Cloudy Urine Emergency-half scenario, half rant

[Riblett]

Here is the scenario:

You are called to the local nursing home for a sick call, emergency traffic.

(You know the type of nursing home, where the residents can be smelled from the front door, no one knows anything about any of the patients, and every staff member just magically arrived at work even at three am. Every patient "just got der." Every nurse is "from dee odda hall." And every patient "ees not my patient." Ok I made my point.)

So you stand at the front door for about 10 minutes. You are starting to wonder, if this was such an emergency that warranted a 911 call and an emergency response, why is no one waiting for you or even coming to the door? When you finally get inside the staff members are sitting around watching CSI Miami and don't seem to know who called you. Finally after a long phone conversation in what sounds like some strange variation of French, they tell you to go to room 303. You have been on scene for about 15 minutes and still have no idea who/where the patient is or what the problem is.

You find a generally well-looking lady sitting in her room watching TV. The nurse aide (or whatever she is) tells you that the patient has had cloudy urine and needs to go to the emergency room. With your best attempt at a straight face you ask if that is why she called 911. Yes. No other symptoms/complaints? Nope, just cloudy urine. Ths little old lady says she does not need to go the hospital, and that she is "just fine thank you very much." In fact, she says she is down right not going and the nurse aide proceeds to tell you that the doctor ordered it "so she has to go."

Great. Right about now you are wishing you were still had your icecream you were eating before this call went out. This lady is fully dressed, ambulatory, and seems to be pretty competent, but she can't seem to tell you the exact year. You look down at her paperwork under the medical history section finding little more than some hypertension, high cholesterol, and then you see the magic word: dementia. What now?

Here is the rant:

Ok, seriously, why are you here? I have no problem helping people who need/want my help. Gone are my days of wanting to run all the codes and traumas. But this seems ridiculous, especially when there is a shortage of units to start with. The lady has no complaints and the supposedly ambulance-worthy symptom is certainly not an emergency. Especially considering there are zero associated complaints, no fever, no mental status changes etc. This patient probably has a urinary tract infection. But what she needs is a urinalysis to confirm it, and some antibiotics. Why this can't be done at the nursing home I don't understand. Maybe someone can enlighten me. What exactly warrants an ER visit? Or even a 911 call?

Do the primary care doctors ever actually see these patients? A urine test and phone order by the MD for some Bactrim or Septra seems like a logical solution. Or even a next day doctors appointment would do. If this lady is taken to the ER she will be using an ambulance that someone else may need. And she will be taking up a ED bed for several hours which is sorely needed by other patients. Then another ambulance will be called to take her back to the nursing home, even though she is perfectly ambulatory because there is no other way for her to get back in the wee hours of the morning.

Maybe I have been reading my grad student co-worker's Healthcare Economics textbook too much, but this seems ridiculous. From a financial perspective this unnecessary ambulance ride is going to cost about $500. Then the ER bill will be anywhere from $3000 to $5000 or more. And the inevitable ambulance ride back will be at least $300. And Medicare will be footing the bill. With this being done around the country hundreds of times a day the country's health care debt is looking more and more like a black hole. Where does it end? When do we start telling nursing homes to stop using EMS as a taxi and the ED as a 24 hour patient dumping ground for even the most minute issues? EMS seems to be the first link in the chain.

I won't lie and say I did not get irritated. I did try to explain why they should not have called 911 for this. I tried to explain to this very dense nurse aide that first off, if she needed a routine transfer done she should have called one of the several contracted BLS ambulance services serving the area. Her response, "a ambalanz be ambalanz." My response, "Um no, an ambulanz do not be an amblanz." and told her why. Secondly, sending this lady to the ER for this was probably a little over the top. A next day doctors appointment would certainly suffice. Some would say it is not my job to educate her about this, that I should have just taken this lady to the hospital (which I did). But what I want to know is, whose job is it? Because they are certainly not doing it.

[Timmy]

I’m in the middle of a 3 months placement in a high care geriatric facility. This is ridicules!

If this was in Australia and I walked into a geriatric facility described as you have my first phone call would be to the Department of Human Services to report the facility.

In Australia geriatric facilities must meet strict government regulations and guidelines in 44 different areas all encumber 80 points which range from how the residences are treated clinically and as a person to how environmental services clean the toilets, no stone will be left unturned. I think it’s every 3 years a facility will be inspected but they may have multiple spot inspections within those 3 years. If you fail to meet these standards, depending on the severity they may give you a warning and set a timeline for review or they’ll shut you down then and there.

A simple urine analysis would be ample for the time being, a quick preliminary dip stick test, a sample off to pathology and a quick set of vitals. Even if she had pain on voiding and other symptoms I doubt this would warrant emergency ambulance transport. I don’t know why they didn’t just make an appointment with the general practitioner. I would like to see the LMOs order for the ambulance.

I’m lucky, our geriatric facility is attached/part of the hospital. We have all the equipment to deal with most problems that may arise and if not we’ll just transport them across the footpath to the acute ward. Our doctors are pretty cool with anything we want to do, we can take a pathology sample, send it to pathology and email the patients doctor who will then send a request.

Its quiet sad to hear what is happening in some facilities. These residences are someone’s loved one, there more than likely going to die in this facility and they disserved good quality care.

I get the feeling there is more to the story, so please enlighten us.

[JPINFV]

In Australia geriatric facilities must meet strict government regulations and guidelines in 44 different areas all encumber 80 points which range from how the residences are treated clinically and as a person to how environmental services clean the toilets, no stone will be left unturned. I think it’s every 3 years a facility will be inspected but they may have multiple spot inspections within those 3 years. If you fail to meet these standards, depending on the severity they may give you a warning and set a timeline for review or they’ll shut you down then and there.

So? I'm willing to bet that any facility, regardless of quality (or lack there of) is completely different during any inspection (announced or otherwise. Word will spread quickly). I was a volunteer at a top notch hospital during my undergraduate when it came time for their accreditation (JCAHO) to be renewed. There was a ton of changes that happened for the inspection (e.g. not propping the door to the medication room that's located in the nursing station, moving the patient's ins and outs record away from the door to their room [privacy issue], etc) that were quickly undone when the inspection team left. Similarly, I imagine that the nurses at sub par nursing homes become experts on their patients when an inspection team is on site. The other 364 days of the year, those patients are some other nurse's patient.

[Just Plain Ruff]

I would bet that the cloudy urine was in a catheter bag that had not been changed for the past 3 - 5 weeks hence the cloudy nasty urine.

[CBEMT]

I have no problem walking out the door, after telling them tocall their private contract ambulance (most of our nursing homes are pretty good about doing that in the first place). Hell, I can even have my dispatcher do it if that's just too much work for them.

[Riblett]

This is a regular day at this facility. As far as the staffing goes. And Ruff, the foley thing is true for like 90% of my patients in nursing homes, but the lady did not even have a foley. That was what was so fishy about it. How would the staff have even known her urine was cloudy?

I don't understand why nursing homes are allowed to get away with using EMS as a taxi and using the ER as their patient dumping grounds. Is there anything that can be done about it?

[Marius357]

If the woman is alert and oriented times four, and has no neurologic disorder, Alzheimer's, Dementia, etc, I would no transport her. Just because they have doctor's orders does not mean anything, Once you get their and assess them they are your patient and you follow your protocols. If the woman refuses to go you can not force her regardless of what the nursing home says.

I do know what you are talking about with nursing homes I see it all the time, but you have to remember that not all the time the people you are dealing with are nurses, especially here in NC. Majority of the time they are med techs who have very little training in medical knowledge, they can only do what the doctor tells them to do. I do agree that alot of times they abuse us but remember if it is an emergency to them we have to take them.

They may have called all of the other services and no one would transport them in a reasonable time frame. Also they may have to go by EMS, in the county I work anything that goes to the ER has to be evaluated by a Paramedic and none of the convalescent units are Paramedic staffed.

[dougd]

[ Why this can't be done at the nursing home I don't understand. Maybe someone can enlighten me. What exactly warrants an ER visit? Or even a 911 call?

I don't know, but I see this exact same situation all. the. time. I always assumed a SNF or an ECF would be able to get some basic lab results back or get a FM consult in the morning. (I mean, my FM doctor can get lab reports back in 24 hours.)

The other one I see all the time is where Facility X gets tired of dealing with Patient Y because he's a pain / moaner / angry / whatever... so they claim altered mental status and want you to ship them off to an ED for a couple of hours of peace and quiet. There's a fine use of Medicaid dollars. :roll:

[celticcare]

Can totally agree and atest to the inspection rounds, and whilst we have a different level of funding and services here in New Zealand, it is still unfortunatly the same thing over and over. But you'll find the homes and other facilities, will spick and span everything, the new gear is pulled out the closet for the inspection and whisked away at the end of it. Its just sad how mentalities and societies work.

I worked in a nursing home as a student nurse for extra cash, we had a lady fall and collapse, all the staff knew I was an EMT and third year nursing student *remember nursing degree is three years here so was in my final year*. Heamatoma to the forehead, disorientated *for a lady who is normally all there* the nurse was flustering like a panicking monkey and so I grabbed the equipment and took over, asked the other nurse aides to help me position her etc and all they were concerned about was changing her diaper because it would make them look bad and got snappy when I said she could have a c spine injury *tingling etc* and said no and just get me the O2 and gear. I was told to leave the room and when the medics arrived *who I worked with* they came straight to me to find out what happened and boy did I get in the proverbial. So I left after that. *Plus after having a choking patient in another nursing home I worked in and performed the hiemlich and asked for oxygen the nurses reply was "We don't want to waste that on her, shes fine" *whilst still cyanosed* and when I went to dial an ambulance got slapped down*

It makes me appalled at times how some *and I say SOME of these homes and nurses as there are some great ones out there* of these places and people work and ashamed at times to say I am an RN how they act and treat patients/clients/residents.

It is a case of ship em off cause they are too noisy or we want a break, but its not on in the long run.

End Rant

[Timmy]

So? I'm willing to bet that any facility, regardless of quality (or lack there of) is completely different during any inspection (announced or otherwise. Word will spread quickly). I was a volunteer at a top notch hospital during my undergraduate when it came time for their accreditation (JCAHO) to be renewed. There was a ton of changes that happened for the inspection (e.g. not propping the door to the medication room that's located in the nursing station, moving the patient's ins and outs record away from the door to their room [privacy issue], etc) that were quickly undone when the inspection team left. Similarly, I imagine that the nurses at sub par nursing homes become experts on their patients when an inspection team is on site. The other 364 days of the year, those patients are some other nurse's patient.

The 44 different areas need to be backed by evidence based practice and data that needs to be presented upon review. The nurse unit manage and her accreditation team work throughout the 3 years to meet these requirements. This is how long it takes to develop what you’re presenting to the review panel and to answer there questions in a certain timeframe. I’m not saying it’s all perfect but it works pretty well. The Department has just closed 2 nursing homes in my state in the last few weeks.