Ethics: "Every minute counts..." or not?

[parolang]

Hi. I'm not a nurse. I'm a PCT who has been working at my clinic for over two years and, judging from many of the threads on here, there's quite a bit of experience on here. I just registered this account on here because Googling some of the issues I'm having, this site is the only one I've found where I've found dialysis nurses and even some PCT's talking openly about their experiences.

I need perspective. Because a lot of times I'm trapped in my head in situations where I'm thinking, "Is this wrong? Or am I just being overcritical? Or what does it matter what I think anyway, I'm just a tech!" That said, my clinic has made a great deal of progress since I started, and I feel we take pretty good care of our patients.

Yet, I feel a lot pressure, depending on who works, to cut treatment times whenever anything goes wrong, or sometimes when nothing goes wrong. I'm the only PCT left at this clinic (there has been a lot of turnover since I started), so at some level my job is to basically do what I'm told and take care of my patients.

They don't "usually" tell me to cut people's times, but they will if there is the slightest excuse. They will tell me that a patient came late, and now I question if that patient was really late, because they usually come while I'm busy. Today is really the first time that I confirmed that an LPN was lying about a patient coming late. His treatment was cut by 20 minutes, and the charge nurse had to explain to his wife when he came off treatment what AMA meant.

I've had the charge nurse scowling when she went around and looked my patient's take-off times, even though it is within five minutes of their scheduled take-off time. She one time accused me of putting a patient on late when I looked at the patient's treatment schedule and I started the patient on time. I've gotten used to having to double and triple-check patient schedules because of these kinds of interactions.

I did go to the FA about this one time, because it is something that bothers me deeply, and it feels like an ethical dillema each time for me. But seriously, if the Charge RN wants to cut patient's treatment times, why can't she either do it herself, or tell me explicitly to do so. I'm not insubordinate. But it's like she doesn't want to be held accountable. But I went to the FA one day when we had to restart a patient's machine several times during treatment because it was failing to take blood pressures (weird quirk of our new machines), causing the treatment to go into bypass for several minutes each time waiting for conductivity, and thus pausing the treatment. This stressed out the one LPN I worked with who said I need to cut his time, and the Charge Nurse heard this and also agreed "Yeah, we need to cut his time." I eventually did this, because I'm not insubordinate and had him sign an AMA, but I had this sense of guilt and lets say nausea for cutting a patient's treatment short for no fault of his own.

I told the FA what happened, and she told me to push back on this. I told her that I'm only a tech, and she said I should still push back. The patient coming on after him was a non-compliant patient who was coming in for a make-up treatment, and she didn't see any reason to cut a compliant patient's treatment short so that a non-compliant patient could get on earlier.

Sorry for writing so much, but there's been so much more about this that has been going on in my head these last two years, that it's hard to be brief. Today again I had that nausea feeling when I found that the LPN had cut our last patient's treatment short by 20 minutes and lied about him being late, and I really don't have a high sense of disgust. I wanted to confront her about it, or at least give her a chance to explain, but I was stuck between not wanting to hear her lie to me and not wanting to know that this is what she does.

And these are the most senior members of the team!

But I remember way back when I had to watch these training videos and they had all of these RNs chanting together that "...every minute counts...". And now I don't know what to think, or do, or feel, or say. My sense is that this is really common, that at least one of our charge nurses and LPN's do this, and probably others because they trained them. Or is this not that common, and I'm projecting? Plus I don't know how to push back exactly without being insubordinate.

Any opinions are welcome, even if you think I'm blowing this out of proportion. It's like there are much worse things than this that can happen in a dialysis clinic, and at least they are getting their treatments. These nurses are capable and giving good care for the most part.

But I have issues.

[StarBrownRN]

The FA told you to push back, but didn't say they would address it?? That sounds suspicious. Have you spoken with the clinical coordinator?

And I'm curious as to why the LPN and Charge RN are cutting patient times when the patient is in your pod?? Are you causing them to stay late??

If I were you, I would not cut anyone's time unless I was specifically and directly instructed to and I would have the person instructing to prepare the AMA.

[parolang]

The FA told you to push back, but didn't say they would address it?? That sounds suspicious. Have you spoken with the clinical coordinator?

The charge nurse, in this case, is the clinical coordinator. There might be some kind of conflict here that I don't know. The FA is also an RN, I say this because it sounds like this isn't always the case. I know sometimes the FA adds patients to the schedule, and the Charge RN/Coordinator will get upset about this. This clinic has been all over the spectrum in the past, from three shifts, to going back to two shifts. But I'm not talking about adding an extra shift.

And I'm curious as to why the LPN and Charge RN are cutting patient times when the patient is in your pod?? Are you causing them to stay late??

Thing is...nobody is staying late. And I'm getting all of these patients to start their treatments on time, or within say fives minutes of their start time. The pods are a bit vague because it is expected I take patients in other pods, or I put them on because I don't want them getting on late.

If I were you, I would not cut anyone's time unless I was specifically and directly instructed to and I would have the person instructing to prepare the AMA.

Yeah. It's all the vagueness that messes with me. I just don't want someone coming along later, and the nurse being able to say "I don't know why they came off early, the tech must have done it." I take pride in what I do.

Thanks for responding.

[Chisca, RN]

Fact:

During any month, each time you shorten your

treatment by 10 minutes or more, you have an

11% increased risk of dying.

http://www.musiccitykidneycare.com/wp-content/uploads/2015/08/CKD-10-2014-Time-on-Dialysis.pdf

[Duncan6]

Wow, if I'm understanding this correctly- the staff is deciding to cut treatments short for various reasons, and then making the pt sign AMA to cover themselves? I haven't been in dialysis for 10 years, but I have a previous 11 years of experience (and am starting back in January). I would have a big problem with that, too. If I recall correctly, IF there was a valid reason for terminating a tx early, it was documented clearly and the physician made aware. A pt only signed AMA if they were the one insisting on shortening their tx. Are your physicians aware of this- I'm assuming not- because any provider I have worked for insists on a full and complete tx with termination only happening in extreme cases. I do recall way back in the '90s that on Christmas Eve we would run short txs for pts with small fluid gains- but that was done with a specific physician order. Your FA needs to back you up and address this. I would also refuse to cut the tx short (in the most respectful way possible)- if the charge wants it done- she/he needs to do it and be the one documenting it. I'm sure it would be difficult to confront due to how close the staff work together, but in the long run it will hopefully be better for you and definitely better for the pts. I'm a RN who has done charge- and I can't imagine telling the other nurses or techs to cut txs! Every minute does count.

[Duncan6]

One other brief point: Unless things have changed, the treatment time is a physician order- cutting the tx short without an ok from the physician is then not following the physician order and could result in a lot of hot water for the nurse/tech that is doing it.

[AlabamaBelle]

The only time(s) to take a patient off early is: a) there is a medically indicated reason and MD notified; and b) patient ACTUALLY requests to come off early and MD is notified. I also note that patient was educated about risks of coming off early (30 minutes or more) and patient verbalized understanding. MD is also notified.

Treatment times are a prescription, a doctor's order. Don't contravene the order. I might run from that facility.

[SmilingBluEyes]

So much wrong with this. You NEVER cut patient run times if you can help it. Every minute counts to clean that blood. Adequacy at your unit will fall and your charge nurse WILL have to answer for it. So it would behoove your charge nurse to get grip on this and stop this nonsense. It's unethical and will get your patients and staff in BIG trouble. And the State WILL see this, trust me. Never cut tx times, tell the nurses if they want them cut to adjust the times themselves and let THEM answer for it. Make darn sure your CN is aware of what is going on. Unless he/she is an idiot, they will put a stop to it post-haste.

[parolang]

Thanks for all the feedback. Some things have changed since the first post, and all for the better (I hope).

First, the FA added a third shift of patients to the schedule on these days, because we have several more patients now. This doesn't bother me, and also removes the incentive to cut treatments short.

The Charge Nurse who I'm complaining about doesn't work as "charge nurse" anymore. At least she hasn't been scheduled to do this for some time. I don't know exactly why, it wouldn't be appropriate for anyone to tell me, but I can only take it as good news. I also haven't had to work with her much at all in quite a while.

The LPN who I caught cutting times basically got her final written warning. Not for this reason, but because she is just slow, especially after turnover, and does a fraction of the work that the rest of us do. I don't see her lasting very long, because I don't see her as being able to pick up the pace or do more work. She's been with DaVita for 10 years, but she makes *so* many mistakes and can usually only put like two patients on after turnover before she basically has to find some excuse to stop (takes 30 minutes to take off a patient, etc).

I'm on vacation now, but before I left I talked to the FA privately and she told me about some changes they are going to make next year, one of which is that they have increased our labor budget by quite a bit. She even seemed to be overwhelmed by how much help we are going to have, and she wants work on the team as far as focusing on patients and being attentive to them. I am just in awe...this is practically what I've been fighting for for two years! She even told me that that I was her best team mate, and while I think she was talking about focusing on patients, she kind of left that hanging.

I just wanted to respond to say that things do seem to have been turning for the better. I just think that this CN has had too much influence over this clinic for way too long, and it wasn't until recently (probably after our state audit) that they started taking notice.

[parolang]

The only time(s) to take a patient off early is: a) there is a medically indicated reason and MD notified; and b) patient ACTUALLY requests to come off early and MD is notified. I also note that patient was educated about risks of coming off early (30 minutes or more) and patient verbalized understanding. MD is also notified.

Treatment times are a prescription, a doctor's order. Don't contravene the order. I might run from that facility.

I don't think the MD is ever notified if a patient comes off against medical advice. I run to print out the sheet, get it signed, and hand it to the charge nurse. But we have a *lot* of AMA's at our facility.