Transitions of care: Quit blaming us for the bad 'stuff'
You know you're a nurse when ...
OK, so we all know that the pressure ulcers always form in the ambulance on the way back to your facility from the hospital.
And your resident's healthcare acquired infection (HAI) didn't start in the hospital, despite the fact that they HAD to put that Foley in the ER to get that culture (because a straight cath just won't due in a hospital) … and it just happened to get left in for the entire stay (but, of course, the signs and symptoms of the systemic part of the infection didn't show until the resident was back in your facility because it takes 5 to 7 days for that to brew).
And the fact that your resident's albumin dropped to 2.9 because he or she was restrained in the hospital bed since he or she was “confused” and the dietary staff dropped off the food tray and picked it up an hour later — but didn't notice that no one actually fed the poor old soul. No, this had nothing to with the drop in pre-albumin, and now the resident is at risk for a myriad of life threatening downward spirals ...
But it's ALL YOUR FAULT. Bad, LTC, bad!
My point is, we want to do everything we can to prevent transitions because we know that not only are transitions to the acute care setting traumatic emotionally, they can have really severe negative physical and emotional effects. So I thought I would start a blog series about this HUGE issue.
Let's start with the transitions you can't prevent. Do you often get the call from irate ER staff that goes something like, “Why didn't you send us any medical records on this patient?” And you know darn well you or your staff did send medication sheets, treatment sheets, diagnoses sheets, current labs, payor information and progress notes, AND filled out a detailed transfer form and whatever else was pertinent to this transfer.
Or have you ever gotten your resident back from the ER wondering why in the world the hospital staff didn't address what you wrote on the transfer form (the reason you were sending the resident in the first place) and instead returned the resident with (yep, you guessed it) a UTI and dehydration? Don't even get me started on this!
And then you wind up sending the resident back to the ER because the actual problem was never addressed. (Hey, acute care hospital, we're not idiots in LTC, we really aren't. We have actual degrees and everything.)
Like, let me loose on your medical team and I can teach THEM a thing or two about the BUN/Cr ratio in an 80-year-old — "dehydration," my butt!! And have you ever heard of bacteriuria??? AND if I tell you my patient's crit dropped and is vomiting coffee-ground material, investigate that! ... OK, Jackie, just breathe ...
Well, there are a couple of reasons this “stuff” happens. First, did you know that the nurses and the docs in the ER can't see the payor information on your resident? It's to protect the resident from prejudice or being treated according to payor source.
So the information you just sent gets taken to the front desk where it sits for all eternity. Tip No. 1: Place the payor information in one envelope and mark it as such and put all medical records in another envelope and mark it “For ER medical staff.”
Oh, and find out if your emergency transport service needs a copy because sometimes they keep the records for their purposes.
OK, now here's the visionary part for Tip No. 2. I know, I know, I'm a crazy radical, but... how about calling the ER and talking to an ER nurse about your resident and give the hospital a little history?
Maybe check at that time, too, if the medical staff actually got the transfer paperwork and are seeing your resident for the REASON you sent her or him?
We can do this, and if we're treated disrespectfully, get a name and have your medical director call back and go Medieval on them!
There's a lot of free help out there, too. I've mentioned the NTOCC before (that's the National Transitions of Care Coalition, where I represent you). Its site has amazing tools to assist with making transitions smoother. There is also AMDA's free Transitions of Care in the Long Term Care Continuum Guideline, which gives best practices guidance in each phase of transitions.
So let's get this discussion going. I want to hear from you. What are some of your best practices that help make those transitions smoother? Or what do you want to discuss about transitions? Either way, let's get it out there that the problem isn't just one-sided. We need a little bit of communication and cooperation to do what's best for the frailest of the population, the ones we have devoted our lives to, to make that difference!
Keeping it real,
The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC — a real life long-term care nurse who is also the director of clinical affairs for the American Medical Directors Association. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet.