Help with NICU prioritization???

[iheartpreemies]

I'm a neonatal intensive care unit (NICU) RN with 4 years of experience in several Level III NICUs, but keep running into problems with my time management relating to proper prioritization of tasks/assessments. I'm a little more OCD than your average NICU nurse, and have a really tough time cutting things from my routine, esp as every new hospital i go to (and every nurse I get advice from) has their own set of priorities and rationales for those priorities. But instead of helping me to become a better nurse with more broad experience, my exposure to various facilities seems to be hindering me from sticking to the truly critical basics, and more importantly, from completing things within a reasonable time frame. It seems that most NICU nurses who I've worked with over the years are cutting things out that I feel (or other nurses/supervisors/protocols/conferences have given me good reason to believe) are equally important, so when I get the advice of "oh, that's not too important, just move on," I feel the urge to ignore that advice for the sake of avoiding sub-standard care to these fragile infants with complex issues.

I'm really interested in hearing advice from both experienced NICU RNs who have been dealing with this balance for years, and any RNs who are fairly anal like me, and like to give the best, most comprehensive care, but who seem to be able to magically do it all in a timely fashion!

Desperately seeking any advice...

Thanks!

[Jolie, BSN]

Having moved and changed jobs frequently, I sympathize whith your experience that every unit has "their own way" of doing things, setting different priorities and often doing things by tradition rather than evidence-based practice.

For example, in one unit, we weaned preemies very aggressively from the vent, fed them very slowly, and focused on developmental care. In the next unit, preemies were kept intubated forever and fed very quickly, usually with umbilical lines still in place, but developmental care was not a priority.

Perhaps if you caould give some specific examples, we could be of more help.

Hang in there!

[Tweety, BSN, RN]

Welcome to Allnurses. We have a NICU forum where I'll move your post, where hopefully you'll get some posts. Good luck.

[Olivereindeer]

:pI am a NICU RN with 1 year experience in a Level III unit.

I also sympathise as each nurse seems to have their own set of priorities.

It has taken me almost the whole year to learn how to prioritise - the hardest thing being it is SO different from adult nursing.

I too am anal in some respects to the point of focussing so much on one thing that I get behind in the others.

Sadly the whole 'have to get everything done on morning shift' mentality that is so rife in adult nurses has spilled over to NICU where it is not considered 'professional' to leave someone else with a 'mess' including having the baby out with the mother for the next nurse to have to put back into the incubator. It is to the point of ridiculous sometimes.

Have you lost your confidence from this repeated feedback?

The most important thing to remember is that the babies in your care have been safe with no compromise. The rest is niceties (important but not life threatening).

I find I need structure and I write myself a timetable. Where I work we only have one ventilated patient to one nurse or perhaps 2 CPAPs (3 if desperate but very unusual) One nurse to an oscillator too.

Here is how I go about my shift:

1. Take handover and clarify any issues I have with the nurse going off..go through all the med charts too and anything unusual laying at the bedside I will query. Qjuick look at the baby together.

2. Check all my equipment - bag/mask, neopuff, 02 etc. This should only take a couple of minutes. Check alarm limits/vent settings, IV's

3. Write my timetable: on an hourly basis - write down all meds to be given, feed times, ob times, cares times - I also jot down at the top of my page the amount/type formula etc. I roughly estimate when everything is going to run out and write a tentative time for that on my list. I also check when the bed change, feeding tube or circuit change is due. For the big things I will wait until there is time at handover (we have 2 hours of double staff at this time) so it is easier with both of us.

4. I get everything I need all ready - EBM/fortifier/formula close at hand and made up, I make 'whiskers' ready for CPAP, chin straps, put a nappy in the incubator to warm. I get my suction ready, I have a syringe attached to my saline in the incubator to warm all ready, thermometer out, TCM equipment, gases taking, bandaids. The key to me being efficient is setting it all up.

5. We dont disturb our early premmies unless at times of cares or we have to so when the cares are due that is when I do most of my assessment. Mostly we cluster cares every 6 hours but with very unstable ones I will do a small thing each hour (suction one hour/temp the next, nappy the next) I find that they dont tend to drop sats so much and are much quicker to recover.

I suppose the thing to remember is that these babies wont die if their nappy isnt changed exactly on time, they wont die if you dont have great developmental care for a short time, they wont die if they dont get fed exactly on time..but they will die if their respiratory system is not the first priority and the vital drugs come in a pretty close second.

Dont be too hard on yourself...look back on your 4 years and remember that the babies in your care have been ok..that you are doing your best, that your care has been appropriate but maybe a little disorganised.

I can get very anal about things like positioning and making sure they look comfy and being tify around the bedside - sometimes I just have to sit for a minute without running about and ask myself what I HAVE to do now and what I WANT to do now.

Goodluck

Rani

[iheartpreemies]

Thanks so much for all of your quick and supportive responses!

Well, let's see. My biggest problem is that my assessment routine seems to be getting longer and longer (with more stuff I'm trying to squeeze in) instead of becoming quicker or more efficient.

So I end up getting decently behind on my 1st set of feeds, and while I'd ideally like to try to catch up on my next round, I often feel that if I was too far behind on my 1st set of feedings (30min or so, at worst 45min)... it's not fair to catch them up to speed in the 2nd round, as I wouldn't be giving them a proper chance to digest their food, and so I try to only push feedings up by 15min or so each round, to avoid having large residuals and therefore appearing as though it's the infant's inability to digest that's the problem!

A couple of examples that come to mind of what gets me behind in my assessment in fact involve GI assessment and feeding tolerance:

1) In my original hospital where I was trained in NICU as a New Grad, we were taught that the NICU population most at-risk for NEC were the tiny preemies, usually with a PDA or other circulatory issues that might draw blood away from the gut, and who either had been NPO for awhile and were just begining feeds, or were fed too aggressively early on. And from what I remember, the few conferences I attended in my first few years as a NICU nurse were congruent with this mode of thought. However, at my next 2 hospitals as a travel nurse, we had one case in each of a 33-34wkr- who was on or close to full feedings by bottle- who suddenly got NEC and became very ill; one of them even passed away from her aggressive disease. This all seemed strange to me based on my previous knowledge, and I became ever more surprised (not to mention quite frightened!) to discover at my next hospital that they're of the belief that the later-aged ex-preemie is the highest at-risk population for NEC, once their feeding volumes are rather large. What this left me with was entirely cutting out one of my shortcuts- doing a quicker basic assessment on the older, more stable preemies prior to feedings so that I don't get as far behind on their feeding times, and then maybe finish up certain parts of my assessment after their feeding (or part-way through if they're the ones who need a little break and/or reawakening to get through their whole bottle feeding). Now I'm terrified at the thought of not completing a FULL abdominal assessment and girth prior to these infants' feedings, which seems to just continue to set me back on feeding schedules.

2) On a related note, I have a real pet-peeve of gavage feeding tubes that have been secured in the wrong place- only because this is also potentially damaging to the baby if it is too high, or makes them appear falsely unable to digest their food if it is too low (I can usually deal with 1cm off as long as it's not a tiny baby, but when it's 2-3cm off, I feel I have to rectify the problem- and also get pretty heated that my colleagues are too lazy to measure appropriately, and now I have to rip another piece of tegaderm off a poor preemie's face!). I seem to be the nurse who often gets a larger residual than everyone else- sometimes because I re-measured and re-taped the tube, other times I think I just give it a bit longer than others do when I aspirate on the attached syringe. I'm honestly not sure why it is, but of course this can be an important indicator of feeding intolerance and associated GI complications, and often the baby appears to be digesting just fine all day until I come in at night (or even intermittently on days while each night I have problems. And of course many doctors these days aren't too concerned with small residuals, and even the occasional large one. But sometimes it also leads to the baby being suddenly made NPO again, or even a septic work-up. So I'm always a little torn, but it seems that knowing the facts (ie TRUE assessment of residual along with the rest of the abdomen) is critical to the full picture of feeding tolerance. So why is it that so many tubes are incorrectly placed, or that I'm one of the only nurses getting residuals back from particular babies?

3) Another feeding issue is our all-too-famous ex-micropreemie who really doesn't know how to bottle feed yet (or who has other complicating lung disease or GI factors that prevent successful bottle feeding)... and yet we're supposed to do everything we can to give them the appropriate chance to try it out when they're awake/alert enough to do so. (And worse yet is the baby who just won't eat their minimum, but we're not allowed to gavage anything to see if they'll eventually get hungry enough to work it out for themselves over a few days!) I realize this is of course inherently par for the course in the NICU, but when you have 2 or 3 (or the dreaded 4!) babies paired together who don't know how to eat... and when you're already running behind schedule as I tend to be... it's an absolute nightmare! So I find myself seriously struggling with the efforts to give them every possible chance of getting themselves organized before I drop in a feeding tube, trying to get myself back on track with my other cares/charting, the frustration of not getting them to succeed, and the guilt of giving up too soon and gavaging the remainder of the feed. Not a pretty picture! And it's tons of internal struggles similar to these that keep me battling with myself about "what's best for the baby" over the long haul, and which consequently keep me from actually getting my tasks done and staying on track! (And believe me, if I didn't truly love and care for this pt population so much, I'd consider that maybe I'm too anal about preventing these big-picture mistakes to be working in this dept)

Other things that tend to set me back are general things like not being able to palpate good pulses, not having the ability to detect murmurs appropriately (or a variety of noise factors that prevent you from hearing the heartbeat well enough to say one way or the other)... and generally crying/flailing babies that don't make things like abdominal girth (or anything for that matter) easy. I'm very big on the calming/soothing part of developmental care, not only for the sake of the baby's stability and general welfare, but for making my job in assessing them easier. So I always have a pacifier (and Sweetease when appropriate for procedures) at the ready, and always try to give breaks for recovery when the baby's too agitated, or I'm not getting anywhere with my assessment. But this is just one more factor that sets me back, and I don't always see it coming.

And of course each time I switch to a new hospital, it takes awhile to figure out where all the equipment and supplies are, and procedures for obtaining, double-checking, and charting medications, and esp things like what to do / who to call when your medication/fluids aren't where they're supposed to be at the scheduled time! And even more frustrating is the process of figuring out each hospital's policies, procedures, and protocols, how to access them, and most importantly your best resource people for when you have questions regarding these things! I found in my last job that it certainly wasn't the people you'd expect- like your long-time, experienced charge nurses!

Anyway, many nurses have advised me to simply start everything earlier to allow myself more time for unforseen complications... and yet once I get behind on my very first assessment, I find it extremely difficult to ever catch up, let alone begin early. I of course have a much easier time taking on a particular patient/full assignment for a second or third consecutive day, as I'm already familiar with my patient's baseline, but that first day back (or when your assignment completely switches around often) is a killer for me.

I often find myself missing my break time in order to play catch-up, which other nurses will often remind me that not only is that not too smart for my well-being, but that over the course of a 12hr shift, it will certainly affect my ability to give good patient care. And sadly, even without breaks, I find I rarely clock out on time! Which is not only frustrating to me, but especially to my management. Really not a good situation!

Anyway, sorry for rambling (and ranting a bit much!)... hope this clarifies some of my specific problems at work.

[Olivereindeer]

From you reply I can see that you are exceptionally thorough and quite particular about your care. In fact it made me feel guilty that I dont seem to do as much as you assessment wise but then I remember that I still do assess my babies (yes, without girth measurements etc) and my babes are fine.

You do seem to be quite bogged down with the pedantics and when you say you are OCD are you serious? I almost wonder if you just cant NOT do those extra things that you do as it would be too stressful for you. Do you actually have a degree of OCD? I have anxiety and a small degree of it but have a reasonable degree of insight into working out when I am getting a little OTT. You do seem to be particular about NEC etc..(I know this is important) but I wonder if you are overly concerned with certain aspects of care.

I really dont mean to be rude or horrible and I do know how hard it can be to be worried.

Have you considered working with a respected peer or educator that you trust so you can have some honest feedback about what is vital and what you are going overboard with.

I hope it all works out for you - sounds like you are giving yourself a hard time as well.

[iheartpreemies]

wow rani.

yes, yes, and yes. you're absolutely right, and i certainly don't think you're being even remotely "horrible"

i do acknowledge that i'm certainly more OCD than i'd like to admit, and sadly even a bit more than i seem to be able to manage on my own. i'm fully prepared to seek a little professional help in that dept now that i seem to be geographically stable for a bit! the problem is how i cope with the daily stressors of work in the meantime!

and yes, i would love more than anything to consult someone i respect and trust in my field about these issues and better prioritization skills... the problem is i don't seem to have anybody locally at the moment, and i'm unsure as to how much anyone would be able to help me over the phone or out of context of an actual pt care assignment- only because things are always way more complicated in a live situation!

but nevertheless, that's one thing i'm trying to get working on... figuring out who i know that i feel would be an appropriate source of help (since some of the coworkers i know and love dearly, i don't always feel give the same kind of comprehensive care i'd like to give). i know there's a few crazy anal NICU nurses out there who manage to get it all done on time, so they clearly have a much better sense of how to truly prioritize even when being comprehensive and perfectionistic... i just need to find someone in that category whom i can openly confide in, and who's also willing/able to help!

but thank you so much for your time and support... and please feel free to continue to drop me advice or ideas of how to straighten out my head a bit!

out of curiosity, in what part of australia do you live and work?

[wjf00]

Every time I hear the word 'prioritize' I think of a poorly staffed unit. I gave up on prioritizing. Do all the care all the time.