is this typical?

txspadequeenRN, BSN, RN · May 9, 2006

I dont know about ur situation. But I almost fell in the floor when my mother was d/c'd straight out of ICU to home the day after her carotid artery surgery.

I am a student. I had a patient last week who was septic, MRSA pneumonia, C diff+, uncontrolled diabetic, CHF and renal disease. I worked with her on tuesday. She was discharged that afternoon. This woman looked like hell, could barely breath, BG at 481 before lunch, immobile, in diapers, has a subclavian portocath on IV antibiotics, etc etc.
They were sending her to a SNF, but I was somewhat shocked that she was getting the boot from the telemetry unit. Granted she had been in the hospital for a month, so maybe it was an insurance issue. But I just was unaware that nursing facilities take people who are on contact/airborne isolation and are still that sick.
Is that normal? I don't expect people to be happy and perky and wonderful when they leave, just thought they would normally be a bit more stable and not contagious.

burn out · May 9, 2006

I dont know about ur situation. But I almost fell in the floor when my mother was d/c'd straight out of ICU to home the day after her carotid artery surgery.

Likewise I freaked out when they sent my premie grandbaby home , they just took her off all of the monitors and said here you have a healthy baby

take her home.

However, if we kept all the MRSA people in the hospital until they were clean, we would never discharge one of them. The best that you can hope for is that the MRSA has colonized but even still we tend to isolate even then.

C Diff I wonder if the patient hadn't been recultured to show that it was gone. Alot of times we identify an infection and forget to reculture to show that we have cleared up the problem after treating it.

Tweety, BSN, RN · May 9, 2006

Remember SNF, does not mean "nursing home long term care", it's kind of an in-between unit. SNF's nowadays typically take patients that would have been med-surg many years ago, including isolation patients, and the patients are sicker and sicker. This type of patient is probably going to spend the rest of her life in and out of hospitals. Things have switched to wear SNF is like a med-surg unit, med-surg units are like step down units, and ICU is for the sickest of the sick that would have been dead years ago.

Yes, carotid endarderectomies typically spend the night in ICU for monitoring of airway and bleeding, then go to the floor and are discharge the next post-op day, or even discharged to home from the ICU. Crazy isn't it?

NYCRN16 · May 9, 2006

In my hospital this would be typical. This patient would have never gotten a telemetry bed in the first place unless there was a cardiac issue going on, and probably would have been downgraded if a 2nd set of cardiac enzymes were negative. This patient would have went to a med-surg unit and then back to SNF when stablized. Being that she has a portacath, she will be able to recieve IV antibiotics after she leaves the hospital if that is what she needs. I know its hard to understand as a nursing student, but you will see patients like this in and out of the hospital many times over. They are chronically sick, and there is no way to totally "cure" someone like this. You do your best to get them better so they pull through, but they never get better fully.

Daytonite, BSN, RN · May 9, 2006

yes, this is typical. when the patient reaches the point that a nursing home or home health care can provide the services that they need it's adios muchacho. we can all thank the administrators that run the medicare and medicaid programs who came up first with drgs. they just took the ball and ran with it. it is in the best financial interest of the acute hospitals to move medicare patients out as soon as it is safe because they are paid by the patient's diagnosis, not by the services and products they use. the nursing homes are also now under a similar payment system. it recently was instigated, oops, i mean instituted in the outpatient surgical centers. it's coming to physician's offices soon. who says we don't have socialized medicine? ha, ha, ha!

i've worked a couple of medicare hallways in nursing homes over the past few years and never worked so hard in my whole life. i could handle it, but i saw a lot of nurses who went down in flames because it was just too overwhelming for them. those "skilled" patients were sick. they had iv antibiotics, peritoneal dialysis, all kinds of oxygen therapies, and tubes and dressings you could write a book on. i can't tell you how many times we sent patients back to the acute hospital within a day or two. the latest thing is to send patients home to relatives who are willing to help care for them and send in home health personnel to help out. note i said personnel because it's not just nurses. they can send pt, rt, dieticians, and social services out to homes. medicare pays for all this if they qualify. most of the big insurance companies, like sheep, follow suit.

save your money. heaven knows what our health care system is going to be like and cost by the time you are ready to retire.

harley_fan · May 9, 2006

"But I just was unaware that nursing facilities take people who are on contact/airborne isolation and are still that sick."

A lot of people who have MRSA probably got it from residing in a SNF. We put everyone from SNF on isolation because 80% of the time they are infected.

CoffeeRTC, BSN, RN · May 10, 2006

Yes, Yes, Yes. This is very normal. I work in a SNF and we take these type of pts. Half the time they really aren't ready to be Dc'd and yes we do send them back within a day or two. You can only do so much and take care of so many of these sicker pts in LTC. In addition to this person, I also have 20+ pts to take care of and maybe even be charge. You do the math. It ain't fair....these pts take up so much time. Heck on a MS unit you might have 8 or so of these pts and run your ass off.

Its getting more and more common.

cwgirlqtpie · May 10, 2006

You'd be surprised, overall ... at the general health conditions of residents in ltc, especially the ones who are snf. The facility I work in, there is no differentiation between ltc and snf other than the paperwork end of things for the nurses. Of course, I work a medicaid/medicare hallway. None of my 60 residents are private pay .... there is no isolation, and if someone comes back from the hospital with MRSA, they are usually roomed with someone who already has it. Even with that, I have seen it spread to where most of my original pt load of 32 has mrsa. Same with cdiff. It seems on a good day, at least three or four people have diarrhea per hall and we are constantly doing cultures for cdiff. Meanwhile, until a culture comes back they stay on the hall ... when it is confirmed we finally send them out to the hospital for iv antibiotics. Luckily, where I am we rarely do IV's in house. LA state law does not mean that an LPN is iv certified (I am). That is an elected additional 45 hour course. Because it isn't a requirement, and I am one of only 3 or 4 iv certified lpn's in house ... we get lucky and they stay in the hospital till iv's are gone. We aren't even allowed to flush a line. Can you believe? I feel torn ... it's ok to have mrsa or cdiff and stay on the hall ... but not an iv .... go figure!

Dinith88 · May 10, 2006

, just thought they would normally be a bit more stable and not contagious.

Like everyone else has said, yep it's typical. SNF/LTC facilities are (*like everywhere else*) taking sicker people than in the past....again like others have said.

What struck me from your post was your statement about being 'stable'...

Once you're done with school and been a nurse for a bit you'll undoubtedly change your ideas as to what is 'stable' or not. 'Sick' (even VERY sick) is not synonymous with 'stable'.

Also, you're not alone in assuming SNF/LTC residents aren't 'sick'. Thats an unfortunate reality and can result in those who arent 'in the know' (most lay-people) assuming that SNF/LTC work isnt as difficult or complicated. In fact, in my opinion, LTC work can be the most difficult, under-respected, and dangerous (it's been shown that nurses who work alzheimers-type units are at highest risk for being injured by their patients)...i could go on but i think i'm babbling now...

Dinith88 · May 10, 2006

L. 'Sick' (even VERY sick) is not synonymous with 'stable'.
...

woops. meant 'sick is not synonymous with 'unstable''

zacarias, ASN, RN · May 11, 2006

The student mentioned this patient was septic. A truly septic patient would not be discharged from an inpatient unit would they??