ckalston

Hi, Couple of questions. First I am wanting to find out what a other facilities are doing in terms of nurse:patient ratios on their Acute Rehab units and their Med-Surg units. Second: What type of nursing models are most commonly being used: Primary nursing, Charge Nurse, Charge Nurse taking patients. If your charge nurse takes patients how many do they take. thanks

I had several reasons that made me chose nursing. First I wanted something that within 2 years I could make a difference in my salary, get into a field where there would always be work and to be able to help people. After 7 years with my ADN, I pursued first my BSN and then my MSN/MBA because I realized that I wanted to make a difference in healthcare. Now in management, still with a long way to go to get into a position in which I can make a true difference. I am one male that believes in equal pay for equal work so I don't think I should make more money just because I am male.

I recently became nurse manager of a med-surg unit that uses the primary nursing with a so called charge nurse. I say so-called because 21 patients will often have 3 nurses even with the charge taking patients which is simply not acceptable. We are in the process of returning to the charge nurse model but we are also trying to hire into our matrix which focuses on our ulitmate goal of 1:4 or 1:5 nurse:patient ratio. The important piece is that the charge nurse be effective at the position and not just a person behind the desk. A good charge nurse will make the difference even if the primary nurse has to have more than 5 patients because they can help all the nurses. When they have their own workload, then they cannot take care of their own patients much less help with others.

I have been in nursing for 11 years, married and have two grown kids. Never have been gay, don't need to be gay (not that I am against those who are). I have to say that I may be dense, but most of the guys I know in nursing are very much into their wifes and families and are not gay.

I was 28 when I got my ADN, 35 when I got my BSN and will be 43 when I complete my MSN/MBA :)

I live in the Hill Country (Kerrville). I use to live by Beaumont, then lived in West Texas (near Abilene) and I would have to say the Kerrville area is about the nicest area around. It does get hot, but we also have cool evenings, beautiful sunsets and sunrises and nice people. I like the location because we are about 3 hours (maybe a little further) from the coast, about 45 minutes from Fiesta Texas (Six Flags), an hour from Sea World and of course the 9th largest city in the Nation.

I am working on getting something like that in our computer. We are paperless in terms of charting and most of our charting is canned text (of course we can type patient notes). Right now our choices for airway include: Extubated, Never intubated, extubated within 3 minutes of arrival to PACU. It would be a simple matter of adding the LMA removed intact to the choices, but unfortunately the person that did that for us has left the position. We (managers) start our training in 2 weeks to learn how to update the choices which will be a good thing. Thanks for your comments, Cliff

We are having a discussion about how to properly document a patient who had their airway managed by the LMA vs. the ET tube. Half the group feels that regardless of the LMA or ET tube, the airway was intubated and as such the documentation should reflect that the patient was extubated. Others feel that since the LMA is not the typical intubation (not in the trachea) then the patient was never intubated. I can see both sides, however I am leaning more to the fact that this was an advanced airway management, patient is still at risk (although less) for a spasm or airway complications and as such should be documented as extubated if we receive the patient without an airway in place. Of course patient's who never received any type of airway management (spinals, MAC) should be documentated as never intubated. Any input on this topic??

We recently started labeling our IV pumps and other equipment used by the nursing units with large pieces of paper tied to a rubber band indicating that the equipment has been disinfected and ready to use. While the idea is sound, to take the time and label every piece of equipment used by the floors with a rubber band and paper is time consuming. I am interested in how other SCS departments label their floor use items. I am looking at seeing if there is a break away label that leaves no residue but can be placed over the cassette door or over the on off switch on equipment that has not been used. That way when the label has been removed it would indicate that the equipment has been use. Any suggestions or thoughts??? Thanks, Cliff

Our hospital has been utilizing computer charting for the past 3 years in the OR, PACU, Nursing units and now in the ER. In the PACU and OR setting, we utilize MSM documentation while the remainder of the hospital utilizes Meditech. After the short adjustment period of getting use to doing things a new way, the computer charting is much easier, consumes less time and allows for more accurate, easier to read charting. In many cases, I have been told the OR spends less time charting then previously because with computer charting it's more of hitting look ups to find out what you want to enter. It is recommended, and we do have, a full time person dedicated to taking care of creating tables, updates and so forth for the program. My recommendation and something that our hospital is working on, is to try and utilize the same program hospital wide. When we started the computer charting Meditech did not have the means to meet our needs in terms of the OR/PACU so they went with MSM. I understand now that Meditech has caught up to where we are and as such we may be switching in the next year or so. MSM is nice because you put in the type of surgery being done and it brings in all "the card information" for whatever equipment is needed for that surgery and surgeon wants. This is created by the user so a great tool of creating what you need for your specific hospital. I was anti-computer when it was first suggested at this hospital. Now I don't know what I did before it came. Hope that helps some. Cliff :)

I have no problem when I see ICU nurse sitting outside patient's rooms doing whatever. My problem only occurs when I (as the house supervisor and on call recovery nurse) ask the 3 nurses sitting behind the nurses station playing games on the computer, reading bridal magazines, talking on the phone, if one of them would be able to take a recovery patient coming out. The ICU census is down, the patients in ICU are mostly boarders (rest of hospital is full) and the patients they have are walkie talkies. I don't like being told, we can't we are to busy, when I know better. If you tell me your busy, be busy. Otherwise, I think we need to stop this we are better than anyone else in the hospital and regardless if the patient is walkie, talkie, we won't do any more, when the nurses on the floors are taking care of 6 patients a piece and most of them sicker than the ones being boarded.

We had an incident where the patient was on the OR table and the MD happen to look at the CXR report which said patient had pneumonia. This was a patient that had been preoped as an outpatient, results had been called and faxed to the office, on admission to the hospital, the result was given to the Anesthesia person, and when the patient is on the table the Surgeon goes, we have to cancel this patient has pneumonia. Then they try and blame the nurses. We document every step we take when we get a bad result back. We document who we talk to, when we talk to them, where we faxed the results to and so on. When the surgeon tried to blame the preop nurse, she was able to say I talked to such and such at such and such time, and faxed the results to such and such number as requested by the office staff.

I had one instance when doing sedation for a patient that the MD asked me to help the tech with something. Ordinarily I don't mind doing things like that, but at that moment I was pushing drugs, montioring respirations and documenting my vital signs. I told the MD I would in a minute and he hollered at me and said maybe you should grow a 3rd hand since you can't use the two you have. I told him if I grew a 3rd hand it would probably be to punch him out for talking to me like that. Another nurse said a surgeon called her stupid during a case. She was the scrub nurse and when the surgeon asked for an instrument after calling her stupid she just stared at him. He asked why she wasn't giving him his instrument. She said, I don't know, I must be stupid.

We have a RNFA in our facility with one more completing their education shortly. I think the problem they are having is with reimbursement. In other words who pays. The hospital feels that the nurse chose to get their RNFA on their own and should not have to pay extra for the services. The doctor's certainly don't want the funds coming out of their money. They are starting to work out something, but that has been the headache here in my small part of Texas.

I agree with you kyti. Very good point.

I hear you Janet. It is hard to understand where one is coming from unless we walk in their shoes. We also cover all surgeons that are on call, so regardless of when your on call, someone will be doing surgery. We also have to cover for simple things such as endoscopy, so even for short cases we go in. I also know where your coming from about pay issues. I am in the same situation (almost) as you. I have worked at this hospital for 8 years, make more here then I could get starting somewhere else. My insurance covers my heart condition and other ailments including my family, and if I were to change, I would have no coverage. Sometimes I think a job gets you where they want you and know you really have no choice but to do what they say.

Thank you Dave, I was reading some of the criteria for admission to CRNA school and it reports that a minimum of one year acute care experience is require (it is up to the program what they call acute care).

Hi Janet, We are just now getting to par with enough staff to lighten the overall call. Prior to now, we had 3 nurses to take call for recovery room. That was over 10 days a month of call at time. Getting the overtime just was unavoidable. Those same 3 call nurses were the nurses responsible for working in the recovery room, so it was not unusual to come in on a call at 0200, go home at 0400 be back at 0630 for another 12 hour day. Now we do have 6 people rotating call so only 5 days a month. The problem is getting those who did not experience the 10 days of call to understand how good they have it now. I have never heard people gripe about taking call as much as I do now and they only take 4 or 5 days month. It seems you just can't please everyone (sometimes noone).

Thank you Janet. I had not really looked at this as a risk managment issue, but can see that your correct. I will look into things from this angle.

Hi, I would like to know the thoughts of the room on a RN with multiple years of PACU experience as opposed to ICU experience. Do you know if this experience is considered good enough to apply for a CRNA school.

During the day we have a Pyxis in the same area that we recover patients. We also have nurses working with us so if we can't leave the side of the patient, someone else will get us the medication. However, the Pyxis is within view of all the patient beds. This problem is only after hours. The problem with getting it changed, the boss changed it without talking to us, but now won't listen to us as a group about what we would like to see happen.

I actually had limited experience in my first rotation through the PACU. I worked 2 years of Med-Surg, then 1 year of Special Procedures and then in PACU. I worked in PACU for about 2 years and then returned to the floor. I now have returned to PACU as the Nurse Manager. We don't have actual test here for people to take. We do have a ASPAN Competency Manual that we follow and each nurse has to be checked off in the different areas of PACU nursing. Prior to myself coming down, the nurses hired had little experience even in a hospital setting (which I disagree with). In fact, two of the most recent hires can from Home Health and Rehab and had not Perioperative experience whatsoever. I am a strong believer that a nurse must have a strong Med Surg background at the very least. Critical care skills are a strong criteria, but not always absolutely necessary because one thing I have learned about ICU nurses, many of them are set in their ways and not really open to changing the way of delivering nursing care. In PACU we have usually one or two hours to deliver our care, wake them up, keep them stable and send them to the floor. ICU nurses tend to take a longer period of time in recovering patients because they are use to that length of time. I would be interested in your study.

Thanks for the response. I totally agree with not being left alone with recovery patients, and the argument that has been given to us is the fact that the ICU nurses "are available" as needed. As you may know, being available is not always the same as actually been there when needed. I don't like having to depend on maybe's when I am taking care of my patient. In other words, "Maybe someone can bring me more medication if needed", or "Maybe someone will come down and check on me if I call for help." I like to have what I need at bedside, and to me that means having a recovery pouch with an assortment of the most commonly used medications (MS, Demerol, Phenergan, Versed) and in a large enough amount not to run out in the middle of the recovery.

We also have the Pyxis system. Prior to the new arrangement, we had recovery pouches inside the Pyxis. We would take the pouch out, use the medications (documenting on paper), have the drug waste witnessed by the nurse accepting the patient on the floor, and then we would put the tie back onto the kit and return it. Only required one nurse getting it out and putting it back and the floor nurse could witness the waste on arrival. But now it's a mess.