New Process Admitting Couplets... HELP!!!

[puddles11]

Hi everyone!! I need some advice, some ideas, some help, and some thoughts!!!

I work in a high volume hospital as it pertains to people giving birth. (Nearly 4000 a year)

We have an L&D unit with their own nurses, NICU with their own, and then the postpartum unit where we are trained to care for babies and mothers. Initially when I Started years ago the babies were brought to the nursery and admitted there, and the mothers were admitted on the floor then the babies brought to the mothers when they were all finished. Now of course we have been doing admissions in the room so we are a non separation hospital. Fine, we made it through that transition tho it was difficult..change always is,. So there would be three nurses assigned to the nursery (they would do admissions on the babies in the room, circs, take care of the withdrawal babies once moms were discharged and assess any babies that were in the nursery overnight before bringing them to moms room in the morning). On the floor we each have 6 couplets. When an admission came to the room one nursery nurse would come out to the room for the baby and the floor RN would admit the mom then the baby nurse would give report to the floor rn who then assumed care for the couplet. This has been working very well for us ... Heres the problem... according to guidelines we should only have 4 couplets each. So to combat this, our nurse manager has decided that there will only be 1 nurse in the nursery (withdrawal babies circs, etc) along with the charge nurse (who is COUNTED in the numbers but does not do actual care of any pt... maybe an occasionial circ) then have 3 nurses on each side (we have a south and north side and then each with 12 rooms and then on the floor below we have the south side with 12 rooms to hold NICU moms... which of course always ends up holding couplets as well). ANYWAY .... they want to have 3 nurses on each side with 4 couplets at the most. However, when you have 3 couplets and an admission comes you are now responsible to admit the baby AND the mother at the same time. We have been piloting it for a couple of weeks and everyone is unhappy and it has been an awful time to come into work everyday. The issue is the baby. the mom admission is really quick comparatively.. The baby is what takes time.. say about an hour and a half from start to finish... bath , measurements, assessment footprints..etc. And THEN if the baby need d sticks, or is not essentially a 'well' newborn but not unwell enough to goto NICU, then that more time. So everyone is unhappy... we feel it is unsafe, and that our other patients are being ignored, and with hourly rounding.. its impossible.. (ALSO , it happens very frequently that there will be 2 admissions brought at the same time if not more .. so a lot of the times 2 of the 3 floor nurses are in rooms and leaving the 1 nurse to care for the others on the floor, and we are NOT allowed to ask L&D to hold onto anyone for any amount of time). We have been discussing and searching high and low to try to come to some kind of compromise that will make the flow smoother, and above all else safer. any suggestions?

What is everyone else doing? And if this is how everyone IS doing it... are we just being babies because its just another change that we don't like??

(Personally I feel that my license is at risk because I have to admit 2 patients at the same exact time while I have 3 other couplets under my care) .. and BTW, they are calling mom's transfers...not admissions because they are technically 'admitted' to L&D and just being transferred to us.,.. but she is still a full admit for us... so?

THANK YOU FOR ANY SUGGESTIONS!!!!!!!!!!!

J

[klone, MSN, RN]

Why doesn't the nursery/transition nurse admit the baby, and then transfer care to the m/b nurse afterwards, when mom and baby are both stable and baby is done with all admission stuff?

BTW, 6 couplets is INSANE. 4 couplets is crazy, but doable, but not ideal.

And why are you admitting mom twice? I agree that she's a transfer, not an admission. I suggest that you are probably charting way more than you need to, if you're treating her as an admission.

[klone, MSN, RN]

BTW, the research indicates that delayed bathing is best. It would be ideal to postpone that first bath until several hours later. So that might be one option - the couplet nurse can admit the mom, give meds to baby, and then the NEXT shift can do all the other baby stuff (bath, prints, etc).

[puddles11]

So, we do give the mothers the option to delay the bath . Some do it some dont and according to our nurse manager, once that baby is on the floor it is the floor nurse responsibilty. And their big motto around here is that delaying baby care that is routine such as prints, measurements, etc is not to be held over for next shift... bath only but like I said the floor nurse who has that couplet then has to bathe the baby. (We are trying to advocate for CNA's to be able to bathe the babies... so we will see)

Yesterday we tried having an admit nurse who did all the baby admits (or at least the first set of vitals, measurements and assessment ) then hand off to the floor nurse, however that RN had 6 admissions in her first 8 hrs of her shift and it was very overwhelming to do admissions sometimes back to back and even at the same time.. it was not safe for the baby.

And as far as the mother being a transfer, I agree and we don't do the whole full admission but when the nurses starting saying we are admitting to patients at the same exact time and it becomes a safety issue among others things, the nurse manager said no.. the mother is a transfer .. so that was just a point of how the language is being used to push for this new model.

As far as charting, I personally think it is insane the way they do it here. We have 12 hour shift (altho we do have some that are 8 hours) and we have to chart 2 times on every mother and 2 times on every baby. once at 7 and once at 3. And with the addition of all the charting invovled with a newly admitted baby it adds more onto the floor nurse (also we are responsibl for blood work that all babies need at 25 hours of life (PKU).

sorry, i am not disputing your suggestions, just trying to let everyone see what craziness we are working with!

The way we had it before (which I don't even rememeber if I mentioned in the last post) was 3 nurses in the nursery. Once was charge, one took care of circs, and drug withdrawal babies, and also did every other admission while the other nurse did admissions and took care of the withdrawal babies when their primary nurse was in an admission. Then on the floor we each had 6 couplets (if we had a full house which is pretty much the norm, once one left, another arrived) They want us to have 4 couplets which is what it is according to guidelines and put 3 nurses on each side of the floor, and by pulling the nursery nurses they want to accompolish that. However most of the staff wants 4 couplets, and the nurses in the nursery as it was to continue to admit the babies, and they just won't do it. During the day they say they don't want any nurses in the nursery at all (except for the nurse taking care of the withdrawal babies.. which we ALWAYS have) .

its just an awful situation , and people that have been here for years are seriously looking to transfer to other departments, and its a shame.

Maybe there just is NO easy way to do it?

[ashleyisawesome, BSN, RN]

This is what we do. I will preface this with the fact that *most* of the nurses on my unit are trained in Labor, PP, and nursery. There are a few that only do labor or only do PP/nursery, but mostly older nurses that started when we used to be separate. Everyone is capable of doing a newborn admission assessment.

After delivery, as the labor nurse I recover mom and monitor baby for about two hours and help with the first breastfeeding. Once that two hours is up (or close to it) I do the baby's admission assessment (including weight, foot prints, eyes and thighs--usually takes about 20-40 mins) in the labor room while mom eats. The nursery nurse (we only have one at a time, they are also responsible for circs, monitoring babies that need to be in the nursery, boarder babies, etc) verifies all the orders for me. If mom is unstable or I have a lot going on I can call the nursery nurse to do the assessment for me--she comes to the labor room to do it. If nursery nurse leaves the nursery she has a couplet nurse sit in the nursery to watch any babies that might be in there. Then I transfer mom and baby to PP and the couplet nurse and I get mom settled, couplet nurse does an assessment on mom, and I go out in the hall and give report on mom and baby. Baths are done 12 hours after delivery (recent change, due to EBP showing it helps with temp regulation and breastfeeding) by either the couplet nurse, the nursery nurse, or a PP aide. The mom's admission to PP is pretty much an assessment and putting in a new care plan/education. All of her information is put in the computer when admitted to labor, so PP's admission is very quick.

This is fairly new to us. When I first started we used to send the baby to the nursery 2 hours after delivery and the nursery nurse would do the admission in there and send the baby out to PP when she was done. It took a while for everyone to get used to the new way of doing things, but I think it's doable and I have seen an improvement in breastfeeding since implementing some of these practices.

[LibraSunCNM, BSN, MSN, CNM]

It sounds like the problem is that you are quite understaffed. I worked as a mother/baby nurse at a large teaching hospital that did about 4000-5000 births/year. The system worked as follows: each shift there was one charge nurse who took no patients, but stayed in the nursery and managed the flow of admissions and discharges, did the occasional circ (we had one lone LPN left in our whole hospital who worked in the nursery and basically her only job was circs), and took care of any boarder babies.

There was one admit nurse per shift who was responsible for the admission assessment, measurements, bath, and the (extensive) admission charting for the baby, as well as little things like making the bassinet card and putting the security tag on the baby. She would do this in the labor room, in the recovery area, or in the postpartum room, depending on the flow of the day and what was more convenient for her and the patient. Occasionally moms would actually request the baby be taken to the nursery to be admitted, and we would accommodate this. The bath could be delegated to the nurse's aide assigned to the nursery (generally we were staffed with one, some days not though). L&D nurses took care of eyes and thighs right after birth. Patients could opt to delay the bath but rarely did. It was not our policy to routinely delay, although I believe they have changed that since I left.

On the floor we had 3-4 couplets per nurse. When a nurse got a new couplet, she assessed mom and got her and baby settled. If the baby was being admitted at the same time in the room, she would just work around the admit nurse (difficult in a tiny big-city, shared hospital room but doable). A nurse was never assigned more than one admission at a time, you would at least get a couple of hours. Six admissions in 8 hours is just absolutely insane! It went by rotation and assignments were made with acuity in mind, rather than just giving a nurse one section of rooms, which is how it is done some places, I know. When we had badly staffed days, we would get 6, and very rarely 7 couplets, but be paired with a nurse's aide who would help with all basic stuff and do the hourly rounding. It sucked but it didn't happen TOO often.

My least favorite job was admit nurse on the day shift, because it was so crazy busy and the births were rarely spaced out anywhere close to evenly, and so you'd often have lots of free time and then later be running around like a chicken with its head cut off. I will say that we never had withdrawing babies, so I can see how you would need extra nurses in the nursery for that.

Keep advocating for more staff! Refer to AWHONN guidelines and see if you can make delaying the bath for 24 hours standard, to try to ease the burden of the admission a bit.

[pinkgrl]

2 years ago, our 18 bed MB unit became Baby Friendly. We used to staff our nursery(1 RN) and have 3 couplets per RN, 1 charge with no pts. Now we have 4 couplets, 1 procedure nurse, 1 charge nurse no pts, 1+ tech & 1 secretary depending on census. The nursery is no longer staffed, MB budget was reduced and LD budget increased to staff 1 Newborn admission nurse (NAN). The newborn admission nurse does Apgars, footprints, bands & hugs, weight, measurements, eyes/thighs, lab i.e. blood cultures, hemtocrit, cord blood, ivs-- with help of nicu for PIV. The baby is placed skin to skin immediately after birth for 1 hour as long as baby is transitioning well. After 1 hour, mom is OOB to bathroom while NAN does the above tasks. LD puts mom in wheelchair and NAN puts baby in bassinet and the couplet is transferred upstairs to MB. I admit the couplet, do focused assessment on mom (Bubblehe) with VS and education, and I get VS on baby and do quick shift assessment on baby. All baths are delayed 6 hrs according to evidence based research except for babies born to mothers with + infectious labs- only these babies get baths immediately (by any available staff- tech, primary rn, procedure rn, charge). Everything is done in pp room including phototherapy, MDT/PKU, CCHD, hearing screen, baths, routine labs (i.e. bilirubin, glucose, CBC) The only time infant leaves the room is if infant codes (rushed to code bed in nursery), circs, if Ped doesn't do bedside exam in room, if mom is in ICU, or DFACS baby. This is where our procedure nurse comes in- she along with the tech (our techs can only do baths, mdt, poct glucose) and charge do baths, MDTs, labs, circs, corificeat exams as necessary. The only time she sits in nursery with a baby, is if we have a border baby--mom is in ICU or DFACS baby. Then the tech and charge step up to help with tasks on the floor. If Mom is on Mag PP (or HELLP, hemmorhage), couplet stays in LD until mom and NAN or Procedure nurse care for the baby until she is no longer on Mag and stable to come to floor. We don't separate the couplet unless absolutely necessary (i.e mom is in ICU or DFACS puts hold on baby). For c-sections the baby & NAN (of course after NICU determines baby goes to well nursery) go to PACU with mom and remain with mom until she comes to MB. If vag deliveries happen while NAN is in PACU then LD Charge relieves NAN in PACU while NAN attends vag delivery. Multiple deliveries at same time? LD RN will do Apgars, VS, bands, place infant skin to skin. Our unit loves the new changes, lots of communication, team work, and cross training. And the few RNs who loved the nursery, transferred to LD to be the NAN. Oh and the NAS babies just need scores, and collection of 1st void & stool which is done in the PP room. Babies receiving meds for NAS go to nicu. Also, if our baby is on amp/gent we admin in the PP room on IV pump.

[puddles11]

I want to thank everyone for their input, and if there are any more ideas please keep them coming!! These comments are being kicked around in our meetings and hopefully will lead to policy change.....

Thanks!!

[puddles11]

Also, I am sorry.. as a side not if you guys are willing to... can you put the name of the hospital that you work at? (those that left replies also)... I am running into legitimacy problems on my end when presenting information to others

thanks!

[klone, MSN, RN]

I PMed you. I am happy to talk to anyone regarding what our unit does for staffing/processes.

[blackribbon]

I am a gynmed/surg nurse cross trained to help cover postpartum. We have about 650 births a month so keep very busy. The mother and baby are admitted in L&D during the 1-2 hour recovery offered before transferring to the postpartum unit. We just do a basic assess transfer assessment of both. SGA, LGA, & 37weekers real frequent monitoring...and so do day zero c-sections. We are also "baby friendly" so the nursery is used on a very limited basis and only for short period so time. It is manned by the charge nurse who doesn't have any patients and she might "babysit" a baby but we are ultimately responsible for our babies in there. The staff nurses have a maximum of 4 couplets...anything higher is considered "critical staffing" levels. Babies needing monitoring are transferred to the NICU observation unit. I find it completely manageable on night shift. I think there is a specialty discharge nurse who comes in during the days to help clear rooms as fast as possible during the day time hours.

[ALIkat99]

In our unit, our model works very well for us. Our labor charge nurse has no patients, but attends each delivery as the "baby nurse". Once baby is born, he/she is dried off on moms abdomen and placed skin to skin with mom. While the labor nurse is taking care of mom (starting pit, removing bands, etc.) the "baby nurse" does as much of admitting baby as she can (initial vitals, apgars, eyes and thighs) while on moms chest. Sometimes baby is brought to warmer if anything needs further investigation. If that's the case, she will go ahead and do the newborn assessing, weigh baby, etc. If baby remains skin to skin with mom, she will stop in during the recovery to complete that step or the labor nurse does it while also taking care of mom's recovery. Our unit bathes the baby at the end of recovery by either a floor tech or the labor nurse. That way, baby is admitted during recovery and by the time we get over to post partum, it's a basic transfer of care assessment and vitals that need done.