Nursing homes questioned about emergency calls

[katgrl2003]

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.

 

[HotelCo]

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

 

[abckidsmom]

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.

 

[HotelCo]

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.

 

[abckidsmom]

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.

 

[JPINFV]

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?

 

[HotelCo]

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.

 

[nemedic]

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

 

[mycrofft]

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.

 

[HotelCo]

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?

 

[mycrofft]

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.

 

[abckidsmom]

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.

 

[mycrofft]

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.

 

[medicstudent101]

:deadhorse:
It's one of those things.

 

[LucidResq]

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?

 

[Akulahawk]

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.

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.

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...

 

[JPINFV]

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

 

[Akulahawk]

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.

 

[JPINFV]

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.

 

[CAOX3]

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.