# Nursing homes questioned about emergency calls



## katgrl2003 (May 21, 2011)

http://www.wthr.com/story/14688961/nursing-homes-questioned-about-emergency-calls



> Archer confirms what industry sources tell 13 Investigates. Some nursing homes are calling their hired private ambulance companies for life and death emergencies, instead of 911, whether their crews are the closest or not. They've been doing it for years



The ambulance service mentioned in the article is one I worked for for a few years. This is not news, since I started in EMS, this is how things have been run. I just really don't see anything positive coming out of this article.


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## HotelCo (May 21, 2011)

It's how they do business. They don't have to report private ambulance transfers like they do with 911s.


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## abckidsmom (May 21, 2011)

Off-hours staff at nursing homes stink at making judgement calls.  The trouble is in the staff deciding what is life-threatening and non-life-threatening.

If they started calling 911 more often, the next article in the newspaper might be about how 911 calls from regular people are having a delayed response because the nursing home is "abusing" the fire department.

Or at least that's the way it goes here.

You just can't win for losing, imo.


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## HotelCo (May 21, 2011)

abckidsmom said:


> The trouble is in the staff deciding what is life-threatening and non-life-threatening.



If they're unable to determine a life threatening situation, they shouldn't be taking care of anyone.


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## abckidsmom (May 21, 2011)

HotelCo said:


> If they're unable to determine a life threatening situation, they shouldn't be taking care of anyone.



CNA training is even shorter than EMT and covers completely different topics.  At what point is a fever a life-threatening emergency?  How about a leg wound?  Sacral decubitus?  Even shortness of breath has shades of gray- early pneumonia is not immediately life-threatening, but pulmonary edema can be.

Minimally trained healthcare providers are dangerous to everyone, but they're out there and are going to keep being out there forever, it seems.


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## JPINFV (May 21, 2011)

Wait, you mean respiratory failure secondary to pulmonary edema that is so bad that you can hear it down the road in a patient without a DNR isn't a non-emergent EMT interfacility transport?


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## HotelCo (May 21, 2011)

abckidsmom said:


> CNA training is even shorter than EMT and covers completely different topics.  At what point is a fever a life-threatening emergency?  How about a leg wound?  Sacral decubitus?  Even shortness of breath has shades of gray- early pneumonia is not immediately life-threatening, but pulmonary edema can be.
> 
> Minimally trained healthcare providers are dangerous to everyone, but they're out there and are going to keep being out there forever, it seems.



Those CNAs aren't overseen by an RN? even the crappiest of nursing homes in Detroit have at least one rn on duty.


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## nemedic (May 21, 2011)

HotelCo said:


> Those CNAs aren't overseen by an RN? even the crappiest of nursing homes in Detroit have at least one rn on duty.



While there may be an RN in the facility, it isn't usually near where the issues are. At the assisted care/SNF facility that is a part of the property I work at, there is 1, maybe 2 RNs for the facility(1 of which is the nursing supervisor). There are 6 floors between 2 inter connected buildings, each with an average of 3 CNAs and 1 LPN, with an average of  45-50 patients per floor. So, while they are "overseen" by an RN, it is more often than not an RN that is at least 2-3 floors away


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## mycrofft (May 21, 2011)

*Nursing home will call you for code three if the pt is virtually dead too.*

Then they didn't die in their facility, especially if transfer papers are made out.
We resuscitated a couple of those. One was on a nice tight fitting mask with O2 at 1 lpm. Turning the little green knob clockwise a half turn so the gauge read "10 lpm" did wonders.


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## HotelCo (May 21, 2011)

nemedic said:


> While there may be an RN in the facility, it isn't usually near where the issues are. At the assisted care/SNF facility that is a part of the property I work at, there is 1, maybe 2 RNs for the facility(1 of which is the nursing supervisor). There are 6 floors between 2 inter connected buildings, each with an average of 3 CNAs and 1 LPN, with an average of  45-50 patients per floor. So, while they are "overseen" by an RN, it is more often than not an RN that is at least 2-3 floors away



They don't have the mental capacity to call the RN and ask them what they should do?


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## mycrofft (May 21, 2011)

*No facility would allow an aide or whatever call an ambulance.*

A. Not cheap.
B. Not cheap.
C. Need papers made out, charting, pt eval, family notified.
D. Not cheap.


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## abckidsmom (May 21, 2011)

mycrofft said:


> A. Not cheap.
> B. Not cheap.
> C. Need papers made out, charting, pt eval, family notified.
> D. Not cheap.



I grant you that, but the LPN that's really making the decisions is not much higher up the scale.  

Our local nursing home is a small one, about 50 beds, 1 RN on days, and one LPN per hall (25ish patients) every other time.


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## mycrofft (May 21, 2011)

*I was that RN in my first real nursing job.*

"Reality" is such a slippery concept. Remind me to tell you guys about the time the laundry aide ran away from her husband with the laundry keys in her pocket...

GOOD SNF's (skilled nursing facilities) are so few and far between, expensive, and can slip to "The Dark Side" in a week or two.


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## medicstudent101 (May 21, 2011)

:deadhorse:
It's one of those things.


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## LucidResq (May 21, 2011)

Private/IFT ambulance companies release emergent calls to us all the time. If a nursing home calls them with something like difficulty breathing, they'll just call us (Fire/911 EMS) and give us the call. Anyone else heard of a policy such as this?


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## Akulahawk (May 21, 2011)

abckidsmom said:


> CNA training is even shorter than EMT and covers completely different topics.  At what point is a fever a life-threatening emergency?  How about a leg wound?  Sacral decubitus?  Even shortness of breath has shades of gray- early pneumonia is not immediately life-threatening, but pulmonary edema can be.
> 
> Minimally trained healthcare providers are dangerous to everyone, but they're out there and are going to keep being out there forever, it seems.


From what I understand, CNA training may actually be longer than EMT training, but it covers VERY different subjects. 


JPINFV said:


> Wait, you mean respiratory failure secondary to pulmonary edema that is so bad that you can hear it down the road in a patient without a DNR isn't a non-emergent EMT interfacility transport?


I've seen that waaayyy too many times. 


mycrofft said:


> Then they didn't die in their facility, especially if transfer papers are made out.
> We resuscitated a couple of those. One was on a nice tight fitting mask with O2 at 1 lpm. Turning the little green knob clockwise a half turn so the gauge read "10 lpm" did wonders.


I've heard Nursing staff tell me that they put the patient "all the way up on 3 Liters of Oxygen". I've gotten some stares from the Nurses when I'd take the patient off the NC and put the patient on 15LPM by NRM... with improvement in mentation... I can only guess that the Nurses forgot that we functioned under a different set of protocols than they did...


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## JPINFV (May 21, 2011)

LucidResq said:


> Private/IFT ambulance companies release emergent calls to us all the time. If a nursing home calls them with something like difficulty breathing, they'll just call us (Fire/911 EMS) and give us the call. Anyone else heard of a policy such as this?




It's a system requirement in Riverside County, CA. Personally, I like it. 

http://www.rivcoems.org/downloads/downloads_memos/2009/BLS_Ambulance_Usage_Guidelines.pdf


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## Akulahawk (May 21, 2011)

LucidResq said:


> Private/IFT ambulance companies release emergent calls to us all the time. If a nursing home calls them with something like difficulty breathing, they'll just call us (Fire/911 EMS) and give us the call. Anyone else heard of a policy such as this?


One company I worked for used to screen the calls and if anything came close to a 911 type call, they'd ask the caller if they would prefer 911 instead and sometimes even almost BEG the caller to use 911 instead. Once our crews got on-scene, if they felt that the patient needed 911, they'd make that call themselves... and I've had to do it before several times myself. When I worked ALS IFT, we used the same protocols as the 911 system did, so calling 911 didn't matter as much, however when time to ALS delivery actually was important, calling 911 was usually much faster in accomplishing that goal...

And JP brings up a good point: Most of the systems I've worked in had a timeframe where BLS could take ANYTHING as it was known that it would be faster to transport to the closest ED than for the closest ALS staffed units could arrive. If the load and transport time exceeded that time, ALL BLS crews were to turn the call over to 911.


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## JPINFV (May 21, 2011)

Akulahawk said:


> One company I worked for used to screen the calls and if anything came close to a 911 type call, they'd ask the caller if they would prefer 911 instead and sometimes even almost BEG the caller to use 911 instead. Once our crews got on-scene, if they felt that the patient needed 911, they'd make that call themselves... and I've had to do it before several times myself. When I worked ALS IFT, we used the same protocols as the 911 system did, so calling 911 didn't matter as much, however when time to ALS delivery actually was important, calling 911 was usually much faster in accomplishing that goal...



That's what I like about Riverside's policy. It's not optional. If you call a non-911 provider for, say, low pulse ox or chest pain, it's not an option. That call *has* to be forwarded to the local 911 service. There's no (well, not supposed to be), "Well, just call another IFT" since all of the IFT service" since they all should be referring critical patients to the 911 service. 




> And JP brings up a good point: Most of the systems I've worked in had a timeframe where BLS could take ANYTHING as it was known that it would be faster to transport to the closest ED than for the closest ALS staffed units could arrive. If the load and transport time exceeded that time, ALL BLS crews were to turn the call over to 911.



The problem is how often EMTs are dispatched when it shouldn't. I agree that if an EMT crew gets on scene and transport time is relatively equal or less than paramedic ETA (I'll argue that even if transport time is a few minutes longer than the ETA) that the EMT crew should transport. However, I find it hard to believe that the call-on scene time interval is normally shorter for IFT than it is for paramedics. An IFT EMT crew simply should never be dispatched to a chest pain or altered mental status, or difficulty breathing call if for no other reason than the 911 service should have a shorter response time. 

If a patient needs paramedics, then they need them ASAP, not after an IFT unit clears, responds (non-emergently more often than not), assesses the patient (even if it's a 2 second doorway assessment), calls 911, and then wait for the paramedics to arrive. Everything before calling 911 is a waste of potentially valuable time.


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## CAOX3 (May 21, 2011)

IFT around here is no different then 911 as far as providers go, they can handle emergencies just like everyone else.  If a nursing home chooses to call an IFT truck rather then have and ambulance and four firefighters for a trouble breathing what's the problem, as long as the ETA is reasonable.  Nursing homes begin treatment around here they don't wait for the ambulance to show up to give a breathing treatment or place the person on oxygen.

If the nursing home is accepting extended ETA s and not providing any treatment then shame on them.


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## abckidsmom (May 21, 2011)

LucidResq said:


> Private/IFT ambulance companies release emergent calls to us all the time. If a nursing home calls them with something like difficulty breathing, they'll just call us (Fire/911 EMS) and give us the call. Anyone else heard of a policy such as this?



Oh, you reminded me.  When I was a dispatcher, our company had the contract for all transports within the city limits.  Plenty of times the nursing homes would call for non-emergency transports and we would upgrade them to an emergent response, even adding fire first response if our protocol called for it.

If a nursing home outside of the city called for non-emergent transport with symptoms that would upgrade the call, we turned it over to the county responsible.


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## DrParasite (May 21, 2011)

abckidsmom said:


> Off-hours staff at nursing homes stink at making judgement calls.  The trouble is in the staff deciding what is life-threatening and non-life-threatening.


I can't speak for others, but many SNF's here call the doctor with any issues, and he or she (the MD) determines if the transport company is called or 911.  most staffers can't call 911 unless they get permission from someone higher up than them, for all calls except for a cardiac arrest.

Sometimes the transport company will request ALS based on the nature (before the transport unit gets on scene), but not always.


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## Akulahawk (May 21, 2011)

JPINFV said:


> That's what I like about Riverside's policy. It's not optional. If you call a non-911 provider for, say, low pulse ox or chest pain, it's not an option. That call *has* to be forwarded to the local 911 service. There's no (well, not supposed to be), "Well, just call another IFT" since all of the IFT service" since they all should be referring critical patients to the 911 service.
> 
> 
> 
> ...


Oh believe me, I've had many an occasion where I couldn't agree with you more... In one of the systems that I worked in, the SNF's were quite adept at specifically NOT wanting 911 while providing complaints that vaguely close to what the actual problem was but not so specific that it would throw up an immediate "Call 911, we won't do that" response out of our dispatchers. Consequently, the EMT's that I worked with ended up becoming VERY good at doing Emergency calls. They also got VERY good at reminding the Nurses that 911 should have been called instead without irritating them to the point that they'd cancel our usual transport contracts. 

The upside is that our crews got VERY good at their jobs, to the point where they were the preferred crews if BLS had to run system calls, but the downside was that they shouldn't have gotten the experience because of the way the system had been gamed for so long...


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## JPINFV (May 21, 2011)

CAOX3 said:


> If the nursing home is accepting extended ETA s and not providing any treatment then shame on them.



...and I've had nursing homes leave a patient in bed and wait an hour for a patient in acute pulmonary edema just because they knew that the fire department would only transport to the nearest facility. Unfortunately, this was in the county that doesn't allow private companies to run paramedics, so it was an hour wait for an EMT crew who, in the end, called paramedics and still transported to the nearest facility. 

Then there's the nursing home who sees nothing wrong with a patient who has a pulse in the 30s with severely increased lethargy. Survey says, 3rd degree AV block. Same county, hence EMT transport.


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## JPINFV (May 21, 2011)

Akulahawk said:


> Consequently, the EMT's that I worked with ended up becoming VERY good at doing Emergency calls.


This has nothing to do with the individual ability of EMTs. I used to be the great defender of the IFT faith because my Orange County rose tinted IFT glasses gave me plenty of SNF emergency calls of varying severity, and always without paramedics. There was plenty of people at my first company that I would have no concern putting up against 911 EMTs for medical patients. The problem, though, is not the individual IFT EMTs (however, to be fair, having worked in another state with EMTs who could count the number of emergency runs in a 3 month period on 1 hand, was a scary experience on those rare emergency calls), but the lack of scope of practice needed to treat. I don't care if someone is God's gift to EMTs, if the patient needs a paramedic level intervention (which is not always the case), then the EMT is not the appropriate responder.


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## Akulahawk (May 21, 2011)

JPINFV said:


> This has nothing to do with the individual ability of EMTs. I used to be the great defender of the IFT faith because my Orange County rose tinted IFT glasses gave me plenty of SNF emergency calls of varying severity, and always without paramedics. There was plenty of people at my first company that I would have no concern putting up against 911 EMTs for medical patients. The problem, though, is not the individual IFT EMTs (however, to be fair, having worked in another state with EMTs who could count the number of emergency runs in a 3 month period on 1 hand, was a scary experience on those rare emergency calls), but the lack of scope of practice needed to treat. *I don't care if someone is God's gift to EMTs, if the patient needs a paramedic level intervention (which is not always the case), then the EMT is not the appropriate responder.*


Please, don't think I'm at all disagreeing with you. Our system had been gamed for so long that the County EMSA couldn't conveniently ignore the problems, so they ended up re-writing the BLS utilization protocol so that about 95% of emergency calls out of SNF's that were improperly referred to BLS crews would (in the theoretical sense) be caught and referred to the 911 systems by the crews. Eventually the SNF's got the message and begrudgingly started calling 911 a lot more frequently. A couple years later they also allowed private ALS to operate in the County. They use the same protocols as the regular system units. I'd be completely surprised if the SNF's haven't caught on and started calling the private ALS companies instead of 911... knowing that the call won't be recorded as an emergency transfer out as a 911 call would, while the patient still gets run to the local ED...

Not a fan of that, but that's the way that particular system is set up to be gamed by the SNF's.


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## JPINFV (May 21, 2011)

Don't get wrong, I don't think you're disagreeing with me. The problem with IFT EMTs is that the experience ranges from an emergency once every blue moon to one or more calls per shift, and the ability to handle due to experience becomes quite large, but one that can't be ignored.


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## Bon-Tech (May 22, 2011)

I work PRN as a CNA, and as an EMT I do both 911 and IFT. The main issue, imo, with nursing homes is how understaffed they are. Secondary to that is a seemingly stagnant level of training with their personnel. 

It's not uncommon to have 10 + residents to tend to, and it gets extremely chaotic. There might be LPN's available, but their skill set is usually not much higher and the RN's are either absent or too busy to come help. 

The CNA course is extremely basic, I actually took at the same time as my EMT-B and can honestly say that it was far more of a challenge to get through that (which is not to say much). The sad thing is that being a CNA pays substantially more, but it does suck. My goal with getting it is hopefully landing a ER tech job, for which it is a requirement around here.


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## johnrsemt (May 23, 2011)

Or the patient whose doctor wrote orders for patient to be transported to ED anytime her Pulse ox dropped below 97%:    I live at 94%  I would never get out of hospital.    We would take her 2-3 times a day.   And the nurses knew how stupid it was.

  When I dispatched we had an ECF that would call us, for us to call 911.  If they called they had a bunch of paperwork to do, per the state,  but if we called 911 for them,  NO paperwork.


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## Jon (May 24, 2011)

LucidResq said:


> Private/IFT ambulance companies release emergent calls to us all the time. If a nursing home calls them with something like difficulty breathing, they'll just call us (Fire/911 EMS) and give us the call. Anyone else heard of a policy such as this?


My private service will NOT give an ETA under 30 minutes... but if they accept our ETA, we will send a unit. Management says sometihng about "Medical staff onsite judging the patient is stable enough to wait for our ETA"


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## Shishkabob (May 24, 2011)

1)  Grr, I hate journalists. 



2)  When I worked for AMR in Dallas, we'd often get sent to "Priority 2's" (911-esque calls), however a lot of the time we'd be cancelled enroute due to dispatch contacting DFD instead.  

I know of some agencies, and medics at those agencies, that get cardiac arrest fairly frequently doing these types of calls.



Honestly, though, you're almost better off getting a private ambulance Paramedic in Dallas than DFD...


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## Akulahawk (May 26, 2011)

JPINFV said:


> Don't get wrong, I don't think you're disagreeing with me. The problem with IFT EMTs is that the experience ranges from an emergency once every blue moon to one or more calls per shift, and *the ability to handle due to experience becomes quite large*, but one that can't be ignored.


Of this, we agree.


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