afteralltheseyears

Since proper maintenance of PICC lines vary depending upon whether it is an open or closed end catheter, how do you know how to care for it if the patient doesn't know what type of catheter they have and the catheter was placed at another facility? If you don't know wouldn't you heparinize it? If so, isn't that introducing risk to the patient they might not need to be exposed to? Where can I find definitive recommendations for maintaining the various types of PICC lines. All I can really find is the general statement "follow your facilities policy/procedure". That's the problem, we need to establish our facilities policy/procedure. Do you always flush both lines of a double cath PICC when only one is used? What is the practice at your facilities?

At your facilities--do the therapists (PT, OT or ST) give their recommendations to the Dr and the Dr then writes them as orders for the nursing staff or does your nursing staff follow their recommendations directly?

At your facilities--How do the recommendations of Physical,Occupational or Speech Therapy become part of what the nursing staff follows when giving care? Do the therapists give the recommendations to the Dr and the Dr then writes orders for nursing staff to follow or does your nursing staff follow the orders directly from the therapists? Thx

We are interested in implementing some sort of a communication tool that will inform staff of care needs of specific LTC patients. I don't know what to call this tool but I envision it to be like a Kardex. Our care plans have good, pt-specific information in them but because they are lengthy they are not used when giving report so the information in them doesn't get utilized like it should. The communication tool I'm desiring would convey the important stuff from the care plans in a concise format. Has anyone found a communication tool that serves these purposes in your facility? If so, would you please let me know if you'd be willing to fax me an example. thank you

We are a small hospital with limited funds to purchase staff tracking technology (device that turns on a light above the room door so you can see when a staff member is in the room). Anyone have any ways of "flagging" a room so it is easy to see from down the hall when a staff member is in the room? I looked at the mounted metal flag sets that you can flip a colored flag up when a certain staff member (RN, LPN or CNA) is in the room-good idea but for our 24 rooms it would still be several hundred dollars. It would be money well spent as we waste alot of time hunting for staff going room to room but does anyone know of anything else even cheaper than that?

In my CAH right now, I have 18 unskilled, custodial-type patients who reside here (for the state they are categorized as unskilled swing patients but they are basically nursing home pts). In addition we have 4 unskilled swing patients. We are staffed with an LPN (primarily responsible for the 18 unskilled swings and 2 of the skilled swings) 3 CNAs during the day and 2 on at night and an RN/Charge nurse who is caring for the other 2 skilled swing patients and covers the ER (average 1 patient/day). Staffing in our CAH right now figures out to be 4.6 NHPPD for this mixture of unskilled and skilled swing patients. I'd like opinions if this is too few nursing hours? How about if we admit an acute patient-the ones we admit are mostly 24 hour observation patients. Anybody else deal with figuring the appropriate number of NHPPD in a setting where the patient-type is mixed? I'd like to know how you do it? Thanks

I'm shocked at the staffing ratios I hear on here-1 nurse and 4 aides for 60 patients. HMMM, if you do 12 hour shifts that comes to about 1 NHPPD. That sure doesn't come close to the 3.2 NHPPD that I believe I read somewhere was legislated (somewhere)to be the minimum. I think you're right about the piece of paper not being the tool to getting hrly rounding done. I'm DON in a Critical Access hospital where we have 18 residents (they are considered unskilled swing patients, not LTC patients). The 18 are cared for by an LPN and 3 CNAs on days/2 at night. There also is an RN in house 24/7. I'm making some adjustments so the LPNs will now also have to care for 2 skilled swing patients along with their 18 unskilled swingers. One of them said to me today "Don't you understand, I have 18 patients to take care of, I can't possibly take care of two more". They should go do a shift with some of you. I think they might then appreciate the job they have.

Is anyone utilizing the practice of hourly rounding to assess the 4 Ps (position, pain, personal needs and potty) and if so do you have a log up in the room for staff to document it? This practice has been found by research to decrease falls, calllights and improve patient satisfaction. How is it working in your facility?

I am considering starting a CNA training program in my community. Where can I find a good training manual/curriculum? What is the ratio of LPNs to residents at your facilities? Thx

In your nursing homes I'd like to hear how the change of shift routine goes. Specifically: who sits in on report--all oncoming nurses and CNAs hearing the same report from offgoing staff? OR nurses give report to nurses while CNAs report to CNA? If your CNAs give report to each other (without nurses) does anyone have a formal list of items they report? Also, I'd like to know: what are your ratios of CNA to patients? Thank you

We are the only hospital in our state that has been given the designation of CAH with extended swing patients who permanently reside here (in other words-we have 20 nursing home patients in our hospital who are permanent residents). We don't have to do MDS's on them as we are not considered a nursing home. The other 4 beds are reserved for our occasional observation/inpatient admission or skilled swing patient. We also have a 2 bed ER. I agree that often it feels like much of the paperwork we do is simply to please the state but since we have to do it lets do it in a way that will make it more likely it is kept up and done well....and I think the best way to do that is incorporate it in our care. Is anyone able to pull that off at their facility? I'll check with Briggs to see if they have a kardex like I'm thinking of. Thank you

I wanted to add: to whoever said they love Kardexes I say AMEN. I'm an old nurse too and Kardexes were what we used to give report with and I guarantee nothing important got left out of the report since the items we needed to cover were all right there to serve as a cue. The person who suggested having a notebook in which important changes are written (new meds, condition of a wound, etc) and passed on from shift to shift was something similar like I was thinking of but I was thinking of devising a kardex in which there is a section for the offgoing nurse to write those things plus the patient's problem list and interventions (from the care plans) is also listed and incorporated in report. There is a nursing home about an hour from here that has 5 star quality rating and I was thinking of calling them to see if I can visit to see how they do things and maybe bring some of it back to our place --I'd like to not reinvent the wheel if I don't have to. Regarding LPNs doing care plans: The state surveyors who come here have never said LPNs can't do care plans but I do think the RNs here need to become involved with the care of these patients too. To get our care plans updated I was thinking of pairing up an LPN with one of our RNs (there are only about 4 of each) to be assigned to getting their assigned care plans up to date, then the LPNs would be responsible to keep them up to date. I'm a sincere believer that people most generally want to do things right (I know there are exceptions) and if they aren't doing it right you have to make sure they have all the information (education) they need to do it right. I think information/education and a good communication system is what is lacking for my nurses.

Thanks so much for all your feedback. The system that exists here is alittle flawed I think as the RN on duty keeps to her ER/Acute care patients and has little to do with the LTC patients and the LTC nurse and CNAs take care of her patients and has little to do with the ER/Acute care patients. Report is even done separately (RN to RN, LPN to LPN and the CNAs aren't included in any report with the nurses). Talk about a breakdown in the concept of teamwork. I think that needs to change and the RNs need to be overseeing the care provided by the LTC nurses, which includes being involved with care plan development and maintenance along with the LPNs. I 've got my work cut out for me to change the culture here. Thank you everyone.

Sorry, I'm not explaining my thoughts well. The care plans in use now are ones that have been "copied and pasted" from a care plan template. I don't think they are very meaningfully personalized for many patients. Each of our LPNs is assigned the task of keeping 4-5 of the resident's care plans up to date. They also all know if they are on duty and a different resident (one not on their case load) develops a new problem (for instance, a uti) they need to write a plan of care for that new problem. Not only are they not keeping their assigned patients care plans up to date they also aren't writing new care plans when any resident develops a new problem while they are on duty. If someone looks at the care plans of the residents in our facility they often don't reflect the current state of the resident very well. The nurses notes don't reflect the care plans (or report on new issues with the resident) either. All these were complaints of state surveryors on the last survey. They squeaked by and passed the survey but I know I need to do something to improve their use of care plans as they deliver care and as they document that care. I have a feeling education is a necessary piece of this fix (the LPNs seem to not know how to base care on a care plan) but the tools I'm accustomed to using to communicate (the kardex and shift report) I feel need improvements too. For some time now they haven't used kardexes at all and the shift report is so informal I hear much information doesn't get passed on from shift to shift. So now I'm the DON who sees these issues, must come up with a fix and isn't sure where to start.

Good question. Like I mentioned, there are 19-20 residents. They are cared for by 1 LPN and 2 CNAs. What is a good ratio of nurse to patients that will allow adequate time to do care planning and documentation that is reflective of the care plans? The nurses don't appear to be terribly rushed to provide nursing care (pass meds, carry out treatments, etc) but maybe it's not enough time to write and update care plans?