Quality Corner: Nursing Homes

There is probably no EMS agency on the planet that has not butted heads with staff from their local nursing home. This conflict is inevitable, because EMS and nursing homes are on opposite ends of the medical spectrum.

Many patients in nursing homes are there for end-of-life care. EMS personnel, on the other hand, yearn to safe every life, even if someone’s suffering. In recent years, with help from changes in state laws and protocols, we’ve adjusted our mission to be a bit more realistic and practical, but deep down inside we are all still the same lifesavers and heartbreakers we’ve always been.

After 35 years in EMS, I have come to view the EMS provider as a heroic hard charger with an inherent desire to save the world even when it’s not always practical or appropriate. But that’s how we’re wired, and probably why we do what we do. Much of the rest of medicine is a bit more subdued, and the inevitability of death is never so real, constant and inescapable as it is for the extended healthcare provider.

In EMS we have the luxury of sweeping in, with lights ablaze and sirens heralding our arrival, after the intensity and violence of the sentinel event have passed to deal with the aftermath. We have the further advantage of plying our trade with personal detachment; we typically do not know our patients and are only exposed to their pain and suffering for very short periods of time. In those short periods we are typically too busy with assessments and treatments to be drawn into their agony in any personal way.

Conversely, nursing home staff are exposed to the pain and suffering of multiple patients in various stages of demise every minute of every day. As a result of this environment, extended healthcare providers have been aware of the futility and inhumanity of overaggressive resuscitation in most instances of cardiac arrest long before it became appreciated by EMS and the rest of medicine 

So how do you bridge the gap between these two extremes of medicine? First of all, a little humility goes a long way. While EMS is our entire world of understanding of medicine, it is just a small part of the much larger medical universe.

Second, as with most problems, communication is key. In the case of my agency, Bucks County (PA) Rescue Squad, our closest neighbor—right across the street—happens to be the Silver Lake Center, a nursing and rehabilitation facility. There was a minor incident between our providers and those of Silver Lake a while back. I’ve heard the same complaints since the beginning of my EMS career, and it was always easy enough to blow off as the inevitable culture clash that’s existed since Johnny and Roy wore short pants. This time, however, there was an opportunity for the assistant director of nursing at Silver Lake and I to meet.

When we got together, I met Naira Tichy, who as it turns out is the Joe Hayes of Silver Lake. She is in charge of patient care and keeping things running from day to day without the wheels falling off. I had the opportunity to ask Naira why her colleagues do some things that seem so alien to us in EMS. Naira had all good answers, and just as with me in EMS, not everything was under her control. After just a half hour meeting, I left with a much greater understanding and respect for a very demanding and challenging part of healthcare I don’t think I could ever do myself.

In addition to communication and humility, Naira and I succeeded in identifying areas of common interest and ways to help each other. We decided to exchange cell phone numbers, in essence creating a hotline in case any problems or complaints should arise on either side of the street. We also identified a training opportunity for CPR. CPR was never designed to be used on all cases of cardiac arrest, because most cardiac arrests are the end result of a cascade of events which represents the end of life. Many of those for whom CPR is not indicated are residents of nursing homes. However, there are other people at nursing homes for whom CPR is indicated. These include patients there temporarily for rehab. There are also those extended-care patients who lack a DNR (do not resuscitate) order. And of course, there are friends and family who are elderly with medical problems of their own who come to visit nursing home patients.

We offered to provide CPR training for Silver Lake’s entire staff at a reduced rate due to the volume of personnel to be trained. We did a total of four of these CPR classes to accommodate the different shifts and working schedules. Thus, a major logistical challenge faced by many healthcare institutions—ensuring current CPR certification of all staff—was resolved within a month and with a standard recertification date for all, which was much easier to keep track of.

In addition to CPR, we also made a point of sending fliers over to the nursing and rehab center inviting their nursing staff to attend our Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) classes. Neither of these courses are required at most nursing homes, and their lessons may rarely be utilized there, but they can be valuable career enhancements for nurses and medical assistants.

Nursing homes and EMS coming together in positive, mutually beneficial ways such as this is a perfect example of how stumbling blocks can be turned into stepping stones.