Carlitos

After having traveled a bit during Covid, my wife and I are considering making the move to California. I've already started the process of having my Multi-state Texas license endorsed. While browsing through the different open positions at various facilities, I've noticed that some differentiate what seems to be the same position. For example, one facility has open positions for Staff Nurse ER at rate $XXX per hour and will specify "Union: NO,” while another Staff Nurse ER position at the same facility will have a rate $YYY and will specify "Union: YES.” Besides the difference in pay rates, all else seems to be the same. Can anyone with experience shed some light on this?

Ask for help following your chain of command... Team Leader, Charge Nurse, Clinical Manager, Department Manager, Director/House Supervisor. If all else fails call Safe Harbor. Trust me, if safety is a longstanding problem in your ER, safe harbor will not go unnoticed and will get the ball rolling for a safer ER. Sometimes you just need to put your foot down...

Sounds like you have a pretty good list of things to go over with her. One thing you may consider would be covering the Joint Commission Core Measures for the most common disease processes. You can kill two birds with one stone by teaching her the patho/disease processes and at the same time how the JC expects these to be treated. If she's already experienced this may be an easier and more appropriate learning pathway.

Violence in the EC is far from rare, even common. I would say no, do not hit before you get hit. The best thing you can do is learn how to recognize when a patient may become violent BEFORE it happens. That will give you the opportunity to de-escalate the situation before it becomes violent. Sometimes talking to the patient and finding out what they are upset about and/or calling for backup or security as a "show of force" will be enough to prevent a violent situation. Of course there are those patients that are not re-directable and, despite your best efforts, will become violent. In such situations, most facilities have policies regarding how to handle these situations. Know these policies well!!! As a paramedic dealing with these patients we were taught that our safety comes first, our partners safety second, bystander safety 3rd, and the patient's safety last. This prevents adding more patients to the scene. Do what you can to make sure everyone in the area is safe first, protect the patient as much as you can while restraining/subduing. Sometimes the patient will get hurt during a takedown, but it should never be your goal, per se, to inflict pain or injury for the purpose of restraining a violent patient.

I'd bet that for every one "kidnapping" charge you would find hundreds of "negligence" charges. My take on it is this... it has nothing to do with whether or not they were drinking, doing drugs or whatever. It all boils down to your assessment of the patient's condition when they decide they want to leave. AAOx3 is a poor indicator of a patient's condition and whether or not they are "ready" to leave. If you are going to make a mistake when it comes to patient safety, err in favor of the patient. I don't think any BNE would hold it against you if you decided to err in favor of the patient, even if it means holding them against their will. 'Los

I just re-read your post and realized I didn't answer your question... In my five years as an ER nurse and ten years as a paramedic, I have never seen this happen. I'm sure it does on occasion, however. When it does, my guess would be that it is related to a lack of training on use of the device. It is not just a simple "push it through the bone" technique. You've really got to have a good feel for what the needle is doing while inserting it. Kind of like when you get use to the familiar "pop" while inserting IVs. 'Los

If it was obvious that it was "through-and-through" I would have informed the doctor of my concerns and let him/her know that pushing the saline is not advised and not safe. If the MD insisted on pushing saline through the line I would have handed him/her the syringe and let them push it, then document, document, document. If the MD chooses to take a chance and the saline infiltrates, make sure the doctor writes a physician's note explaining what happened and what his/her plan of care is. Remember, as an RN you are not required to do what the doctor says if you do not feel it is safe to do so. 'Los

I think you missed the point here. We can't possibly teach a new grad EVERYTHING they need to know in the EC in the 6-8 weeks that they typically get. Just like when we took the NCLEX... We were being tested to make sure we would be safe RNs, not to make sure we knew everything. Likewise, in the EC, we precept new RNs to bring their skill and assessment level to that of a safe and prudent EC RN. As great a nurse as one might be, I somehow doubt that anyone knows everything. The only exception to this rule, of course would be me. But I can't possibly precept everone. 'Los

I don't know about $10/hr, but I do know that most agencies offer lower pay for orientations. The main reason for this is that the agency does not bill the facility for your orientation time, so this money comes out of the agency's pocket. They are not trying to short change you. Just remember that you are there to shadow, and you are not to make patient contact. Some facilities require extended orientations for computer classes, mandatory nurse classes (blood administration, point of care, infusion pumps, etc.), and facility orientation (just like their new employees), and the agency does not get paid for this time. Some agencies won't even pay you for the orientation until after you have worked a certain number of "billable" hours for them. Carlitos

We do CT Angios of the head all the time. It's usually up to neuro/neuro-surg to make that decision. I don't think anyone is touting them as a "golden" option. But they are just that... an option. I, too, would like to see some research on the IO supporting them as improving morbidity/mortality. However, I don't believe there is any research showing that a large bore PIV, Fem line, IJ, EJ or any of the other means of veinous access improve morbidity/mortality in the patient population that would require IO access, either. Research on M/M outcomes in only patients with IO access would not prove/disprove the superiority of other means of veinous access in this patient population. I here you on the Solu-Medrol for spinal injuries. Although, we do it all the time. Interesting case a couple of weeks ago... a middle-aged woman involved in a MVC came in, had decreased sensation below the chest and almost no movement of her lower extremities. When asked to move her feet, at best we would see a toe "twitch". Turned out she had a C6 on C7 subluxation. Steroids were started even before we went to CT. When we saw the CT all of our stomachs dropped. C6 was basically in front of C7. Hard to explain without a picture. Anyways... ortho came down and did a closed c-spine reduction. Within about 30 minutes she was able to move her feet. About 1 hour after the reduction, we took her to MRI to image her cord. Neuro check showed she was able to move both legs. I took her straight to NICU after the MRI. I followed up with ortho (they seem to spend most of their time in our EC) about 4-5 days later and they told me she was in rehab... Walking!!! Was it the rapid c-spine reduction that minimized her loss or was it the Solu-Medrol reducing secondary injury? Who knows? If it was my neck, I'd take "good in theory" any day! 'Los

Thanks, NedRN! That is what I was expecting. For some reason, though, all of the quotes I've been recieving are for 200/600k. I figured since they specialize in insuring staffing agencies, they would have quoted me on the 1/3M policies. When I asked NSO about higher limits, they told me they don't provide policies with higher limits, but that they would forward me to Affinity Insurance (?) who does. I have yet to get in contact with them. Interestingly, I did some reasearch and found that, here in Texas, legislation has placed caps on malpractice suit damages to $250,000. I'm wondering if that has something to do with the quote limits I'm recieving. NedRn... what state are you in, and do they have similar caps? Carlitos

I am starting up my own agency, finally, and I'm close to opening my doors. One of the few things I have left to do is research insurance requirements. I was wondering if anyone here can give me a ballpark figure of what hospitals generally require in terms of coverage. Specifically, I'm looking for Per Incident and Aggregate coverage for professional and general liability insurance, as well as the insurance ratings required by hospitals. Any other information you think will be helpful will... ummm... be helpful.

I've been lurking the AllNurses forums for quite some time now and have gathered some information on starting up a nursing agency. My question is: Are there any reputable resources / books to guide me? I've seen quite a few online but don't want to waste money on books with nothing but useless filler. Has anyone here purchased a good book(s) that was helpful in starting your own nurse staffing agency? My plan for now is to start small. I'll be my only employee for a while until the reimbursements start coming in, then as my capital grows and the hospitals need more coverage, I can hire one nurse at a time. I'm sure this will be the safest way to work out all the kinks. Then, once I become more comfortable with all of the "ins-and-outs" and my business begins to grow, I will look into getting a small business loan for a more rapid expansion. Any good resources out there? ideas? 'Los