Just how bad is it out there?

  1. I am just wondering how bad it is a fellow nurse's place of employment. I want to know how bad I have it in the scheme of things. I will tell you a bit about where I work to compare. I work on a 34 bed step down unit, mostly CHF, MI's, post PTCA, CABG, drips, etc. We are currently a department manager, and our assistant doesn't have a clue as to what is happening on our unit. She is supposed to be charge nurse, and she shows up 15-30 minutes late every day. We have a 6:1 ratio, and our staff is skeleton. We have float nurses from PEDS and OB to staff us, and sometimes we have travelers. We have had major incidents on the unit, and a pending lawsuit (that we know of) I just wonder-is it like this everywhere?
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  2. 19 Comments

  3. by   Jason-ACNP
    Ouch.. I get the feeling it is that bad in many places. My best friend who works in Portland, OR told me that a local agency is paying $95/hr for critical care nurses.

    I'll tell you three brief stories.

    Four years ago, a seasoned RN in the hospital in which I worked “accidentally” infused 1500 mg of Demerol within a 20-minute period. Now clearly she is at fault, because it does take only a second to TRIPLE check the drug being given. She thought it was an experimental anti-biotic, which the pharmacy tech who brought it to her said it was. She was so stressed from caring for 15 patients on days, she just hung it quickly and moved on. She’s gone now.

    A few months later, I was working ICU when a code was called overhead. The time was at 6:00 a.m. The patient, who was mottled, was lying in a coagulated pool of blood. Early during the night, he apparently pulled out the Swan-Ganz introducer port by accident (possibly confused or while sleeping). Anyway, he was taking Coumadin, and his INR must have been way out. We stared in amazement while the RN pleaded for help. We told her, “Rigor mortis has already set in. There’s not a thing we can do”. He clearly died soon after the shift began. The nurse was so busy, she had not a chance to go into his room until preparing for shift change.

    A year later, I was a traveler in Memphis when I was pulled to a general ICU. I received the two sickest patients there. I picked up one of the patients from an RN who had made a lateral shift from the pysch ward. He had never worked ICU in his life, but was in “training”. The patient, who had chronic renal insufficiency, had been on a dopamine gtt at a renal dose of 2mcg/kg/minute. The patient had been dropping her pressure, and thus he called the physician. The physician said, “Okay, titrate the gtt as needed”. The nurse (I swear I’m not kidding) increased the Dopamine from 2mcg/kg/min to 22 mcg/kg/min (2 mcg above the maximum recommended dose) in one shot. Her pressure shot up of course, and I imagine her SVR was through the roof. When the nurse told me what he had done, I thought he was kidding. Then he had a puzzled look on his face and said, “She hasn’t had a drop of urine in her foley since soon after I increased the Dopamine”. At the same time, I was picking up a patient (ventilated) who was in extreme mixed acidosis with hypoxemia. ABGs were 7.26/65/55/19 at the beginning of the shift. I called the pulmonologist who was already irritated with the previous nurse. He gave explicit orders to extubate the patient immediately (in a pissed off tone). I simply made vent changes instead and was going to draw immediate lab, with subsequent ABGs. Yet, the resp tx. took it upon herself to extubate. Needless to say, I had two codes on my hands at the exact same time. While I was attempting to conduct both codes, I had someone call the physician for each patient. Within three minutes, five physicians were on the phone wanting to talk to me at the same time. End result? One patient died (the ARF), and the other lived (after being reintubated and NaHCO3 pushed).

    These are a few… sorry they weren’t so brief. But I think that your situation on your floor is representative of many places across the country.
  4. by   JennieBSN
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    Last edit by JennieBSN on Dec 8, '01
  5. by   Zee_RN
    I'm aghast Jason. But I don't understand how a Swan-Ganz patient could just bleed out and die without anyone's knowledge...this patient was not monitored?! With a swan in? Wasn't he on a monitored unit? I'm horrified.

    Our 18-bed unit is frequently understaffed, with nurses having 3:1 ratio and on rare occasions 4:1. But thank god I cannot relate such horror stories as you just did. I have seen some things that I know wouldn't have happened with adequate staffing but your stories are truly frightening.
  6. by   CEN35
    Well Holy crap you guys!!!!! That sounds terrible. While I have not heard of stuff like that in our hospital, I know we always have ccu/icu/csicu/tele-medsurg openings available. Seems PACU/OR/L&D?ER, are the only ones that can keep people and don't always have job postings up. of course that will change bu the sound of things.



    Rick
  7. by   nurs4kids
    wheeeeew...no, it's not like that everywhere..thank God! But I'm afraid it's not far away. I'm on a 20 bed med/surg unit and our average ration is 4:1, not to mention that we have parents at the bedside at all times as our second eyes. We are starting to bring in agency nurses to staff, so our worst is probably coming (not because of the agency nurses, because this indicates how severe the staffing problem has become). I have the solution You guys can come work at my facility with the 4:1 ratio, and we will all be able to continue working in favorable conditins. j/k


    These things listed above are the reasons we have got to do something! I don't know the answer, but we need an organization that will look out for nurses so that we may focus our energies on patient advocacy. Obviously the organizations we have now, are not doing this.
  8. by   Jason-ACNP
    You aren't being a pain in the ass. I noticed that after I submitted the post, I needed to clarify a few things. I was waiting for someone to catch the confusion. You are very astute.

    The patient WAS NOT in an ICU. I failed to mention that. I was working in the ICU on the 6th floor when this incident happened. The patient was also on the sixth floor, (on a med-surgical floor)

    You are absolutely correct to assume that the patient should be monitored continuously if a Swan-Ganz catheter was in place. In addition to my failing to mention that he was on a med-surgical floor, I failed to mention that the actual catheter was already removed. The floors don’t have SVO2 monitors or monitors to read the PA pressures. Thus, the catheter ALWAYS came out before we sent them to the floor. HOWEVER, the physicians always chose to LEAVE the introducer port intact, because it had a single-lumen IV access. (The introducer port we use is a very large bore and is inserted at least 5” into the IJ vein.) Thus, the nurses on the floor could obtain blood samples for lab without having to stick the patient every morning. (I realize that may not be the policy in some, or even most hospitals, but it was there).

    The patient’s heparin had been discontinued the day before. PTTs were discontinued immediately upon discontinuation of the heparin, because heparin has a fairly short half-life. It was said that the patient was placed on Coumadin at that point. I have absolutely no idea what his loading dose was, or if they had even checked a PT/INR that a.m. (Some docs give a loading dose and then titrate based on that (the next day), whereas other docs start low for a couple of days (2-3) and then draw a PTT, which I don’t like. I want to know the INR the next morning).

    I only suspected that his INR was way out because of the massive amount of blood (pouring from a major vein of course). The other explanation was that the patient, (who was very large) tore the internal jugular vein (even slightly). He was huge. I’ll be honest. I have no idea if he was confused. I was grasping at straws. The dressings that the hospital uses are EXTREMELY irritating to the skin, causing significant itching. Some patients cannot wait to get rid of the dressing. It drives them crazy. I thought that maybe (unwittingly) pulled at the Swan-Ganz in a light sleep (like shooing away a fly or something irritating), and pulled hard enough to tear the IJ vein when the catheter came loose. The only thing is that you have to pull VERY HARD because the adhesive on the transparent dressing is like glue.

    As far as the coagulation question goes, let me explain the scene. There was a MASSIVE amount of blood that, via gravity, pooled to the center of the bed. The HOB was elevated 45, and the end of the bed was slightly elevated. The massive pool of blood had a gelatin consistency (vs. being a hard, crusty consistency). While I was in nursing school, I worked with the coroner in homicides, suicides, automobile accidents, etc. Anytime the there was massive blood loss that formed a pool, the coroner (an M.D.) referred to it as coagulated, which made sense to me (due to its gelatin consistency) However, I may have used the word (coagulated) out of context.

    One more thing, and this are huge. Vital signs are to be taken on that floor every four hours. The CNAs in that hospital are not very efficient, and many are lazy. (That is not an attack on CNAs in general.. I’ve worked with some of the best that have greatly eased my life in the critical care units). The CNA falsified vitals. The nurse was supposedly busy that night with confused patients, dressings, bed baths, etc. She did have 15 patients that night. The CNA admitted to falsifying vitals (so I was told) once the time of death was actually determined.

    As a result, (or soon after), head honchos said that vital signs on the floors would be done every four hours by the nurses. Furthermore, they now wear these damn tags that monitor where they are at all times, and how many times they enter a particular patient’s room that shift, and how long much time they spent each time. YES! NOW THAT’S A SOLUTION!!!! I wonder how many hundreds of thousands of dollars the hospital spent on their new toy….it took effect over the entire hospital (except ICUs).

    I left the hospital soon after that incident to go traveling. It wasn’t worth the $11.88/hr they were paying me.

    I hope that answers your question, but feel free to tell me if anything needs clarification.

    By the way, 2.5 to 3 years later, I heard that this case was still in litigation. HUGE LAWSUIT! HUGE! I have no idea if the nurse was suspended. Like I said, I was quick to leave (to go traveling).
  9. by   Zee_RN
    Originally posted by Jason-ACNP:
    [QB]As a result, (or soon after), head honchos said that vital signs on the floors would be done every four hours by the nurses. Furthermore, they now wear these damn tags that monitor where they are at all times, and how many times they enter a particular patient’s room that shift, and how long much time they spent each time. YES! NOW THAT’S A SOLUTION!!!! I wonder how many hundreds of thousands of dollars the hospital spent on their new toy….it took effect over the entire hospital (except ICUs). [QB]
    OMG...that is just awful! It gets worse & worse! Should this happen in my facility, or become the norm for nursing, without a doubt I am out of the field. Aacck...I cannot begin to say how appalled I am.

  10. by   PhantomRN
    Thanks for the clarification, Jason. I can't say I am totally surprised to find that underneath it all we have a RN who was overwhelmed and overworked. This is just a sad example of things to come if the nursing shortage really heats up.

    As for the monitoring system they enacted post incident. I have seen those things implememted at other facilities. Many nurses quit once that policy was enacted, and I can't blame them. I think it is administrations band-aid solution to the a bigger problem they either cannot or will not address.----Insufficient Staffing Levels.
  11. by   mustangsheba
    Fifteen patients!!! My calculator tells me that's 32 minutes per patient in an 8h shift. I figure I spend at least two hours per patient provided they're not fresh post op or frequent transfers. Heaven forbid one should have someone who is confused or who needs to be fed or who needs to be changed or requires two people to position or you have IV antibiotics and pain management. There have been evenings when I haven't seen all my patients the first hour - the doctor needs you, there are phone calls from family. I feel sorrow for this nurse; however she should have refused this assignment.
  12. by   Jason-ACNP
    Yep..15 patients. They take the team approach in that hospital where there is a RN/LPN/CNA team taking care of that many patients. (This was on nights - a supposedly slower pace - I'm guessing that the person who came up with a 3 man crew to take care of 15 patients never heard of Sundowners Syndrome.

    I asked an LPN once how he managed the medication administration. He said, "Some days (really busy days)I start at one end of the hall and begin passing meds until I am done". " I replied, "What about meds that SERIOUSLY need to be given at the scheduled time. (i.e. Don't give one gram Vanc 3 hours after the last nurse infused it). He simply repeated, "I start at one end of the hallway and make my way down", meaning that he gives every medication to that patient at that time, whether it is late or early.

    How could you even keep report on these patients straight in your head?

    You are right however. Nurses need to say "No". If they don't, they may find themselves in a court having to answer for why she/he "Just didn't say no". In the end, it is your license .
  13. by   PhantomRN
    I find it hard to believe that this patient wasn't monitored with a Swan in. I also find it hard to believe that in 8 hours (I assume you have 8 hour shifts), she was not able to get in there once. If that was the case I wouldn't want to work there if they are so swamped they can't see the patients, nor would I want to be a patient there.

    If the pool of blood was there for 8 hours why wasn't it dried on instead of just coagulated?

    How high was that INR? Way high, then shouldn't that patient been on Q6hr PTT/PT's. So lab would have been in there some time during the night. Didn't they notice he was bleeding or had checked out?

    Also do you have techs, who cleaned him up at 3:00am and who took his vitals all night? If he was on the machine- didn't it sound off when there was no pulse or pressure?

    I am not trying to be a pain in the a** i really would like to know, how this could have happened that a CONFUSED patient with an invasive line in was left to his own devices ALL night.
  14. by   Jay-Jay
    Scary stuff! God, let's DO something to keep this from happening!

    My own experience with ICU: I was working as a PSW, assisting a vented pt. with ALS whose care was just too demanding for the RN's on the unit. (I had my RN at the time, but obviously, was not qualified to work ICU! However, the agency I worked for begged me to take this asst. because they though I was one of the few with the knowledge to handle it safely.)

    The ICU was dividied into two sections, each working independently from the other. At one point, there was one nurse covering my section, all the rest were at supper. A patient started to crash, and in desperation, the nurse pulled me away from my patient, and asked me to sit at the nursing stn. to answer the phone, and watch the monitors! I'd had no training in telemetry, but a lot of the data on the monitors is self-explanatory, and, of course, alarms would go off if anything serious happened...

    I was there for a good 20 min. before the first nurse came back from supper break. Luckily, all the other patients remained stable during that time...

    Oh, yes, should add that the patient who crashed had to be intubated for a couple of days, but survived...

    [ May 04, 2001: Message edited by: Jay-Jay ]

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