Subacute Care Forum

Orienting Hospital Nurses to Subacute Care Units

As subacute care units open in nursing homes in New Jersey, our consultant pharmacists have encountered a need to provide basic orientation information to hospital nurses who work both full-time and part-time in these units. The hospital nurses are very adept at more advanced types of care-such as intravenous therapies or difficult treatments-but they are not necessarily informed about long-term care regulations that the state of New Jersey and H.C.F.A. apply to all beds located in nursing homes.

To solve this problem proactively, we developed and provided several in-service programs to orient hospital nurses to subacute care and applicable long-term care regulations.

The source of the problem has not been that the nurses do not know the relevant aspects of clinical medicine nor that they do not know the pertinent procedures. Rather, it is simply that they have not been exposed to long-term care and its unique regulations and requirements. Further, they are not accustomed to the level of scrutiny consultant pharmacists give to mundane tasks such as charting of doses given and preparation of doses for administration.

Several in-service programs have now been provided for hospital nurses who have been hired in subacute care units in our facilities. The basic information we provide covers medication pass procedures, rights of nursing home residents, drug interactions and other clinical details, and pharmacy ordering procedures.

Activities surrounding the medication pass are a key focus of our concerns. While ostensibly similar to acute-care units, our subacute units are different with respect to oral liquids that must be measured, crushing of medications for administration through nasogastric tubes, or patients unable to swallow. Oral liquids are more likely to be available in premeasured unit dose containers in hospitals than in nursing homes. Likewise, solid oral medications must be crushed for some long-term care patients, and we have found many hospital nurses to be unaware of which sustained- or delayed-release formulations cannot be crushed before administration.

Residents' rights issues also creep into the medication administration discussion. In the subacute care unit, patients are more often confined to bed, but they remain free to ambulate in the facility. Hospital nurses are not accustomed to patients moving freely away from their rooms. When nurses track down residents in public areas such as activities or cafeterias, privacy issues arise about what medications residents can be administered. Also, hospital nurses generally have orders to give refused oral medications by injection; they are surprised that nursing home residents have the right to refuse medications and that orders to inject refused medications are considered unethical and illegal.

Issues of restraint use also must be discussed. While there are double side rails on every patient bed in a hospital, this can be considered an inappropriate restraint in a nursing home.

Finally, basic information about pharmacy procedures and processes must be provided to new nurses. Tasks as simple as reordering medications are foreign to nurses whose work experiences lie solely in acute care. Also, of medications must be charted after they're administered, along with any required clinical monitoring.

On many of these in-service topics, the nurses already know what to do, but they are unaccustomed to anyone checking on it. One key factor makes all the difference in our nursing home-based subacute care units: the activities of the consultant pharmacist. The incoming nurses need to know about long-term care regulations, both state and federal, and learn about the drug regimen review and the important role that pharmacist recommendations make in the care of residents.

The survey process must also be explained, including scrutiny of records documenting pulses before digoxin dose administration and blood pressure monitoring before antihypertensive agents are administered. Again, these are new experiences for nurses trained solely in acute care.

Need for Ongoing Information

Staff turnover and the need for timely information have resulted in implementation of ongoing in-service programs for nurses in our subacute care units. We have set up a schedule for routine presentations that cover emerging issues as we gain experience in these increasingly common step-down units in our client nursing homes.

I. Barton Frenchman, RPh, FASCP
Pharm Rx Consultants
1238 Stuyvesant Ave.
Union, NJ 07083
908-686-2063