How many admissions & visits in an 8 hour shift?

[hospicechpn]

Almost a year ago our small non-profit hospice moved to electronic medical records. For many reasons this is a good thing and I feel competent with the program. Charting by computer definitely takes longer but we still prefer it. Our patient census is 90 to 100; we have three part-time case managers and five full-time. We are the only hospice in the area without a ceiling on census.

My question regards admissions. Each admissions RN is required to do 2 field admissions per 8 hour shift. This includes meeting with the family and patient, explaining all aspects of our services, signing consents, assessment of the patient, assessing caregiver learning style, verbal and written instructions for care of the patient, use of comfort meds and other comfort measures, review of the hospice binder, etc. After assessment of the patient we need to enter the information into a template, enter visit frequencies into a separate section, input all the medications, DME, functional limitations, allergies, diet, hospice admission criteria (checklist plus narrative), global functioning scale, open all problems and interventions on the care plan, chart another clinical note on each problem and why we opened it (this also in narrative form), fax the doctor for orders and make sure they sign the orders, call the pharmacy and DME companies, obtain the signed schedule 2 for narcotics from the MD, leave report for the case manager, the social worker and the night RN. We're not able to fax or synchronize from the field so we return to the office to do that. It we miss a detail there are repercussions. We are mandated to get the comfort meds into the home the same day, which we agree with. What we have trouble with is trying to do this for two patients and be finished in 8 hours. Actual time spent in the home is anywhere from one to three hours and averages about 1 1/2 to 2 hours. We usually don't take the computer to the bedside so as to give our patient and caregivers full human attention. If I have a patient who adores technology and is curious, then I'll whip out the computer and show them how we input the info.

My supervisor thinks we're "inefficient" for not being able to get everything completed in under 8 hours. We hustle and we're thorough. It's exhausting.

The program we use is Allscripts. I really like it but it is a long admissions assessment. Does anyone else use this program and successfully get two admissions done in 8 hours, along with all the extra stuff that has to be done? Why aren't we able to finish? What are your secrets? When we did it exclusively on paper it was a much quicker process. Despite my long description post here, I am able to keep my nursing notes succinct and relevant. Travel time one way ranges from about 20 to 90 minutes.

If doing a routine home visit for established patients, 5 or 6 a day is manageable. We see our patients at least weekly.

Suggestions?

[Kabin]

That's too much to do and sets up increased chance for error, poor pt/family education, etc.

Of course some larger hospice agencies have dedicated admissions nurses. You could suggest scaling back the number of tasks an admission nurse does. That might be minimized assessments, no HMHAs, no DME unless necessary, etc. Let the assigned CM do clean up on the first visit.

[enchantmentdis, BSN, RN]

I started a new hospice case management job about two months ago. I am just getting used to the routine visit computer documentation. We use Allscripts too. Our orientation (3 new RNs) consisted of one day learning re-certs, one day learning admits, and 3 days learning case management and routine visits. I wish we had 3 days learning the admissions before being sent out with with nurses to actually do the admits. This week they gave all of my patients to other case managers so I could learn how to do admissions. It is cumbersome. It takes forever to get an admission done, even if the family are quiet and just listen. The two nurses who are training me do not chart the admit visit in the patient's house. They go home or at a Starbucks to do it. In the home or facility they do the consents, call a local pharmacy for comfort meds, call the equipment company, check the DME, hand out supplies. Because they are training me it takes a good four to five hours to get all the details entered into the computer. It is a nightmare. Management at this hospice is very nice, friendly, but they have had a high turnover--a "senior" nurse who has been here only a year said over the past year they've had at least 6 RNs hired, fully trained; and that they all left. Nearly all of the RNs are new. I am scared to death to do an admission on my own. I noticed one of the nurses who has 15 patients in her case load had to do an admit after hours last night and her IDT note was time-stamped for midnight. Poor thing. I'm just going to have to wing it to keep this job. The others who were hired the same week I was are already looking for an easier job. Allscripts admissions take hours. I'm not used to being so inefficient.

[Buckeye Liz]

We use Allscripts also. Our comprehensive assessments (done on admission and recent) have been customized to make them much more manageable. They are very complete but eliminate a lot of it. Someone at your agency should know how to customize the assessment templates. If not, contact Allscripts for help in doing it.

[dshebest]

We use Allscripts also. We have been working very hard to make the admit visit less cumbersome. One thing we have done after consulting with other agencies that also use Allscripts is change our process such that on admission the nurse is only addressing the most pressing issues for the pt at that time, including the basic hospice info/review. The goal is to be in an out around 2 hrs with most documentation done and then we automatically schedule a 2nd day visit to tie up loose ends. We've pared done the admission assessment and 2nd day is built like a routine. We've found that pt/families are reporting higher satisfaction and the nurses like this process better also.

[TammyG]

I think it is impossible to do more than 2 admission visits per day. Say 30 minutes to drive to the admission, then 90 minutes average for the admission (tho some can take much more). Then you have to order equipment, supplies, type up an email for the team, call the AMD and HMD for collaborations, log the visit, enter the initial order and medications, and followup with any problems/issues such as whether hospice will pay for out-of-formulary meds. No way I can do that in less than 4 hours. Plus you have to deal with overflow issues from yesterday's admissions . . .

[snicuradrn]

I am a new hospice nurse, I have 20 years of ICU and Interventional Radiology nursing experience so it has been a huge change for me. We use Allscripts for documentation as well, I find it difficult to maneuver at times and you are not alone when asking about the likelihood of getting 2 admits completed in 8 hours. Our company has a fulltime admissions department with 3 fulltime nurses, they manage to get up to 4 per nurse admitted daily (although this thankfully not the norm). The only way they manage so well is they work extremely well together and each nurse readily steps up to assist on getting it all done. I am not sure how many of you are still following this post but with the new allscripts upgrade (june 2014) there is even more documentation to perform however it seems to be a good upgrade as it directs you specifically on topics you may not have thought of making your documentation more complete in what federal guidelines are pushing for. I work as an OPT nurse primarily in a new inpatient facility and since we use the same programs for all documentation there is a lot of monotonous documentation that is not relevant such as evaluating for fire safety- you know the questions I am referring to I am sure. I do find that trying to document clinical notes on nightshift when patients are sleeping throughout trying since it is required to have some documentation every 1-2 hours. I mean how many times can you write in a patients chart, " resting quietly with eyes closed, resp. even and non- labored. Bed in lowest level point, call bell within easy reach and HOB elevated in semi-fowlers position". Any thoughts to this clinical documentation dilemma? It feels so generic to write this and not specific enough for the pt although if they are there for symptom management and are sleeping what should I document? Thanks in advance for any responses.

[SCgirl1962]

Allscripts is time consuming and not user friendly. Getting everything documented in the computer for an admission and all of the notifications to DME, pharmacy, MD's and other team members can take as much as 4 hours depending on the patient. My best advice is to try to really familiarize yourself with the admission template. I jot things down on a piece of paper - Vital signs, assessment findings etc, and then input it in the computer after I leave the patient's home. I know that negates the point of bedside charting but you just can't give the family your attention and do the allscripts charting at the same time.

[toomuchbaloney]

I also don't much care for that software.

Why would the nurse starting the hospice benefit need to open "all" problems? That is an admission visit, the problems for the POC determined during that visit should be pretty standard other than immediate needs related to pain/comfort. Otherwise the plan initiated at SOC addresses location for death, CPR status, caregivers, etc. The case manager and the full team (including the pt/family) create the full hospice POC...not the admission nurse.

If they want the admission nurse to admit 3 patients they could have the MSW visit with the patient/family to explain the hospice benefit, answer questions, and sign the EOB and other appropriate/necessary consents. The RN then follows to complete the nursing assessment portion of the lengthy visit.

[SCgirl1962]

Did an admission today. Spent 2 hours in the home explaining the hospice benefits, doing the initial clinical assessment, getting paperwork signed and getting a list of all medications. Came home tonight and spent another 2 1/2 hours inputting the data into the computer. Tomorrow in the office, I will spend another hour completing paperwork, faxing notifications to the DME company, pharmacy, Pharmacy benefit manager, coroner, etc. etc. It is a very exhaustive procedure. No one understands just how much time it takes unless they have actually done an admission with this software. I have a love/ hate relationship with the computer. Love having the information from all of the visits at my fingertips, but hate the amount of time that has to be spent with this program.

[SCgirl1962]

Forgot to add that on top of the admission, I did 3 routine visits and spent a few hours in the office doing administrator duties..... :)

[nur18]

I work in adult acute care and the admission process is pretty much the same as described. Depending on the new cases in my area I would have to do 2-3 admission daily. If the patient need wound care or any other care that have to be done as well. All this while making sure I see my daily wound care patients and try to keep account of any other patients I am responsible for. Homecare is very stressful, and will alway creep into your personal time. I find it best to do as much of the computer work inside the home including any phone calls that have to be made.