Nurse at LTACH, need help if it's different than the ICU

[Beautiful_Beginnings, ASN, RN]

My background:

after nurse graduation I worked night shift on a tele floor. Our floor was the Covid floor when everything hit. I stayed for 9months, had a house fire. I had to leave the floor to take care of my husband. I did home health for a 1. Now I'm wanted to go back into the hospital. The ltach had a very high pay. It was called a critical illness recovery and you can earn a CCRN. I thought it was the ICU. It was not. CCRN stood for  critical care recovery certification. I wanted to go into the ICU because my brain works with in depth thinking. I need more in-depth information on my patient. I love a thorough history. I work well with concentrating deeply and assessing on a few then spread out to a ton. I love to learn.

As a LTACH nurse, ratio 1-5. All the patients have tons of tasks like wound care on all, mobility x2( out of bed), q2hour turns(important I know/ with 5 it's tough), review every patients food Breakfast, Lunch. Dinner on 5) , bath and mouth care, incontinence for all 5. findings a vital machine to get vitals for  5 patients, all my patients have TONS of medication. Some patient have TF and on vents, some are awake and talking asking for items, some patients are on vents and need more nursing assessment and management, the charting is ALOT per patients. I truly can't give my sicker patientz meds and report changed if seen. Some patients are on drips and need blood. It's just ALOt, while others need to go to MRI or surgery, labs need to be walked down. Meds are due all day long with 5. 

Honestly, I feel like this is soo much. My time management is a lot slower. I feel like I honestly can't assess my patients because I am split between 5 patients.

Personal I  have been thinking just to stop pursuing hospital nursing all together ir the profession if I'm severely not being the best and growing in this dynamic. It's so busy most shifts I don't drink water, pee, or eat lunch. We have the computer WOW. We sit in the hall instead of at a desk.

We have providers on our floor. I can ask questions and give updates, request new orders but mostly they do not want to be bothered. ( I don't mind this much). I still do what's best for the patients 

Does it get better anywhere? At one time I thought of going into the ICU. I wanted to really dig into my patients medical history, and assess and use my nursing skills, observe changes and treat. 

Like I said it seems many nurses excel. I'm trying to get faster. I hate having to many patients. 

I just would love to hear any input anyone has.

[Nurse Beth, MSN]

The terms are confusing because CCRN is a registered trademark and certification by the American Association of Critical-Care Nurses (AACN), not a "critical care recovery certificate."

While you may earn a certificate, it is not the same as certification.

Have you thought about step-down units or progressive care units in acute care? The nurse-patient ratios vary from 1:3 to 1:4, which is more manageable.

From there, you could transition to ICU, with a 1:2 nurse-patient ratio. 

 

[Been there,done that, ASN, RN]

Time to move on. Your unit sounds like he... double hockey sticks. Start applying  for ICU positions.

 Best wishes.

[marienm, RN, CCRN]

Yeah, this sounds awful. Those are all the tasks I do in the ICU with a 1:2 or 1:3 ratio.  The main difference (I think) between what you're describing and an ICU is that the LTACH patients are probably "stable-ly sick" and ICU patients aren't.  Mr. Smith in the LTACH might be chronically anemic and get blood 2x a week, but Mr. Jones in the ICU might be a new admit with low H&H for unknown reasons...gotta go to CT scan, maybe the OR, send repeat labs, give blood, go back to CT scan, place an NG tube, intubate, do a colonoscopy, etc... Some shifts in the ICU none of those things happen, and sometimes they all happen!  I think you should look for ICU positions and try to shadow at any place that offers it.  My own preference would be for a teaching hospital; the ICUs in smaller hospitals tend to send their sicker patients out for a higher level of care.  Of course, consider the compensation package at all places--some teaching hospitals don't pay well because of the prestige of working there.  You'll have to decide what you can work with in that regard.

[londonflo]

Is this a Kindred Hospital or the like?

[JBMmom, MSN, NP]

That sounds like a TOUGH place to work! Those ratios with sick patients sound unacceptable and certainly would not allow you to focus the time you need for the patients or your own learning. I would also recommend if you're interested in ICU you should apply. I think with a 1:2 ratio you will be much happier. You have familiarity with many aspects of critical care including vents, trachs, wounds, etc. The one area you probably don't have is the titrating medications like pressors and inotropes. 

I would caution with respect to the recommendation that you find a teaching hospital, you should ask the nurses during an interview what level of autonomy they have in the facility. Coming from a non-teaching community hospital ICU where we did ship out a lot of critically ill patients, we also took care of many others. I am now working with the nurses in the teaching facility and find that their practice is often limited because "the residents need to learn". Nurses do not put in OG or NG tubes. Nurses cannot choose to make a patient NPO, they cannot check a blood sugar level, they can't even bladder scan without a provider order. My understanding is that the reasoning is that these things would suggest a change in condition and the provider should be notified to assess the situation. In reality it's a pain for the nurses that are trying to track down residents and interns that aren't always timely in their responses. In my small ICU we had a very large amount of autonomy, especially on night shift, (sometimes skirting the scope of practice in critical situations), but we've developed close relationships with the providers that trust us to do what needs to be done for the patient. It can be a great learning environment. 

Good luck to you!

[marienm, RN, CCRN]

Fair point @JBMmom there can be a lot of variation in facilities!  Our residents do not place NG/NJ/OG tubes in the ICU, but I should make clear that our nurses don't actually intubate or do colonoscopies...we prep the patient,  push meds, & monitor the patient.  I can't think of anything nurses *could* be doing but are told we need to save for the residents.  We do need orders for pretty much all treatments but we have protocols for certain situations like stroke symptoms we can check a blood sugar, or make someone with new dysphagia or vomiting NPO.  Both of those are changes in condition that our providers should be made aware of anyway, but I also work nights and sometimes we do things first and then update them.

[londonflo]

marienm, RN, CCRN said:

we have protocols for certain situations like stroke symptoms we can check a blood sugar, or make someone with new dysphagia or vomiting NPO. 

On a general med-surgical floor these are normal nursing interventions that do not require an MD order. 

[Alex_RN, BSN]

Sounds exactly like my first job at a Kindred LTAC.  

[Beautiful_Beginnings, ASN, RN]

Thank you all  for your great insight. It looks like I can't answer individually. However, everyone's response was a blessing. Thanks guys!