Fire in the CVICU

[psuICUbb]

Hi! So I’m a nurse in a CVICU/CTICU at a level 2 hospital. I started 7 months ago and this is my first nursing job. I’ve been trained to take impellas, balloon pumps, CRRT, ecmo and so much more. Due to covid our unit was being transformed into the covid ICU (or so I was told) but when I started it was decided covid would be confined to the ED And 3 other med/surg floors and if they were an ICU pt an ICU nurse would float to take an assignment on that floor. Prior to covid patients with critical care/intensivist consults would be managed in our MICU and CT/CVICU. Once I started the head of critical care decided he wanted all of his consults confined to one floor and that was determined to be the MICU. Now, our CVICU does not get any sick patients whatsoever. The ratio is 2:1 sometimes 3:1 but these patients are rarely on pressors, sedation and aren’t even intubated. Occasionally one patient on the entire unit will be intubated but that pt goes to the most experienced. Our MICU has everyone intubated and sedated. They’ve started taking a lot of our patient population away from us all because of one doctor who didn’t want to walk down a flight of steps to manage patients. The CVICU has become a glorified step down unit. Majority of patients are  aOx4 post cath, actively in withdrawal or requiring bipap, frequent GI bleeds. Occasional lung or CABG. All of our cardiac arrests go to the MICU, our ruptured AAA go to the MICU. But here’s the problem the MICU nurses don’t know how to care for them. They don’t have the training. If a patient is on an impella or balloon they try to lateral transfer it to the MICU. I received more training orientation and education than the MICU yet they’re getting the sickest patients. I hate my job. Like I said it’s a glorified step down unit and there’s so much animosity between the MICU and CVICU because they think they’re the best now. I don’t know what to do. Other nurses on my unit are mad as well and since I’ve started and all these changes occurred 30 nurses have quit from my unit. It’s currently staffed with new grads and travelers. I was offered a job in our MICU the same time as the cvicu but I didn’t take the MICU because I was told higher acuity patients go to the cvicu. Now MICU gets all the patients I wanted and was excited to learn about. I want to transfer but my manager has blocked all staff from transferring since so many nurses quit in the last month. What do I do? I am so sad about all of this. 

[igtgrnokbye]

The answer is with you. How long can you tolerate this?  Where do you see the Covid trajectory going ? Do you honestly feel it’ll be like this forever? 

[Cowboyardee]

It's a bummer when the job you get restructures and the reasons you had for taking the job no longer apply. My condolences. Are you on a contract? The upside of this is that your manager can't really keep you from transferring forever - eventually, either she'll come around, or you can force the issue by getting a competing job offer, or you can just take that competing job offer if they still won't transfer you. I don't know your local job market, but there's plenty of demand for ICU nurses right now, and it won't be too long before you'll have a competitive resume.

With that said, here comes the tough love section.

In general, I see a lot of newer ICU nurses kind of fetishizing super sick patients and advanced therapies. And frankly, that often seems to come along with a tendency to turn their noses up at many of the more important skill sets in critical care nursing - it leads to ineffective, task-focused nursing, to say it bluntly. I don't know you and can't say that you're guilty of this tendency, but a few lines in your post have me wondering.

Of course, there are some things you won't learn unless you're exposed to them; but at mostly 2:1 ratio with less sick patients, you have plenty of time and opportunity to learn every aspect of your patients' management. Unless you can round with an intensivist and know every order they're about to make before they make it along with why they chose the medications and therapies they did rather than some alternative, you still have plenty of skills to build and room for growth in your current environment. And at 7 months into your ICU career, there's no way you know all that stuff yet. Also at 7 months into your ICU career, you are unlikely to be a reliable judge of whether the nurses in some other ICU are less qualified than you to run some therapy or another. Concern yourself with doing your job well and not with whether those snobby MICU nurses look down on you.

No shame in wanting to treat the kinds of patients that you signed up for. They're interesting. And if you keep applying, asking for a transfer, etc., you'll get there in no time. But chasing prestige as a bedside nurse is a fool's errand if you ask me. Better to make the most of every learning opportunity you can and put in your best work in any environment you find yourself in - that's how you actually become good at the job. 

[marienm, RN, CCRN]

Keeping COVID ICU patients in the ED...?  Obviously every institution is different, but this seems like a weird choice.  However, these are weird times and hopefully your institution has an actual plan.  No offense to you, OP, but at 7 months in it's very possible you aren't privy to all the details.    Example: my hospital has made a lot of changes within the last 2-3 weeks to accommodate the influx of COVID patients and I see it getting worse before it gets better.  My specialized ICU has been converted to a COVID ICU.  We have a small staff and so we tend to take the more-stable COVID ICU patients.  And meanwhile our specialized burn population is going to the S/TICU, which the hospital has determined will be the last ICU to ever receive COVID patients.  So, it's probably the best place for the burn patients but it's still hard to feel like we can't use our expertise.  And the last few weeks have been a big challenge in terms of learning all about the management of COVID patients, which our unit hasn't done before.

We're not the only unit in the hospital doing this--far from it.  The mother/baby unit is taking non-COVID, non-postpartum adults.  The pediatric unit is taking adults.  Ortho and neuro units have been converted to medical COVID units.  I do have confidence that my hospital has a plan (with a lot of contingencies built in for when things get worse or better) and I actually believe that the plan is designed to isolate the COVID units from the non-COVID units...it doesn't feel like it's just the whim of one doctor.  And I believe that after the number of COVID patients begins to shrink, my specialized unit will go back to taking our specialty patients.  So, being reasonably confident of all those things, I'm willing to stick it out on my current unit.  It doesn't hurt to learn new skills, and we're not the only ones doing it.  But if I thought our unit was going to stay like this forever--if we weren't ever going to get to care for ICU burn patients again and just be converted to MICU-lite, then I'd be looking to move too. 

From the hospital's perspective, it's simply not about us.  I don't know your hospital, OP, so it's up to you to decide how long you can put up with a temporary(?) situation.  (Maybe it's not temporary?  I'm guessing there's more to the situation than you're aware of but maybe the intensevist has a lot of sway.)  I didn't start my nursing career in the middle of a pandemic, and I don't envy you.  But that makes me a little more willing to think "this will pass."  That's me, though.  The hospital will take care of itself, for better or worse.  Only you can take care of yourself, with the caveat that every choice you make (especially now!) has advantages and drawbacks.