I just attended a very informative two-day conference on hemodynamic monitoring. . . and was blown away!!
I work in an ICU/CCU for a very small community/rural hospital. The ICU/CCU ward is five beds (35 total beds for the whole hospital). Our usual patient population are r/o MI's, MI's that are able to be treated medically, drug OD's, vented patients from nursing homes needing IV antibiotics, COPD exacerbation's, CHF, occassionally babies with bronchiolitis, tele-type patients for arrhythmias, new cardiac pacer implants, and a lot of medical/surgical overflows. The last time I saw a pulmonary artery line was February, 2001. . . since my two year stay at this hospital, I've seen about 3 PA lines. . . and I'm a relatively new ICU/CCU nurse of two years! (Spent about 8 years as a hematology/oncology/BMT nurse with my last nursing job.)
So, here I am at this conference about hemodynamic monitoring feeling like we shouldn't even consider placing PA lines in any of our patients. We do have a part-time cardiologist (who is wonderful). He usually does echocardiograms to assess his patient's cardiac functions. . . and then ships the the really ill cardiac patients out to a hospital which handles more intense and invasive cardiac care. However, there may be indications for a PA line besides that are not strictly cardiac-related. I can honestly say that most of the nurses on my unit feel the same way as I do with regards to the use of PA lines . . . dread!!! We just don't see enough of them . . . neither do the doctors!!! (We have no real intensivist . . . except for our part-time cardiologist.)
We do inservice each other in an attempt to maintain some kind of competency with regards to PA lines and other seldom-seen ICU/CCU scenerios. Heck . . . this is the THIRD time I attended a conference on interpreting the data from PA lines and managing the medical/nursing care as dictated from the data.
How do other nurses in similar situations manage their critically ill patients, where all of the attending physicians are Internists at best. . . where they are expected to be able to manage PA lines (and other ICU/CCU type stuff), and may see only 2 to 3 a year . . . if that many??? How do you maintain competency for seldom-seen ICU/CCU issues (and still be expected to manage)?
About 90 to 95 % of the time, the patient acuity of our unit is fairly to very managable. To their credit, the ER doctors/nurses and the regular hospital attendings know when to "ship" the patient to an appropriate hospital. It's that 5 to 10 % of the really, really acutely ill patients (usually not admitted to our unit, but slipped through the crack or just took a turn for the worse) that I'm concerned about.
Like I said, I'm feeling a little blown away right now after attending this conference. Glad I went!!! But I'm also very aware of our unit's weaknesses, the largest being competency with seldom-seen ICU/CCU stuff (PA lines, ARDS, neuro-related stuff, cardiogenic shock, advanced speptic shock, etc...).
Thanks, ahead, for reading this, and for your imput!!
Last edit by Ted on Sep 25, '01
Sep 26, '01
I worked in a 16-bed ICU/CCU in a rural regional hospital (we would usually average 8 patients at a time). We had two intensivists, and several cardiologists and internists, so I quickly developed a comfort level with Swans. However, on average of 2 times per year, we would get someone from the cath lab on the IABP. The very first time I took care of a patient on the IABP, (this was 6 months after my "competency") I had to climb into an ambulance and travel an hour North to a larger hospital where I was ridiculed by the "big city" nurses and made to feel like a country hick, (but that's another post!) PLUS, once or twice a year, we would get a neuro patient with an ICP monitor or a camino. We would go over this stuff once a year in our competencies, but we all know the only way to get comfortable with a skill or piece of equipment is to do it or see it regularly, right?
After my "ride North" with the IABP, I was then considered the unit's "expert", believe it or not! Now I work in the cath lab and actually teach the IABP to new ICU nurses, however, almost every one that goes north with a balloon pump now has a cath lab nurse travel with them. Our hospital is getting open heart by July of 2002 and then all ICU/CCU nurses will have to get comfortable with them because they will be common.
By the way, when I was in ICU, I refused patients' with ICPs or caminos because I did not feel competent nor comfortable enough to give good care. Whenever my competencies were due, I would never sign myself "competent" because I was not.
Fortunately, I was never challenged for this because we rarely got these patients and the older nurses would take them when we did (and these patients usually got shipped north too).
To answer your question how do you maintain competency and still be expected to manage, most of the time you just do. When you do have a patient that has a Swan, try to be assigned to him/her and play with it. If you have a patient on your unit with a Swan but not assigned to you, ask that patient's nurse if you can watch or help when they do hemodynamics. Have a non-sterile one that you can get your hands on to look at when things are slow (I know, how often does that happen!)
Maybe you could team with the ICU at the nearest large hospital (for example, the hospital you usually refer your more critical patients to) for you to use as a resource when you have a question or need to troubleshoot and your doc is ignoring his pages. I know this wasn't much help, but hang in there. There are lots of small units just like yours all over the country, and I think you all do a great job!
Sep 26, '01
Ted, I work in a large metropolitan hospital in a 22 bed CV-ICU and our problems are maintaining competencies with CRRT patients and Nitric Oxide! In other words, we all have trouble maintaining competencies in rarely used technologies.
Just remember that; no one is an expert at everything. I've taught classes on hemodynamic monitoring in the past, but it's been over 10 years since I taught one the last time and I'm sure I'd be rusty teaching it at this time.
My guess is that the instructor probably talked way above your skill level and shook up your self confidence. Get a good book on hemodynamic monitoring (I used to use Daily's "Hemodynamic Monitoring" as a good resource) and maybe get a core group of your nurses to form a study group and work on it together. Or put up a "waveform of the week" in your break room, or any other questions that might inspire your staff. Join AACN and ask them for suggestions. Also, if you can arrange to go to the hospitals that you send your sick patients to and "shadow" a nurse there in their ICU for a day (or ask to observe nurses caring for pts. with PA lines), this would help you care for your patients better and help you meet some nurses who could serve as resources for both you and your hospital.
By thew way, I have NO idea what a camino is, and I haven't worked with an ICP in at least 5 years!
Sep 26, '01
You know, this thread is a great example of exactly how "a nurse is a nurse" thinking is completely outdated. After all, is "a doctor a doctor?" Of course not! They have their specialties, we have ours. I work in a CVICU of an urban teaching hospital. I feel very comfortable with PAs and IABPs, but feel completely lost when I float to the Trauma/Neuro ICU and have to deal with anything above the chest. Give me an open-heart patient anytime and keep the Roto-Rest beds to yourself.
Nevertheless, we all have to maintain some competencies "just in case". I'm sure it's harder if you're in a small unit that doesn't have a specialty all its own. Frequently, large hospitals (especially teaching hospitals) have periodic critical care and hemodynamics classes for new nurses and interns. If possible, see if your unit can work out a deal with a bigger hospital to have your nurses attend their classes a couple of times a year. It might not be as in depth as a large conference, but it will keep the basics in your head enough to calm your nerves when you get the odd PA line.
Sep 27, '01
Thank you to those who responded so far. Your comments and suggestions are appreciated.
We've discussed the possibility of doing some work at our bigger, "sister" hospital to help maintain competency with AP lines. The problem is that we're so tightly staffed, we really can't afford to have a nurse go away on vacation much less go to another hospital to shadow other ICU/CCU nurses (although, it would be very cool if we could do such things!!). Right now, it seem like the best thing to do for ourselves as a unit is continued inservices, case conferences, and "week-end" conferencing. I think I'll join (as someone suggested) the AACN nursing organization and attend some local meetings.
The problem of maintaining competency is not only for the ICU/CCU nurses. It's also with the physicians. Most of the doctors are GP's. A few of them, besides our one cardiologist, took a course in 12-lead EKG's and provide an extra service in reading the 12-lead EKG's for our patients . . . but that's about it. There is NO full-time intensivist.
I had a discussion with our one and only part-time cardiologist, earlier yesterday, about my concerns. Interestingly, he said that the hospital tends to "ship" those patients out who requires the intensive monitoring associated with a PA line. (As I stated in my original post.) He also said that our happy little community hospital will most likely put its focus on telemetry beds verses ICU/CCU beds. We already seem to do this anyhow.
This leads me to a quandary. If I stay here, I'll never really learn to manage to truly ICU/CCU type patients. However, I like working here at this very small and quaint hospital. I guess I have some soul searching to do . . .
Again, thanks for reading my post and providing any comments and/or suggestions.
Sep 27, '01
I know how you feel, Ted, though not from personal experience. I have several friends who work in small hospitals (though not as small as yours seems to be) who have wanted the experience of a larger facility, but didn't want to leave.
Two suggestions: 1) Depending on how far away the larger hospital is, you could hold two jobs and split your time. Not always easy, I know, especially with weekends. You could remain on call with your current unit. If staffing is as tight as you say, you might be able to pick up quite a few hours.
2) Depending on your comfort level and confidence, you could join a pool and work through them at the larger facility. As I mentioned, though, this will depend on the confidence you have in your abilities. After all, you don't want to put yourself in a position where you will be in over your head with no resources.
Sep 27, '01
Thanks for the suggestions! I've thought about working part time/per diem at a bigger facility. There are about three to choose from, near where I live, which is cool. Will probably do that once a few personal projects are finished.