by jbp0529

So here's my situation: a few months ago, I changed jobs from a teaching hospital CVICU (for personal reasons), and thought I'd try out another CVICU in a private hospital. Interview process went well, staff are friendly, facility is nice looking, etc. Well, it wasn't till after I started working that I noticed how strange things are at this place (I guess that's true with many jobs - you dont really see how things truly are till after you start). Alot of the surgeons at this new place are very old and set in their ways. Here are examples of what I mean:
- surgeons routinely use glass bottle chest tubes
- only labs done on arrival to ICU are: potassium and hct
- vent settings ordered with no peep and/or no pressure support
- no ABG prior to extubation...you are just expected to pull the tube
- once extubated, many of the surgeons here dont want incentive spirometry. no one has given me a good rationale for this. maybe post op pneumonia/atelectasis is a good thing?
- insulin gtt's are rare; no clear indication when to start. I've had many a pt at this place with sugars in the 200-300 range and been told to just continue with subcutaneous insulin.
- chance of the pt having a swan is bout 50/50; when they do have one, surgeons dont care about critical #'s when called.
- rarely does the pt come back with pacing wires.
- one surgeon (who is especially old) uses a transthoracic swan. its tunneled thru the sternal incision into the PA. its essentially useless except for PA #'s. Cant infuse thru it or shoot outputs since its directly in the PA.
- no propofol and/or any other type of gtt for sedation. they dont even come out of the OR with anything on board but what anesthesia pushed. if we can't get them extubated, or are told to keep intubated, we have to use morphine and valium iv push around the clock (seldom use versed).
- if a pt is crashing,... start up an "Epi-Cal" gtt (we have to mix this ourself, I dont think pharmacy this is in pharmacy's formulary. its basically 4 mg of Epi and 2 gm of calcium chloride)

- If a patient has a IABP...OMG the whole place just about shuts down! The pt is kept 1:1, which is fine, although I've had many an IABP paired with another pt in the past. Cath lab and OR do not run their own balloons at this place, only the CVICU nurses. If an MI is in cath lab and needs a balloon...cath lab doesnt know how to set it up, our nurses have to go. If a pt has a balloon pre-cabg, our nurses have to go to OR and sit thru the entire surgery and run the pump. It's truly ridiculous, but as I'm frequently reminded, "this is how its done here."

I really hate to be the type of nurse that comes into a new place with exerience, complains about the status quo, and says things like "well at my last place this is how we did it"... so I dont. I just keep my mouth shut and go with it for now. Occasionally I do regret leaving my former, more "progressive" CVICU, bc IMHO this new place needs an injection of fresh ideas and practices.

Re: very old-school, behind-the-times CVICU

Does sound like your new employer is a bit behind the times. Unfortunately there isn't a lot you can do without the support and cooperation of the medical staff. You are right in the fact that you aren't going to make many brownie points with the ol' "at my last job..." pitch. Your best bet is finding ways that promoting current best practice guidelines can cut costs and reduce LOS. -Glucose control for one is a hot ticket item and is a well defined problem that has lots of good research to back up implimentation of solutions. Ask your nurse unit manager if you can get input from other departments and if so- talk to your ID, wound care, endocrine, dietary.... anyone who will offers to add thier voice to yours in implimanting an insulin drip protocal. Once you have one victory you have pulled apart the thread that holds the "we have always done it that way" blanket together. Change an be stressful- even if it is for the best. Go slow, expect little, and be thankful for each small step. Who knows?- you may be running the place in a few years!!

Re: very old-school, behind-the-times CVICU

OMG, sounds like a nightmare!

Re: very old-school, behind-the-times CVICU

I'd get a new job. You may find yourself reciting essentially the same thing to a lawyer when the place gets sued.

Re: very old-school, behind-the-times CVICU

glass chest tube receptors function well. don't get snobby over technology. look at the patient success rate. Are the patients surviving inspite of what you think is behind the times.

Re: very old-school, behind-the-times CVICU

Originally Posted by pawashrn

glass chest tube receptors function well. don't get snobby over technology. look at the patient success rate. Are the patients surviving inspite of what you think is behind the times.

I politetly disagree with your statement "are the patients surviving" Using evidence based practice is important. Keeping post-op hearts euglycemic is crucial in promoting wound healing, keeping new vessels patent, etc. Patient care isn't just about survival rates, but also about giving our patients the best quality care available.

Re: very old-school, behind-the-times CVICU

I have worked in several CVICUs as a traveler and as staff. I have also worked in other countries (volunteer) and seen the gamut of the most high tech to least. However, evidenced bases is evidenced based. In pedi CVICU's in less technologically developed countries we give them bubbles to blow or baloons (in leiu of I.S). There are several things in your post that are alarming because the surgeons are not keeping up with EBP and what produces the best results. In an American hospital, there is not reason to not use an insulin gtt (insulin costs like 2 bicks a bottle). Also not using an I.S? I can;t imagine a rationale for that. In my humble opinion, get out now. I had the priveledge of starting my CVICU career at a Magnet facilities associated w a medical school so now I find it hard to stay at a place that does not constantly try to improve.