Skilled Nursing Facilities: An Oxymoron?

Since my last post I've been pondering (yes, I ponder) what I should kick this off with. I bounced back and forth between a few ideas until I finally settled on the one that really gave me the idea to blog my thoughts and observations in the first place.


Warning: this topic has the potential to go off of multiple tangents, but I'm going to do my best to keep it focused.


Nursing homes.


Now, correct me if I'm wrong, but nursing homes exist to provide those that can't care for themselves, and are beyond being cared for at home, a controlled environment with trained staff that is able to help them with their daily activities, as well as provide some medical care (that would be the "nursing" part of nursing home). In fact, Merriam-Webster's Medical Dictionary defines nursing home as, "a privately operated establishment where maintenance and personal or nursing care are provided for persons (as the aged or the chronically ill) who are unable to care for themselves properly."



So why is it then that I will routinely transport patients from their nursing home to a hospital emergency department to receive care that could be provided at the aforementioned nursing home?


Here's an example: Last week I was dispatched to an area nursing home for an elderly female patient with a possible UTI (urinary tract infection).


I'll pause there. In order to test for a UTI, urine samples must be obtained and sent to a lab for a urinalysis. If the urine is positive for an infectious process treatment typically involves oral antibiotics but sometimes may require IV antibiotics especially in resistant bacterial strains.


Back to the example. On our arrival at this nursing home, we stop by the nurses station to receive "report" (which is typically the staff tossing an envelope at us and telling us where the patient is and nothing more). The staff member (I honestly don't know if she was an LPN, RN, CNA, etc.) hands us our patient's information and tells us she is just around the corner in a wheelchair. I confirm with her that the patient is going to the hospital for a possible UTI, to which she responds that the patient most certainly has a UTI as they sent a urine sample earlier in the day and it came back positive for E. Coli. Our patient apparently also gets UTIs fairly frequently.


Again, I'll pause. So, at this point the nursing home knows with certainty that the patient has a UTI. I should also mention that all of the nursing homes have physicians on staff (in most places they generally do rounds during the day and there is an on-call doctor available at other times).


I respond to the staff member with questions regarding the patients mental status because if infections go untreated for too long it can lead to a condition called sepsis, or septic shock, which is essentially when the patient's bloodstream becomes overwhelmed with bacteria. Sepsis causes symptoms such as changes in mental status, low blood pressure, elevated pulse, and in the most severe cases can lead  very quickly to death. The staff informs me that aside from a decreased appetite over the past few days the patient is acting as she normally would.


Here's what I'm thinking at this point: If the patient's urine has been sent to the lab and their results say that the patient has a UTI, why is it that the physician has decided to sent the patient to the emergency department as opposed to writing a prescription for antibiotics?


After checking the patient's vitals (which were well within acceptable limits) we move the patient to our ambulance on the stretcher and take her to the hospital that her and her family had preselected she would receive treatment at upon being admitted to the nursing home. We arrive at the hospital and turn our patient over to an ED nurse with a full report. As I'm giving report, the RN in the emergency room begins to have a puzzled look on her face as I tell her that they confirmed with the lab the patient has a UTI and that's why she's in the ED. She stops me while I'm giving report and essentially says absolutely everything I had been thinking since we first got dispatched. If they think the patient has a UTI, why don't the send urine to the lab? If they sent urine to the lab and the lab said she had an infection, why didn't they prescribe antibiotics at the nursing?


These are all questions I've been asking myself for some time now.


Now please don't take this the wrong way. I'm not complaining about having to do calls. As a matter of fact, I enjoy doing calls (that's why I'm a Paramedic). But, I was taught in both EMT and Paramedic school that as healthcare providers we need to be advocates for our patients.


Wouldn't it be in the patient's best interest to receive treatment at the nursing home instead of in an emergency room?


Taking a chronically ill patient out of their (somewhat) controlled environment must put a lot of stress on them.  Especially those patients with dementia and memory problems who need some sort of familiarity on a regular basis. And now we're also exposing them to the hospital environment where they could possibly incur additional ailments that they wouldn't have otherwise been exposed to.


I have endless examples of similar cases, but I'll limit this to just one more brief incident. One day I was dispatched to a different nursing home for a patient with dehydration. Again, I think to myself that if they know she is dehydrated, why doesn't the doctor order IV fluids and have the staff (that would be the skilled nursing part) start an IV and administer them?


Upon walking into the patients room I was shocked to see an IV pole with a liter of normal saline next to the patient's bed. My initial surprised reaction changed quickly back to complete puzzlement as to why we had to take this patient to the hospital. So I posed the question to the staff. Apparently the doctor had ordered IV fluids, but the staff there was unable to obtain an IV on the patient.


Wait! So now you're telling me the patient needs to go to the hospital simply to have an IV placed?!?


Just have the staff had left the patient's room, I introduced myself to the patient, conducted a brief interview and exam while my partner obtained vitals, and  promptly successfully established an IV on the first attempt and hung my own liter of fluid for the patient.


I can't even begin to describe the looks on the staff members' faces as my partner and I walked by the nurse's station with the patient on the stretcher with the IV and fluids that had been ordered earlier in the day. I seriously considered asking if we could just leave the patient with them since the IV was already in (but I wasn't about to fight that battle).


So I guess my point is this: What's the point? What is the point of putting chronically ill patients in "skilled nursing facilities" if every time they have a suspected (or confirmed) acute problem that could be treated within the facility (much like you or I would go to our own primary care doc and get a script for something). Doesn't it defeat the purpose to constantly send them back and forth between the hospital and use the emergency departments as primary care?


I'll leave you with that to think about for now. And this to make you laugh a little.