Jacke Vance

We all know that if we can get someone to change the way they view something, that they react to that something differently, right? So, what if we got our nurses to rethink unplanned rehospitalization. 

We’ve all seen the panicked, it’s-all-about-me-the-nurse attitude, like “it’s off shift and the patient/resident is experiencing a change of condition and I’m super busy so I just want to get the patient out of here” mindset. 

Come on, we’ve all read “those” notes: Something like, “This nurse went into resident’s room. Resident appears lethargic, stated they just don’t feel up to themselves. This nurse called the doctor on call and asked to send the resident out to the ER. Doctor agreed. 911 called …”

And those of us who read this note are like, “What the what?” Does that nurse own a stethoscope? Even know how to use one? Did it even occur to that nurse to assess the resident, perhaps request labs … ANYTHING?  

What usually doesn’t occur to the nurse is the physical and mental toll a hospital transfer takes on an older or vulnerable adult. What if we get our nurses to treat rehospitalization like a diagnosis of cancer? Older adults who are rehospitalized have a 35% mortality rate within one year after the hospital transfer and 33% suffered from functional decline.

That’s a higher rate of mortality than any single diagnosis of cancer. Think about that! Shouldn’t we avoid transferring people to the hospital if we can treat them in place? Come on, nurses, stop, take a breath, put on your nurse’s thinking cap, and ask yourself, what can I do to treat this patient here? 

How about sending a nurse to the ER just to observe how chaotic it is there? Then ask them to think of their favorite resident, lying on a gurney for eight to 10 hours since nothing is critically wrong with them, and imagine what that is doing to their favorite resident. No food, no water (because they haven’t been assessed yet), no bathroom breaks, etc. It’s physically and mentally horrible.

And, doctors, now I’m talking to you. I can’t tell you how many times I have had conversations with nurses in dozens of states who say that the doctor won’t let them treat in place. Picture this conversation. The nurse reports a suspected pneumonia change of condition in detail via SBAR format. The nurse recommends (yes, the R in SBAR is for the nurse’s recommendation) a stat chest X-ray, STAT labs, IV fluid bolus, whatever. The doctor says, no, send them to the ER.

Most of the time, it comes down to two reasons. The first one, the doctor has patients in 20 nursing homes and doesn’t want follow-up calls. Let somebody else handle it. After all, he or she isn’t penalized by high return to hospital rates.

Then we have the doctor in rural areas with critical access hospitals. It is their jobs to fill the beds at the hospital, and they get a higher reimbursement to do the medically necessary visit at the hospital. In this case, the doctor is incentivized to treat at the hospital and like above, he or she isn’t penalized by high return to hospital rates.

In all cases, it is the patient/resident w paysho the worse price. So, let’s rethink this embrace the power of being a nurse, realize that our patients/residents suffer from transfer trauma, we are mandated to treat in place if possible and put patients first!

Just keeping it real,

Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, Senior Director of Clinical Innovation and Education for Mission Health Communities, LLC and an APEX Award of Excellence winner for Blog Writing. Vance is a real-life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.