SNF Refusals

[MedicPrincess]

I seem to have a "high" refusal rate at our SNFs and ALFs. In the past 3 months, I have taken 5 refusals at these types of facilities.

Today the staff met us stating the pt has has an "acute onset" of AMS, beginning x3 weeks ago. She has begun to wander into other residents rooms, go through their things, refuses to go to her room, refuses to take meds, ect. They finally contacted their physician who instructed them (no surprise here) to call EMS.

On our arrival, the pt is found to be walking up and down the halls. She is pleasent, CAOx4, refusing transport by EMS. VSS, no complaints. I explain to her why we were called and she tells me essentially she does get confused at times, but she is "working on it." I spend a few minutes talking to her, attempting to convince her to come with us "to make everyone happy" and she continues to refuse.

The staff is wanting her to be placed under baker act (involuntary psych) d/t the above mentioned. After explaining those are not Baker Act criteria, however they could go to court and attempt to have her placed under a Marchman Act, we reach the point where I tell them we will not be transporting her against her will.

Each time I have done this, I always call our MD as I completely understand their situation. They have orders from a physician to send her to the ER. We are not about to wrestle this LOL down and tie her to our stretcher. And each time our MD backs me up and says don't transport, but if they would call us when the pt really is altered, we'd be happy to take'em.

Do you guys have a policy/protocol specifically regarding refusals at SNF's/ALF's? Have you been in the fairly awkward position as to not transport from these facilities? Its always slightly on the tense side, as the nurses are just beside themselves that we would refuse to transport when their Dr says to send them out. I always end up spending a little extra time explaining to them our position and what they can do (usually it is call us when the patient IS altered....dont wait hours/days/weeks).

 

[KEVD18]

in ma there are only two ways you can transport a patient:

voluntarily- self explanatory

involuntarily- this can be done one of two ways. if they are altered and pose a significant harm to themselves or others we can take them if they say no. logic being that an altered person cant reasonably refuse treatment. the other is by what we call here a section 12(referencing MGL C123s12a) which is an involuntary psych order. it can be signed by a doc or a police officer.

bottom line for me is if they are caox4 and dont want to go, they stay. i dont kidnap people, which is important to say because some people ive worked with do. but give me a pink slip(section 12 orders are printed on pink paper) and thats another story.

 

[mdtaylor]

A refusal is a refusal and the only thing that can change the terms of it is when the pt is a minor. ALF, SNF, or the ball park, the location makes no difference.

 

[VentMedic]

A Marchman Act is a means of providing an individual in need of substance abuse services with emergency services and temporary detention for substance abuse evaluation and treatment when required, either on a voluntary or involuntary basis.

http://www.fadaa.org/services/resource_center/PD/WebEx/MarchmanAct.pdf

http://www.dcf.state.fl.us/mentalhealth/marchman/marchmanacthand03p.pdf

Baker Act

The Baker Act allows for involuntary examination (what some call emergency or involuntary commitment). It can be initiated by judges, law enforcement officials, or mental health professionals. There must be evidence that the person a) has a mental illness (as defined in the Baker Act) and b) is a harm to self, harm to others, or self neglectful (as defined in the Baker Act).

http://www.dcf.state.fl.us/mentalhealth/laws/index.shtml

What are the criteria for involuntary psychiatric exams in Florida?

Excerpts from the statute:

Florida law permits a mental health professional, law enforcement officer, or judge who issues an ex parte order to initiate an involuntary examination only when a person meets the following criteria:

If there is reason to believe that he or she is mentally ill and because of his or her mental illness:

(a) 1. The person has refused voluntary examination after conscientious explanation and (a) disclosure of the purpose of the examination; or

2. The person is unable to determine for himself or herself whether the examination is (a) necessary; and

(b) 1. Without care or treatment, the person is likely to suffer from neglect or refuse to care for himself or herself; such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services; or

2. There is a substantial likelihood that without care or treatment the person will cause serious bodily harm to himself or herself or others in the near future, as evidenced by recent behavior.

If this is a psych issue that may also have medical reasons, she can be admitted to a medical facility that accepts Baker Acts with a referral by her physician to a receiving facility with an accepting approved mental health professional. Of course, it would be nice to have the physician's signature on the correct paperwork.

 

[VentMedic]

I am going to elaborate a little more on this since geriatric psych is unfortunately a booming area of health care.

You need to ask the right questions of the nursing home nurses.

Who specifically made the recommendation for transfer?

Has another physician accepted to assume responsibilty for her care at that facility who is qualified to Baker Act on arrival?

What specifically is documented?

Can one of the physicians call your medical director for appropriate orders?

Does the hospital you are transporting to have a geriatric psych floor that can take involuntary commitments?

Does the facility have a mental health professional available to assess the patient?

Has the physician reserved a bed for the patient on the geriatric psych floor?

If not, does he expect that to be a bed available at that facility once the patient is cleared with the routine medical assessment by the ED doctor?

You can use those questions to make your point to the facility for having their ducks in a row for transport. Once you start asking specific questions for documentation, arrangements, accepting physician and bed availability (something they can relate to) for admission on a psych floor, they may get you the appropriate information and/or agree with you.

EMTs and Paramedics are not trained to adequately assess mental illness or competency except in the short term for some medical intervention which is obvious. Asking the right questions takes special knowledge and training to truly assess mental competency. CAOx4 may mean very little except for immediate care in the street for the obvious.

Mental health professionals also know they don't know everything about all areas of medicine and that is why patients are screened medically.

Law enforcement officers have the ability to Baker Act and may do so at you request in a medical situation. They have this power because they can legally detain if there is perceived just cause. The Baker Act may be voided at the hospital by at the request of a physician, mental health professional or judge. The patient may be held only long enough to get two professionals opinions for release.

A Baker Act is a serious intervention and that statute has under gone some reform due to past abuses.

If the patient is suffering from depression and other mental illnesses, especially in geriatrics, many health symptoms can manifest that are both real and perceived. It is sometimes very difficult to diagnose and treat these patients with out specialized services. Thus, many nursing home patients are transferred to a geriatric psych facility to help them cope. There they are followed by both a medical doctor and mental health physicians with various degrees. Sometimes, the problem may be a medication interaction causing the symptoms or the inability to face their own mortality after the death of a room mate at the nursing home.

Transporting patients for involuntary commitment is not for the faint of heart. It can be an ugly situation especially where geriatrics are concerned. With the proper documentation, you must still be respectful and gentle but cautious because they may not go down willing. Since many of these geriatric patients will need medical clearance in the ED first, EMTs and Paramedics may never see inside a locked geriatric floor. They may also never see more than the receiving area of most Baker Act facilities.

This information pertains only to Florida. California's 5150 is similar and that state also has many provisions for geriatric psych facilities.

For Florida, this link describes the various statutes that you will come across in your career in EMS for protective services, guardianship and involuntary confinement.
http://www.pbcountyclerk.com/courtservices/mentalhealth/mentalhealth.html

The site includes:
Adult Protective Services Act
Baker Act - Involuntary Examination
Baker Act - Involuntary Placement
Developmental Disabilities - Involuntary Admission
Developmental Disabilities - Guardian Advocate
Emergency Protective Services
Marchman Act - Involuntary Assessment
Marchman Act - Involuntary Treatment
Petition to Determine Incapacity
Restoration to Capacity
Tuberculosis

Yes, it includes my favorite:

Tuberculosis Control - Florida Statute 392.56 The Department of Health may petition the Circuit Court to order a person who has active Tuberculosis to be hospitalized, placed in a health care facility or isolated from the general public. The person may be confined until such time as the risk of infection to the general public can be eliminated. A hearing is set with the court, notice is served on all parties and counsel is appointed for the patient. An Order For Hospitalization may be entered placing the patient for up to 180 days.

The only remaining state hospital for the treatment of Tuberculosis is A.G. Holley State Hospital, Lantana, Florida. A.G. Holley accepts court orders from all judicial circuits in Florida.

http://www.pbcountyclerk.com/courtservices/mentalhealth/mentalhealth.html

 

[AnthonyM83]

Is your doctor able to speak with the nurses directly through your phone/radio? Maybe it would help if they got it that an MD was fully appraised and assessing the situation, they'd take it a little better.

Sometimes I feel like putting together a flier for nursing homes explaining when we can and can't take someone, as well as basic tips for emergent patients (No NRB's at 2lpm, You need to do CPR on full arrests, if the patient is a cardiac arrest you should call it in as one, not as a sick or ALOC, etc).

 

[MAC4NH]

I have found that unless they started in EMS, nurses have no idea about anything involving EMS. The reason for this is that no one teaches them. Nurses on hospital and SNF floors do almost everything based on orders from a physician. They are trained to follow those orders. A "problem child" nurse (often one who started in EMS) may notice a problem and speak up but most just do as instructed. This is hard for many of us in EMS to deal with because we are granted a large degree of autonomy when it comes to patient care (especially here in NJ where all the BLS is performed under standing orders). The only thing we can really do is understand where they're coming from and try to educate them about our procedures and policies.

 

[VentMedic]

I have found that unless they started in EMS, nurses have no idea about anything involving EMS. The reason for this is that no one teaches them. Nurses on hospital and SNF floors do almost everything based on orders from a physician. They are trained to follow those orders. A "problem child" nurse (often one who started in EMS) may notice a problem and speak up but most just do as instructed. This is hard for many of us in EMS to deal with because we are granted a large degree of autonomy when it comes to patient care (especially here in NJ where all the BLS is performed under standing orders). The only thing we can really do is understand where they're coming from and try to educate them about our procedures and policies.

NH nurses do not promote themselves as EMS experts. However, some EMS providers promote themselves as experts in geriatric medicine and maintain that their 100 - 1000 HOURS of training is superior to all professions including doctors.

If you have not worked in a hospital or NH you may not know the frustration of watching a patient's condition deteriorate before you as evidenced in the OP post. The physician many not be the most responsive to the needs of the patients he/she is responsible for. If you are a nurse that cares or one as you mentioned with an EMS background, you may try whatever to get the patient some care.

The autonomy in EMS comes from the fact you have at least 2 EMS providers for each patient and usually only one patient at a time. The overall skills are limited so the protocols can be short and to the point for emergencies. A nurse at a NH may be responsible for 20 - 40 pts on each shift. Long term care is a very different form of medicine than EMS and also requires extensive skills and knowledge in that area.

As an nurse you have responsibility to the patient and attempt to get the patient to a higher or appropriate level of care by utilizing the policies and protocols of that facility. Unfortunately, not all policies in a NH are written in recipe form as in EMS since there are many situations to consider. Thus, they leave room for error. This should not make it an opportunity to bash an other wise very competent nurse who is just trying to do a difficult job.

As an EMT or Paramedic, you may only spend 15 - 30 minutes with a patient and then they are out of your life. NH nurses may spend 12 hours/day 3-4 day/wk with these patients. To make matters worse, when they do call for an ambulance, the dispatchers may misinterpret what the RN is trying to say and run you CODE 3 anyway. Then, the RN must put up with attitudes from EMTs and Paramedics who really HATE nursing home calls as evidenced by the many threads bashing them. Yet, if you truly don't understand geriatric medicine, you may not be the best person to lecture a nurse working at a NH about it. I, myself, have intubated many patients in the ED that were considered BS by Paramedics who couldn't recognize sepsis if it bit them in the hind parts.

EMS professionals do not get that much geriatric medicine education and mental health issues concerning the elderly. Many also do not take advantage of the classes designed for EMS in geriatric medicine because they are not the glamorous trauma stuff and bring up images of NHs.

It is also your responsibility to educate yourself about the correct state statutes for when you do attempt to educate others. It is your responsibility to know that another state's statutes will not apply to others. It is also your responsibility to know that all you read on forums is not accurate. For this reason I post links to the actual statutes. I, too, may make a mistake in stating something. One needs to do some research on their own and get their medical director to provide more informed and up to date information.

In Florida, there are forms that can be downloaded from each county's court system or the state's mental health web site. You can carry a couple of these forms to show and/or give to the NH to have filled out and signed for the next time they call. If you don't want to carry the paperwork, make a list of state websites and give them that information and they can research for themselves. That would be much better than getting into a peeing contest or bashing mess with other professionals.

Anybody that has read some my prior posts knows that I am very much an advocate for the elderly. I believe they should be able to make as many of their decisions as possible. However, if there is something that can be diagnosed early such as Alzheimer's or some disease process that could be treated before it advances when they first display subtle symptoms, I believe they are entitled to quality health care. EMS, nurses and physicians should work together and not against each other to assure the best interests of the patient is carried out.

 

[BossyCow]

We have problems with the Adult Foster Care facilities. Everyone with a spare bedroom is putting one of these in, charging an arm and a leg to the family to have gramps 'taken care of' in a 'family situation' when the reality of the situation is often a minimum wage 'caregiver' who is instructed not to do anything (though they must be certified in CPR and F/A) but to call 911 if there's a 'problem'. The caregiver is scared spitless over the liability to themselves if they actually help Gramps off the floor when he falls.

EMS is doing the work while the owner of the facility collects the pay.

 

[MedicPrincess]

If you have not worked in a hospital or NH you may not know the frustration of watching a patient's condition deteriorate before you as evidenced in the OP post.

This was actually fairly frustrating for me. The particular nurse I was talking to seemed almost frantic that we would not be transporting, almost to the point of tears. Apparently, she has had another similar situation, with a different crew, and that other crew was.... shall we say not as nice as they could have been to her. She agreed wrestling the pt down and restraining her to our stretcher was not the proper way to go, but you could see that it was almost like the pt was her own Grandmother she was watching change. We ended up spending quite a bit of time talking about other options to get her to the hospital, other than in an ambulance, which the pt was absolutely opposed to. We ended up agreeing on calling her family member, who assists in taking care of her.

In regards to the geriatric psych/bed, acceptance, ect. All answers are no. We were going to be transporting her to the ER, for evaluation of AMSx 3weeks of a CAOx4 pt, with the "hopes" the ER Physician would be willing to Baker Act her. She would then be transported to one of 2 local intake behavior units for BA pts, general population type setting.

My weaknes is "old people." I miss my Grandpa with every cell in my body and my Grandma - as mean as she always has been (had to be, she helped raise me ) isn't going to be here much longer either. I "hate" the NH calls as much as anyone else, but not because they are such a PIA. It absolutely breaks my heart into a bazillion pieces to see these great men and women laying in bed, helpless, seemingly forgotten by their families they sacrificed for so many years to raise.

I feel bad for the nurses who are truely wanting to do so much more for their pt's in the SNF/ALF facilities, but their hands are tied. Unfortuantly, as with any profession including ours, the ones that are there collecting a paycheck and couldn't tell the difference between neck pain and unresponsive with gurgling respirations tend to stand out more in our minds.

 

[VentMedic]

In regards to the geriatric psych/bed, acceptance, ect. All answers are no. We were going to be transporting her to the ER, for evaluation of AMSx 3weeks of a CAOx4 pt, with the "hopes" the ER Physician would be willing to Baker Act her. She would then be transported to one of 2 local intake behavior units for BA pts, general population type setting.

In Florida, as well as other states, geriatrics are rarely sent to regular psych hold facilities. They are usually admitted with the dx of AMS and the hospital will keep them until they are certain it is not a medication interaction/reaction or something else going on. Going to some 72 hr hold facilities can be worst than a holding cell in a jail at some facilities. Overcrowding is also a big issue which makes for a very unsafe environment go a grandmotherly type. That is why many hospitals now have geriatric psych floors.

The Baker Act is used very conservatively in the elderly population due to the legalities with declaring someone mentally incompetent even for 72 hours. If you look up the reasons behind the Baker Act Reform Bill, you will understand this better.

If you were to have a drug interaction that would make you "loopy" and some well meaning Paramedic had an LEO Baker Act you, your paramedic license would be gone until you could get a judge and two physicians, one of what is a psych specialist, to get you re-instated.

couldn't tell the difference between neck pain and unresponsive with gurgling respirations tend to stand out more in our minds.

Remember these nurses may not be the brightest stars when it comes to EMS stuff, hence, they call you. But, they can pass 200 - 400 meds per shift hopefully without errors, check and bandage decubitus ulcers, pour feedings for every one, follow sepsis prevention plans, chart on 20 - 40 patients a day and deal with transfers. I just think the people that work in EMS could give them some courtesy when they do ask for help. They know their limitations unlike some in EMS.

'caregiver' who is instructed not to do anything (though they must be certified in CPR and F/A) but to call 911 if there's a 'problem'. The caregiver is scared spitless over the liability to themselves if they actually help Gramps off the floor when he falls.

EMS is doing the work while the owner of the facility collects the pay.

Even picking gramps off the floor may be annoying, but there may be some concern of injury, again that is why you are called. They are unsure because they know their own training limitations. If they had picked gramps off the floor and he was truly injured, how much crap from the EMTs and Paramedics do you think they would have taken then? These HCWs are caught in the middle of a no win situation with someone, be it the doctors, families or EMS providers wanting to yell at them for whatever reason.

These elderly people also paid taxes for a long time that helped to get many EMS systems started. They should not be treated with bad attitudes from EMS providers because of the "Nursing Home BS call stigma".

Not referring to you on that MedicP...., just ranting because I see UPS bringing packages into the hospital with more compassion than some EMS providers bringing in the elderly NH pts regardless of how sick they are.

It is unfortunate that EMS providers take their anger out on these patients when they are just the victims of a horrible healthcare and political system as well as fragmented EMS systems. They should not be the ones being penalized for that. They have no choice in the matter. Rarely to the even get to decide which facility they go to. Bed availability and insurance (having it does not always mean better) dictates where they will get stuck at. If they go to the hospital in some situations for more than 7 days, they must relocate to another facility. This might mean leaving behind any friends they made at the other facility.

You also don't have to get old to experience this. I know a lot of young 20 -40 y/o trached and/or ventilator patients in the sub-acutes and SNFs. One bad ambulance accident you may get to know what a Respiratory Therapist is up close.