What clinical servcies does your LTC facility provide

[jiggetts45]

With the new guidelines surfacing related to fining hospitals for readmission for same diagnosis within 30 days what clinical services are your facilities providing to build a patrnership with hosptals and to keep residents hospital admissions low. My facility is looking at providing services such as TPN etc Thanks for any input

[CapeCodMermaid, RN]

We are developing a CHF protocol. I am currently writing policies on IV Lasix and IV Solumedrol. We have implemented INTERACT II to try to keep everyone in the building. We do not do TPN because the reimbursement isn't worth the work involved, but I have sent 2 of my RNs to class for PICC and MIDline insertions.

[BrandonLPN, LPN]

I think working toward policies for keeping residents in the facility is wise. Where I work, residents are shipped to the ER at the drop of a hat. We don't even do IV fluids for dehydration. It's a huge expense and it's very traumatic for the poor, elderly residents.

BUT..... I question how a LTC facility can have nurses administer IV push lasix for acute CHF episodes. How can a nurse who has 40 other residents possibly monitor such a sick pt? Aren't you setting her up to fail?

[CapeCodMermaid, RN]

Brandon...it's a process. I am in favor of IM lasix since it works almost as quickly with fewer chances for a castastrophe AND you don't need to have a line established. Our local hospitals are pushing this so the admissions team is too. I just hired a 3-11 supervisor who will be able to spend the time with a really sick resident.

[Aem1215]

My facility does IV Lasix, IV Solumedrol, TPN, maintenance weight based Dobutamine infusions, and maintenance weight based milrinone drips. I know it seems scary, but really it's not as bad as you would think. We take LVADs and Life Vests too. We treat acute CHF episodes all the time. Usually, the person gets a foley temporarily to monitor output while on the IV Lasix. We monitor pulse ox, lung sounds and vital signs while acute. For TPN, I require that the hospital have the complete TPN orders to be by 11 am the day they are coming. They also have to supply me with the confirmation of PICC placement at the same time. We also write a prn order for D10 at the same rate as the TPN in case something happens that the TPN can't run. You have to keep it in house stock. We do labs twice weekly, and if the MD prefers, the pharmacy will adjust the TPN formula based on the lab results. For the Dobutamine and milrinone, we call the weight in to the pharmacy each day to get the daily infusion rate. When we started taking these things into the building, my pharmacy provided me with the drug protocols, so I would suggest talking to them when thinking of doing these things. I review each of these referrals carefully to ensure we can provide the care before they come in. Actually, the Life Vest is the thing that hangs me up the most when considering taking the referral. Life Vest does a good job of selling their product, and even though it says in their literature that the candidate should be alert and oriented and able to care for the vest independently, that is not always the case. I ended up with an extremely confused Life Vest resident once, was walking down the hall and heard the alarm that signals a shock and got to the room in the nick of time to stop the shock. The resident had the pads wrapped around his head. We use the Interact II and care paths.

[NurseGuyBri]

This completely terrifies me, but I know there will be changes soon that I must make. We are in the process of using Interact as well, but I just cannot see the nurses being able to handle these patients. Our current ratio is 30:1 and mixed SNF. I get the shivers thinking about it - Not that the nurses aren't GOOD enough, they undoubtedly are- but it's not fair to them either. I'm in a saturated market and it's hard to get admissions sometimes so I need an edge, I just am clueless at the minute how to do it. That is very scary. Has anyone thought about opening / quartering off a "sub acute" section? maybe 5 beds or so? I don't know. I worked in ICU and love it, but in a facility? Hmmm...

[NurseGuyBri]

Sorry I got off subject :) Clinically, (mixed snf) we offer heavy wound care, behavior monitoring, IV Fluid/ABT, Hypodermoclysis, and some other mild skilled things. Our practitioner is a large group and the one that comes in (other than the MD) is an ACNP, so I'm hoping to foster more things we can do. Im not sure how to go about it

[CapeCodMermaid, RN]

Most of the facilities around here DO have sub acute units. Trouble with this....the staff to patient ratio is still 15 or 20:1, and most facilities mix long and short term together to keep the beds filled, so in one bed you could have someone going into flash CHF and in the other bed someone thinking they're the Queen of Spain and demanding to get the royal jewels. The entire industry AND the insurance companies, including Medicare and Medicaid, need to wake up to how much nursing care our residents really need and how it isvirtually impossible for us to keep people in the facility if they need close monitoring. It's not because we don't have the skills...it's because we are expected to be able to monitor too many residents. Our colleagues in med surg gripe if they have more than 5 patients!