Observation patients
As of 9/6/22 we will start keeping observation patients at TSQ. Please read the attached policy…it is in final review but not active yet. Between the policy and some information below, I hope it answers many of the questions you may have but please ask me anything not covered! I value your input and thought into details that we may have missed or that will make this a better experience for you and the patients!
· In the policy you will note that the TSQ FED physician and staff will agree that observation at the FED is the best thing for the patient and can be done safely. If the GST Dr wants to send a patient to TSQ for obs but there are 18 patients, the GST Dr would be requested to send them to the hospital. If there are 18 pts at TSQ but 16 of them have houses for discharge, physician/staff might make a different decision.
· Gail wrote a great welcome letter to explain some things about a patient’s stay in obs at TSQ. Also, in the back right corner of the supply room there are obs packets with non-skid socks, toothbrush etc. Please provide these to obs patients.
· I included a pic below that shows a lot of people AMA related to refusing admission. I am unsure if they just want to go home or if they don’t want to go to the hospital…I am hoping we can capture some of this (obs) population and convince them to stay with us.
· Of course an obs patient can leave AMA; I’m not advocating forcing anyone to stay. However, to bill for observation the patient is supposed to be here for 8 hours past the first “treatment”. This consists of protocol orders or orders placed by the physician. TRIAGE DOESN’T COUNT in the 8 hours.
· It is likely the physician will evaluate if a patient is ready to go, stay long, or transition to full admit at around 16-18 hours but have a conversation and find out that plan.
· A PATIENT CAN NOT STAY PAST TWO MIDNIGHTS…so conceivably some patients must be discharged or be transitioned to a full admit at around 24 hours. For example, if a patient receives their first care at 2350 then before the next night at 2359 they must be discharged or be fully admitted and slotted to go to main or another facility. They don’t have to be out of the building and can stay longer as an “admit” but the accepting physician at a hospital is now the one in charge.
· The FED Dr will have two sign-ons. One is what they use to place the observation order and the other is the regular FED one. The regular one is what they will use to place obs orders so that they do not have to log out and in constantly between ED and obs patients. The physicians have received special credentialing to be approved for this; if we have a new locums at TSQ they likely will not be able to obs
· You will continue to chart in Cerner Firstnet as always for the observation patients. There are not any “admission” special assessments or different elements to capture but a couple of things to look out for. ER doctors almost never write prn orders; if an observation patient has a prn order it must be followed exactly or be changed by the physician (or RBVO etc). For example, if Tylenol is prn for “pain 4-6” and the patient has a pain level of 2 OR you want to give it for fever…it can’t be given and the order must be changed. If the doctor writes for morphine for pain “7-10” and the patient has a pain of 8 but wants the Tylenol “pain 4-6”…..that is actually ok and it is written into policy that the patient can pick the lower pain level med just not the higher level.
· If a patient has an order for a cardiac monitor or oxygen, be sure and chart that it is on. We will always need to associate monitors and scan pumps on obs patients.
· One RN will assume primary responsibility for a patient. Either the CN or acting CN will assign the patient or two partners will come to a mutual agreement on assignments. The nurse assigned should chart the “bedside report given to X RN” etc and the oncoming do the same. This doesn’t mean that the other nurse doesn’t help but it ensures that there is one person making sure they receive the antibiotic or breathing treatment and so on.
· There should be some type of hourly charting about the patient condition or activity
· FOOD: NW has a “diet liberalization” policy which means that they let patients chose items they would normally eat at home unless there is a specific order for NPO or a special diet. Family are welcome to bring food, we have drinks and snacks, and the Jason’s deli process. If you don’t know about ordering from Jason’s Deli, please ask another staff member. There is a book at each location with instructions and menus. For some reason the JD on Coulter can’t find our charge name so we always order from the other one. The receipt with a patient sticker should go in this book. If you suspect you will have a patient for breakfast and lunch or lunch and dinner, place both orders for delivery at one time and place it in the patient fridge as we have to order a minimum of $25 each time for delivery.
· It is an expectation that obs patients will be placed in the hospital beds. I have a ticket for a second one to be brought to TSQ. Please don’t forget family…roll in a stretcher for them if they stay the night. I’ve ordered 3 recliners as well.
· The dr should only order necessary home meds. The pharmacy is increasing our medications that are typically home meds in the pyxis to assist with this. We are not going to allow for patients to take meds they bring from home…the policy to do this is for the pharmacist to have a “facetime” with tiger text then they would confirm what the meds are and stickers would have to be printed for the meds. This is too complicated and time consuming for nursing to make this a standard practice so we will just opt out of the brought from home med option. HOWEVER, if there is a rare, or trial, or chem med, or other situation where it simply can not be missed, there is a policy to follow in policy tech for on how to have the pharmacist approve home meds. While I would always refer you to policy tech for the most recent version, I attached policy MM 008 Patient’s Own Medications
· The house sup will be a great resource and can contact case managers to assist with unusual situations.
What questions do you have or what do I need to clarify…I highly doubt I covered everything!
Thank you, I’m so proud to work with each of you and the amazing team we are building!
Andrea