SNFs dumping patients...

[john_boston]

<begin rant>

An increasing and increasingly irritating phenomenon I've noticed among the "skilled" nursing facilities (and one in particular that inspired this post) is dumping patients at the ER for the slightest problem. Of course this is nothing new, just something that seems to be happening more and more frequently for utterly indefensible reasons.

A few days ago we transported a discharge to aforementioned SNF and the MD forgot to note in the paperwork that the patient's IV haldol was discontinued. Instead of calling to clarify the order and saving the extremely infirm pt. an unnecessary trip back to the ER, then back to the same SNF, they called for an ambulance giving a meaningless c/c from the pt.'s PMH. We arrive with x lbs. of gear on our backs only to be told that the patient was to go to the ER because the MD didn't note that the order was discontinued. "So what, exactly, would you like me to tell the triage nurse is wrong with this patient?" "Well, the IV hal--" "I understand that, ma'am. But what is the complaint? I cannot bring someone into the ER who has no complaint." "Well, you ARE bringing her, you don't have a choice..." etc. Sure enough, we transport her back and she gets left on a hallway stretcher for who knows how many hours.

Today, the very same facility pulls the same stunt. This time it's because they claim the pt. we brought to their facility less than an hour before has an NG tube. The pt. had the NG tube in place when we brought her in, nobody had a problem with it until about an hour after we left. When we brought that pt. back to the ER the very same nurse I saw two days before was shaking her head. "I know, it's ridiculous." I said. "No, no," she replied. "They did this yesterday too. Three times this week so far."

I am so disgusted by these facilities calling EMS for "altered mental status" when the reality is the patient would like their diaper changed or to make a telephone call to their family. When they're ignored for hours or days and become quite distressed and nasty the nurses go "Hooray!" and call us for "non-cooperation w/ meds, going in for psych eval." Or if there's a one page of the nursing referral missing, rather than calling and requesting that it be faxed over, why not just dump the pt. first to EMS, then to the ED. The lazy, burnt-out nurses win because now they have less work to do and the EMS service's owners win because they bill (often the taxpayers) $800+ for each of these five-minute rides back and forth between the hospital and rehab/SNF. But the EMS people become demoralized, ambulances are taken off the road, the ERs are overloaded with pts that do not need to be there, and, worst of all, the patients have to suffer the agony of being loaded and unloaded repeatedly, coming in and out of all types of weather, and wondering what the hell is going on the whole time.

It's a scam and a disgusting one at that. And people wonder why our health care system is broken...

</end rant>

[VentMedic]

Lazy nurses?

Do you know how many patients each of these nurses have? One less or one more isn't going to make that much of a difference.

The nurses are also caught in a legal and medical liability issue that damned if they do and damned if they don't. Often they are following predesigned directives by doctors, their superiors, AND your superiors . Since this is also a billing issue check first with your company to see if there are any agreements on the books that you may not be aware of.

Before accusing people of being part of a scam, you seriously must have your documentation very accurate and able to prove your allegations.

Yes, Nurses are jumpy and believe in covering all bases because RNs are not afforded the same immunity from liability as EMTs and Paramedics are.

Unfortunately some NG tubes require X-Ray confirmation. If would be nice if your area offered the service of portable X-Rays or a routine transport truck. But again, check the agreements with your system.

Many of the things you listed can also have a very serious underlying medical cause which can progress quickly and could lead to death in an elderly patient. Maybe you should check out a course on Geriatric Medicine to broaden your knowledge. I lost count at the number of seriously ill NH patients that EMTs/Paramedics have literally dumped on our stretchers while mumbling "BS call".

As an EMT-B you should be looking through the history for other reasons that might warrant why such "simple" things could be a big issue for different patients.

But the EMS people become demoralized,

How do you think the geriatric patient feels to be caught in the middle of the American Healthcare system mess? Or being dependent on others? Do you think they like being a bother? And of course by you arguing with the nurse about taking them to the hospital, the patient probably feels real special.

Assess your patients instead of trying to find fault with other professionals or a broken medical system. Your attitude toward NHs and SNFs may keep you from adequately assessing the patient because you are too busy assessing for fault with others.

[spenac]

Vent play nice. The only one really screwed in this situation is the patient. As to needing geriatric course, that would not hurt any here, but at times BS is just BS. And yes at times BS turns out to be bad. I have seen doctors, nurses, paramedics, really all medical fields say BS at times just to have the patient turn bad. So it is not just us under educated EMS folk.

There are good nursing home nurses and aids just like there are good Paramedics and EMTs in EMS. But in saying that there are bad ones to.

I have seen a nursing home nurse that would dial 911 and report an event that required paramedic response. None of her calls were anything. Patients often were not even removed from the cot at the ER. Doctor would meet us in the ER and send them back. We started noticing it only happened on days a certain medic was on duty. Turned out she had the hots for him. When he was on duty policy was he could not respond to the nursing home unless no other ambulances were available. I feel bad for all the poor old people she abused hoping to see him. Funny thing he didn't even like her.

[sirduke]

One of the problems we have is the nursing homes sitting on patients until they are circling the drain, then calling us.

The other is they call 911 and we rush out there only to find its a direct admit to the floor.

But there are good nurses there who take care of their patients, the balance is about 50/50.

[VentMedic]

Okay I'll be nice but let me give you another example:

EMT-Bs or even EMT-Ps respond to a SNF where labs have already be done by an outside agency. Pt is slightly altered with a Temp of 38 C. Significant labs included a Serum Lactate of 6 mmol/dL.

When patient arived to ED, we had already had copies of the labs with a report from the RN. What we got from the ambulance crew is "Can you believe we got called for a fever of 38?!" They were unfamiliar with labs and the RN did not have the time to explain each value but the EMTs did admit to hearing something about it when asked. So often what is cast as BS can in reality be significant if you look for and listen to. In this case, they just didn't know lab values and that is understandable but shouldn't be taken as BS.

If you ever noticed in the majority of scenarios on the EMS forums, no lab values are mentioned even if they are in the middle of a modern ED. Yet, some believe they can "name that diagnosis" and that is the definitive answer. Lab values are not part of EMS programs but are still valuable tools even if the EMT or Paramedic doesn't study them. Many times the RNs realize what may be askew in a patient by the meds or other sutle symptoms that the Paramedic may not have studied. Thus, they may be working on lab values or the need for further evaluation by diagnostic testing. In other words, it takes a lot of balancing to keep a patient in long term maintenance. That part is not studied in EMS.

Med-Surg nursing is a whole medical science in itself and many good ED or ICU RNs still reflect on those hard days in their career. The nurses that choose to work in long term care facilities take med-surg and geriatric medicine to the Nth degree. Just being responsible for passing out 200 - 400 meds a shift accurately is an amazing feat.

[EMS49393]

I'm going to have to agree with Vent here. Most basics and paramedics have no idea what normal lab values are and have very little education in care of the elderly. Care for elderly patients is different then care for a normally healthy young adult, or middle aged patient. These patients are normally suffering from several life-altering disease processes. For example, a patient that has been a diabetic for forty years may now have kidney damage, be a dialysis patient, have poorly controlled hypertension, non-healing wounds, and a host of other effects. A change in lab values is can be a VERY big deal for these patients.

As for NG tube placement, my question would be was this a feeding NG tube? Did a nurse attempt to use the tube, attempt to withdrawn residuals from it? What if she couldn't feed through the tube, flush, or withdrawn from the tube. How do you know that it wasn't dislodged, broken, or kinked in the time frame you gave? How would you like it if you were told you'd have to starve because it's demoralizing to have a paramedic come take you to the ER for confirmation of NG placement?

Look, I understand both sides of the fence here. It's frustrating to feel that you are dumping on the ER's. It's frustrating to have several nursing home patients requiring total care in the ER at one time. The fact is, most of those nurses have ZIP for free-thinking. They assess and report. The physicians are the people that ultimately make the transport decision for them. They are required to follow their orders under medical direction or face loosing the license they worked hard to get. Critical care and emergency nurses are often afforded pathways to initiate treatment for specific complaints. This is not the case in nursing facilities.

I hear paramedics constantly complain about having to take a patient to the ER for abnormal labs or a fever. Because I work in an ER now, I see those patients, and I know the outcome for them. I'm not going to go in depth in explaining why you need certain levels of potassium, sodium, calcium. I'm not going to explain that a hemoglobin of 5 is a medical emergency. That should be taught in the paramedic program, and if it isn't, then that program sucks. I also shouldn't have to explain how incredibly easy it is for a person that spends most of their day in bed to get pneumonia and become septic in a matter of a few days. Vent would be a better person to explain respiratory pathologies in the elderly.

If you're trying to use the argument that it's uncomfortable for the patient, there is an easy way to fix that. Cover them according to weather. Move them gently. Drive gently. Treat them respectfully and with kindness. Giving them the impression that you are just too important to deal with their problem has to be the most uncomfortable, inconsiderate you could do to them.

Honestly, the typical paramedic doesn't have the education (or freedom) to tell a nurse that their patient doesn't require transport to the ER. A doctor has ordered the patient be transferred, period. Standing there and arguing with the nurse only wastes time, you're still going to have to transport.

[spenac]

Okay I'll be nice but let me give you another example:

EMT-Bs or even EMT-Ps respond to a SNF where labs have already be done by an outside agency. Pt is slightly altered with a Temp of 38 C. Significant labs included a Serum Lactate of 6 mmol/dL.

When patient arived to ED, we had already had copies of the labs with a report from the RN. What we got from the ambulance crew is "Can you believe we got called for a fever of 38?!" They were unfamiliar with labs and the RN did not have the time to explain each value but the EMTs did admit to hearing something about it when asked. So often what is cast as BS can in reality be significant if you look for and listen to. In this case, they just didn't know lab values and that is understandable but shouldn't be taken as BS.

If you ever noticed in the majority of scenarios on the EMS forums, no lab values are mentioned even if they are in the middle of a modern ED. Yet, some believe they can "name that diagnosis" and that is the definitive answer. Lab values are not part of EMS programs but are still valuable tools even if the EMT or Paramedic doesn't study them. Many times the RNs realize what may be askew in a patient by the meds or other sutle symptoms that the Paramedic may not have studied. Thus, they may be working on lab values or the need for further evaluation by diagnostic testing. In other words, it takes a lot of balancing to keep a patient in long term maintenance. That part is not studied in EMS.

Med-Surg nursing is a whole medical science in itself and many good ED or ICU RNs still reflect on those hard days in their career. The nurses that choose to work in long term care facilities take med-surg and geriatric medicine to the Nth degree. Just being responsible for passing out 200 - 400 meds a shift accurately is an amazing feat.

It is hard to include lab values in scenarios when other than when doing transfers labs are usually not available. Myself I respect the efforts of the good nurses and aids, just as I respect the efforts of good Paramedics and emt's. I could site examples where doctors actually read the lab values wrong and wrongly shipped patients, and I caught the mistakes during the transports and was able to give the correct values upon arrival at receiving hospitals. But again I realize that everyone makes mistakes so I am not bragging. I actually thought I was wrong the other day, but I wasn't.

I know you are not meaning that every call that EMS providers call as BS actually is serious patients or have more going on. I'm sure you mean at times that we get blinded and do not do a good exam and thus presume that it is BS and so miss the major issue. I'm also sure you mean that for most EMS providers this is a rare occassion, but sadly there are some bad providers that just don't care or try. I hope I'm right in the above. Just trying to make sure I understand you correctly, because if you don't mean it some where along the lines of the above I will be very disappointed in you.

[VentMedic]

Spenac, I am so not used to your gentler and kinder way of putting things.

The scenarios I was referring to should have had access to a lab since some of them have the patient in the ED. Usually the critical diagnostics can be done at beside and within the first 5 minutes of arrival. Once you cross that threshold out of the "prehospital" phase and want to continue the scenario within the walls of the hospital, anything should become fair game. If not, that is ignoring a large part of medicine.

Just wanted to show that the generalizations in SNFs and nurses can easily be applied to EMTs and Paramedics. My criticisms are for some to get the idea that there is so much more to medicine and even with advanced degrees some of us learn something new each day or at least strive to.

Unfortunately, if RRTs, MDs and RNs make the mistakes you used in you examples, we can be subject to penalties even with the promise of no blame medical error disclosure. It is lucky you did catch the errors.

SNF RNs have a big responsibility and they know their limitations. They don't try to "guess" with patients that are multi-system broken. For some of these patients, you plug up one thing and something else springs a leak. Age is no longer a factor since I have many 30 - 40 somethings that have more extensive histories than the 90+ y/os.

It would be nice if there were more mobile hospitalists and labs to accommodate routine calls but this is the U.S. Right now we do have a few doctors that makes house calls for the well insured.

Yes, there could be better education on some things for SNF nurses but by the time they take their RN CEUs, mandatory recerts, state safety mandatory classes, med refreshers, and etc, they have may easily have over 200 hours invested in education. Except the CEUs and CPR, the others are usually yearly.

I stick up for these nurses because there is not way I would want to do their job. They are treated like rugs even by EMT-Bs who think they know so much more than MDs. SNF nurses do have parameters to function with but again they are trying to view ALL the systems in a LTC patient. That is not easy. In a teaching hospital it will take no less then 15 minutes and sometimes up to 1 hour to review all the data on a complex patient. The complex patients will probably end up in a SNF to finish their recovery or existence.

If the patient doesn't warrant transport, let it go MD to MD. If there is truly a legit complaint against a facility "dumping", let the Medical Staff (MDs) use their channels for investigation. I can tell you they, too, will be cautious with accusations and it is more than protecting one of their own.

[spenac]

Spenac, I am so not used to your gentler and kinder way of putting things.

The scenarios I was referring to should have had access to a lab since some of them have the patient in the ED. Usually the critical diagnostics can be done at beside and within the first 5 minutes of arrival. Once you cross that threshold out of the "prehospital" phase and want to continue the scenario within the walls of the hospital, anything should become fair game. If not, that is ignoring a large part of medicine.

Just wanted to show that the generalizations in SNFs and nurses can easily be applied to EMTs and Paramedics. My criticisms are for some to get the idea that there is so much more to medicine and even with advanced degrees some of us learn something new each day or at least strive to.

LOL. Thanks I think.

You are right though that there is much more to medicine than the small amount of education we get in EMS. Myself I learned much about lab values and meanings on my own because of events in life. Sadly in EMS lab values are barely a mention if at all in most EMS courses, usually it is just mentioned when taught to draw blood as you start IV's. It would be nice to have at least some required basic understanding of what all those numbers mean. I sure realize that I know very little and the more education I get the more I realize I don't know.

Now our OP of this topic though deserves a break. I'm sure that they do treat the patients kindly and gently. So when they get frustrated they find this a good place to vent. I would also bet they realize that not every call is BS or that not all nurses are bad but only like 99.9% of them.j/k

[itku2er]

Well I will say Vent you are doing a great job in explaining what goes on in a SNF. Being a nurse in one it is good to see someone try to stick up for us nurses.

Its easy to say that nurses in SNF are lazy and only want the residents out of the building. Which in some cases may be true but very few are in reality that way. We are with the pateints every day we know what is normal for them and what isnt, but too many times the ambulance crews are quick to judge us because we KNOW when something isnt right with the residents. I run with or have ran with all the providers of EMS that come into the facality where I work, we all have one thing and that is common respect and that goes along way.

John_Boston maybe you and your crews should go to the different facalities in your areas and get to know the personell. I would be a good place to start to understand the reason we do thing and why we do things the way we do them.