Kitty Hawk 9,757 Views
Joined: Jun 15, '05;
Posts: 551 (20% Liked)
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Hospice Case Manager; from
5 year(s) of experience
hospice, ortho,clinical review
Interesting you say that. Because that exact thing happened. Too high and apparently a mismatch between the PT/INR something about the ratio wasn't right so the MD ordered a stick. That result was 2 points off but I've since had to do 2 more blood draws which were successful so rather than driving out of my way for this machine that has to be babysat (can't be too hot/cold) I'm just going to keep perfecting my skills with a peripheral stick. Thanks for the answers!
Funny thing is I used a different one. (I'm not sure how many we have we have 2 visiting nurse locations that we share with) and it only sucked it up 1/2 way but still gave a result that was deemed faulty. The other nurses have used different ones from what I know.
Sounds like you approach from the side too. Thanks for answering!
If you use this. I've used it successfully and not so much. My question pertains to the "5" error which is the blood wasn't applied properly. I go in from the side and it seems a crap shoot if it works or not (and fellow nurse state the same it works 50% of the time) I'm wondering if I'm doing something specifically wrong?
Like maybe touching the skin along with the drop or ??? I've not tried the turn the finger to drop the blood because that seems like to precise of an aim but idk? I know you nee a pea size/ladybug size drop of blood but I'm just wondering if you use this thing and have honed your skills, what seem to have helped perfect them?
Or maybe I really need to just practice blood draws even though I suck worse at those
Oh, and another huge benefit, is the doctors actually respect and listen to us because we are the ones there. IME in the hospital I was not able to question or suggest things to the MD only report s/s as all but 2 of the surgeons (ortho) thought they were gods including residents and one even ordered enough dilaudid to kill the patient and didn't appreciate it when I questioned him!
I got to suggest prednisone for a patient who had encephalitis when I explained to the MD at IDT meeting pt lost his appetite but "wanted" to eat and the s/e of the med was increased appetite and maybe with the brain swelling it could help...well it did and the family has the best remembrance of the holidays and 40 family members traveling in to have one last holiday like the old times....that was a priceless privilege to have been able to suggest an intervention that gave a family back their loved one for just a short while (prior he would just nap in a chair and barely eat) They got 3 mos of quality time with him.
So it's being able to actually use your critical thinking skills and make suggestions that is pretty cool. Again not to insult hospital nurses because maybe some really do have respectful relationships with their MD's. I was treated like a robot to carry out orders and now I'm a respected team member. BIG difference. IMO
I guess it depends on where you work. I'm paid hourly, no pay cut (but I didn't have years of hospital experience so I was starting from the base tier at the hospital) and sometimes too much overtime right now, but that's at time and a half. It's def not about the money, but if we ever went ppv I along with most of my co-workers would find another job because we would not be compensated appropriately for our work. Same thing with salary, the office employees are salary and are often there until 9p or 10p
On the flip side for the overtime, even though I'm not crazy about it as I work to live not live to work, if it's an admission after hours we can just gather the info we need from the patient's home and come back home to finish up which I think we're pretty blessed. As long as no one abuses that, but I write everything I'm doing and phone calls and computer work all has time stamps. If it's an admission during the day, we can again gather up the info and go somewhere else to finish up. If we're close to one of our affiliated facilities, we can go there, if not we can go to a Panera or even a park as we have hotspot connection to the internet as long as we're not too far in the boondocks! So those perks def outweigh being in a tense hospital atmosphere working OT.
That's a huge benefit of hospice vs hospital. In hospice if you have a tense or crazy situation, you only have to deal with it in small doses and you can leave. Fix the problem and leave. In a hospital, you are stuck with said situation for 8 or 12 or more hours. No thanks. I thank God when I'm in a facility seeing patients or at a hospital doing an eval....that I get to leave and go back to the sanctuary of my car! And then there are the situations that I mentioned are a privilege to be a part of from start to finish, so I can't even believe I'm getting paid for those experiences.
I have a difference experience than described above. I worked LTC and in the hospital, also did 2.5 years of review work and I absolutely LOVE my job with the exception of on call but I believe we're working on that as we're growing.
I couldn't stand the hospital for the politics and the crabby nurses that loved nothing more than making people feel small and there are plenty of those unfortunately as NanaPoo pointed out, the hospice team is generally awesome that makes all the rest of it bearable and for me, even enjoyable.
I blessed to be a Case Manager in my back yard for the most part (average 30 miles per day) but I have been called out for over hour long drives for pronouncements and admissions, but when you meet that family...all your grumblings will melt away in what that family needs and what they give you and what you get out of it, far exceeds what you do. It is absolutely the most humbling rewarding job I know of. And most days I feel privileged to be a part of someone's most intimate last days on earth.
Like NanaPoo I don't mind the driving that much as I'm getting paid to unwind and listen to music for the most part instead of listening to above said "crabby nurses"
For pronouncements, once we call the funeral home, if family doesn't need us, we can leave. It's up to family but again I find I generally stay because there's a reason greater than I understand why I was called there and I generally leave with a "wow that was amazing" feeling.
Thanks! (and sorry that was SO long, I didn't realize until I saw it!) I agree it's about what you get out of this job that exceeds what you give sometimes. I think we just had a crazy September, all worked out and we even had 2 other nurses that had melt downs, one snapped on another nurse and ending up leaving their post for the day (office position) and another was upset over the constant changes and resigned but later realized it was a rash judgement after a stressful on call weekend and retracted the resignation which they accepted.
I'm hoping they see that all this overload is causing people who otherwise can handle the job and stress calmly are hitting breaking points and they do work on getting us an on call team for evenings and weekends. I'm willing to wait as this is the first job with the exception of on call, that I absolutely love.
Okay, as usual I only find the time to come here when things go haywire!
First the setup to the weekend. I worked Labor Day, not a big deal, I was only called out during the day for 2 visits. (but as you all know, there's stress for watching the phones)
I had a usual stressful week and was informed mid week I would have a new employee that would be with me the upcoming week so that was stressful. From Thur to Sat I found out my census was going from 15 to 19 and one of them would require a qd visit at the local hospital for in-pt status. These 4 all require prep work as I create index cards, review meds, hx etc...So I'm ready for the patient. I did all this on Sat from home as I knew Monday I wouldn't have my usual cushion with the new employee present, plus I attend a weekly Monday meeting at the facility that I also serve.
Okay, Sat was fairly uneventful, I was not called out during the day at all as we have 2 LPN's working, one weekend RN til 430p and an admission nurse til 9pm (who can also do visits) The office leaves at 430p (or more like rolls the phones to the answering service from 430pm-7p for me to then get, and our IPU's pick up the calls after 7p to 7a)
I typically won't eat dinner until after 7p because that's the "safe time" that I will only get calls if I need to go out because the unit can triage problems for us. I have IBS that for the most part is okay, but when I'm nervous, it's just not a wise idea to eat! I got a call at 650pm for a CTB around an hour away. I head out and return home after 11pm and finally ate dinner at 1145pm went to bed and averaged 2-3hrs of broken sleep because on top of the usual stress, my phone kept randomly shutting down (new one on order) so I gave the unit my personal cell but it is far quieter than work phone and I don't sleep anyway.
Uneventful evening and Sunday morning arrives. I was already pre-scheduled to go out for an admission with our sw that was planned for a late afternoon with a wild family that could only accept 2 hour time frame. Our sw's don't usually work Sundays, but this was planned by upper management.
I was still in good frame of mind, ready if need be to do visits prior that were in and out types. I'm not the fastest at admissions because field nurses don't do them all that often, usually only when on call which averages 4x month,weekend on call is generally q other month for us.
I got word at 10am there was a "possible" admission over an hour away and then approx 45min from the planned one, well I went into an anxious panic. I found out one of the LPN's was not called in because she had yet another excuse for being ill. (she is on call q other month as is known to "get out of her day on call" and refuses to work overnight with an insomnia excuse, so another LPN picks up for her from 830pm to 8a.
I was upset figuring staff wasn't being utilized in best way. We do not have an admission nurse on Sunday as previously we did not accept admissions on Sundays/Holidays however that has changed in recent months without a direct knowledge just more, "we all were figuring it out".
From my perspective, I had 2 hours of sleep, I was being sent for a mess admission ( I was foretold the family is v wild) and to do another right before it which to me, the exhaustion level of what an admission does to me (of not in July,I had back to back admissions that took 12hours total) not sure if I would be able to comfortably complete one (not knowing family acceptance etc...) before going to the crazy one. And also there was back and forth that morning because it wasn't even known if the insurance was okay!
Back and forth phone calls were made by mean to my back up admin who also did not give me a direct order to go because she was also upset the one LPN faked getting out of work (she said it happens all the time) and that she would let me know. I tried calling my main boss who is supposed to always be avail to us, but her mailbox was full.
This could have been nipped by her saying, look, you need to go. But understand, I physically felt I couldn't, I really felt close to a breakdown and like I was expected to be a machine after 2 to 3 hours of non quality sleep, driving 3 to 4 hours of drive time (also exhausting) the brain power to do proper admissions, I mean our 12 hour admission nurses usually average 3 or 4 per day, it just seemed really unreasonable.
I let my "big boss" know I was avail to talk if she wanted to know what happened from my stance, in other words, I was not hiding from anyone and actively trying to get direction. I also know my physical capabilities and felt that I was treading v close to a bronchitis from being run into the ground, little sleep, stress.
Also of note, we are notoriously busy on Sundays from 7p to 8am Monday with high probability of being called out. I should mention, they did send another nurse that was filling in for us during the day to the first admission. I did not know she had previously arranged to work light that day. As I offered to take the 4 visit from her, I just couldn't fathom a brain exhausting admission, so I wasn't trying to get out of work at all.
I did get a call at 130 am for a CTB an hour away, I was headed out for that when barely out of my neighborhood I was told not to come as family funeral home could be there in 10min and family just wanted rest asap, fine...I still had to close out the case type a note so another total 1 hour.
Monday was a disaster with the boss, suffice to say it didn't go well, but I didn't really find out how bad until a day later.
My immediate boss was in my corner saying that on call previously for the weekends was a v grey area, the office person sending everyone out also agreed it is v grey and they don't always know who to call.
But because this has been an ongoing problem, with nurses refusing to go out on the weekends (I did NOT refuse, I was just questioning if we all were being utilized in the bet way) and previously our immediate boss would sometimes get upset if an RN was sent for something that they could send an LPN for as we cost more to send out as this is all overtime for us after working our normal 40hour week. So all of this was too swirling in my head as I've gotten questioned before on going out for a CTB instead of using the LPN when I didn't know where that person lived and maybe wasn't thinking clearly at 2am!
So I've spent the last week in more tear than not. I have been told by my immediate boss that I am an excellent nurse, I do not call off, I have not even used any vacation time yet (which is also a problem for my burnout level) but I have some time coming up next weekend. My big boss does not really know me, nor my work ethic v well. We are all strong Christians who work there as that sets us apart from other agencies ( not that others aren't, we are just known for it)
Also of note, the person that does the schedules even thought she was putting me in a predicament of working Labor Day before that with the weekend but the weekend was already in place and she did call me to okay if I could do Labor Day and I told her I would. I figured it would be like a tidal wave that I wouldn't have time to dread the weekend (as I usually do because they have been v hard lately) and I was right, it was over and done before I could think about it.
Lastly we are a census of 200 covering 7 counties. It feels especially daunting to cover that for 48hours even though we have a couple LPN's the main county that is over an hour from me is usually the problem one and I am always the closest scheduled q time the LPN's were each a 1/2 hour further from me.
So I still feel crummy as my immediate boss still needs to talk to my big boss to take care of any reprimands other than a verbal (which in itself is crushing as I have a strong work ethic) The big boss feels I refused, which I did not, I was questioning but in hindsight, I see it was not my business to question anything even though I have been a doormat in the past and want to avoid that.
That's the funny thing, I now feel in the wrong, that I just should have went and sucked it up though that's the funny thing about hindsight, it seemed so unreasonable at the time. I learned I can do an admission in about an hour, 1 1/2 in the home and leave to do paperwork part, med check etc...
I also feel I failed God in that, I try to be a good disciple and do all with a servant's heart, so I see I failed God in that he was calling me to go and I put up a roadblock.
I just feel sometimes we are expected to be machines. My husband thought it was crazy what they expect of us....but idk, maybe this is just hospice? I'm still rather new (little over a year) and still learning. This is why my immediate boss, along with knowing my heart is willing to defend me. I'm just sick if it's not good enough for the big boss.
If you got through this novel, I thank you! It's my weekend and I still feel sick over this, so was my initial reaction normal or wrong in the hospice world?
Certainly families can call the mortuary at time of death, but doesn't the patient have to be pronounced before they can remove the body from the home?
Oh and ktwlpn, I do go in on my follow up visits when explaining hospice (and if I'm the one doing the admission) do educate the family that even though we are 24/7 we will try to walk you through symptom management over the phone. I don't like how some CE's will say we will come 24/7 when they call, because when asked that I always correct the family and again teach them I am empowering them to handle the care. That we will come if it's an emergency, but first we try to help over the phone.
I even did a direct transfer from hospital to IPU by getting nurse's report which was appreciated instead of running out there. Hospitals sometimes feel we need to actually see them but if they're appropriate by MC guidelines that seems a waste.
Sometimes I wish our answering service could tell the ones that want to know "when is the nurse coming?" that we will get back to them in the morning or even to call us back as that's not even close to something that needs answered after hours. But that's not customer service so....
Most clients of hospices in this area are instructed to call the undertaker at TOD,the hospice physician signs the death certificate later.Most casemanagers in this area are given a day off before they take call for the weekend,granted these are large companies.If you could you would do 1-1 at the bedside during end of life few but it's not possible.That's why the education is so important
I don't agree,I think on call staff doing admissions is a waste of time.In my experince the case manager never seems to catch up....and The on call as neededstaff never seem to know all the p and p.f
.When the regular staff take call daylights and on weekends they are given other time off so they can recharge.
Newhospicern I agree! We've been saying that for awhile. Before though, I heard it was worse before we got our evening nurse so they're always telling us how lucky we are that she's there. And we are thankful as we usually don't have to go out, but it's there looming so... They also tell us they will get us a news crew (evenings weekends) as we grow, right now we have an average census of 190 spanning a few different counties.
ktwlpn- you are correct! I should make that my mindset but working =48 hours is what's mindblowing. Granted it's never actually that. DH thinks that someone else should cover the phone starting at midnight since I need to be ready to go tomorrow at 8am for my regular part.
Interesting your comment about not going for pronouncements as we have new guidance and we may be leaning that way, to have families call 911 to pronounce, others feel it's taking the heart out of hospice.
I don't often stay with a pronouncement as I usually don't know the family. We are told to use our judgement but if a family "wants" us to stay, as I specifically asked her as I could tell she was becoming anxious after we got her mom cleaned and dressed, then we stay. Was I thrilled? no, but if I could provide that comfort...then I don't take that lightly.
As far as using more MSO4, we teach patients that they can use 20mg q1h until comfort, if still not comfortable with that, then they need to go to IPU for IV symptom management. We do have CE's that tell the pt we can do everything they want which drives us crazy sometimes doing damage control when we case managers have to go in and burst bubbles but they are taught (our company standpoint at this time) if family is not comfortable at any time they can in their best interests revoke and seek aggressive care and call 911. Our job is to keep them comfortable at home but if family can't handle that....we do not just keep giving MSO4 in the home exceeding 20mg an hr. I usually don't have concerns in the home much with that. I have bigger ones in the facilities where they look at us like we're angels of death euthanizing people when we ask for morphine q3h routine as well as PRN doses. We have even done in services to educate staff and still there's resistance.
Frankly there needs to be more education on what hospice is and isn't. It's not the automatic death sentence that some think it is. I have seen a huge improvement in quality of life for a few patients in my care, some are even able to enjoy some fresh air for who knows how much longer...but it's brought back their joy for the time. So not all our destined to come through our doors and pass in days but we have many of those as well.
I know we're different than a lot of our competition for hospices. Our reputation has spread because of our faith based principles and so much of our "business" right now is word of mouth and families stating over again how impressed they were when "John Doe" was on our service and the difference it made for them and how wonderful the care was and that's why they chose us. And we don't want to lose the core of who we are or how we got here.
I was in the hospital Friday doing a eval for our IPU and this mega hospital actually has their own hospice. One of the nurses came up to me and couldn't say enough about the care her family member got and how much she loves us! Many love our particular serene setting for one of our 3 hospice houses. Most everyone that has seen it has remarked in awe how this should be how everyone dies, it's just that peaceful.
I agree though, it is to empower the caregivers, that's us doing our job. We always enjoy the ones that think there's a "poop squad" that will come and clean up their loved one after hours and then we have to explain they need to hire extra caregivers for that kind of care.
Thanks! That's just it, we have awesome doctors I mean doctors that I wouldn't hesitate to call, just fantastic human beings that never make you feel inferior, bad etc... I generally can figure what to do and so far it hasn't been extreme but I guess there's always that "chance" that gets me.
ktwlpn: To answer your question, yes/no! It depends on the situation and how comfortable the family is as well as what they've been taught. We do often say that we know we've done our job (teaching) when the families are okay and don't always need us and can do the care. This lady was a bundle of nerves, which oddly kept me calm because I had to be! Plus you can't fix a problem and worry, you just do it! But when she called in she just said it wasn't draining and the call to go came from my office (we have office people that triage from 8a to 4p on the weekends as well as 2 weekend nurses but we still can get called for back up emergencies, admissions) so I wasn't able to trouble shoot and I doubt she would have been able to fix it with her mindset. I did do teaching before I left, but IME if your anxious it's like hitting a brick wall and not much is retained. I did say SEVERAL times to keep the long pants off for the most part!
If it's the middle of the night, if they are not in pain and it's leaking we can try to walk them through removing it and padding the pt up until morning.
I had a call this morning on a pt who slept on their hand and family was concerned as it was swollen. I instructed to ice and elevate and and then she said mom didn't seem "right" as she wasn't readily speaking just staring etc...(I immediately thought CVA and offered a visit because that's happened) but then she said maybe it was how she slept last night and she wanted to wait a bit to see if she came around and so she declined the visit.
Even in a case where the family is freaking out we can offer for them to go to one of our IPU's if they are overwhelmed and we can even do this over the phone if it's bad enough and I'm pretty good at deciphering where family is on the spectrum of phone vs visit vs send pt to IPU!
I've walked in on a normal day for a COPD pt in respiratory crisis and that one after several tries with MSO4 and Lorazepam, family opted to call 911 because transport would take a few hours as it's never an emergency for hospice pts to get to an IPU (that's a whole other kettle of fish that I don't understand!)
My point with all this rambling (sorry I'm sleep deprived again as I just don't sleep well!) is I can usually figure it out or know where to go to get the info if I can't and like mentioned we have awesome back up. Right now I have my office nurse triaging, she is has our 2 weekend nurses out and will call me if needed. If not the phones will go to me starting at 4p until 7p (at 7p one of our IPU's rotates calls till 7am) If after 7p I get a call, that generally means I need to go out because the IPU can trouble shoot over the phone.
The last time that happened I got called for a pronouncement, I got there at 1030p and couldn't leave until 115am because the funeral home was from another state and was a 2 hour drive! She told me she understood if I needed to leave and I said "do YOU need me to stay, because I can" and she said she would feel so much better and that was it. She gave me ice water and reminisced on the wonderful life of her mom and it was a privilege to be included. The funeral home arrived and the thanks that we always receive is so humbling. My husband even didn't mind waiting in the car for 3 hour as he ate my snacks haha! (he likes to go with me on the night ones, so I'm blessed there too!)
So yeah, see? What is my problem? I think it's because I'm not an adrenaline junkie. In fact when the EMS showed up on my COPD pt and thought I was killing him with the measly 10mg of MSO4 SL and they were questioning me etc....I HATE that, I don't care for their over inflated egos (granted some do not, but many do, but I've run across some awesome friendly EMT's as well)
It's that fear of the unknown and even though logically I know that God doesn't give me something I can't handle, it's the waiting for the phone to ring and not knowing if it will and jumping when it does!
My co-workers express the same stress, the not knowing and not being able to relax. I just wondered if there's some tip we're missing! My husband says just go about your day and if it rings it rings! Great in theory but I can't really apply it! But then when it's over I usually think "ok that wasn't so bad"
I would just love to get past this. It's the one thing that nearly has me running and thinking I need to find another job! Especially with the 48 hour on calls But it's only 3x month if I have a weekend,(one weekend plus 1 week day night) or it's 4x month with no weekends on average. Otherwise I love this job! I love the flexibility the different days, (some days there are meetings, others, not) sometimes I will go on a 48hr follow up with my social worker and I love her because we get things done for people. I love the fact I can go in and fix a problem and leave! It really is the best job, so I get there's always going to be something you don't like about work, but when I'm in the midst of it my anxiety level rises and I write pages of nonsense! (I get how nuts this looks writing it out)
So I appreciate any/all feedback. Maybe just to commiserate!
Not sure there's an answer for this as all of my co-workers voice the same complaint. But how do you stay "on" for on-call without letting it consume your nerves? I love my job, the first time I can say that in nursing and I'll be here a year in June. I love my co-workers they are awesome. The only thing I don't like about my job is the on-call.
Right now I have the weekend which for us is Sat 8am to Mon 8am. There's a 12 hour nurse with me til 9p. We have an IPU that takes calls until 7am starting at 7pm and if there's an emergency I would need to go out. Because we are slow tonight, the 12 hour nurse has the phones, but quite often I would be triaging calls from 4p to 7p from answering service.
I had to go out earlier today with a foley not draining and it was no big deal. The pt was wearing briefs AND long pj bottoms so it was all twisted and an easy fix. But I guess I hate that unknown and not knowing what crisis it could be and other nurses voice the same.
We are blessed as we only have on call weekends approx every 6 weeks. However if you don't have a weekend that month you are generally scheduled for more overnights (for us that's 430pm to 8am) however we do have an evening nurse that works from 9p to 7am and for the most part we never go out after 9p as she catches it all for us. We do frequently have admissions though after work if we are on call or tuck ins, which can go until 10pm, so it's exhausting.
I just can't relax when I'm "on" I'm always on high alert, can't sleep etc... because you just never know I would rather have an assigned shift than this. I've gotten better for it not darkening my mood totally but I do find that I will sometimes be thinking about it the week before, dreading it's upcoming which is nuts because then I'm losing piece of mind on 2 weekends! Writing it out makes it sound nuts!
So how do you relax and just let what happens happen? I usually am v good about trusting God and his plan and any time I've been called out, it really does have his plan and purpose imprinted on the experience but I still don't like "not knowing" haha.
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