Perhaps someone can help me with this question that more than concerns me.  I work an an RN with the elderly population and when an incident happens like them hitting their head after a fall or being found on the floor with pain I am left to call the paramedics.  If the resident choses to go to the ER, when they return there has been a bare minimum of care provided on the Medicare dollar. 

For example a case study;  88 F, code status DNR, found on floor for unknown amount of time c/o pain to R Shoulder, R Hip, and she hit her head.  BP 180/70, P 100, T 99.2, R 16.  Her face is flushed, tremor to bilat arms, and she is stuttering her words (which are all new symptoms).  She returns after 2 hours and ER took an xray of her R shoulder which was negative.  Her urine was not checked and no labs were drawn.  These are simple first line procedures used to rule out basic problems.  The hospitals have access to all the necessary departments to recieve results fast.  Am I expecting too much?  I feel like I'm left to start over and my facility has the bare minimum for supplies. 

I feel like Medicare dollars are being wasted everytime someone needs to be sent to ER and I don't understand why.  Is there a correlation with having medicare, their age and code status?  Even if these people were walking, talking, eating, and drinking fine yesterday?  I care for these people and their families like they are my own.  Is there anything I can do to improve the system?   

Thank you for your response!  I want to hear all sides for better understanding and execution of the issue :) 

I understand that she is a DNR .  But that has to do with not resusicating her if she is not breathing and has no heartbeat in an emergency circumstance.  DNR and advanced directives are much broader than the assumption of what health care providers think based on age.  (sites listed at bottom for review)

Individuals choose comfort measures when on hospice services at the end stage of a terminal disease (Cancer, CHF, parkinsons, COPD, ALS (Lou Gehrig's disease) ect - Chronic disease that is continuely declines) .   Even on hospice, nurses treat illness not related to their terminal diagnosis.  For example if a hospice patient with terminal cancer has a UTI, you still treat it although you might not even dip it (to save cost).  You might trial pyridium for bladder spasms.   

Just because a patient has DNR attached to their status doesn't mean they have no quality to life.  We are a team caring for individuals on an individual basis where everyone has the right to be treated.  

"Her urine was not checked and no labs were drawn.  These are simple first line procedures used to rule out basic problems.  The hospitals have access to all the necessary departments to recieve results fast."  The xray on the R shoulder might have even been the most expensive test done.  I'm not a biller or coder.  I just wonder why they chose an xray vs labs vs urine.     

The above are not heroic measures and my job is to advocate for these people (and this generation!).  These family members and patients are displeased with the waste of money and service they are being provided.  They now have to find another way (and possibly pay more) to r/o simple infection or chemistry imbalance. 

I'm still asking for more advise on how to improve the quality.  More responses welcome!

http://en.wikipedia.org/wiki/Do_not_resuscitate

or

http://www.nlm.nih.gov/medlineplus/ency/article/001908.htm

mrbrownrn49 says ...

She's 88 and a DNR. To me that means comfort care only from your simple declaration of DNR. A urine test? Why? Why not a complete chem panel and a CT scan?

She's afebrile so massive infection seems unlikely. Her VS appear stable as you posted them.

Sorry but when I'm that age just keep me comfortable and do not do CPR or any other such stuff that is silly on people that age. And I'm 60 and aging faster every day. I have thought about what I wrote way before today.

I guess what I'm saying is be comfortable with the decision this lady, or her family, made about DNR.

DNR does not mean comfort care......you have to have a specific order to place a patient on comfort care.

mrbrownrn49 says ...

She's 88 and a DNR. To me that means comfort care only from your simple declaration of DNR. A urine test? Why? Why not a complete chem panel and a CT scan?

She's afebrile so massive infection seems unlikely. Her VS appear stable as you posted them.

Sorry but when I'm that age just keep me comfortable and do not do CPR or any other such stuff that is silly on people that age. And I'm 60 and aging faster every day. I have thought about what I wrote way before today.

I guess what I'm saying is be comfortable with the decision this lady, or her family, made about DNR.

With all due respect, mrbrown, I must disagree.  A temp of 99.2 is a fever in an elderly person.  Baseline basal temp tends to go down in the elderly.

To RedStateBlueNurse:  The ER is only required to do a medical screening exam to determine whether or not a true emergency exists, according to EMTALA.  This sometimes leads to ER docs cherry picking patients based on their insurance and family situation.  Either the ER doc really felt nothing more needed to be done, or he was cutting corners.

With a temp of 99.2, I believe a UA should have been ordered.  UTI is the most common cause of death of the elderly in nursing homes, and a common cause of AMS.  Do not code does not mean do not care or treat.  A head CT also should have been ordered, along with electrolytes.  Why?  Because the patient was found on the floor and a LOC cannot be ruled out.  There were definate symptoms of AMS.  So you gotta rule out UTI, hyponatremia, and stroke or subdural hematoma.

If this patient had come into any of the ERs where I've worked, those are the things that would have been done.

I am scared silly every time i put a DNR patient to sleep....

Kittyrn says ...

Agreed; DNR does NOT mean no care.  It means to keep the pt safe, and treat acute illnesses such as UTI, FX's, and Fevers.  In my experience how much care a DNR recieves is often dependent on NOK.  If the NOK, says Mamma,  wouldn't want to have (fill in the blank) than it's not done.  Recently took care of a 90's something pt, that went for a MRI due to MS changes, and low sodium with negative CT.  Thought was she may have had some type of brain lesion......Dr was against ordering it, pt had to be talked into it, but family stood there and cried and screamed that no one was doing anything for Mamma and she deserved the best care, just because she was old and a DNR didn't mean we couldn't help her blah blah blah.  In the end, all the family has to do is threaten a lawsuit, and either too much care or you see something tragic like an elderly pt forced to die because of lack of treatment for a fracture.  TORT REFORM TORT REFORM...

The MRI was unnecessary.  It is unlikley to have shown anything the CT didn't; even if there was a bleed it probably wouldn't show up for 24 hours.  Hyponatremia alone explains the MS changes:  tune her up with some fluids and send her home.

I think educating the public about how the health care system works is a better idea; patients know more about what tests are available but they don't always understand why or when they are ordered and when they are unnecessary.

MRI is a way more definitive test than CT (hubby is a ARRT (R))  He has to explain it to me too sometimes, Theala.  It has to do with tissue density. 

For me both the CT and the MRI were too much.  For one thing, they weren't looking for a stroke, they were looking for some type of mass, I think near the pituitary gland.  IF they found it, than what?   Surgical treatment WAS NOT an option because of all her medical conditions and her age (mid 90's).  Additionally, she was responding to treatment to correct her electrolyte imbalance, and her confusion was slowly improving.  At that age, it might never return though.  But because the family cried and screamed, the pt didn't want it, but her daughter(?) literally bawled, and begged, they went ahead and did it.  Which in the end was negative, and a waste of money.