nurse call response times in Ontario hospitals

[fizzydrinks]

Hello, all. To introduce myself, I am not a nurse; rather, I am the son of an elderly patient - my father - currently in hospital in Mississauga, ON. In fact, I am writing this from his bedside.

My father, 84, is suffering from renal failure and also has severe dementia and has been plagued with both for many years now. My mother, 77, has cared for him at home all this time. It has been a very rough road for a very long time, but with tremendous care from my mother and his doctor, he has - sadly in a very real way - persevered. That said, his doctor explained that should he ever need to go to the hospital again, there would not be much he could do, going so far as to recommend getting a DNR form registered. We agreed as a family and my mother has done so.

He is now in hospital since last Tuesday as he had experienced a severe increase in fatigue to the point where couldn't walk. The ER doctors explained that his creatinine level was 500 - very high. What we thought was just a rash from diapers turns out to shingles. They confirmed everything we had already established about not treating him any further and that we are looking a palliative situation. They were quite compassionate and we all prepared for the end. We were told we would be admitted and they would do everything possible to keep him comfortable. In a way, this was very much a relief as my mother was at the end of her rope and unable to care for him any more. That's when things went south.

Without getting into too many sordid details, the net result is that the care we have received since being admitted feels woefully inadequate. We have been in the hospital a few times before, so we understand the disjointed nature of the doctor-nurse-hospital relationship, but this round has been the worst.

First, we were never advised that the shingles outbreak would warrant isolation. The first night nurse saw the chart and went into a frenzy installing a HEPA filter in the room and getting everyone into gowns and masks.

The next day, this man who has no gas in the tank still has the werewithal to want to relieve himself in the bathroom. We - my mother, brother, and myself - don't know what to do, so we try and get him there using a comode chair. We're successful a couple of times, but one time not. Mess on the floor. Nurse calls are usually answered immediatly, but no one actually shows up for several minutes - usually well over 10 or 15 - while my dad is sitting in, and staring at, his own feces. Nurses walk into the room asking us what supplies we have. Gowns, masks, diapers - nothing's ready.

Later that day, after talking to a palliative care doctor and going through this conversation again, we were transferred to a negative pressure room. Again, supplies are constantly lacking. At one point, again after a bathroom call, I see the nurse running around looking for a fresh night gown and bed pad. No bed pad - using another night gown instead. Wait times have gone through the roof. Usually 30 minutes or more now.

My father has been issued sedatives to sleep at night so he doesn't try to get up on his own. My mother being my mother, is sleeping with him in his room every night. First room had a spot to lay down, new room does not - we brought in our own cot. Nevertheless, last night, my mom did not notice my had had gotten himself up and halfway to the bathroom. Thankfully she got to him just in time to catch his fall. No time to ring the nurse. After she finally situated him so she could call, it took more minutes than I would expect to respond - 5 or more, as I understand. What would have happened had she not been here? He's behind double doors as it is, then stuck in the bathroom to boot with no comprehesion that he's even in a hospital. When my mother raised the notion of a bed alarm, they told her there were none available. I may well spend the night tonight for fear of another fall.

As for nurse compassion, it's up and down, but mostly down. We've had really great and compassionate nurses at times - they are angels that make a world of difference. We haven't really had that this time, and most just don't care at all. We had one nurse who I guess just assumed my dad was deaf because he's old and literally yelled at him while he's half out of it. It startled the hell out of him and he yelled back at her. It's a revolving door of nurses here - usually no more than 2 days in a row with the same nurse and we are always starting from scratch trying to explain the situation and my dad's needs.

All this is to say nothing of the unbelievable lack of cleanliness throughout the public areas of the hospital - gobs of dust everywhere, blood on the walls in the bathroom (something I immediately brought to someone's attention, only to find it cleaned over 24 hours later), and on and on. This whole situation is feeling a little sureal. But I digress.

I apologise - too many sordid details after all!

Back to my primary question. Compassion and supply issues aside, what can/should I expect for nurse response times in a hospital in Ontario? Should it matter if the patient is in isolation? I intend to bring the whole situation up with patient relations - at the suggestion of one of the doctors, and I know I can't change the world overnight, but I would at least like to get an idea of what I should be expecting. If nothing else, to ease my and my family's own minds.

Any insight is appreciated and if you have bothered to read this far, my gratitude for allowing me a chance to vent a little.

[loriangel14, RN]

Unfortunately nurses are dealing with an ever increasing workload and dwindling staffing levels. Yes sometimes we are run off of our feet and cannot answer as promptly as we would like to. It's really not realistic to expect the same nurses all the time and yes then we do have to become familiar with the patient when they are new. Not having some kind of bed alarm is odd. Ours have them built in.

i would not advise trying to get him up to a commode by yourself. Let the staff do that.

[fizzydrinks]

Hi, loriangel14. Thanks for the prompt reply. I will not deny the do-more-with-less situation that nurses are facing. It seems to be an epidemic everywhere, really. I guess this is, in fact, at the root of my question. How does one gauge how long is too long?

Regarding both response times and assisting my father, the real wrinkle here - to put it ridiculously mildly - is the dementia. You simply cannot explain the situation to him and expect him to wait. You can't really explain anything to him at this point. I, we, would love nothing more than to have the staff take on these tasks. Indeed, that is why we are here. But if it takes 3 calls and 30 minutes to get someone to come and help (and again, that is on mulitple occasions), the consequence is definite - he will fall. Bed alarm or not. Frankly, my helping him is the only option at this point, short of severe sedation or strapping him down. And, from what I have seen with other patients in a similar boat with no family support, that's pretty much what happens. Honestly, we will do everything we can to help - feed him, entertain him, clean the room, stay by his side 24x7. All we ask is that someone come when we call the first time and show up in less than 10 minutes. I fully appreciate there are many other higher priority technical duties you are responsible for - meds, chart logging, etc., and it is absolutely critical they be carried out professionally, but a hospital stay is more than just meds and charts, isn't it?

[loriangel14, RN]

He may be reaching the point where getting him up to toilet is no longer appropriate. Does he have a catheter in place? Has anyone discussed what to expect as his health declines? Quite often the dying process can be scary when you don't know what to expect.Is he on a unit dedicated to palliative care? Even for the nurses that are very caring giving meds and charting have become huge tasks. Sedation is a reality for many of my palliative patients. Be sure that any pain is being addressed as well. This can make many patients very agitated.

Perhaps you could speak with a charge nurse about your concerns.

[fizzydrinks]

No, no catheter as yet. I couldn't agree more about fear of the unknown. We continue to press for information on what to expect, but essentially the message so far is that it is hard to tell. I should mention that at this point, we are in a holding pattern in isolation while his shingles scab over. During this time, we are told they will monitor his condition primarily through observation and creatinine levels to help determine what direction he is headed. From there, we are told they can advise us as to what kind of palliative care we are "eligible" for - i.e. what facility he can go to depending on how long he is expected to live. Meanwhile, today, he sat up in a chair to watch TV for an hour or so. The whole thing is bananas. If nothing else, I have to thank you for your time - it's nice to have a sympatic ear to "talk" to, especially in the middle of the night. Again, thankyou.

[nursinghealth]

I am a nurse and I have been a patient - and the loved one of a patient - as well. I understand both sides.

There are times when I hear the call bell ringing for me and I'm literally up to my elbows in poop with a patient, I have another patient waiting to be returned from the bathroom to their bed, a new admission literally waiting for me on a stretcher, and I'm behind on my meds (a big no-no). It breaks my heart that I cannot be there right away for people such as your father, but the reality is that I can't be. It's a systemic issue.

This doesn't excuse poor nursing care, which I have also seen. There is no excuse for yelling at someone and treat them like they're deaf when it's obvious they're sedated and of advanced age. I see this happen too.

I am very thankful when my patients have family members at the bedside. I can't be in 5 places at once to prevent falls. As much as I hate restraints (it breaks my heart, trust me!), sometimes there are few other viable options to ensure my patients' safety when I am caring for 6 patients, three of whom are fall risks and actively trying to climb out of bed.

I think 5-15 minutes is a reasonable amount of time for a response. 5 min is ideal, but I can see how waiting 15 min can be required at times.

Someone who is a fall risk requires more attention than a regular ward nurse can provide. Some families have hired sitters to remain at the bedside for this reason. Is this something you've considered? I know it's not ideal, but at that stage in his illness it may be your safest bet.

[loriangel14, RN]

There are also hospitals that have units dedicated to palliative care. How long the process will take is anybody's guess. No one knows. Yes hiring a sitter is a good suggestion. I know that having attentive families that will come and sit with a confused loved one are a god send.

[loriangel14, RN]

I try to remember that to us the process is familiar but to many families it is new and they don't know what to expect. Plus I find that many physicians are ill equipped to guide families through the dying process. Many won't even be up front with the family about the prognosis, leaving it up to nursing staff to deal with questions about why they aren't getting better. My hospital has an awesome Palliative nurse that deals with all the cases in the hospital. She counsels the families and advocates for symptom and pain control.

[fizzydrinks]

Thanks for the feedback, nursinghealth. I guess I/we ultimately understand there are much larger systemic issues at play here. It is definitely frustrating and scary. Still, today, when I had to go out to the desk to find out what was going on after waiting over half an hour, the nurse told me she was on break when we called initially and that no one had told her. This is not systemic in my opinion - this is just not doing your job - the admin? in this case, or whoever answered the call on the intercom.

Still, so much of this can be mitigated with a little compassion. I can tell you both have it simply from your "tone" (not to mention the fact that you are bothering to take the time to respond here). Really, I feel tremendously better just conversing on this. You both recognize how important attentive families are. I can tell you that taking a few minutes to show some compassion and caring and recognizing our efforts makes all the difference in the world and gives us the tolerance we need to be patient (no pun intended) while dealing with the system. As it is, we often feel we are just pests, despite being told to call whenever we need something. It should be noted that we are not calling every 5 minutes, either. I'm only talking about 1 or 2 times in a 24 hour period. So, after having to call and call and wait and wait, only to have an insensitive nurse be less than courteous to us, you can understand how patience runs low and frustrations rise.

Yes, I have definitely contemplated hiring a sitter. I'm not exactly sure where to look for that as yet, but I will be investigating next week. I suspect this is something we'll need for some time to come.

[loriangel14, RN]

The nurse being on break is a poor excuse. Anyone could have helped you. Where I work we are all responsible for all the patients , not just our assignment . If the assigned nurse is on break then you provide what the patient needs. Passing the buck is just lazy. On my floor you would get lambasted if you used the excuse that a certain nurse was on break. Like what the heck was wrong with whoever answered the bell?

[fizzydrinks]

As for the process of dying, loriangel14, I have to say just about all of the doctors we have spoken to have been fairly good at helping us at least get our head wrapped around the idea that it's coming. I would still like to know a lot more about specifically what is coming symptomatically. Again, I'm not so sure anyone is holding anything back, but rather really cannot say in our specific case, perhaps because of the dementia factor?, and so would rather not say anything other than "it's hard to tell". Still, given what appears to still be a fluid situation, maybe this is the best for now, particularly given that my mother (and me and my brother, for that matter) tend to latch on to little details, desparate for the comfort of knowing what's coming. This can lead to great dissappointment when things don't pan out as expected. For now, the focus is on surviving this isolation room for a week while we monitor his progress. I am hoping that regardless of the outcome by the end of the week that we will eventually get transferred to palliative care of some sort or other and then start getting the more dedicated support like that you are referring to. In defense of where we are now, it is a nephrology ward, not a palliative ward. That does not excuse many of the deficiencies, but it does perhaps explain to some extent the oft-felt seeming indifference.

[loriangel14, RN]

Well the main obstacle is that each dying process is different so no one can tell you how things will unfold. He will have good days and bad days. Does the facility that he is in have a palliative care unit?