High turnover in LTAC's?

mschrisRN · Sep 5, 2012

Working at a a LTAC will give any nurse experience beyond belief. Unfortunately.....Hospitals still view them as "nursing homes" due to their lack of understanding of what an LTAC is....even though they send the patients they failed to get home. So a nurse who has worked at an LTAC has more selling to do about her experience than other nurses in acute care.

I'm a new grad working in LTAC and I can't agree with this more...everything Esme said is spot on. I have gotten tons of experience with "chronically, critically ill patients." These pts are basically the ones that have survived major traumatic insult who, 20 years ago...some even 5-10 years ago, would not have. They come to us with multiple active disease processes, many of them (somewhere between 50% to 70% in our LTAC) with antibiotic resistant bacterial infections. They have chronic wounds, both DQs and surgical. One shift that I worked, I had a patient that was a longtime anorexic who had developed pneumonia and been hospitalized in ICU. The patient was discharged to us for wound care and nutritional monitoring. The patient 13 pressure related wounds from the weeks spent in the ICU at the critical care hospital. Lately, we've had a rash of abdominal wounds; massive ones, with huge wound vac sites...some of them with ostomies exiting the abdominal wall through the wound bed. It's challenging; stress is HIGH, time is short, and supplies can be near impossible. And as Esme said, many hospitals still assume that LTACs are LTCs, *EVEN THOUGH* they're discharging their most ill patients to us! That means when you're ready to move on you really have to push that you know your stuff and that you have the multitude of experience that you have. You *have to* "sell it." It's not for the faint of heart or the slow learner. They won't hand hold, but they will teach. Be prepared to ask questions. :)

P-medic2RN · Nov 21, 2012

my pt. load is 55-60 with 3 CNA's. i'm running as soon as i can.

Esme12, ASN, BSN, RN · Nov 21, 2012

my pt. load is 55-60 with 3 CNA's. i'm running as soon as i can.

Are you in Long Term Care/SNF?

I believe they are talking about Long Term Acute Care Hospital. A totally different place. If that staffing is at an LTACH you need to leave!

BrandonLPN, LPN · Nov 22, 2012

my pt. load is 55-60 with 3 CNA's. i'm running as soon as i can.

Even if this were on a low acuity long term ward, this would be pushing it.

nursingilove · Dec 3, 2012

Yeh that's overkill. These pts are a sick I think 6 pts is enough to cover. 56 no way. That's the whole floor???

Esme12, ASN, BSN, RN · Dec 3, 2012

It has to be LTC or SNF....

SquishyRN, BSN, RN · Dec 5, 2012

And probably night shift...

RNikkiF · Dec 12, 2012

Are you new to nursing? If so, I would recommend against starting out in LTC. This is why: I have been a nurse for two years. I spent most of that time on the floor in the hospital setting before switching things up with LTC. This is what I have seen:
I have encountered the predominant majority of RNs and LPNs in LTC not to be critical thinkers. They do not know the vitals for their residents before administering b/p meds, do not assess, and even give meds they have no idea about because "they are too busy". The month that I did LTC, I had within one week two people that I had to send out when I assumed my shift at 2200: One which was hypotensive with a 80s systolic with frequent liquid diarrhea and emesis and another g.i. bleeder with three large, tarry stools that showed the classic presenting s/s of a g.i. bleeder. For the exception of my assessments, no one had assessed these two. On the former, no one had taken vitals on her since January of this year. I, however, took vitals on those people who did not appear well or who were on any cardiac meds because that is a safe standard of care. For the latter, while getting report on my 36 residents, the LPN happened to mention one tarry stool. No mention of an assessment of the resident. She said she had called the PCP, informed him of the one bm, and was told to do a H&H on the resident the following day. When I spoke with the CNAs from the LPN's offgoing shift, I was told that the resident had three large, tarry bm's. I always assess first, and noted all the textbook s/s of a g/i. bleeder. Regardless, I was sending both residents out.
Lack of supplies is another issue. You will run out of things important for the nursing care you provide.
No training. In the hospital, you will receive never ending training. In LTC (at least where I was), training was non-existent. There was a high turnover. A RN was usually there from a couple days to 2 weeks at the most because of the bad care environment. I was an overachiever: I was there for a month, and am going back to the hospital to stay with a new job.
Another thing that I detested: Paper charting. Too much paperwork! Double, quadruple charting for the same thing. Just ridiculous.
To their credit, I did work with a couple good RNs and LPNs. However, out of the entire staff, I could only say this of 3 of my colleagues who were on point with their nursing care. The rest: not so much.
In a hospital, you will see muliple pathophysiologies. You will grow so much as a nurse. In LTC, you take care of the same people every day who, for the most part, take the same meds every day. You do not develop your critical thinking as well as what you would in a hosptial.
For those nurses in LTC: I do not mean to insult your profession. After a month of full time experience in a LTC, this is what I saw and what I know. If you can provide another point of view, please do. I, however, would not recommend any new nurse to go to LTC. However, if the new nurse really wants LTC, at least get some hospital experience so that you know your abnormal assessments so that you can get the residents help when they need it.

Sounds like you work in Long Term Care (read: Nursing Home). Long Term Acute Care (LTAC)is very very different from that. LTACs handle the same diagnoses as "standard" acute care hospitals, but for longer amounts of time. Pts at LTACs generally would be ICU/SICU/MICU/IMCU pts at traditional hospitals, but d/t CMS, they no longer qualify for care in that setting, or they continue to need intense care, but are generally stable so they no longer qualify for an ICU type setting in a traditional hospital.

We see dialysis, vents (a LOT), complex wounds (a LOT), peritoneal dialysis, continuous bladder irrigation, TBI/ABI, cardiac issues, uncontrolled DM, bariatric care, post S/P pts, post CABG, cancer and end of life patients just to name a few. These patients are VERY VERY sick for the most part. We provide nursing care in the same manner as nurses in standard hospitals.

The facility where I work seems to have ebbs and flows of high turn-over. Mostly it is because of management practices. All of the nurses that I have spoken to (including myself) love the level of care and the types of patients and challenges that we see.

I started my first nursing job at a prison (ACK!) and when I moved, I went to LTAC, so I had never been in a traditional hospital setting. 6 months ago, I decided to give it a try on an Oncology ward... 3 months is all it took for me to know it wasn't for me, and I am now back at LTAC. In LTACs, you get to KNOW your patients... not just their diagnoses. It gives you a more complete picture of their true needs and you're able to more quickly spot any changes.

You have FAR fewer resources. No RRT on standby, MDs not in house 24/7 (although my facility will be hiring 4 in house hospitalists as of Jan 1... we will see how it goes). You have to be able to think on your feet and rely heavily on the experience of those around you as well. You can't operate in a vacuum.

LTAC is not for everyone, but I feel that in LTAC, even though the pace gets HECTIC, I feel that I have the opportunity to provide better overall, person-centered care.

The politics are infuriating, and the governing boards are CHEAP, and yes, there's even some backstabbing among staff, but those things are everywhere. You have to be on your toes at all times.

Bottom line... LTAC is okay for newer nurses IF you find a mentor and ask a lot of questions. Don't assume you know everything. That's a quick way to get yourself or a patient in trouble in LTAC.

bioniclewoman · Dec 13, 2012

I don't feel like there is a high turn over in my LTAC. With night nurses maybe, seems like we hire alot of night nureses. Turn over for day nurses is pretty low. The ones that do leave are new grads that get experince, and then move on to something else. We have our group of CNAs that have been around for a long time, and a handful that keep coming and going, but I think that is pretty normal. RTs have had zero turn over since I've been around. Charge nurses and administration has a very low turnover too. Unit secretary is a revolving door, and so is case management.

RNikkiF · Dec 13, 2012

We have a new CNO every year or so. And we don't have a huc at all. Makes things hard. We do have a lot of nurses who've been there 5+ yrs. some others have been there 15+ but most have been there two or less.

August RN · Apr 15, 2013

Wow; that many patients in LTAC the poster that said ten to fifteen? No way in world would I receive a patient load every day I work as such in LTAC.

When I worked LTAC, our ratio was 1:4 with charge not taking an assignment. The thing that made we walk away was one night many call ins and we had nine or ten apiece. Prayed my way through that entire shift and never looked back. I was PRN, but worked full time hours, so never gave anymore days and went on to full time management in LTC.

No, LTC and LATC are not actually the same but let me tell you that the residents in LTC are more sicker than ever too. Many come straight from the hospital, needing to go to ICU let alone LTAC but are put in the nursing homes and less than a few minutes on their way back to the hospital.

There are complex patients in the nursing home. Vents, IV and not peripheral IVs either, extensive wound care with multiple system failures that circle the drain even though chronic and becomes acutely quickly. Vent patients are accepted that can be weaned but many aren't.

It is, in lots of LTC, hard to be the nurse on any level but as house supervisor especially due to several can go bad at once and usually that house is the only RN in the building, needs to know the LPN she works with, critically thinking is a must to see the most needing patient first. Have the LPN, within scope of practice, do those things and calling the MD and nine one one and so forth.

Remember, LTC gets those patients time has run out on funds, and just need to be removed to needing that bed in the acute setting and not that they are "well" enough to go home or nursing home. Some Admin and some DONs and some Admission nurse accept patients in nursing home to fill the house knowing quite well that their facility and some of their staff is not capable of helping those patients.

As long as nurse settle for what someone other than a nurse, usually, think we can and cannot handle, we will remain in the same state of our profession.

August RN · Apr 15, 2013

Glad to hear I was not the "only" nurse who took vitals, when I ended up on a cart when the LPN called in, before cardiac meds or did not seem right to me. I took them myself.

In some LTC, LPNs aren't allowed to call the MD. There are many variable to any setting of work and no matter where you work, some, cna, LPN, RN, will do great nursing and some will not. Period.