SNFs dumping patients...

[BostonEMT]

<begin rant>

An increasing and increasingly irritating phenomenon I've noticed among the "skilled" nursing facilities (and one in particular that inspired this post) is dumping patients at the ER for the slightest problem. Of course this is nothing new, just something that seems to be happening more and more frequently for utterly indefensible reasons.

A few days ago we transported a discharge to aforementioned SNF and the MD forgot to note in the paperwork that the patient's IV haldol was discontinued. Instead of calling to clarify the order and saving the extremely infirm pt. an unnecessary trip back to the ER, then back to the same SNF, they called for an ambulance giving a meaningless c/c from the pt.'s PMH. We arrive with x lbs. of gear on our backs only to be told that the patient was to go to the ER because the MD didn't note that the order was discontinued. "So what, exactly, would you like me to tell the triage nurse is wrong with this patient?" "Well, the IV hal--" "I understand that, ma'am. But what is the complaint? I cannot bring someone into the ER who has no complaint." "Well, you ARE bringing her, you don't have a choice..." etc. Sure enough, we transport her back and she gets left on a hallway stretcher for who knows how many hours.

Today, the very same facility pulls the same stunt. This time it's because they claim the pt. we brought to their facility less than an hour before has an NG tube. The pt. had the NG tube in place when we brought her in, nobody had a problem with it until about an hour after we left. When we brought that pt. back to the ER the very same nurse I saw two days before was shaking her head. "I know, it's ridiculous." I said. "No, no," she replied. "They did this yesterday too. Three times this week so far."

I am so disgusted by these facilities calling EMS for "altered mental status" when the reality is the patient would like their diaper changed or to make a telephone call to their family. When they're ignored for hours or days and become quite distressed and nasty the nurses go "Hooray!" and call us for "non-cooperation w/ meds, going in for psych eval." Or if there's a one page of the nursing referral missing, rather than calling and requesting that it be faxed over, why not just dump the pt. first to EMS, then to the ED. The lazy, burnt-out nurses win because now they have less work to do and the EMS service's owners win because they bill (often the taxpayers) $800+ for each of these five-minute rides back and forth between the hospital and rehab/SNF. But the EMS people become demoralized, ambulances are taken off the road, the ERs are overloaded with pts that do not need to be there, and, worst of all, the patients have to suffer the agony of being loaded and unloaded repeatedly, coming in and out of all types of weather, and wondering what the hell is going on the whole time.

It's a scam and a disgusting one at that. And people wonder why our health care system is broken...

</end rant>

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[docB]

I am so disgusted by these facilities calling EMS for "altered mental status" when the reality is the patient would like their diaper changed or to make a telephone call to their family. When they're ignored for hours or days and become quite distressed and nasty the nurses go "Hooray!" and call us for "non-cooperation w/ meds, going in for psych eval." Or if there's a one page of the nursing referral missing, rather than calling and requesting that it be faxed over, why not just dump the pt. first to EMS, then to the ED. The lazy, burnt-out nurses win because now they have less work to do and the EMS service's owners win because they bill (often the taxpayers) $800+ for each of these five-minute rides back and forth between the hospital and rehab/SNF. But the EMS people become demoralized, ambulances are taken off the road, the ERs are overloaded with pts that do not need to be there, and, worst of all, the patients have to suffer the agony of being loaded and unloaded repeatedly, coming in and out of all types of weather, and wondering what the hell is going on the whole time.

I agree with you wholeheartedly. You are especially correct that the SNF managers don't want this to stop because they want their patients "cleared" by the ER daily to minimize liability, the nurses get to dump a patient for the shift and the ambulance companies and the ERs make money from the churning. It is wrong. It will not stop until the liability concerns are ended (tort reform?) and/or CMS decides that any trip from the SNF to the ED was probably "preventable" and therefore not billable (like they're doing with foley infections, in house falls, etc.). Then the pendulum will swing the other way and the elderly will be left to die, poorly cared for in their beds at the SNF. We have that too now so maybe it'll be hard to tell the difference. This is why everyone in medicine and EMS has told their families we are definitely DNR.