soon as practical. The way I see it, it was an MD order to send resident to hospital, and we can loose our license if we fail to obey orders without a reasonable rationale. I'm a newer LTC nurse myself, I get the second guessing. Hang in there.
Specializes in Gerontology, Med surg, Home Health.
Not being there to assess the resident myself....YOU were the nurse who was there. YOU were the one who was responsible for this man's life. YOU made the call you thought appropriate at the time. I worked for a company once where the regional nurse would email me every Friday and tell me I would get a $100 gift card if no one went to the hospital over the weekend. Wow....really? I told her I didn't like sending resident's out for something we could treat in house but I was not going to second guess the nurse who was there in the building with the resident. Turned out I did get a few gift cards because no one had to be sent out....I used them to buy coffee and treats for the nurses who were in the building and taking care of the residents while I had the luxury of being home.
I got 'spoken to' by the administrator last week because I sent a resident out. I am a nurse with more than 30 years' experience. The resident had acute abdominal pain and hypoactive bowel sounds. I assessed her and thought she needed to go. She was diagnosed with kidney stones and acute renal injury and was admitted.
Any DON who wants to be notified before someone is sent out is more concerned with the bottom line than the residents' well being.
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.
We we too have this battle on in house management and I had a nursing supervisor question shipping a resident. I looked at her and said "doc says pt needs to go, he wants pt direct admitted. If you want to disobey a direct order, here's all the paperwork and here's the doctors number. Talk to him. I'm charting you took over care." She decided pt needed to go after all. Inservices have been about minimizing re admissions... How bout don't accept people we can't care for? Don't discharge unstable people? Don't wait until they code to transfer? It's frustrating.
nrsang97, BSN, RN
2,602 Posts
Concern for sepsis was right on. This pt had 3 SIRS criteria elevated temp, HR >90, and RR >20, and suspicion for infection. So I give props to the medics on this one.
Glad the pt got sent out. Your director sounds a bit crazy OP. The hospital would rather send him back if your facility can treat than keep him.