They Want to Transfer My Mom Out To LTAC, But What if My Mom Needs a Blood Transfusion? Can They Safely Do That?
Published: Sat, 08/05/23
Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED” and in last week’s episode I answered another question from our readers and the question was
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS
ANSWERED” I want to answer questions from one of my clients, Angie, as part of my 1:1 consulting and advocacy service! Angie’s
mom is in the ICU with a tracheostomy, on a ventilator, and has low hemoglobin levels. She will be transferred to a Long Term Acute Care Facility (LTAC). Angie is asking if it’s safe to transfuse blood to her mom in LTAC.
Angie: The nursing charts, we cannot see the details of.
Patrik: Okay.
Angie: But we can see
medication she’s taking for that day or within the last few days.
Patrik: Yep. Okay. Would be good if you could send me what medication she’s on because there may be something in there that would also foster the argument to keep her where she is.
Angie: Got it. Yeah, I can. Sure. I can send that along. Or-
Patrik: Either send me a screenshot, or email it to me, whatever the best way.
Angie: Okay. I will email. Yeah.
Patrik: Because there may be something in there.
Angie: But she’s on her own medications, plus gabapentin for pain.
Patrik: Okay.
Patrik: Okay.
Angie: For her arm.
Patrik: Yep.
Angie: But there’s no antibiotics, there’s no vasopressors, for the last two weeks.
Patrik: No? Okay. Send it-
Angie: Yeah. That’s pretty much all the medication.
Patrik: Yeah. Sure. Okay. Okay.
Angie: Yeah.
Patrik: Send it through. Send it through, because let’s just have a quick glance. Let’s just leave-
Patrik: I’d say they need to start with something. Did you say she had a CT (Computed Tomography)
scan a while ago?
Angie: she had a CT, and one of the attendings was slightly friendlier, and more talkative, I requested a CT, so yes. But the report that I could see, was very short. So, I’m kind of going back in time, trying to find it. If I can read back, what… It was sufficiently lacking in detail, the view I could
find.
Patrik: Right.
Angie: So-
Patrik: I have another idea. I have another idea, Angie.
Angie: Yep.
Patrik: With the hemoglobin so low, have they referred this issue to a hematologist?
Angie: Maybe I should have brought that up, you’re right. No. No, they have not done that. And actually, my mom has a hematologist who attends this health system.
Patrik: Mm-hmm.
Angie: And we were in the process, of trying to understand why her red count was low.
Patrik: Mm-hmm.
Angie: So you know these genetics-based testing? They call it Heme-STAMP (Hematopoietic and Lymphoid Malignancies-Stanford Actionable Mutation Panel
here.
Patrik: Mm-hmm.
Angie: I think, it checks 124 different mutations.
Patrik: Right.
Angie: I think she had one, they didn’t tell me which one. But they told me one of them, there was one mutation.
Patrik: Yep. Okay.
Angie: But this is right before she fell.
Patrik: Right. Aha.
Angie: So she has a follow-up with the hematologist next month, so she never got to the next step of getting a diagnosis, and seeing if maybe she can go on EPO (Erythropoietin), or if there’s a solution for
her.
Patrik: Yeah. Yeah. Yeah. Yeah. Okay. Well, so what you are implying potentially, is you’re implying that maybe a hemoglobin drop happened, prior to her fracturing her arm, and maybe that’s contributed to her having a fall?
Angie: No. No.
Patrik: No?
Angie: No. The day we came in, her… I can find those. Because she received a good workup when we came in. She had a chest CT, had a head
CT. She had blood work done; everything was normal.
Patrik: Mm-hmm.
Angie: Everything was normal. Hemoglobin was 11 point something. But her red count was below where she should be, for her age. So, the lowest level is 3.3. She was probably 3.2, something like that.
Patrik: Okay.
Angie: But after she became critically ill, acute respiratory distress, et cetera, et cetera, it dramatically, they were cut in half. They became divided in half.
Patrik: Okay. So I would argue Angie, that she shouldn’t go anywhere until someone, ideally a hematologist, has looked into the issue. Right?
Angie: Okay. I’ll try that.
Patrik: But I would try that. Try the hospital policy around discharges. I mean, the way I explain this to clients is always, anything in a hospital has a policy, anything. Mopping the floor has a policy, and cleaning the
window has a policy. Anything.
Angie: Sure.
Patrik: So discharging a patient to another facility, has a policy too. It has to. And I argue that in this policy, it would be saying something like, “With family consent,” or patient consent. Okay?
Angie: Okay.
Patrik: That policy I would want to see. Another thing that I don’t trust, is you mentioned that they said something to you, that the insurance only
pays for X number of days. And that is probably accurate. However, if the insurance has not contacted you and said, “Hey, your mom is running out of entitlements, she needs to leave ICU by Tuesday,” I wouldn’t put any weight on that, whatsoever.
Angie: Okay.
Patrik: If the insurance contacts you? Absolutely. Absolutely.
Angie: Sure.
Patrik: But if they don’t contact you, in my mind, it’s all gospel.
Angie: You’re right.
Patrik: My understanding is that the insurance pays for up to 60 days in ICU. That’s my understanding.
Angie: Okay.
Patrik: And I can tell you from experience, that if by day 60 someone still needs ICU because of their clinical condition, the insurance, everything is negotiable. Do you know?
Angie: Right.
Patrik: Yes, of course, they have to work with guidelines. Do you know?
Angie: All right.
Patrik: But they’re not letting people die, either.
Angie: Right. Right. I think there’s a process of appeal. There is one.
Patrik: Oh, there is definitely a process of appeal. That’s why I’m saying, if they’re telling you, “Oh, yeah. The insurance is kicking you out,” that doesn’t mean anything to me. If the insurance calls you on Monday, or today, and says, “Look, we’ve got to get moving.” Different story.
Angie: Right. Right. I know.
Patrik: Different story. You have-
Angie: No. I think that’s a bluff. That’s a bluff, I think.
Patrik: It’s not a bluff that the insurance will stop paying at some point, that’s not a bluff. But usually what happens is, they will contact you and the hospital. They contact both
parties.
Angie: Yeah.
Patrik: Both parties need to be informed.
Angie: Sure. That makes sense.
Patrik: Right?
Angie: Sure.
Patrik: So I wouldn’t stress about what they’re saying in terms of the insurance. I wouldn’t stress about that, at the moment.
Patrik: I would focus on the hemoglobin side of things. And I would focus on what happens if your mom needs a blood transfusion at LTAC (Long Term Acute Care),
can they do that? Right?
Angie: Mm-hmm.
Patrik: And the other question that I would have, is what happens if there’s
deterioration? Do they have an ICU attached to there? So here is one of the really bad scenarios that I’ve seen over the years, Angie. So someone deteriorates in LTAC (Long Term Acute Care) and they need to go back to ICU. Yes, some LTACs have an ICU attached. Okay?
Angie: Right.
Patrik: The LTACs that don’t have an ICU attached, people bounce back into ICU. However, they don’t necessarily bounce back in the ICU, that they came
from.
Angie: Okay.
Patrik: Meaning your mom could end up in three places, within days, or weeks.
Angie: Right.
Patrik: Now, that’s…
Angie: Right.
Patrik: You know? I mean, one of our arguments always has been, why would you send a patient that is so vulnerable, to another place?
Angie: Right.
Patrik: Now in my mind, that’s just unbelievable.
Angie: Right.
Patrik: You know what I mean?
Angie: Right. I agree.
Patrik: Your mom is in such a vulnerable position, she goes to another place, people need to get to know her, she needs to get familiar with the environment. You need… There’s just a lot of room for error.
Angie: Right.
Patrik: Your mom doesn’t-
Angie: Yeah. That’s my big worry.
Patrik: Yeah. Your mom doesn’t need any more errors. It’s… Anyway.
Angie: Yes.
Patrik: So, you can see where I’m coming from with this?
Angie: Yes. Yes.
Patrik: Another thing that can buy you time, is you may threaten them, with a lawyer, or an attorney. And I’m not suggesting you should get one. But often the threat is big enough, to buy you some time. They don’t want to deal with lawyers.
Angie: Okay.
Patrik: They don’t want to deal with lawyers, generally speaking.
Angie: Got it.
Patrik: Right? So there’s a bit of a bluff there, of course. But I have seen this approach work.
Angie: Got it. Got it. But how do you compel them, to start the weaning process? I mean I’ve asked, but they don’t
listen.
Angie: They keep repeating, “She’s stable, she’s stable.” I should have called you earlier, but as of last Saturday, so the whole last week they’re saying, “Oh, she’s stable. She’s stable. Ready to go to the next level of care.” And they kind of stopped all the daily blood tests, and other labs. And whenever we bring up the subject, just, “No, she’s stable. We don’t do that.” So I’m not
sure how to handle that.
Patrik: Do they have a respiratory therapist, seeing her every day?
Angie: They keep
changing. Even… Yes. Yes. On both shifts, day and night. Somebody comes here, gives her COPD (Chronic Obstructive Pulmonary Disease), medications, and looks at the ventilator setting, so they’ve been good about that. And I talk to all of
them, and that’s how we tried the Tracheostomy collar. Which I tried to initiate it first through the respiratory therapist, instead of me in
the rounds. And the person went to the team and said, “This guy is ready for a tracheostomy collar.” This is probably last Saturday.
Patrik: Yep.
Angie: And they shut her down.
Patrik: Oh, my goodness.
Angie: Yeah.
Patrik: That sounds really highly-
Angie: That’s-
Patrik: That sounds very-
Angie: Yeah. I know. That’s why I’m saying that to get you involved. As long as I know this attending is… I mean, I don’t want to make it personal. But I think they’ve made it personal, I guess, in my mom’s case. So I don’t
think I’m going to get anywhere, as long as this person is here. But of course, on Monday she will change.
Patrik: That’s shocking. I mean I also believe with that in mind, I do believe you need to go to hospital administration. Because that’s so bad.
Angie: Yeah. Yeah. Yeah. Of course, I did not know, you are telling me this course, the respiratory technician telling me this course. I mean, because it’s not my field, I did not push for it as hard as I should have, at that stage.
Patrik: Yeah. Yeah. Yeah. Yeah.
Angie: But now I’m hearing from you, what’s the harm in trying five minutes off the ventilator? She might desaturate, you hook her up again.
Angie: It’s not the end of the world if you try it.
Patrik: Correct. But-
Angie: So…
Patrik: Do you think-
Angie: Please?
Patrik: Do you think that
you can… I mean, I believe I can talk to them. Do you think you can get me on a call with them?
Angie: I’m skeptical. They do when I request through nursing, somebody stops by. Usually, it’s not the attending, unless they want something from you. Usually, they send, depending on their mood, they usually send one of the residents, and sometimes a fellow shows up.
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