There's a Mousetrap In My Med Cart - page 4
As some classmates in our RN nursing program gathered around in a small group this morning, I sided up and listened to a story that quickly carried me back in time when I was a newly licensed... Read More
Mar 22, '09the amount of pills our patients get in LTC is quite ridiculous. add to that the low level of nursing coverage allowed by fed standards...quite a quagmire. i find it quite difficult to give quality 1:1 care and pass pills, check blood sugars, monitor vitals that are med related, blah blah blah, within the 2 hour window.
Mar 22, '09All this concern about the med pass times in LTC boil down to "to many medications". Now, that being said, is that to many meds to GIVE or just to many meds IN GENERAL? The buckets of pills that these residents get is mind blowing. It's no wonder that these folks don't want to eat, they are full of PILLS!! How do you think we can better serve our residents and get some of these meds discontinued? I don't mean insulin, BP meds, antibiotics, etc. I'm talking about the vitamins or minerals more than once a day, the QID glucometer checks when the residents on metformin, you know the rest. The orders we get from the docs need to be reviewed and meds/treatments/checks of all sorts need to be DISCONTINUED WHEN NO LONGER NEEDED!! Everyone is so busy trying to get done what's on the med/tx sheets that they have little time to think about if this actually is something that is still needed by the resident (let alone call and get a D/C order). You out there in LTC land know what I'm talking about. How many residents refuse the same meds day after day or never have a BP/pulse/BS that is within the parameters for medicating? How many hours would be saved if you didn't have to do these and then the charting that goes along with it? The busy work is what's killing me, how about you?Last edit by WYDiceDancer on Mar 22, '09
Mar 22, '09That's the point: it ISN'T possible, and we all keep pretending it is, and the LTC facilities have the Boards of Nursing on their sides, saying it is and that it's legal, and we keep trying to kill ourselves to get it done. IMHO, a maximum number would be (maybe) 25 residents per nurse in LTC, instead of the 50 my state says is okay.
Mar 23, '09Dear All,
I can fully commiserate with the issues raised here.
Equivalent to your LPN's, i have worked for ~2years in LTC facilities (called Residential Aged Care facilities here/RACF's) and have recently gained my endorsement to give medications.
Reading the story tugged at my heartstrings,
for I too have had to compete with time clocks, especially when ratio's are blown out the window due to RACF manager funding greed (and the mt Everest paperwork that goes with it including repeated electronic and paper based assessments) and the ever increasing acuity of our aging populations; which is another matter of ethical debate.
As an agency nurse, i have been to many facilities that hover around the 100+ room numbers, and despite being encouraged to go into Aged Care for the basic nursing care skills practice and adoring the older people who sometimes dont see any family once admitted, lately the pill rounds have been tortorous and a source of aprehension before a shift.
At one faciltiy, after my agency booked me for a night duty (10pm-7am) then placed me on an afternoon shift (2-10.30pm) at a RACF 2hours away through traffic, the 5pm round began at 1630 and concluded at 1900, after a 20min scoff of dinner and managing to get the charge nurse to clarify where the 3 antibiotics were that 1 lady needed (all via PEG tube, 2 liquids that she hastly poured as vs my training to get exact dosage and mixing them which again, was taught as a no-no as to determine which AB caused reactions if given one at a time) she then crushed the 3rd AB and sent it forcefully down the peg "bombs away", this lady also needed 2 topical creams, asked for more moisturiser on other limbs, was developing sacral pressure areas due to lack of turning and also needed a nebuliser with a normal saline neb post, the charge nurse also talked me through suctioning her mini trach...all this took 30mins, so to all auditors doing med time checks, handle these types of patients then get back to me.
Throughout the shift i was hounded about how far down the hall i was/progress, how long it was taking me and that some stronger analgesics needed to be given (our opiods are all kept in a seperate lockable box and checked with the charge nurse and cannot be stored ie must be given after being removed from the box).
Add to the glucose checks, insulin which according to policy and as a reassurance to newly endorsed nurses, have to be checked by the charge nurse (to prevent unfortunate tales of 50 units not 5 units being given, again task vs critical thinking nursing?), it leaves no time at all for wound dressings, obs etc ontop of continence, pain and nutrition suppliment assessments/paperwork. Some facilties i have heard also expect the med nurse to take on a reduced patient load, i wouldnt dream of leaving a loaded insulin pen whilst i helped someone to the toilet!
The charge nurse even asked me to 'sign then give' to speed up the MAR documentation and write 'refused' if the client happened to spit, throw or honestly refuse the med, telling me 'many might refuse cos your not familiar to them', no kidding when i'm agency.
By the end of the shift, running on 4.5hours sleep, i collapsed and cried in the staff toilet adjacent to the handover room, i was completely spent and questioning my own ability to a) nurse and b) do the pill rounds.
Some residents have 2 full MAR's full of ceased then recomenced meds, with med lists feeling like a game of minesweepers (oops, that was ceased yesterday and restarting wednesday).
Another facility had me as the only qualified nurse for the evening shift, making nurse patient ratio 1:52, with insulins being given by visiting community nurses which happened with lost specific paperwork (to shared annoyance) between visiting GP's ordering sedatives for one mentally ill lady experiencing trouble sleeping.
I too agree that ratio's need to be reconsidered and medication times or quantities need to be re-evaluated. I believe that 1:25-30 max could be a limit for pill rounds, with extra understanding for agency nurses who have not been to the facility and do not know the residents being in staff forethought. As for non medication nursing, our ratio's have been as high as 1:9 in aged care and in one instance was blown out to 1:18 after my 'buddy' in the wing decided to have a 2hr smoke break without letting anyone know her location.
It all raises/reinforced issues of nurse recruitment and attrition especially as i have experienced some savage behaviour from other nurses who have all tried to discourage me and insult my methods of double checking medication orders including the 'rights' ie patient, drug, time, dose, frequency, route. If the nurses dont get along, the patients know in a heartbeat. Are we trying to determine committed nurses ie those that can tolerate the political minefield to those who think nursing is still the female based role where good doctor husbands can be found???
Mar 23, '09Hi JackieSue07...God Bless you! I have worked both ltc and acute care. Honestly, I feel that LTC is more stressful and the work is more physically and emotionally demanding. I admire you because you say you love what you do...and you must love it or you wouldn't be able to keep doing it for 14 years! Acute care nurses tend to think that ltc is easy...on the contrary, it is very hard work! I admire you very much for doing what you do with love.
Mar 24, '09As far as crushed meds thru G-tubes; I used to crush the meds that were compatible with crushing and use just a little bit of applesauce to bind the powder together then add water to this to make a slippery slurry, then add a little more water. This helps prevent it from clogging the tube ( sort of like making a creme base for cooking ).
It may also help to call the pharmacist to convert as many meds as possible to liquid form.
Hope this helps as far as Tube Feedings are concerned.
PS: JACHO is a self-regulating "club" industry that needs some real (federal) regulating in it's place.
Mar 25, '09I just have to say how much I appreciate the frustration of my fellow nurses. I work at a jail (which shall remain nameless), and am responsible for passing approximately 130 patients' meds at any given med pass, along with seeing emergencies, diabetics, patient questions and demands, EKGs, BPs, blah blah blah. There is only 1 nurse (sometimes we luck up and have 2) along with 2 or 3 med techs for the entire facility (of 1500 give or take). Not to mention that the calibur of my patients is somewhat lacking, and I can count on being cursed at or threatened at least 6 times a shift. THAT, my friends, is the epitomy of overworked and underpaid
Mar 25, '09for the most part i am so excited to become a nurse...and then i hear things like "mouse trap"!!! it's that kind of story that gives me the 'anxious' feeling about becoming a nurse!!!
Apr 4, '09I found my heart pumping as I read this post. How many times have I wanted to be in compliance but found it impossible. I remember working at a facility where I had 30 patients, 15 fingersticks of which at least 10 required coverage. It was nothing to have a 4 hour med pass in fact it was more of the norm. Then I had to find time to chart. Great posting.
Apr 4, '09In my state, NO nurses are required to be on staff in assisted living facilities. Some of the better chains have LVN meds nurses but the majority do not. Caregivers (not even CNA's) are allowed to pass meds after an 8-hour training class; that's the NEW requirement. A "med tech" may be expected to pass meds for as many as 60 residents, many with dementia or on hospice, none of whom wear ID's. The corporate offices think the med error rate is low because not many are reported. That's because they don't know they're making them!!! They don't have the background to understand what they're doing. I went into such a situation as an Assisted Living Supervisor (the only nurse) and found lots of errors, many very serious. I was fired because they said there were more med errors after my arrival than before. I was following regulations by reporting and correcting them! But administration would rather not know about mistakes; ignorance, to them, is truly bliss. Our seniors deserve better than this. If you have a relative being placed in an ALF, ask who gives the meds. It could be a matter of life and death...
Apr 5, '09I love your post. Such a typical med pass - when I'm finally done with the med pass and all the issues (assuming no one has fell - oh well there's always some kind of A&I to be done for sure) then contact the doc with all the current issues and orders of course. I sit down to finally chart and do orders - then, the family's line up with their issues (or non-issues) and resident's enter the line as well "I need my medication" (the one they already received and asked for 6x) - oh gosh, must be pleasant and accomodating to all needs - BUT make sure you punch out on time and finish all your paperwork!... Thanks - it's nice to see I'm not alone!
Apr 6, '09What a great article! I printed it out to post at work. Everyone can identify with you. Hang in there, I've been a nurse for 35 years, it doesn't get better. But, you make a difference in each life every day!
Apr 14, '09my gut reactions to your post: 1) agree with person who stated your true calling could be writing (which i believe is mine as well, but life happens, 2) my hair stood up and my stomach was churning in response to the unpleasant familiarity of the situation you explained - although long past, once one experiences what you have described, the nervous system does not forget! i have been a nurse for close to 20 years of which 17 are in ltc, short-term sub-acute, hospital based snfs as a don, nurse manager, nurse consultant, dsd, qi director, and all of the other hats possible, including charge nurse, med nurse, treatment nurse, iv nurse, etc. etc.
what a great way to bring to light issues still faced by many nurses in the ltc and elder care arena (and some acute care units as well) too many patients, too many meds, patients getting sicker, and some unrealistic expectations, not enough nurses, not enough help, not enough tools and time to succeed! i have continued to do what i do because i know i make a difference. "never underestimate the difference you can make," quint studer.
my current favorite thing to say is, "i believe there are enough of us who care about what we do as healthcare providers, who truly believe that by teaming together we can make a difference in the lives of the people we touch, such that we can work through the challenges we face today and influence, coach and mentor those under our wing." however, in order to impact systems and make some practical changes, here is what i would suggest if you have not already tried these steps (these are directed to those especially new to ltc regulations, etc., or those who are simply looking to vent, as well as those looking for some practical suggestions).
- follow your chain of command - ask to meet with your supervisor or don, go as a team if you feel there is more accomplished with more people involved. you may say, "what if the problem is the don? or you have already approached the don and nothing changed?" ask for another meeting again, but in this meeting, present your concerns in this suggested format:
state "we have discussed these concerns before, but we feel there has been no change" (be specific - avoid generalizations). proceed to say, "we would like to follow our chain of command to resolve these concerns." (be prepared to provide suggestions/solutions to the concerns you bring forward). then state, we are documenting this meeting and we would like to either formulate a plan with you with a goal date, or meet with us again on a future date to present us with workable solutions". set your goals and timelines. then be clear that since you are following your chain of command, that if certain goals are not met, or you feel you are not being heard, you will go up the chain of command following usually facility protocol. continue to document with follow-up meetings and refer back to your notes as needed.
an investigative body (be it regulatory, quality, corporate, legal) will usually ask these things when something happens, "did you follow your chain of command? if not, why?" by failing to take advantage of the chain of command process, you may be placing yourself in a disadvantageous position, and may even be treated as part of the problem, whatever it may be.
this above process only addresses things not considered to be emergent, urgent, or a threat to the safety of the patient. remember, patient's safety comes first.
- when you are working on solutions as a team, involve as many people as possible - develop some quality action teams within the workgroups (2-4 people mini-committees) to be champions (leaders of the solution)
- consider the split time for med passes as another writer suggested. increased staffing is not always an option especially with the nursing shortage. some facilities i worked in split the big halls into 2 for physician order writing/times actually in mars based on room#s (am meds are 0800 for 1 group and the rest of the med pass times are adjusted to this time schedule, and the other group starts at 0900)
- work with your pharmacist and physicians ideally upon admission (or within 72 hours) to review duplicate therapies, combining some bids into single dosing when it doesn't impact the clinical effect, moving non-significant meds to noon for the daily meds (such as multivitamins), studying the necessity of each single medication being given. we are not doctors and cannot prescribe, add or d/c medications. however, a consulting pharmacist usually has tools that nurses can use to help streamline meds and reduce unnecessary medications. call your pharmacist for those!
- consider putting your insulins/hypgolycemics on a separate medication sheet on a different color (we have used pink - for diabetes in some facilities). so, at the beginning of your pass, you can quickly leaf through the pink sheets and id your insulins prior to the beginning of the rest of the routine med pass.
- we all know we have residents who have highly individualized needs/requests - for the known ones, one of the tricks we used was a medication pass instruction page, or an alert page in front of each resident's medication profile, so in case someone forgot to give you specific instructions or some tricks of the trade on specific residents/meds/etc. - you can actually look at it as you are flipping to the medication sheets
- gather the assistance of team members to keep medication passes as uninterrupted as possible - easier said than done at times. but go back to following the chain of command, one of the things you will have to ask for is administrative support of reduced interruptions, additional assistance from non-technical staff (presence) while you are conducting your heavier medication pass (unless urgent, try to have them take messages).
- institute bedside rounding - will be tough at first especially with bigger facilities, but will pay off in the long run. if you have too many patients (this is subjective since levels of care differ, and acuity differs), at least do the bedside hand-off on your priority patients (new admissions, change of condition, post fall), so as you are reporting off, you are eyeballing the patient.
- engage your don and administrative team to problem solve with you, what systems need to be put in place. the medication pass is not all that you do. however, it does take up more than half of your day's work, so any other duties and responsibilities will appear minor when you have a horrible and never-ending medication pass.
- if some of the tactics do not work right away, ask for the manager team to shadow a licensed nurse for the entire shift strictly for observation (an assist of course) of how your day goes.
i hope and pray that through venues such as this, we can continue to grow as a profession, nurture each other, and prepare each other to deal with the challenges we are yet to face in the future. more power to you all!