It appears that there will be some big changes coming for the staff in our PICU, and I suspect they're not going to be good ones. We're having a real problem with staffing and I think it will only get worse if what my gut tells me is going to happen. If my allnurses.com PICU peers could help me gather some information about how other units function, it would be of enormous help. How about it? Please answer the following:
1: What level of care does your unit provide? (Do you have a cardiac surgery program? Do you have an ECLS/CRRT program? Do you have a transport team? Transplants? Neurosurgery? Complex ENT? Trauma?)
2: How many beds do you have? What is your usual nurse to patient ratio?
3: Does your unit employ ancillary staff such as CNAs or patient care techs to assist with hands-on care or is the nurse responsible for total care of the patient(s)?
4: How do you manage breaks in your unit?
5: How is continuing education provided in your unit?
6: Does your unit hire new grads? What kind of orientation program are they given?
7: How difficult is it to transfer patients out to other levels of care when they're ready? Do you ever discharge patients home from your PICU?
8: What is your turnover like?
I know I'm asking a lot of questions, but this information will be of great help to me when I meet with management and administration in a few weeks. And the more information I have, the better my position will be if forced to advocate for my coworkers. I'll thank you all in advance.
Specializes in NICU, PICU, PCVICU and peds oncology.
You'd think so, wouldn't you? But that seems not to matter nearly as much as making the parents happy. The kid I mentioned who has been intubated each of the 364 days on earth went outside for the first time ever on the weekend and guess what... is now septic. The transport nurse who made the trip says everyone should have the chance to see the sky before they die...
Yes, every kid should have the chance to see the sky before they die. They should also have the chance to catch a ball, swim in a pool, go to school, ride a horse, and many other things. Sad hard fact is that sometimes that is just not possible because they are too unstable! I understand what your docs are trying to do, I just worry for the RN who actually has to make that road trip- I mean, My God, there are kids I don't want to take to CT, yet alone the ambulance bay to watch to cars go by! Hey, why don't your docs accompany these kiddos to their social events? That has to be a big strain on the unit staffing wise!
Specializes in NICU, PICU, PCVICU and peds oncology.
It's a huge strain staffing-wise. There has to be an RN and an RT at the very least for each of these trips, and a nursing attendant to help push the equipment. For some kids, it's a parade of five staff, the bed, the vent, the IV tree and the parents. I wonder what our regulatory body (or a judge!) would say if something happened to the kid while on one of these trips.
One long weekend last summer when the unit was super short-staffed, our manager came in to take a kid out for a walk. She didn't come to cover the breaks nobody was getting, or to take charge so the charge nurse could take a patient. We filed a complaint about it with our union, but really got nowhere.
Specializes in NICU, PICU, PCVICU and peds oncology.
So get this! All three of the patients who went sightseeing last Saturday are now critically ill again. One of them they were able to wean down to 0.12 of norepi by giving him three litres of fluid, another clotted his hemocath and is still needing major inotropes, and the third ended up in the OR last night for a laparotomy. Does our dear MD see the pattern? Of course not.
Specializes in NICU, PICU, PCVICU and peds oncology.
Our nurse manager is so far out in left field checking out the dandelions that she doesn't even know enough to do the assignment. Our nursing director thinks we're all a bunch of whiners and need more to do. The hospital CNO is a figurehead. Last summer, when we had a different patient care manager, she actually was on rounds when our MD suggested taking a kid with an open abdomen outside and she spent quite some time arranging for it to happen. So to make a short story very long... NO. The turnover in our management is almost as great as it is in bedside staff, and they can't keep anyone in the job. None of us has had a performance evaluation in 2 1/2 years. And we've got new staff who are maybe marginally competent being shuffled through orientation because they will be one more name on the assignment sheet. It's getting harder and harder to get out of bed and go to work.
I don't know how you stand it. As a group of nurses can you not stand together and refuse at LEAST to go on outside excursions? If they are sick enough for PICU, they need to wait. I'd argue that if you are bothering to treat them they deserve the best chance possible. And if you are bothering to treat them presumabley someone in charge thinks they may have more stable days ahead when it would be reasonable to take them out. If they are on palliative care then sure....but let's hope they aren't in PICU if that is the case.
Specializes in NICU, PICU, PCVICU and peds oncology.
Canoehead, I can't even get them to agree to sign professional responsibility forms when we're so short-staffed no one pees for 12 hours except the patients. There's a climate of fear (of management and administration) in our unit that you'd have to see to believe, and as a result there is very little team spirit. Everyone looks out for their own interests. Those who do look out for others, like myself and a few others... all older and very experienced nurses, are the ones who keep the unit safe (all things being relative). We have a very high staff turnover rate, as I've already discussed, but at the same time we have a huge number of nurses who have never worked anywhere else and don't know that a lot of the things that are forced on us are not normal. And for every new hire we get that has at least some nursing experience (not even ICU experience, but nursing in general) we get 10 who are fresh out of university. I've had people come to me six months after they've finished their orientation telling me they have to put a foley in their patinet and they've never done it on a person before. And they're working in a quaternary care PICU. They're not likely to foresee all the potential disasters awaiting when you take a chronically critical kid out for a walk because they can't even foresee the effect of taking too long to change out your epi syringe. I've worked on this unit for 6 years as of September 9. There are times when I walk into our report room before a shift and I've got more time on the unit than every single other person in the room combined.
Our standards used to be very high. But lately they've been allowed to slip. Patients aren't being turned or bathed, they aren't receiving oral, eye or foley care, they may be found lying in stool (Oh, when did he do that?), dressings are being left on for days, the list is endless. We've recently seen an upswing in unplanned extubations, dislodged NG/NJ tubes, self-d/c'd foleys and chest tubes, central lines and left atrial lines that "fall" out, pressure related injuries in places that shouldn't have them (heels being a big one lately), interstitial IVs left running for hours (one had 3% in it and the kid has a Stage 3 extravasation injury) and on and on. I'm getting tired of filing incident reports. Usually the blame is placed on staffing.
I found out on Wednesday that the purpose for the meeting that provoked this thread in the first place is not what I was expecting. There are big changes coming to the way we do our scheduling and there will be some very annoyed people. The changes have all been scrutinized by our union and found to be contractually compliant (very important in Canadian hospitals) and very good for the unit, but they will result in some people having to work nights, weekends and holidays where they've managed to schedule themselves not to for years. There will be a more balanced number of staff on each shift and our OT should finally subside a bit. Right now there are shifts where we might have 9 scheduled (baseline is 18) and others where we have 24. I expect there will be a mass resignation shortly after the meeting. I might even make an Amazing Karnak list of the people how will be on the train, just for laughs.
I want to thank all of you for your input and support. I still want to try and bring this unit back to what it was when I started here and you're helping me do that.
Specializes in NICU, PICU, PCVICU and peds oncology.
Oh, I also meant to say something about palliative care. We are often forced to admit kids who are DNR. The physicians believe that if the kid is admitted to PICU, then the question of resuscitation won't arise... they'll already be electively intubated and on pressors before they reach coding territory. For example, we have two little girls who have spinal muscular atrophy, both of whom have greatly exceeded the average life expectancy of such a diagnosis. They both are admitted to PICU for BiPAP when they start having respiratory issues. They then progress to hypotension and we start them on dop. When their gases start looking a little crappy, they are electively intubated, where they remain for weeks because they don't have the respiratory muscle strangth to overcome the atmosphere. Then they go back on BiPAP for several weeks until they finally graduate to CPAP and can go to the respiratory ward. Another little girl has Bowen Conradi syndrome (PM me for more info), which is a highly lethal congenital disorder found almost exclusively in Hutterite populations. Death is usually within the first months of life. The last time she was admitted with respiratory distress, she was already a year old. Her family has agreed to DNR, but she still comes in occasionally for BiPAP. Something she absolutely hates! I always look after her because I have more knowledge of BWCNS than the average person - my daughter is a genteicist and her best friend has done the gene mapping for it, so her parents ask for me. Each time she comes in I pray she decides she's done.
There are a number of other seriously compromised kids who have outlived their expected lifespan who come in routinely for several weeks. We do everything but compressions and send them on their way again eventually.
JanI work in a city hopsital free standing children's hospital. We have ECMO, CRRT, oscillators, neuro, transport team. The cardiac kids go to the cardiac icu. OUr pt ratios are 2:1 or 1:1, ECMO or CRRT usually is 1:2. We have 32 bed capacity, typically 18-24 pts. We relieve each other for breaks, and unless your pt wa very busy and you desparately need a break we do not leave anything to be done. We also typically sedate beofre our break. It isn't always that difficult because you really are just watching and making sure the pt is safe while your coworker is gone and vice versa. We do have techs, but the mainly stock and help us with transporting pts to CT, MRI, or to the floor. We don't typically dc home unless they are a cronic or a vent/trach type pt. We do have computerized inservices for ceu and updating our annual check offs. I was a new grad, the orentation was six months long and very intense. OUr docs are always on. there is overnight a resident, fellow and attending, although the attending sometimes goes to sleep and let the fellow run the show (depending on year of experience). Our night shift group is very good about team work and we all tr to help each other out. We do have a fairly moderate turnover rates.Hopefully this is helpful.
Specializes in NICU, PICU, PCVICU and peds oncology.
RNNPICU, thanks for your input. The computer learning packages I was referring to aren't for CEUs or annual recerts, they're things like learning to use the Smart Pumps, learning about the changes to our cytotoxics policy, our disclosure-of-adverse-events policy and wound care practices, patient safety issues and so on. Things that our educator should actually be educating us on. But she doesn't have time, she's too busy orienting new staff.
I have about a week to pull together everything shared here before our big meeting. I've just sent out a notification to our staff that they really need to be at this meeting in big numbers and (totally unprecedented!!) the hospital will pay straight time for attendance. I talked to our PCM this morning before I came home to sleep and told her quite bluntly that if she expects people to come in from home for a meeting, the agenda for which I'm not allowed to discuss, out of the goodness of their hearts, then there will be just her, the CNO and me in the room. Then I discovered just a little while ago that although she asked me to set up this meting and communicate it to the staff, she's changed the time and the place without telling me. I think this meeting might be make or break for me. I can't imagine not working in peds critical care, but this unit is killing me.
Oh Jan, I feel for you! I wish you the best of luck in your meeting, and hope you can all pull together and get some changes in place. I hate to hear that you are so unhappy on your unit, but it sounds like a very challenging place to work.
NotReady4PrimeTime, RN
5 Articles; 7,358 Posts
You'd think so, wouldn't you? But that seems not to matter nearly as much as making the parents happy. The kid I mentioned who has been intubated each of the 364 days on earth went outside for the first time ever on the weekend and guess what... is now septic. The transport nurse who made the trip says everyone should have the chance to see the sky before they die...