[mommy2boysaz]

Here is the situation.
I work in a small hospital and we do about 450 deliveries per year. We are a LDRP unit without separate post partum and nursery departments. We "do it all". Our usual staffing is 2-3 RNs and 1 aide on day shift, 2 RNs and sometimes 1 aide on the other shifts.
There are 2 larger hospitals with excellent NICUs within 20 minutes of our hospital and that is where we ship our "sick" babies when necessary. This happens probably an average of once or twice per month. The babies are usually just needing some CPAP or something like that and we don't have that capability. We are a level 1 "well baby" nursery. We monitor babies on oxygen prn and up until about 4 years ago, that was all we did. If the baby required an IV, they had to be transferred.
Well, a few years ago, a new pediatrician came and decided that we were going to keep babies with IVs, umbilical lines, etc. Mind you, none of us had any training in this type of thing and if one of these babies was admitted to the nursery, it obviously required a onene nurse, which is a problem, when you only have 2 nurses for a shift to begin with!

To try to make a very long story shorter, after some training and much outrage by the nurses, we gradually got a little more comfortable keeping some of these babies. The pediatrician left her practice. Now, we
have a new nurse mgr who feels that because we are a level 1 nursery, we shouldn't be keeping babies if they need IVs. We aren't qualified, staffed, etc.
The RNs agree! BUT, she also seems to think that we aren't aggressive enough with our care of babies. We went from no routine glucose testing on babies unless symptomatic or with diabetic moms, a few years ago, to then doing glucose testing on all babies at birth and repeating Q 2 if under 30, to repeating if < 40, to now repeating if < 50! We get vitals on babies Q 30 min. x 2 hrs at birth, then Q shift if stable. She wants to change this to Q 2-4 if stable, clear up until discharge.
Now, our delivering docs are upset because our mgr is trying to get more babies transferred out. I don't know if she thinks we don't know anything? The docs are worried that their patients will not want to deliver here anymore is there is such a great chance that their baby may have to be transferred.
Our mgr is being forced to assess the possiblity of changing us to a Level 2 nursery. We could never afford it, in my opinion. How on earth could you staff a Level 2 nursery that has 2 babies per month in it?

It's all very upsetting to all of us. We feel we give good care to our patients. Our stats are great. There haven't been any missed issues with a baby or anything else. Our mgr is from a larger hospital and I think she doesn't see that things are done differently in a small hospital. Our care is NOT worse, just different. We don't tend to be as aggressive. Her attitude is that a baby is sick until proven otherwise. Ours has always been that a baby is healthy unless proven otherwise!

After all that, my main question is to those who work in a similar size facility, what do you do? How often do you assess babies? Do you staff a nursery? What do you do with babies who require oxygen or IVs?

Thanks in advance!!

[rninwch]

My experience and opinion...

I work in a unit very similar to yours, though we are about 50 minutes from hospitals with NICUs. We do about 380 deliveries/year, LDRP, and staff with 2-3 RNs/shift with no aides/techs. We are a level 1 nursery BUT we keep all babies with IVs, rule out sepsis, and those needing O2 via hood or nasal cannula for mild respiratory distress and small pneumos. We transfer if the baby isn't improving, is getting worse or if they are early and need CPAP or a vent. We also transfer any infant needing surgical care.

I don't feel a baby with an IV due to low sugars, abx or initial resusciation needs to be transferred as long as they are stable. Do you transfer babies undergoing phototherapy who have IVs? Those kids are usually just getting fluids to prevent dehydration...they don't need a NICU or even a special care nursery. Most of the time, that is when the parents are "with it", stable kids with IVs can go out to moms room and be cared for. We even set up the bililights in mom's room so that she can still be with her kid. We attempt to limit mother/baby separation as much as possible.

Our vital signs are q 15min x 2, q 1h x 4, then q 8h until discharge. Infants are to be checked on q 2h until discharge, but assessments are done q 8h. We only check blood sugars on babies with diabetic moms, SGA and LGA kids and if symptomatic. If the first is OK, we don't retest. If the first is under 40 we'll feed then check in 1/2 hr. If still low then treat and recheck. Once glucose is above 40 we don't recheck unless symptomatic.

OK, so that's my .

Debbie

[NurseNora]

Check with your state licensing agency to see if they have definitions of what can be done in a level 1 nursery. In my hospital, our level 1 nursery does IV's and O2. If a baby needs an umbilical line, it gets shipped out even if we are the ones to put it in.

The STABLE program advises treatment of babies with blood sugars under 50, but they're talking about babies that are sick to start with (STABLE is a program to teach nurses how to stabalize infants for transport and is worthwhile if you haven't had it). We check sugars on infants at risk for low sugars: diabetic moms, SGA, LGA, low apgars, forceps or vacuum deliveries, lousy strips, GBS+, chorioamnionitis, or symptomatic. We are OK with sugars over 40 on infants that are otherwise healthy. Check the American Pediatric Association website for glucose management policies and check your hospital protocal against that.

We check infant VS on admission then Q30min X4, Q1hr X2, then Q6hr or prn. Again, check what other hospitals in your area do, what your docs want to do, what your hospital policy is, what is the APA policy is. It sounds like some of your policies need to be updated. Do the research, don't just let her write something off the top of her head.

We try to always staff, or have on call a nurse who is comfortable with sick babies as most of us on the night shift are not that comfortable with infant IVs, etc. Although we do couplet care, many of our moms want to send the baby to the nursery for the night so we have to have someone able to sit in there with the babes.

[rninwch]

I didn't say it, but like NurseNora, we don't keep kids with umbilical lines either. If they are sick enough to need the umbi line they go, though we do put them in and maintain them until transport arrives.

Since we are about 50 min from our tertiary hospitals we do have a vent that we can use for short periods while awaiting transfer. Rarely, it has taken children's transport several hours to arrive. The worst was about 4 hours. If they are busy and both of the transport teams are out and we have the baby stabilized they'll put us on the end of the list since they know our pediatrician (she still has privileges at the childrens hospital).

All of the RNs on the unit have NRP and STABLE, which is a huge help for newer nurses and those unfamiliar with sick kids. We also have had the educator from the childrens hospital come out and do inservices on IV insertions and things like that, which was immensely helpful for many people.

The only way to gain confidence is to do it, help care for as many of these "sick" kids as you can and then once your confidence is up help teach the other nurses the things you've learned and remember you're never really alone you can always call the doc or ask another nurses opinion.

Debbie

[mommy2boysaz]

Thanks for the responses.
Our nurses are all NRP certified and have received the STABLE training. (I missed itbecause I was on maternity leave when the rest of the unit did it, but we are retraining in May.) I think STABLE is what our mgr based the glucose>50 on, but I agree that a normal, healthy baby shouldn't be required to be >50.

I will check out the APA site for recommendations. Thanks for that suggestion. I guess I'm assuming that our mgr knows the definitions of what is permissable in a Level1 vs Level 2 nursery. Maybe I shouldn't assume.

The overall frustration just comes from the fact that it seems like the "higher-ups" either expect things that are really out of our scope OR they think we aren't capable of ANYTHING! It would be nice if they had a little more realistic view of what we do and what we are capable of. I'm quite sure that those frustrations are universal.
A part of it is also that our new mgr seems to think that because we may not do things exactly like her last place of employment, we do things wrong. Also frustrating. We have an excellent group of nurses who care about patients and the unit in general. There's sort of a feeling of, "We were providing excellent care before you came and had satisfied patients and healthy patients. We must have been doing something right!"

Thanks for the input!! I'm sure we'll get through this transition!