Hospitalizations – Entry 1

Dear Diary:

We nearly had to send Hattie back to the hospital today. I feel so bad for her. She hasn’t done so well after returning from the hospital following her hip pinning. This morning, Hattie’s daughter, Carol came to my office very concerned. Carol told me that Hattie hasn’t been eating or drinking well for a few days. Yesterday Hattie didn’t recognize her when she came to visit, which has never happened before. She’s been talking to Sherry, the nursing assistant, about her concerns for the past two days, but Carol doesn’t think anyone has called the doctor. Apparently, Hattie’s temperature was 100.5 today. The nurses are talking about sending Hattie to the hospital again, and Carol isn’t sure Hattie will make it through another hospitalization.

I had a talk with Hattie’s nurse, Anna. It sounds like Hattie may have developed a urinary tract infection, probably from the indwelling catheter inserted when she had her hip surgery. Anna wasn’t aware of Hattie’s decreased appetite or increased confusion until today. She assured me that she put a call in to the physician and has the SBAR form ready to report the change in condition. I’m so happy she’s using the form! However, she’s concerned about Hattie’s fever, is afraid she may be septic, and would like to recommend to the physician that she be transferred to the hospital. I reminded Anna that we have been trying hard to avoid unnecessary hospital admissions; might this be one of those?

Remembering our recent INTERACT training, I reviewed the UTI Care Path with Anna. We are able to monitor Hattie’s vital signs, push fluids, give antibiotics, and even IVs if we need to. Anna made those suggestions to the physician when he called back and he agreed to treat Hattie here as long as she is closely monitored. I’m not sure that would have been the case had Anna just asked for a transfer order. So, that transfer has been avoided, but there’s still work to be done! Why wasn’t Anna aware of Hattie’s change of condition earlier? What can we do to improve communication among staff? What can we do to stop the nurses from asking physicians to send residents to the hospital as their first option? I’m afraid I found out about this potential hospitalization by accident which makes me wonder just how often this is happening with other residents.

Signed, Donna


  • SS and I review each of our hospitalizations monthly. We look for patterns such as same Physician sending to ER/Admitting, review what tx the resident had at the hospital if it oucld have been done at the care center. We still need to get our nurses to suggest to Physician to keep resident here and to try tx here.

  • I had a meeting with both the nurses and the CNAs here. The focus was on how to prevent unnecessary rehospitalizations. I wanted the CNAs to know that the work they do is appreciated and that they are the ones in the front lines. They are the ones who are most likely to notice subtle differences in the patients/residents. I re-introduced the Stop and Watch program. Some of the aids told me that they have (in the past) given a Stop and Watch paper to the nurse only to have the issue ignored. So now the aids are making a copy of their concerns and putting them in my mailbox to make sure the issues are addressed. I tried hard to focus on the fact that it takes all of us paying attention and acting on changes to help keep our residents and patients here. I stressed that we can provide many of the services required and re-introduced the form our medical director came up with for nurses when they plan to call a doctor. I have also started providing education so that our nurses can actually perform as nurses. Our lab is not open after 6PM M-SA and is closed on Sunday. I have an inservice next week so that we can draw our own labs after hours and on weekends and have them sent to the hospital via courier. I am noticing that many of the rehospitalizations involve residents who are declining rapidly and are still a FULL CODE. So I am working with the nurses to learn how to tactfully approach family members regarding the subject of Comfort Care. I hope my ideas help someone else.

Share your nursing home perspective on this quality improvement issue.