Helpful Hints for SKILLED Nursing Facilities

[Dustdevil]

With all due respect Dusty, in my area there are a number of CNA's in facilities that get paid the same, if not less than what the 'ambulance drivers' make.

With all due respect, I didn't say anything about CNAs. :wink:

[katgrl2003]

I had an interesting conversation with a CNA at a local NH. According to state regulations, to be certified as a CNA, she has to also be CPR certified. But at her nursing home, she is not allowed to do CPR. If she does, she can be fired. Tell me if that makes any sense at all.

[VentMedic]

I had an interesting conversation with a CNA at a local NH. According to state regulations, to be certified as a CNA, she has to also be CPR certified. But at her nursing home, she is not allowed to do CPR. If she does, she can be fired. Tell me if that makes any sense at all.

That actually has been a recent argument even in the hospital setting when we were revamping our Code and Rapid Response Team protocols. There is no reason why the licensed people should be the only ones doing CPR. CNAs are very capable of doing CPR. When I posed that question to Nursing Administration "They have other duties". (???!!)

Despite what many EMS workers believe, unless it is a teaching hospital, you don't have a lot of people to respond to Codes in the hospital. Usually 1 RT, 1 CCU RN, RN supervisor (paperwork and administrative) and hopefully the RN who has the patient can break away from her other 10 patients to join us. Rarely can other RNs participate due to their patients' acuities. Hopefully there is another RT is available. But, the ventilators in the ICUs have to be monitored by RT although RTs can usually bend the rules easier then nurses when it comes to emergencies. The Radiology Technologist who shows up for the CODE usually ends up helping with the CPR. We also can not depend on an ER doctor to be available. Since the hospital has an established Code Team with established protocols just like and beyond a Paramedic on the street, there is not a need for the doctor to respond immediately if at all. The medical control for the RN and RT will be directed by the ICU Intensivist.

It has just been part of the nursing culture to exclude CNAs from our training scenarios which for the longest time I have thought to be a mistake. At one hospital they trained the transporters in CPR and utilized them everywhere including the ER. That worked great! They were also the lifting and moving masters especially for the bariatric patients and the Hoya lifts.

We also have hospitals that own free standing nursing homes who have enough ACLS and BLS trained personnel to get the CODE initiated. The hospital then sends their own CODE TEAM/CCT usually consisting of RN/RT and maybe a doctor (teaching hospital - usually senior resident) by way of the Security department's van. An ambulance service is called if transport is needed to the hospital once the patient is stabilized.

And then, we have SNFs inside of or attached to hospitals that must call EMS for a code who then works the code and wheels them to the hospital's ER. I have read the regs a 100 times on that one and am still puzzled. And, heaven for forbid if I am passing by at the time of the code, get things started and intubate while waiting for EMS to catch a slow elevator after arrival. My function as a Hospital Code Team member is to go to the ER and wait for EMS to bring the patient. But, if they don't get an ETT placed in SNF, I can then tube the patient in the ER.

So, healthcare makes little sense in so many areas. Regulations and out of touch administrators have done everything possible to make systems that weren't broken or should run smoothly and turn them into an internal disaster. I have come to realize that I may never become a top level manager because I hate wasting time on the obvious.

SNFs and long term care facilities are usually privately owned (even if State or City owned) and operate on a ridiculously tight budget as mandated from the various reimbursement agencies. It is rare to have ongoing education or much of any additional education except for the initial orientation of who to call for an emergency.

[john_boston]

Here's a few:

1) If a patient is complaining of 10/10 chest pain radiating to her lower back, describes the pain as "crushing" and "worse than anything [she's] ever felt", has a history of angina and a sense of impending doom, don't wait an hour and a half before you call an ambulance because you think she's faking her symptoms.

2) If a urosepsis patient has a GCS of 3 or 4, an irregular pulse, and a BP of 68/34, don't call it in as "high creatinine with increasing lethargy" and decline ALS. Call it in as full blown septic shock and ask for paramedics. They can at least get a monitor and IV going.

3) If the patient is DNR that doesn't mean you don't have to care for them. Also if you want me to honor the DNR/DNI, you should probably have the paperwork.

I could go on but just thinking about this sort of thing drives me nuts.

[triemal04]

3) If the patient is DNR that doesn't mean you don't have to care for them. Also if you want me to honor the DNR/DNI, you should probably have the paperwork.

Actually, there's ER and floor nurses out there that this needs to be explained to.

[paraloco]

I've seen housekeeping doing compressions in a pinch. Security too.

[Doug]

Speaking of DNR's I have had NH staff tell me that the reason they didn't call for patient X is because they have a DNR....um....ok so explain to me how that keeps you for calling for the obvious hip Fx..

[kristo]

I second that comment about EMTs acting like jackasses when they come to nursing homes. Having completed the 4 week "nursing practise" required for 2nd year medical students here, I have witnessed and heard of some eye-opening scenerios, like a nurse (nursing here is 4 years of education post-college) taking shit from an EMS crew for calling them to transport a patient that, in their opinion, could have gone by taxi.

An educated, licensed healthcare provider should NOT have to take that from the EMT-I in the yellow jumpsuit, OR his EMT-B partner, especially if they willingly took that extra shift on the designated interfacility transport ambulance to make some extra cash.

[mstovall]

We have our problems with NHs also. Like today we (a BLS truck) was dispatched on a "schelduled call" for a transport for a direct admit. The patient was schelduled for 2 units of blood. Get patient in the back of the truck and when she is asked about hurting anywhere, she says she has had this chest pain all morning and nobody is listening to her. Arrived at ER in less than 2 minutes. They diagnoes STEMI and had her in cath lab within an hour of us getting her there.

That being said, I have found one thing that has made my life at NHs a lot better. It has taken me about 9 mos, but now I get, "hey I'll be right there to help, I'm printing off a face sheet for you and be there to help you move X to the cot if you would like."

Pray tell what is this secret I have discovered..............................I point out the vitals I have taken on every patient I bring back to them. This lets them know A) I care about the patient I have. I know you are busy and if you want the vitals I took less than 5 minutes ago for your records, here they are. C) We are part of a team.

Karma is rampant...........What you do to others will come back to you. Maybe if we show others we care about X in the NH, they will catch a little bit of it. I take a few seconds and say hi to those I know I have transported that are in the halls. I will give the little old person a short wheel chair ride to clear a congested area (always moving them in the direction they were headed unless it is out the door). i hope someone might take the time for me later in life. I also like the relationships I have built in the different homes.

Like the person posting above..........maybe we should look at how we are acting versus how others are acting.

Michael

[VentMedic]

I got a chance to look at EMS from the other side this past year. I actually had no complaints with the hospital, SNF/convalescent center or the hospice center. The ambulance company on the other hand left me baffled as to where the pride in one's profession has gone.

My mother had to endure 5 ambulance rides (1 ALS and 4 BLS) during the month prior to her death. I have considered forming an advocacy group for nursing home patients who have had to be transported by "bored" and/or burnt out EMTs and Paramedics. Dialysis patients would be welcome to join also.

I think the final act of inconsideration was when I had to pluck the iPod earphones from the EMTs who where "jammin" out while trying to put my mother on the stretcher and not hearing a word about her pain or discomfort. If she had not been in pain from a recent surgery I would have called a taxi because there are many taxi drivers who offer much more consideration when transporting the elderly especially in Florida. I have offered my services to that ambulance company to teach a couple of their EMT recert courses. I may use the day room at a local nursing home for classes and let the residents do the grading when it comes to assessment skills.

Also, you could not pay me enough to be an RN in a nursing home. The patient load and understaffing are bad enough. But, if the RN tries calling the physician for transfer orders and then gets chewed by BLS crew for waiting too long. However, if the RN recognizes early sepsis or AMS and something is not right, bypasses the physician and calls 911 for ALS EMS, he/she will get chewed by the ALS crew for a "BS - BLS" call. There is no winning for the staff at the nursing home. Eventually the RNs that loved geriatric medicine and wanted to make a difference leave and you will find less qualified people willing to work under those circumstances.

For those of you that do care about the patients and recognize other professionals as team mates, don't stop.