Emergency Department to Dialysis

NurseRies, BSN, RN · May 14, 2014

Outpatient dialysis is the most physically demanding job I've ever had. I used to work as a server for 7 years and it didn't even come close. Mentally, maybe not as bad as other nursing jobs. It is repetitive, so once you get comfortable, easy. The patients are mostly Walkie talkie. The nurse to patient ratio may be 10:1 or 12:1. You will have 2-3 pcts for those patients. But your day all depends on how good your pcts are. I am going to search an old post I did on a typical day in outpatient and copy and paste for you. Bottom line- outpatient dialysis is very physically demanding. I never sat down, my feet killed me and I was only 24 years old with no health problems. Shadow a day though and see what you think!

NurseRies, BSN, RN · May 14, 2014

What's a typical shift like? Do you start IVs or do most patients have their access already? Is it more being able to monitor vital signs and understand fluctuations from baseline?

I'd love to hear what a typical 8-hour OP Dialysis RN shift might be like (granted, I understand no two shifts are the same!)

Thanks in advance :)

Well, most dialysis positions are 11-14 hour days. I very rarely see 8 hour days. But anyways, a typical day if you are the opening nurse would be to arrive between 4:30 and 5:30 am depending on your clinic. You would get there and verify the water system with the tech before any patients come inside.as charge nurse, I would unlock the doors, print out necessary paperwork, count meds, draw up 15 vials of heparin for each morning patient, and once everything seems ready and safe, give the go ahead for the first few patients to come in. This would all happen in the first 30 minutes. In a matter of 10 minutes, you need to do 3-4 patients assessments for pre dialysis, document, and then push heparins after the tech has stuck the patient. After the first 4 patients are on, it's time to verify that the tech did everything correctly and treatments are safe. Don't sit down yet, the techs are now bring in 4 more patients to put on the machines and its only 15 minutes since the first 4 came in. You repeat again. You do 4 rounds of this in 1 hour until all 16 patients are running on the machines. Now it's time to verify safety on everyone. Keep in mind vitals signs must be recorded on all 16 patients every 30 minutes. If you're lucky, the techs are responsible and will do this. Now you need to push medications. Usually there are 3, epogen, iron supplement, and a vitamin d supplement. Make sure you give all 16 patients their IV meds safely. The phone will be ringing off the hook for you. The MD may round between 8-9am. You must follow all his orders and are responsible for adding them into the computer. Coordinate with secretary to make cardiac appts, schedule surgeries, etc. you hopefully can take a breakfast break after everyone else has gone. Keep in mind, you've got 16 patients to watch, who are bottoming out on BP, asking to take a bathroom break, complaining about how cold they are, asking for water, etc on a constant basis. Just as you come back from break, it's time to get ready for the first "turnover". All 16 patients will start coming off the machines in 15 minute intervals, and 16 new patients will be in the lobby cranky and wanting to get on the machine at their exact scheduled appointment time. So you've got techs returning blood, while you're running around verifying that the post assessments are good and patients are stable to go home. You should already have your heparins drawn up for 2nd shift. A tech might have a time frame of 30-45 minutes to flip a chair, meaning get patient out after they're done bleeding, clean machine, re- setup new machines, and get next patient in. Get next patient on the machine fast because their other patient is about to come off the machine in the next chair over. The tech will have 30-45 minutes to flip that chair, and so forth. You better hope nothing goes wrong! And it does, all the time. You as nurse will be expected to ensure safety of all patients, you may also have to flip a few machines yourself since the techs get caught up with problems and difficult patients. You will work faster then you ever thought possible. The changeover lasts about 3 hours of nonstop chaos. After the chaos subsides, you can get ready to do your second med pass. In the later afternoon, you may be able to do some assessments or education, but usually you end up picking up the slack work since the techs have other duties in the back that need to be taken care of. You will be doing vitals signs, returning blood, making phone calls, etc. you will be wearing a plastic gown all day, no exceptions, and usually a face shield and mask.

To put it plainly, you will never sit down and you will go through about 500 pairs of gloves per day just yourself! Buy good shoes, be prepared for chaos, and if something goes wrong, it's on you. Most people quit during training. If you like it, stick with it, it can be a lot of fun, but it is very hard work.

Trauma Columnist · May 14, 2014

My RN exp is mostly level one trauma center. I'm now a dialysis APN. ER was by far more stressful.

The RNs in the units I go to all get breaks and lunch, something I never could do in the ER. The repetition would be mind-numbing to me if I was doing the RN job. However that is just me.

ErinRN84 · May 14, 2014

The ER I work as is acting level two, technically level three. I guess I will have to see when I shadow. Ironically, it will be with a former coworker. The day I interviewed I saw another former coworker. They say it is an improvement. We will see.

Guttercat, ASN, RN · May 28, 2014

ErinRN84,

Did you shadow yet? How did it go?

I used to work ED, and found outpatient dialysis to require similar amounts of "miles on foot per day." As TraumaRUs stated, the repetition can be mind-numbing. It begins to feel like a rapid-fire assembly line, but of people, not widgets. However, it's a different sort of stress, and might be a good fit for you.

Given your background, I would suggest also looking into acute dialysis. If you have adequate support/back-up, it can be the best of all worlds.

SmilingBluEyes · May 30, 2014

Think hard on this. Dialysis, while it may not be as stressful, is certainly not an easy job, physically. You will spend a LOT of time on your feet, running around from patient to patient. On days when there are no complications with the patients, it's easier. But let 1 or 2 have issues, and you will be busy. I spend very little time sitting on any given 10 hour day. Some clinics have 12 hour days. No one I know works less than 10. I also spend time helping patients get situated. A good number of them have amputations who need either Hoyer lifting or your assistance getting from the wheelchair to the treatment chair. Some of those lifts can be physically-taxing.Your techs cannot do this work alone, and you will be called upon to assist.

Turnover (when patients leave and arrive) is very busy. Often, you will be called upon to help your techs with "ons" or "offs". More time on your feet. There is a lot bending/stooping when putting needles in patients and cleaning machines and re-stringing them, for sure. And you will have anywhere from 12 -16 patients for whom you are responsible, running every 4 hours. LOTS of charting and medications to be given.

The good thing is, I almost always get my lunch breaks, which in the hospital was rare to have a lunch without multiple interruptions and my food going cold. If you are organized, you will have plenty of time for a 30 minute break to eat and relax. That part will be good for you. But don't think you won't be very busy, and running around a lot in dialysis. You will be.

I wish you luck. See how it goes, shadowing and maybe it will be for you!

SmilingBluEyes · May 30, 2014

Someone suggested "acute dialysis", meaning in the hospital. I am not so sure that is a good idea. There is running around there, too. The thing about acutes that is unacceptable to me, is being on-call. For example, you can have a 10 hour day planned and as you are finishing up your last run, when you get a call from the ER, saying there is a patient being admitted who will need dialysis when he gets to the floor. That can mean another 4+ hours piled up on your planned 9/10/12-hour day. OR , they admit a patient after you have gone home who needs dialysis; guess who is going in? Yep you. Nope not for me. I left the hospital because I love not being on call, or working Sundays. Acute dialysis days can vary. On low-census days, you may not work much, but on high-census days, you day can easily go to 16 hours or more.

Think about that idea carefully! Again, good luck to you.

SmilingBluEyes · May 30, 2014

PS: you asked how many miles a day we walk. Well, I have worn a pedometer and it's been easy to walk more than 10,000 steps or more, per my meter, without even thinking about it, on an average 10-hour day.

ErinRN84 · May 31, 2014

I shadowed and it went well. It is a different type of stress that I can handle. The thing is Davita is taking forever to let me know something. Everytime I have called they say they are still in the interviewing process and will call me in "such and such" time frame. Then they don't call. I called back and the same thing happened. I guess I'm not getting the job.

madwife2002, BSN, RN · May 31, 2014

Davita does not rush the hiring process

lawandaluxnurse, ADN, BSN · Jun 2, 2014

I was just hired by Davita 1 week ago after waiting to hear 7 weeks post interview, they do take their time.