Why do people don't like it when we send resident out?

[ChampRN]

I've been working on a long term care facility for a month now, on the 3rd shift. Recently, a diabetic resident had a rapid decline in condition. Moments earlier, I happened to pass by her room when she was about to go to the bathroom, had a small talk and assisted her. About 10 minutes after, when I was about to give her meds, CNA rushed to the station and reported her vital signs (BP 200/140, Temp 103, Pulse 90, RR 22) and that the resident looked like she was in distress. So I went to her room, did a quick assessment and she told me he felt cold. I checked his blood sugar, it was 300+. I called two of her doctors but did not get a call back, one went straight to voicemail and one had to be paged. After 5 minutes, I called again and still got no call back. All the while, my resident's vitals just kept getting worse, she was dazed and started vomiting small amount of blood. One of the old nurse told me to wait for the doctor and keep her here but my gut told me otherwise and call 911, and so I did. I was worried she might go into a CVA. So she was sent out, I informed the family and finally got a call back from the MD like 45 minutes after. I called the hospital and asked what admitting diagnosis was and was told it's fever but they're still evaluating her. When the day nurse knew about this, she was like "you called 911 for fever?" and got a "pfft" face. ***** What am I supposed to do? Wait for an eternity for a doctor's order? They also always check if someone was sent out first thing in the morning. What I don't get is why ltc people seem to not like it when a resident is sent out? and when am I supposed to call 911 without doctor's order? I used to love coming to work but now that I get to see how politics, bureaucracy and "business" plays out, I can't wait to pack up and leave.

[LadyFree28, BSN, LPN, RN]

The only time I sent two residents out; one was in active a-fib and ended up on a cardizem drip; the other ended up needing chemo...both had very vague symptoms and their Vs were borderline, but I trusted my assessment, and it worked in my residents favor.

The best assessment can guide whether or not you can intervene in house; it is an art that takes time.

[chrisrn24]

Every time I've sent a resident out, with the exception of one, they've been kept at least 2 nights at hospital. I trust my judgement. You did the right thing.

[BuckyBadgerRN, ASN, RN]

I work in a smaller community and am fortunate enough to have MD's that LISTEN to us. Just tonight I had a sweet little lady c/o her arm hurting. Turned out to be more of a tingle sensation. Hand was cool to touch, pulse hard to palpate, weakened grasp, pale in comparison. Called on call MD for her group and he said send her. My f/u call two hours later revealed she had been transferred to a larger hospital for a probable blood clot. It would drive me crazy to not have a call returned for what I knew was a serious situation!

[CMLPN08]

You did the right thing always use your judgement!! Remember it's your license!

[tallafa]

Definitely did the right thing !

[bluegeegoo2, LPN]

Some nurses, believe it or not, get their ego bruised because they didn't get to be the "hero" and send someone in need to be treated. In the last facility I worked in, a nurse found a resident on the floor, left side flaccid, facial droop, etc. Resident was sent out. The resident received acute care quickly enough that the CVA she had suffered left very little residual effect. In fact, she came back to us ambulating as she was before. The DON told the nurse that sent her out that she did a great job, and that the family was very grateful for her quick action. Another nurse on that shift overheard that exchange and had several negative remarks to say about the situation. The very next day, the miffed nurse sent out a resident because "she just doesn't look good." VS were all good, although the resident was a little sleepier than normal. Hospital held the resident for the obligatory 4 hrs, sent her back with a Dx of UTI. (Go figure.) That nurse was angry that the resident was sent back. She wanted her parade as well. Crazy, I know. But there are nurses out there like that.

[HappyWife77, BSN, RN]

Did she have prns ordered for Hypertension or fever? I would have tried those things. And seen if I could have brought those down.

Follow your gut , don't sweat the attitudes of day shift though. Tell them they can make their decisions on their license and you'll make them on your license. Better safe than sorry.

Our local ER doesn't even like taking DNR patients. It's ridiculous sometimes when working professionals want to stick there personal preferences on others care. It's like really.....just because someone is a DNR they should not be treated for anything?

[Nascar nurse, ASN, RN]

I work in a smaller community and am fortunate enough to have MD's that LISTEN to us. Just tonight I had a sweet little lady c/o her arm hurting. Turned out to be more of a tingle sensation. Hand was cool to touch, pulse hard to palpate, weakened grasp, pale in comparison. Called on call MD for her group and he said send her. My f/u call two hours later revealed she had been transferred to a larger hospital for a probable blood clot. It would drive me crazy to not have a call returned for what I knew was a serious situation!

But what is the hospital doing for a clot that can't be managed within your facility? Lovenox injections? A simple trip out for an ultrascan and right back to her own "home" with staff she is familiar with is a much better option (with better long term outcomes) than several nights in a hospital with unfamiliar staff, increased risk for pressure ulcers, increased risk for serious infections & a higher rate of delirium. Not to mention the increased likely hood of getting a foley and a dose of Haldol.

With the OP scenario, I would have likely notified the Dr with a request to try Tylenol to reduce the fever (and probably would have resulted in lowering the b/p) with the parameters to send to ER if b/p went up or more bleeding occurred.

I think the big picture here is, often times we are too quick to say "They're too sick for us to handle" but then we take great offense when our hospital nurse counterparts infer that LTC nurses are stupid. A little critical thinking can go a long ways. ** Disclaimer ** Yes, I'm well aware that some residents need sent to ER without hesitation...I'm ONLY saying often times we really are too quick to send them out.

[amoLucia]

To OP (and others newbies) - sometimes when there is a delay of a call-back by an attending MD, you might be able to go up the physician chain-of-command and call the medical director for SOMETHING SERIOUS. I've had to do so a couple of times but it's usually a last resort. You need to check your in-house protocol (some places want you to call the DON first for further decisions).

The major problem that occurs with calling the med dir is if an associate in the practice is the on-call MD and is notorious for not calling back himself. You're back at Step One! Grrrrrr!

Just another idea for your situation.

[misstrinad]

I see a few things I would Want to clarify before I can give an accurate idea of what I would have done. What she in distress as in uncomfortable or as in respiratory distress and when you saw the pt 10 min before the cna came to you was there absolutely nothing wrong with her and so these symptoms occurred very rapidly? If not in respiratory distress and the bloody emisis was only small amounts I must say I would be inclined to have kept her there and monitored. However if you were not comfortable with that and considering how long it took for the Dr to call back I do feel that you did not do anything wrong.

It is far better to be over cautious than under. You have to trust your judgement when you are the one there. Once I had a pt with out of control aggressive behavior and no matter what we did he continued to pose a serious safety threat to staff and other residents. I had the Dr on the phone telling me to give him a po 0.5 mg ativan first before sending him in despite my explaining that I couldn't get within 8ft of the res without him lundging at me trying to throw me on the floor. The supervisor was luckily on the other phone already having ems come pick him up for transport to er.

[SmilingBluEyes]

You did the right thing>follow your gut, not "old" nurses' reactions. You did right by your resident; feel good about that.

[ktwlpn, LPN]

But what is the hospital doing for a clot that can't be managed within your facility? Lovenox injections? A simple trip out for an ultrascan and right back to her own "home" with staff she is familiar with is a much better option (with better long term outcomes) than several nights in a hospital with unfamiliar staff, increased risk for pressure ulcers, increased risk for serious infections & a higher rate of delirium. Not to mention the increased likely hood of getting a foley and a dose of Haldol.

With the OP scenario, I would have likely notified the Dr with a request to try Tylenol to reduce the fever (and probably would have resulted in lowering the b/p) with the parameters to send to ER if b/p went up or more bleeding occurred.

I think the big picture here is, often times we are too quick to say "They're too sick for us to handle" but then we take great offense when our hospital nurse counterparts infer that LTC nurses are stupid. A little critical thinking can go a long ways. ** Disclaimer ** Yes, I'm well aware that some residents need sent to ER without hesitation...I'm ONLY saying often times we really are too quick to send them out.

Once they hit the hospital the plan of care is out of our hands. It may look like something "simple" but you know the hospital is going to perform the million dollar work up. They have to cover their butts, too.And not too many family members are really going to advocate to get their loved one back to the home asap,in my experience.

I hear what you are saying but we can't forget to factor in the other 30 to 45 resident's whose needs must also be met by one nurse . No nursing home wants to be dinged by the DOH for "delay of care" and if the resident tanks quickly by the time that resident finally does arrive in the ER the staff there starts throwing the home under the bus....and the family screams "neglect"