New nurse / new to HH / tons of questions

[tinyRN72]

Hi all, I just graduated and got my license. My first job is home health. My first week is over and I have found that I have a ton of questions if anyone doesn't mind taking the time to give me some input.

1) Where do you normally get lab supplies? I have been told to get them from the hospital lab, but the lab tech doesn't seem to want to supply me. She did for the patient I have right now, but I am not sure that she will in the future. I don't want to take the cost out of own pocket, and the office isn't giving me any either.

2) A doctor told my patient that I can take his staples out. I know how to use the staple remover, but, again, don't want to pay for one, especially since they are one-time use. I told him that I can't. Does this sort of thing happen a lot?

3) How do most agencies pay? I get a flat rate for each visit and that is ALL - no car allowance, not even benefits. Is this normal in home health?

I really like the work, and could't get a better job right out of school, but what do you guys think of this stuff?

I will stop with just these for now. Thanks to anyone who is willing to help. Any other suggestions?

Thank you!

Melissa

[tinyRN72, BSN]

I am actively looking for a new agency / internship / or just about any job.... and I am studying OASIS on my own - thanks to this site I found out that I really need to know it. It is ridiculous. I just keep thinking that if I can just stick it out for 6 months (if nothing else comes along) then I can change to a better agency. It is really a shame because I greatly enjoy the actual work. I didn't expect to go into HH, but I really like it a lot and I can see that I would love it if I were working for company that isn't such a joke.

Thanks all --- at least I now know that it isn't just me who thinks this is crazy.

[KelRN215, BSN, RN]

You should NOT be paying for any supplies out of your own pocket. I get lab supplies from the lab- one lab that I use has a program where they supply (free of charge) lab supplies for specimens that are coming back to them. We order the vast majority of our supplies from them even though the vast majority of our labs don't go back to them. There is one specific tube that that lab doesn't use but the one at the hospital that most of our patients come from do use.... I just try to ask for a bunch of them every time I go to drop off labs.

Doctors/the hospital frequently tell patients "oh just have the home care nurse do that" without ever checking to see if it's something the agency/nurses actually can do in the home. The most glaring example I can come up with is... a patient had a clotted PICC line. His mother brought him to the ER- they did an XRay and confirmed its placement and then changed the cap. They sent the mother home and said "tell the VNA to tPA the line." When she ever told me this, I couldn't have been more mad... they had kept her waiting in the ER for 4 hours to not actually do anything which was more than enough time to tPA the line. We don't carry tPA, the MD never sent an order for tPA, it would have had to be delivered by the infusion company and then it would have required 2 visits within 2 hours of each other to instill and withdraw it. Not a practical thing to do at home when the patient was there in the ER where they easily could have done it.

Another one that was annoying as could be... a patient (who is followed for every other week IM injections and we do his labs monthly since we're already in there) was at a major hospital for a Renal appointment. Instead of just doing the labs that the patient needed done on that same day, the MD called the agency and requested us to draw a slew of labs (including one that had to be delivered on ice on a day in August where it was 90+ degrees out) on a week when the patient wasn't even due for labs. Why would you just not hand the patient a lab slip at the appointment and say "stop at the lab on your way out"? This patient is not homebound and is fully able to wait at the lab to have his labs drawn. Why ask that we go out and do them on a SATURDAY when they will be A) brought to a lab outside of your hospital's system and B) the results will not be available to you for a week after the appointment... you could have had the results THAT SAME DAY and made treatment decisions before we even got in there!

[tinyRN72, BSN]

Hi KelRN215,

Thanks for the stories. Wow. Here is what I got today:

You must got to this patient TODAY, no matter what, must get there today to change her PICC dressing. Ok, it was on my way home anyway, no big. I called the house, and guess what? No supplies for changing the dressing. My supervisor told me to have them go to CVS for the supplies. I relay this to the patient's husband. He insists that he doesn't know what to buy and asks if I can just stop and get them on my way, and he would pay me back when I got there. Ok, NO! I told him to meet me at CVS and I would show him what to buy. I waited there for him for about 40 minutes before he finally showed up.

[KelRN215, BSN, RN]

CVS sells PICC line dressing kits? If that happened in my agency, I would instruct the patient to call their DME company and to call me when they had the supplies. If a PICC dressing is changed a day late, it's not the end of the world.

[tinyRN72, BSN]

CVS doesn't have biopatches, but they do have tegaderm. Thankfully the patient did have 1 biopatch left.

[LaRN]

I would tell you to quit, but this is getting pretty interesting.

[KelRN215, BSN, RN]

CVS doesn't have biopatches, but they do have tegaderm. Thankfully the patient did have 1 biopatch left.

You need more than tegaderm to change a PICC line dressing properly though. We don't use biopatches but the vast majority of PICCs that I deal with have Stat-locks that also need to be changed weekly and you need everything else that's in the PICC line dressing kit- especially sterile gloves and chloraprep. I would not change a PICC line dressing without the full kit in the home.

[LaRN]

I would not change a PICC line dressing without the full kit in the home.

exactly....the end of the cath goes all the way to the sup vena cava. if the patient develops any kind of infection or complications, that substandard bandage will be the culprit.

[jammycakesRN]

You are in a very dangerous situation & I would get outta there YESTERDAY!

[stephanie.]

Don't risk your license for a sub-standard company.

[mother1strn2nd]

Hi Missy. It sounds as if you work for a very small home health agency as I do from the things that you have posted.I am the DON and we do go through what you are describing at times. My company does not have a large supply closet filled with all the supplies you can imagine. Actually we have basic supplies such as gauze, abd pads, kling, tape, tegaderm, duoderm,NS, wound cleaner; the BASICS like I said. If we do not have the supplies that are needed to provide care to a patient in the office, we will ask the nurse who has accepted the case if they can obtain those supplies and we reimburse them once they send the receipt in. Did your agency mention reimbursement? Items like picc line dressing should have been arranged by the insurance company to deliver to the patients home. Were you administering iv infusions. When the patient is in the hospital they send a referral to the patients insurance Co. The insurance is then responsible for making sure all special equipment and necessary supplies like picc dressings are sent to the patients home.

In regard to drawing blood we do not go into a lab and obtain supplies. We use lab in a box and all the necessary equipment are in the boxes. Lab in a box is specifically geared for home care so your agency should know about it. If not, inform your supervisor about this and let them know it is free.

Now in regard to pay, my agency does not pay for mileage either. We pay per visit and how we think of it is as an hourly rate. 98% of the time a visit does not take more than an hour to complete so that per visit rate if you think of it as an hourly rate is not too bad. Again we do not pay mileage and that its because we ask our nurses how far they are willing to travel and staff them when we have cases within those areas. If they accept a case farther than they have agreed upon we will increase power visit fee to accommodate gas cost.

I am not here to defend your agency because they may be as bad as they sound but I just wanted to explain from the agencies stand point. Hope this has cleared some things up for you.

[paradiseboundRN]

IMHO (and experience), a visit including the documentation takes about 45 minutes. That leaves about 15 minutes for travel both ways. So, if I worked for your agency, I would never accept a case that was more that 7 1/2 minutes (5 miles) away from my home. The mileage pay is to cover the wear and tear on your car. The IRS standard deductible mileage rate for January 2013 is 56.5 cents per mile. Most agencies pay about .50 cents per mile. You are really screwing your nurses!