LTAC'S without ER's that do acute care as well?

  1. I'm a fish out of water in my new 'home' AND TRYING TO ADJUST...lol!

    Rural LTAC who will be doing some surgeries(even pedi) and acute obs patients. No ER. No doc on premesis. BUT a 5 bed ICU where they want us to be able to 'do just about everything an ICU could handle including pedi' which I'm having some trouble with ...as no doc or CRNA around.....I'm NOT a pedi ICU nurse either which concerns me.

    Asked my administrator the other day what my responsibility will be if a chest pain drives up. (even tho we do NOT have an ER perse it happens) Call EMS and do what you can til they get there was the answer, which is fine. But if they need intubation what then? He said "You have ACLS, right?" Well yah but I've never intubated and really don't WANT to......so how do others in this situation cope with this?? Guess I would bag and let RT deal with it til EMS arrive.....?

    But inpatients will be expected to be managed in our 5 bed ICU and I'm concerned a bit about what I'm getting into and the liability associated...sounds like we will be expected to 'handle' a lot of stuff with no physician around ..how do other small facilities deal with this stuff????

    Sorry I am rambling here...new experience for me and have been very spoiled up to now I guess...have always had an ER doc and anesthesia around to help....along with doctors hanging around to grab for that unexpected patient deterioration...

    Anybody have any hints about questions I need to ask my DON and/or policies we should be writing to protect us?? I am having an uneasy feeling this stuff is not being addressed yet and I may be biting off more than I wish to chew....LOL!!! Maybe I'm wrong....

    Would appreciate all input greatly...Thanks all!
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  2. 10 Comments

  3. by   mattsmom81
    Hmmm...guess by the lack of responses this is not the usual?
  4. by   Ted
    All I can say is, "WOW" and "YIKES"!!

    I work nights at my teeny-tiny rural hospital and we have one "in-house" E.R. doc. (And only "on-call" respiratory therapists on nights.) There are times when I can LOUDLY say that I'm not happy about this. Having NO physicians in the hospital at ANY time gives me more gray hairs just thinking about it!

    Like you, I'm interested to see how other rural hospitals deal with "no physicians" in their facility. How does a patient who's coding be handled in such a case? Do the RN's intubate? Why not if they demonstrate the skill?? But then where does one get the practice for such a skill when working for such a small facility (assuming that it is small)??

    Good topic!

    Ted
  5. by   gwenith
    That whole scenario is not that unusual here - just the ratio of ICU beds is unusual. Our Rural and remote hospitals usually only have 1-2 ICU beds and they are only to handle patients UNTIL they can be transferred via either RFDS (Royal Flying Doctor Sevice) OR Air ambulance.

    I have though, worked in Rural.regional ICU's that did not have medical cover save for the 1 doc in the hospital (i.e. no-one on the floor) we just made sure that we had GOOD protocols and procedures in place and that the patients stayed intubated until morning. I have actually been faced with and have attempted intubation on a patient - gun shot wound to the head - it was one of those "go through the motions" kind of things.
  6. by   canoehead
    We have no docs at night but we have a PA in the ER who will come up and handle an emergency while the doc is coming in. Our PA's are wonderful, better than our docs when it comes to emergencies, so I guess we've felt pretty secure with the arrangement.
  7. by   mattsmom81
    Thanks for responding guys!! I appreciate it! I've met with my RT's and most feel confident about intubating so that is 'one' less worry for me <whew>

    I've approached my DON about soliciting a few $$ hungry medical residents to sleep in house at night...to cover us in the event of a major emergency. She is considering it...

    I do worry about being held to medical standards in codes as have always relied on a doc to eventually take charge (even tho I will run things til they get there). Our docs do not come in if they can possibly get out of it...altho they must if they are not DNR's...to pronounce. All 5 of ours are ACLS codes ...

    We have 5 vents (ETTs) now in our ICU (transfered from acute ICU's) and they are still fairly acute on drips with complications, etc. Sure would feel better about having a doc in house....

    I have a major hospital 20 minutes away with ER, cath lab, MRI, etc...so I am having some ethical problem with why some of these patients are here when they are on life support and drips, etc...and the family wants everything done. Many are being unrealistic in their loved one's long term prognosis for recovery but I worry about liability.

    I am guessing $$$ is the issue/reimbursement must be there for acute LTAC.

    Have any of you approached docs and families, administrators to get a patient transferred to a bigger facility?? I am concerned I may get to that point and am trying to choose my words and think ahead of time where I will draw the line. I am thinking I will have to advocate for them ethically ...my biggest fear is what if a child goes bad postop and they want to place it in my ICU??? Would I be out of line insisting the recovery room nurse stay and care for that patient...as she at least is a pedi trained nurse with PALS? I'm thinking it will be that or transfer to local children's Hospital IMO.... :uhoh21:

    Appreciate all input!
    Last edit by mattsmom81 on Apr 28, '04
  8. by   mattsmom81
    I am starting to be concerned about a lot of issues with this facility..they seem to want to be considered a 'do it all' specialty LTAC but don't want to provide enough resources for the staff. Currently we have no policies and protocols in place with all this stuff either, which concerns me. With peds hospitals within 30 minutes, I have decided I will NOT take responsibility for a surgical pedi case gone bad in any way, and will have to refuse it in my ICU...just too much liability. they need to keep the kiddos in recovery with a PALS nurse. personally I don't feel these postop pedi cases should EVER go out of the surgical dept, as we are an LTAC with lots of MRSA and VRE.

    With adults I've decided to take it on a case by case basis and be very bold with the doctors and administrators if I'm uncomfortable. I may not be at this place for long...LOL!

    Thanks for the comments guys n gals..appreciated everybody's input. if anybody has any other advice for me, feel free to PM or post here...this is a whole new experience for me so I enjoy the comments.
  9. by   mattsmom81
    OK...update...I resigned from this facility. My reasons aren't due so much to the fact they are rural, but the working conditions and the liability, especially being in charge and one of the few RN's on duty. I just couldn't resolve these issues in my mind so...I am happily back to my agency work..where I DON'T have to be in charge...LOL!.

    Thanks for all the chat about this...it helped me.

    My last shift there was 5 ICU patients, all on vents and full codes, one freshly coded and circling the drain again, another in and out of Vtach. Two on vasopressors , septic, with complications. Only 1 out of the 5 was a 'stable' longterm trach vent. Staffing was me and a medsurg nurse who didn't know anything about vents or critical care. Too scary for this ol' gal.
  10. by   RN34TX
    Quote from mattsmom81
    OK...update...I resigned from this facility. My reasons aren't due so much to the fact they are rural, but the working conditions and the liability, especially being in charge and one of the few RN's on duty. I just couldn't resolve these issues in my mind so...I am happily back to my agency work..where I DON'T have to be in charge...LOL!.

    Thanks for all the chat about this...it helped me.

    My last shift there was 5 ICU patients, all on vents and full codes, one freshly coded and circling the drain again, another in and out of Vtach. Two on vasopressors , septic, with complications. Only 1 out of the 5 was a 'stable' longterm trach vent. Staffing was me and a medsurg nurse who didn't know anything about vents or critical care. Too scary for this ol' gal.
    Best thing for you to do!! The more I read your stuff the more I wonder if this LTAC is part of a big chain that's name starts with a "K"!!
    If so I'm really glad that you are out. I've worked at one of them up in your neck of the woods and I watched them ruin peoples careers with "Group One" one right after another.
    One friend of mine was falsely reported to the board. She was found innocent but it turned her life upside down for almost a year. They were always good to me personally but I quit because I was afraid that I would be next. I finally quit when a female house supervisor was asked to leave for "sexual harassment" and we all knew that the 2 nurses who accused her made it all up. She separated them to different floors because when they worked together they were so mean to other staff. So they decided to get even with her and made false accusations and she lost her job. That was the most evil place I ever worked.
  11. by   mattsmom81
    Quote from RN34TX
    Best thing for you to do!! The more I read your stuff the more I wonder if this LTAC is part of a big chain that's name starts with a "K"!!
    If so I'm really glad that you are out. I've worked at one of them up in your neck of the woods and I watched them ruin peoples careers with "Group One" one right after another.
    One friend of mine was falsely reported to the board. She was found innocent but it turned her life upside down for almost a year. They were always good to me personally but I quit because I was afraid that I would be next. I finally quit when a female house supervisor was asked to leave for "sexual harassment" and we all knew that the 2 nurses who accused her made it all up. She separated them to different floors because when they worked together they were so mean to other staff. So they decided to get even with her and made false accusations and she lost her job. That was the most evil place I ever worked.

    :uhoh21: OMG! Yes you have guessed it...and I noticed some very dysfunctional people breeding there too...this place must be a magnet for them...LOL!! Sounds like the place you describe was the exact one I left.
    Last edit by mattsmom81 on Jun 14, '04
  12. by   kellystaceya
    has anyone work at a select specialty hospital that closed due to low census how much notice do they give?

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