Creative solutions for on-call RNs in small hospice agency in CO

[PsychDNPStudentInCO, BSN, RN]

Hi all,

We are a new hospice agency (2 years) in a rural area in Colorado and are having some growing pains. Currently, our clinical supervisor (RN) and our lead RN are taking all of the call (week on/week off). They are the only FT RNs. We have one FT LPN who lives locally, and one PT RN, who lives an hour away and doesn't want to take call (semi-retired). Finding nurses who want to do hospice/take call has been a struggle, and why we hired a PT RN and an LPN (can't pronounce deaths). We discussed an on-call service, but due to the cost, it has been tabled until we have more growth. Our census is currently 20.

I think the main issue is not the amount of after-hour calls or visits (although that can be a lot on some nights), it's that the 2 call nurses need to have their phones on them at all times, don't sleep well (waiting for call), need to drive separately from their families when they go to dinner in case they get a call, and because we are in a rural area, they and their families are very limited on where they can go so they don't end up in or crossing or ending up in an area that does not receive cell service. Even if others are taking the calls and triaging, they still need to be available and ready to make an urgent or death visit.

Both of our call nurses are beyond burned out. Has anyone been in a similar situation and have any creative solutions?

In Colorado, an RN can pronounce hospice deaths after training. What if an LPN attends a death visit, reports vital sign findings to RN on call (via phone), and the RN pronounces this way? Has anyone heard of this? 

Thank you in advance!

**Bonus points for links (or general direction) to law or Colorado BON scope of practice that supports a legal, creative solution within scope 😉

[canoehead, BSN, RN]

I really sincerely think you need more staff.

On call is a pain for all the reasons you mentioned, but when they took a hospice job they should have been told that on call is required. Being on call 50% of the time is excessive. I think everyone needs to share the burden, and stay in reasonable distance if they are on call. That might mean some hard decisions.

[SunDazed, BSN, RN]

Hi there,

I am an on-call overnight nurse for a hospice in a rural area with a census goal of 102 per day. We are fortunate that we also have a telephone triage service to take most of the calls. I have been doing this job and previously been more of a visit nurse for another hospice. Also, I am in California so won't speak to pronouncing death in Colorado, as here in the great Republic everything even varies from county to county for when to call coroner's etc. 

Some things I would look at to better define your needs....

Why are the calls coming in? Is it only deaths? Is it symptom management crises? Is it falls needing to go to the hospital? With a census of 20, are you churning and burning? Meaning how long are people on for? We go through cycles where we get a lot of patients who are imminent at admission, so they are dying in the first week! Hard to feel like the family can get enough training and support on a daily basis in these cases. If this is the case, any strategies in place to recruit patients sooner so they and family benefit more from hospice? So then 2 months of education doesn't need to happen in 3 days?

If the calls are for more than deaths, why are they calling in? What expectation has been set for follow up by staff? If they really want to call in for a medication refill or supply request, is there an option to leave a message instead of contacting the nurse on call? I find rural families around here to be old school, meaning they don't want people out driving around at night or in a storm. Where I currently live/work, the family can assign the time of death if the patient dies at home (and no unusual circumstances suspected).  We do have to go out and pronounce at assisted living, or board and cares, since it is a facility and they do not have nurses on staff at night or sometimes ever. Again that is county by county in California. And sometimes they don't even want a nurse visit for support at the time of death, just call the mortuary for them. 

Is it possible to set expectations with patients and families to leave a message and get a callback within an hour? We can have horrible cell service here sometimes. 5G and they still blame weather on the east coast if we can't make calls on the west coast? For deaths anyway.... for symptoms, consider different emergency orders for the family.... if you can't get ahold of us and the plan is not working do this and we will follow up as soon as we can. You can always call us twice... That is if the provider is okay with that.

Good luck! 

 

[toomuchbaloney]

In Colorado, the counties decide what the rules are for death pronouncements in the home.  In my limited Colorado experience the health professional must be present at the scene to make a determination of death. 

My recommendations start with putting the LPN and MSW in the phone answering portion of the on call schedule.  Lots of family concerns can be addressed without dispatching a nurse to the home. That doesn't eliminate the need for an on-call visit nurse, but it increases the possibility that they might get a full night of sleep.  

If you aren't doing a daily wrap up report for the oncall staff, start.  In some part, this keeps people informed and also creates some accountability for the case managers actually managing the cases.  

Stress the importance of "tucking" patients in for the night.  With a small census, your call outs should be low. The staff all need to assess the family's access to needed medications at every visit.  Even volunteers can ask about medication supply and notify the nurse if there's a concern.  Patients at risk for after hour anxieties or needs warrant a call or visit during business hours.  

Are you as a professional team member assisting with the call burden until more per diem staff can be secured? 

You need more nurses.  

[SunDazed, BSN, RN]

I like the idea of including staff besides RNs to take the initial calls and then only calling an RN to do a visit if needed. If those others agree, and it doesn't make them run out the door! 

With a patient census of 20, seems like it would be hard to just have more nurses! The caseloads for RN Case Managers are rarely below 12-14 patients each!! Unless you are expecting to grow quickly? 

I think some hospices rely on a weekend RN to cover Friday at 5pm until Monday at 9am. Not sure how easy it is to find someone like that in your rural area. Then everyone else would get some sort of break. I did fill in 8 hour shifts at another hospice from 11pm-7am. We did get paid hourly. Not sure how flexible your hiring plan is. Is it worth it to hire someone to work a few shifts like that each week? 

In this rural area, we are always short case managers. The turnover is faster than the hospital! I think some take a job here to get any job after moving here, then by the time training is over they have been able to complete the hiring process and get a job for more money at the hospital or clinics. For someone with my years of experience, the union jobs at the hospital pay over $20/hour more. There are some really experienced nurses making double what I make per hour. I would never go back to that mess though, so it is worth it to me to cut expenses and feel better about work. 

We also have more trouble getting really good social workers who want to stay. Our chaplains are no longer on call, and none of our SWers are. The only way to keep those slots staffed is let them have the firm boundaries about hours worked and days off.

COVID changed everything here. Not sure it will ever be back to what it was pre-COVID for nurses, social workers, etc. If COVID had not ended when it did, a couple of big hospital chains in California had started working on plans to have more LVNS do team nursing in the hospitals again. They were even going to have them in the ICUs with 2 LVNs under 1 RN, and in other units 4 LVNs under 1 RN. Finding nurses is a herculean task in rural areas!

Not sure that will help. It has helped us to have a couple of per diems who can cover some nights as a second job, so when they work is really dependent on the scheduling of the other job. 

 

Peace