Why did we accept this patient?

[KalipsoRed21, BSN, RN]

So I love the little hospital I’m working at. It is a 25 bed hospital. They are a tertiary outreach facility. So no Trauma certification. They do GI surgeries and orthopedic surgery. They do not have a hospitalist at night, so RNs are left to  asses and recommend action to an on call MD who does not come to the facility....if the patient deteriorated very bad one may go get the ER physician for an immediate in person assessment. 
Now where I’m kinda perplexed and saddened is that I think they frequently do a poor job of evaluating patients for admission and often do not transfer people out who should be. Example:  28 year old comes to ER with seizures. These are new. She had her first one a year ago after giving birth. No other seizures until she came in the ER, had 3 in the ER, was admitted to the floor, had 3 more during the night....we don’t have a neurologist on staff but we do have a telehealth neurologist, but we also do not have the equipment to do further stuff like an EEG. The most we can do is an MRI. So why the hell did they feel she was an appropriate admission? I’ll tell you why. Because we can bill her insurance and as they are asking our NPs and physicians to take a pay cuts along with other reductions in funding, they can’t afford to surpass any revenue. So sad because if we could make the money needed off the more basic patients we do have, this would be a great little community hospital and a valuable resource to a rural community. They are a great resource to a rural community....but due to finances I feel they often take patients they are not well equipped to care for. Another example would be a patient who came through the ER in respiratory distress, was on the verge of needing to be intubated but they were able to stabilize her on bipap...for the moment. Many comorbidities including COPD and a current smoker. Full code, patient did not want to be a DNI. They tried to admit her to the floor. My charge fought hard to say no. We ended up getting out of it because we didn’t accept the patient’s insurance.....but not because we don’t have an ICU? Just very crazy stuff. I have worked there 4 months and there are at least 7 patients I can evaluate like this and go why did we do this? Of course management is like “Well we do have the resources required via telehealth and if they need testing we don’t provide her we will set up appointments where they can get the testing they need then bring them back here. And the respiratory patient was on a bipap, we can take care of bipap patients.” ???? 
In the back of my mind I’m like “ Well if by care you mean let die, then sure.” Medicine is sooooooooo messed up. 

[Hannahbanana, BSN, MSN]

You don't say what state you're in but you might consider going online and looking up your state nurse practice act. I'll bet you'll find something in there that says something to the effect that if you feel your facility can not provide safe adequate care you are obligated to obtain safe adequate care for him or her. If that means calling EMS and getting them the heck out to a real hospital, that that should cover your behind. Document the heck out of it all.

[MD married to RN]

 KalipsoRed21, BSN: Not sure when these patients were admitted. During the peaks of COVID in your area, there just may not have been any place to send them. In such cases, care by you on your floor is much much better than non existent availability at a overwhelmed hospital. And perhaps better than your own ED where people may have been dying in the waiting room for lack of staff to see. The most common cause of seizure presenting to a hospital is sub therapeutic on meds. In that case, on your floor you may be able to control attacks with benzos, keep the patient safe, and load anti-seizure meds during hospital course.

Hannahbanana, BSN, MSN: you said, "If that means calling EMS and getting them the heck out to a real hospital, that that should cover your behind. Document the heck out of it all." With respect, I would consider this a very risky action. This might be considered a transfer. Transfers are covered under EMTALA. If this were to retrospectively found to be an EMTALA violation, the hospital would be subject to investigations from the feds and probably the state. Also, the nurse could be personally liable for initiating the 'illegal' transfer. The fine associated with this action is $50,000 which is not covered by malpractice or any other insurance. 

[Hannahbanana, BSN, MSN]

Please do correct me if I'm wrong, but EMTALA isn't designed to prevent an appropriate transfer to a required higher level of care. I grant you that you have to arrange such a transfer in advance c the receiving facility, and COVID may monkey-wrench the best of intentions in that regard. But I wouldn't like to have to justify keeping somebody we're clearly not capable of providing std of care to just because a bean-counter says so. 

[JKL33]

12 hours ago, Hannahbanana said:

Please do correct me if I'm wrong, but EMTALA isn't designed to prevent an appropriate transfer to a required higher level of care.

That's true. There's no problem in properly executing a transfer to a facility that has resources the sending hospital doesn't have. However, the OP did state that in the latter case the hospital ended up not admitting the patient at their facility supposedly because of they didn't accept the patient's insurance. That is going to get dicey very quickly, especially if admin is going to stand around proclaiming that they do have the resources to handle the patient.

[Hannahbanana, BSN, MSN]

9 hours ago, JKL33 said:

However, the OP did state that in the latter case the hospital ended up not admitting the patient at their facility supposedly because of they didn't accept the patient's insurance. That is going to get dicey very quickly, especially if admin is going to stand around proclaiming that they do have the resources to handle the patient.

Yes indeed. EMS should have a good idea of whether the local shop is capable and do their own sort of triage in cooperation c their radio control en route. However, in the case of a borderline decision, or deterioration in the ER or elsewhere, the administration should be willing to accept nursing judgment on whether or not a patient should be transferred (with the usual contacts to the receiving facility) and should have an explicit policy for dealing c this sort of situation.

[KalipsoRed21, BSN, RN]

So the patient that was having seizures had never been on seizure meds or evaluated by a neurologist. We were unable to get her seizures under control and when she finally was seizing every 5 to 10 minutes we FINALLY transferred her. As COVID was not peaked in my area or the nearest city with a large hospital, I do not feel that was the justification for not transferring her. Unfortunately Hannah, while I agree that there is probably something in my nurse act to justify such action, there are no other job opportunities in this area and as I am the breadwinner for my family I cannot loose my job. There is always the argument that I or other staff I work with could loose our license for not doing best for the patient. But honestly what I have to say to that is nurses are the scapegoat either way. You stand up for the patient you will be fired and blackballed in your area, you choose to continue to work under crappy policy and practice and something happens, the very first thing they do is blame the nurse, fire him/her and then the board takes away your license for poor practice. Does upper management and CEOs ever suffer consequence for the poor policy and  impossible situations they create? Nope. They just have to resign early. Boo,***ing, hoo. I’m done trying to change the world for the better. I’m just going to support my family and hope for the best for everyone else.