[bonesrn]

I have recently taken over as the nursing supervisor at a LTAC facility. Some of the policies we have are very grey and I can't seem to get any clear answers from anyone. We are a 46 unit LTAC facility that takes vent/trach pts, HD pts, pt's with wounds etc..

One...we have tele capabilities and usually have at least one pt on tele, however, there are only a few (2 or 3) RN/LPN who are truely tele certified..meaning they actually took a tele class. The previous supv gave an overview of common rhythms in orientation but nothing on how to measure QRS etc...we run strips on the patients and put them in a book and nobody interprets them. When I questioned the higher powers they said that when we were certified by the state to have tele beds we were only to use them to "monitor the hearts response to exercise and meds" In my mind either your tele certified or not..if someone is on the monitor then someone on staff better be able to interpret that monitor right? I would feel more comfortable if we at least had an RN on each shift who was truly tele certified but we don't. Me being the supervisor I worry about my legal responsibility if there are nurses taking care of the patients who don't know what they are doing.

Second...we have standing orders that state if a pt is on tele we can push 0.5 mg of IV Atropine for "symptomatic bradycardia" keep in mind that nobody is ACLS certified, our crash cart has no meds in it and our AED has no pacing capabilities????? So, should we not clearly define what "symptomatic" is, if the atropine is pushed then what...the nurses don't know what they are looking at on the monitor..what if they push to slow and the pts HR goes down even lower...what if they then become tachy..to many grey areas....so, am I being paranoid or does this seem like something a "reasonably prudent nurse would do with no tele/ACLS training"

Thanks for any input!

[sirI]

Originally Posted by bonesrn

I have recently taken over as the nursing supervisor at a LTAC facility. Some of the policies we have are very grey and I can't seem to get any clear answers from anyone. We are a 46 unit LTAC facility that takes vent/trach pts, HD pts, pt's with wounds etc..

One...we have tele capabilities and usually have at least one pt on tele, however, there are only a few (2 or 3) RN/LPN who are truely tele certified..meaning they actually took a tele class. The previous supv gave an overview of common rhythms in orientation but nothing on how to measure QRS etc...we run strips on the patients and put them in a book and nobody interprets them. When I questioned the higher powers they said that when we were certified by the state to have tele beds we were only to use them to "monitor the hearts response to exercise and meds" In my mind either your tele certified or not..if someone is on the monitor then someone on staff better be able to interpret that monitor right? I would feel more comfortable if we at least had an RN on each shift who was truly tele certified but we don't. Me being the supervisor I worry about my legal responsibility if there are nurses taking care of the patients who don't know what they are doing.

Second...we have standing orders that state if a pt is on tele we can push 0.5 mg of IV Atropine for "symptomatic bradycardia" keep in mind that nobody is ACLS certified, our crash cart has no meds in it and our AED has no pacing capabilities????? So, should we not clearly define what "symptomatic" is, if the atropine is pushed then what...the nurses don't know what they are looking at on the monitor..what if they push to slow and the pts HR goes down even lower...what if they then become tachy..to many grey areas....so, am I being paranoid or does this seem like something a "reasonably prudent nurse would do with no tele/ACLS training"

Thanks for any input!

Whoa, uh, yes.....plenty of liability there, bonesrn.

If you are utilizing telemetry and no one has any idea how to interpret the readings, then how in the world can one recognize a lethal rhythm or the possible devloping lethal rhythm? Doesn't make any sense at all. I would say this is a suit in the making.

As for the "standing order" for Atropine? Are the nurses treating the monitor? Or, do they treat the patient? That is the only way to determine if bradycardia is symptomatic or not. And, if so, one must utilize the algorithm for symptomatic bradycardia, including oxygen and then a pacemaker if the Atropine is ineffective. To do this without the proper training and without a trained licensed individual to conduct this scenerio and trained licensed individuals to treat, is in and of itself, negligent.

You better be sure you can access 911 or whatever EMS system ASAP. I suppose you contact the physician whenever this occurs. But, what if the patient codes? Do you have capability to perform per ACLS protocol?

You all really need to have an ACLS course or something similar and hire nurses who are capable of interpreting the monitors......on all shifts. And, have in place protocols to conduct all the algorithms properly. Drugs and oxygen and equipment including pacer and defibrillator.

Ya'll are practicing on thin ice. IMHO.

[Havin' A Party!]

Bone -- That facility and those in responsible charge are in major legal jeopardy as things stand.

And medically, the clients are in a potentially dangerous environment.

[CaseManager1947]

I agree with both siri and HAP as they have posted. This is a very risky practice environment, and as nursing supervisor you are doubly at risk. You didn't make clear if you are supervising the entire facility or one shift. If you are acting as DON of this facility, either changes need to be made, or I'd be looking elsewhere. If so, demand an exit interview to clear the air as to the reasons you chose to leave. Really not much else to say on this.

Morghan MSN, ARNP
Wichita ks

[bonesrn]

Case Manager...I am the supervisor for the day shift. There is a night shift supervisor and of course the DON. I have documented my concerns and voiced them to the DON and the Risk Management dept. Since the original post we are in the process of sending all of the RN/LPN to an EKG/Tele course. Things are better but still not great. They are trying to run a step down unit without the proper staffing, education, equipment etc. Needless to say I will be leaving the facility. Since voicing my concerns, the DON has just announced that she too is stepping down. Whether or not that has anything to do with my concerns or not I can't say. I say my prayers and document, document, document. Thanks for your feedback.

[CaseManager1947]

Good Luck with your career, It is so great that these forums are here to get feedback from our peers. Keep the faith, and know that you may have been an agent for change for the patients in that facility.

Morghan

[foraneman]

Regardless of any "policy" that says your monitors are to measure the hearts response to excecise or meds (that's screwy to say the least), there are standards of care for monitored patients. Crash cart with no meds, RN's not trained in critical care.....a lawsuit is indefensible. You would be better off throwing the monitors out the window.

[bonesrn]

Thanks for all the input.