RNdaze

Oh my Oh my! An upside to my job ... we can wear whatever we want for the most part, from business casual to "nice" jeans. Honestly though, you need tops with pockets so I end up in scrubs most of the time. I stay away from blue, that is what we provide the pts. :rollI wore some teal scrubs one day and had someone stop me on my way into the nrses station. Actually to my coworker, it's a locked psych facility.

Greetings to all! I need advice, please! I'll try to be brief, but will probably be long. Here is the situation: I've just finished up about a month of orientation as a new nurse, first job. (3rd career, I've been a restaurant manager and a graphic designer, I'm 38) Last Thursday, as I was handed the key to the med rooms, the nrs educator asked me if I was ready to go out on my own. Also asked what schedule I needed. I replied with a nervous chuckle that I felt I need a "few days" to get used to using the accudose and the med passing process (in a psych facility), as well as pointing out a couple areas in which I still felt like I needed some additional experience. I informed the nrs educator that I wanted to keep the schedule I'd been working since I was hired (2nd shift, Friday - Tuesday) but if possible I would like to change that to Fri-Tue and then Fri-Mon alternating for 72 hrs ppp, -or- work 2/ 12 hr and 1/ 8 hr q weekend if possible. I've told everyone I can think to tell that this is my preferred schedule, including the Director of Nursing. You'd think they'd be jumping up and down with glee for a person that wants to work weekends (without a Baylor program). I also expressed some interest in 3rd shift, but wasn't sure. The next day, (unfortunately - after 5pm) I discover I am scheduled to go off orientation the following Monday. And, I was scheduled for the next month - shifts that are not remotely close to what I need. Of course, the nrs educator is gone for the week, and as of Monday, I am under new management so to speak. I am fine with going off orientation, but I feel like I simply wasn't informed. I suppose that I took the conversation with the nrs educator to be the beginning of the process, not a "dumping". I wasn't informed that I would be officially off orientation in 4 days, nor that I would be scheduled for the next month regardless of my shift needs. There is also the issue of where I will be "core" in the hospital. I actually like the unit that most run from screaming (women's acute thought disorder) but I wasn't hired for that unit. I was hired "core" on another unit that's supposed to be men/womens thought disorder, but is pretty much a mixed bag of mood disorders, A&D detox, and an occassionally psychotic pt. It's OK, I like working there as well. HOWEVER, I was recenty told that they don't "really" hire for core positions anymore, and I have to work where the need is greatest. Also that a month orientation is standard, unless there are problems that need to be addressed. When I replied that I wasn't informed of this, the manager said that it's just an "unspoken" policy. What??! I'm a psych nurse, not a psychic nurse. In my quest for information about the availability of positions on different shifts and different units, everything has gotten convoluted. Over the past couple weeks, I've been pointed to one person only to be pointed to another, and so on and so forth, in a maze of supervisors and managers and schedulers. There is almost zero communication between these people. My "core" (but not core) manager said I should have come to her with all my questions, but I was told when I began working that my scheduling and questions etc. were the responsibility of the nrs educator during my orientation. I've only seen my "core" manager a few times since I started the job! All I've ever wanted was a straight answer. Apparently thats an oxymoron in nursing. My first "real" shift was, of course, on the detox unit .... on a Monday. (I need to add that that day we had to put MY 17yo beloved dog to sleep, and I left for work with the whole family crying and upset.) The last time I'd worked that unit on a Monday, they had 17 discharges and 6-7 admissions on 2nd shift, with 2 nurses for close to 30 pt's. I refused the assignment. I'm not ready for THAT! It's dangerous even for a seasoned nurse! I was prepared to quit, in tears, but they moved me to another unit. I felt awful about it, but I know my limits and my capabilities, as well as recognizing my personal distress over the loss of a "family member" as a factor. Now I'm pretty sure I've been labeled a trouble-maker. I'm trying to work out the scheduling problems (I have 2 children with various activities, and babysitting lined up for the dates I "thought" I'd be working). They accomodated me for this coming Thursday, stating that they would just be short staffed but they recognize my children are important to me. (No guilt there.) As for the rest of the month, I'm expected to work their schedule. I informed my manager today that I WILL be writing a letter of complaint. Sorry, I just think this is a bunch of bull. I'm not even sure to whom I should send such a letter, as ALL levels of management within the hospital are involved. Should I start looking for another job? I want to be a psych nurse, I love it, and I'm good at it. There aren't that many other options in psych here at this time. THANK YOU if you've waded through all this. I could really use some objective advice. Warmest regards ~ Daze

Lunch break? What's that and why didn't anyone tell me about it?!?! I recently heard that a fellow RN filled out the form that you are "supposed" to fill out if you work through a meal and/or breaks (since this time is deducted from your paycheck) and the supervisor refused to sign it. But, hey, when I'm the only RN on a unit, I can't leave anyway. Someday .... well, one can dream. :chuckle

Welllll .... it's comforting to hear this isn't out of the ordinary. Thanks for your responses. It's nuts (haha) IMO to expect this to be accomplished in 45 minutes. I've noticed (when I have time to dig in charts a little) that things are commonly missed due to the rushed process. For instance, last night I noticed a psychotic pt on levothyroxine who is not yet stable post 5 days inpt who has never had a thyroid panel run, even though the admitting nurse stated on the admitting orders than it was done in the ER. And I'm supposed to chart that her hypothyroidism is controlled? OOOhkay. I know the admitting nurse is a good nurse. Just a mistake caused by too much to do in too little time to do it properly. Maybe I just haven't found the hidden phone booth where I'm supposed to go change into my Supernurse costume yet!

Greetings to all you wonderful nurses! Apologies in advance for the long post. I'd like to know what you all do in the way of admitting a new psych pt onto your unit as it compares to my hospital. I'm working 2nd shift (3-11pm). Frequently we have pt's that are admitted after 5, often we have multiple admits coming in shortly before or after shift change. Pt's come to us in a variety of ways from all over the area, as we are the only facility that take acute/crisis pt's except for the state hospital (and due to insurance and acuity, most people don't go to the state hospital). This includes counties an hour or more away. Usually, a pt is seen in an ER (that can't WAIT to get rid of them), then they are transported to us. Sometimes they come via the police who call our mobile crisis unit, then are sent to us. Sometimes they are sent by a therapist, or just walk in the front door. This impacts the amount and quality of info we have about any given pt; sometimes we get a good idea of what's going on with them, sometimes not. Sometimes they are frequent flyers so to speak, sometimes not. The RN's are responsible for checking the initial committment certification to make sure it's filled out properly, and then for calling for a 2nd cert, and in some cases, a 3rd cert. We "usually" get a "face sheet" from our admissions office, and if we're lucky, some labs from an ER, or an assessment from mobile crisis. Then we have a nrsng assessment to complete on the pt. First is the physical search, where we, with a tech, go through clothes and do a body search, document any wounds and scars, etc. This can be an ordeal at times. We take vitals, ht and wt. We get medication hx (last night a woman brought in a bag with over 30 pill bottles, all of which must be written by hand on a med reconciliation sheet which then serves as an order form). To get MD orders, we have to get as accurate a picture of the meds they are on as possible, but if the patient comes in actively psychotic, seeing people covered in blood and hearing voices commanding them to cut their wrists, it's pretty safe to assume that they aren't going to be the most reliable historian. Then we have an assessment, about 10 pages long. We take a full medical hx (which is sometimes laughable, sometimes heartbreaking) and a psych hx, a suicide risk assessment, a psych assessment, and a physical assessment with additional in-depth assessments for wounds or pain. Then we are supposed to verify meds (which is often impossible because pharmacies in outlying counties close at 5pm) and then call a (usually) cranky doctor to get orders to admit the pt. One of our on call docs is infamous for hanging up on you if you take too long to give report. Others are just plain disdainful if you have a difficult pt with multiple problems. I am truely perplexed as to why doc's treat nurses this way, like they are doing us a favor by doing their job. (That's a whole other issue I suppose.) By this point, we've filled out by hand: med rec sheets including drug, route, dose, frequency, duration, last time taken (hahaha) with effectiveness and/or reactions, and maybe/hopefully verified the meds; the written assessment, a treatment team plan where we list each major problem in nsg dx form, a seperate nsg dx sheet for each problem (3 -5 usually), a med teaching form, a form for pneumococcal vacination, a nsg flow sheet, the KARDEX, and finally the MD order form used to call the doc. Then, we have to find a secretary (often we have one secretary for 3 units, who is overwhelmed with work) to put all this in the system and then they hand write a MAR for standing orders and another MAR for PRN's. We then have to check the handwritten MARs against the orders. Until the pt is put in by the secretary, they are in pre-admission status. For some reason, certain meds are only available on certain units, so we have to run to X unit for one group of meds and then Y unit for another group of meds. You can guess that the pt is pretty much the same or worse than they were when they arrived by this point. And all they will get are meds (hopefully) and a bed until the following day when they are (hopefully) seen by everyone else (2 doc's, a therapist, and a case manager.) According to management, all this should be accomplished in 45 minutes. Ummmm...... on an easy admit if everything goes smoothly, I can maybe get it done in a little over an hour. If I'm handwriting 30 meds, talking to a pharmacist, writing 4-7 care plans, with a pt who is psych acute with extensive medical problems, it can take hours. With the push to HURRY, I tend to make more mistakes. Then there are 8-12 other pt's to worry about as well. One can only pray that none of the other pt's escalate or have a seizure, etc. This is my first job, so I have nothing except my school clinical experience to compare it with. Is this normal??? Does anyone have any tips to help me speed up the process? Tips on how to talk to these docs? Reasons I shouldn't run screaming out the door? Thanks so much!! -- daze

tsala - i hope you do find the source of your fibro. that is a difficult task indeed. just wanted to add that the info provided in my post is just to give nurses in psych food for thought. we can't dx, but we can be informed. in that vein, i'd like to point to a recent unprecedented event .... ct attny general blumenthal's antitrust investigation of the infectious disease society of america's lyme guidelines. whew, wonder what it feels like to be caught with your hand in the cookie jar. for immediate release contact: melissa chefec, 203-968-6625 or nicole rodgers, 202-822-5200, ext. 249/226 [color=#015351]settlement announced in landmark investigation of lyme disease diagnosis and treatment guidelines [color=#015351]patients' rights groups applaud connecticut attorney general blumenthal's settlement in anti-trust case against powerful medical society hartford, ct, may 1, 2008 - patients' rights groups today hailed connecticut attorney general blumenthal's announcement of a settlement in a landmark antitrust investigation into the lyme treatment guidelines of the infectious diseases society of america (idsa). "my office uncovered undisclosed financial interests held by several of the most powerful idsa panelists," said blumenthal. "the idsa's guideline panel improperly ignored, or minimized, consideration of alternative medical opinion and evidence regarding chronic lyme disease, potentially raising serious questions about whether the recommendations reflected all relevant science." the groundbreaking settlement announced today forces a complete review of the idsa guidelines by a new panel free from conflicts of interest, specifically excluding previous panel members. this panel will consider a range of scientific evidence in a public forum broadcast live over the internet and will be overseen by a specialist in financial conflicts of interest in medicine. "this settlement makes it clear that the idsa guideline development process was corrupted by a commercially driven panel that excluded evidence supporting longer term treatment of lyme disease," said attorney lorraine johnson, executive director of the california lyme disease association (calda). "this settlement allows suppressed scientific viewpoints and evidence to be heard, and it is promising news for patients." this is the first-ever antitrust investigation against a medical society's guidelines development process. "we congratulate attorney general blumenthal for exposing the idsa's conflicts of interest and helping reduce the suffering of lyme patients everywhere," said pat smith, president of the national lyme disease association (lda). diane blanchard, co-president of time for lyme adds, "the idsa guidelines are dangerous for patients who suffer longer-term lyme symptoms that do not fall within the idsa's narrow disease definition." the idsa guidelines are treated as mandatory within the medical community. more than 50 physicians who use longer-term treatment approaches have been investigated or sanctioned by state medical boards. the guidelines can also result in financial problems for patients, since insurance companies refuse to reimburse for longer-term treatment and pharmacies may refuse to fill prescriptions. the majority of individuals involved in the idsa guidelines development process held direct or indirect commercial interests related to lyme vaccines, patents, and/or test kits, and did not take the opinions or experiences of the competing lyme groups into account. while the announcement of a settlement comes as a huge relief to suffering lyme patients, the case has much broader implications for a health care system that often contends with conflicts-of-interest in guideline processes - guidelines which are often used by insurance companies to limit diagnosis and treatment options. "today's settlement marks an important victory for all patients who suffer lyme disease, but it is also a victory for anyone concerned about health care," said johnson. "commercially driven guidelines that limit patient treatment options are a major issue today in healthcare, and this decision marks an important step towards addressing it."

i could only find 10 posts about lyme here, none under psych. i think we are missing a lot of patients with this, all over the country. i also think many don't seek help until their cognitive sx or depression overwhelm them. then, with the "psychiatric pt" label, they are forever held at arm's length, stripped or their credibility, and spiral downward. what do you think? see? overview of neuropsychiatric lyme disease lyme disease may affect the brain in many ways, the most common of which is a disturbance in thinking (cognition). other symptoms that occur frequently include headache, mood swings, irritability, depression, and marked fatigue. this section will describe some of the typical and less typical features of neuropsychiatric lyme disease in adults. lyme disease is transmitted by an ixodes tick infected with borrelia burgdorferi. the spirochete which causes lyme disease (borrelia burgdorferi) can invade the central nervous system within days to a week of initial skin infection, as a result of dissemination through the blood stream. the majority of patients who are treated early with antibiotics do well and incur no long term problems. patients who are not treated until later in the illness may have a more complicated course. while the symptoms often seen among patients with neuropsychiatric lyme disease are not specific to lyme disease and can also be found in other disorders, knowing the typical clusters of symptoms can be helpful when considering lyme disease as a possible diagnosis. the more multi-systemic the symptom presentation and the more clinical features observed in a patient from the list below, the more strongly lyme disease should be considered. other diagnostic possibilities need to be considered in the differential diagnosis, such as mood or anxiety disorders, collagen vascular or autoimmune diseases, spinal cord compression, multiple sclerosis, metastatic diseases, endocrinological disorders, fibromyalgia, chronic fatigue syndrome, and residual damage from past brain trauma or toxin exposure. a few points should be emphasized regarding late neuropsychiatric lyme disease. first, although arthritis is helpful in the diagnosis of lyme disease, the majority of patients with cognitive troubles due to lyme disease (lyme encephalopathy) do not have joint problems at the time their cognitive symptoms become manifest. this is not widely recognized among physicians, although it is well documented in the medical literature. second, the bedside neurologic exam does not usually disclose neurologic findings and standard office-based cognitive screening tests may not detect cognitive impairment. to detect thinking problems, the more sensitive tool of comprehensive neuropsychological testing conducted by a neuropsychologist is needed. third, lumbar puncture while important in the differential diagnosis should not be used to exclude neurologic lyme disease, as roughly 20-40% of patients with confirmed neurologic lyme disease may test negative on routine csf assays. among patients who develop chronic cognitive problems, the typical time course for the manifestation of lyme symptoms is as follows: very early: erythema migrans (a red, round, expanding rash) 1-2 months after infection: cardiac or early neurologic involvement (meningitis, encephalitis, cranial neuropathies) with mild to marked neuropsychiatric symptoms 6-10 months after infection: arthritis of multiple joints 2-8 years after infection: chronic cognitive problemstypical symptoms among patients with neuropsychiatric lyme disease: fatigue: this ranges from mild to severe, resulting at times in a need for prolonged sleep at night and additional naps during the day, much akin to chronic fatigue syndrome. low grade fevers night sweats migrating arthralgias (joint pains) or arthritis (joint inflammation or swelling) muscle pains sleep disturbance frequent and severe headaches cranial nerve disturbance. while facial nerve palsy or optic neuritis are not frequently seen, patients may more commonly report facial numbness and/or tingling. sharp, stabbing, deep/boring, burning, or lancinating (shooting) pains multifocal numbness or tingling in hands or feet (signs of peripheral neuropathy) thinking problems: may include problems in attention, memory, verbal fluency, thinking speed. patients may report problems with concentration or the need to rely on lists or others because of new memory problems. for more details about typical cognitive deficits, please see cognitive aspects in adults. cognitive overload: some patients experience normal environmental stimulation as being excessive, resulting in a cognitive "short-circuiting" such that the patient may start to feel confused, lose focus, stutter, or panic. it is as if the normal filtering mechanism of the brain has been rendered ineffective, leaving the patient vulnerable to a confusing array of numerous stimuli. brain fog: patients with lyme disease often use this term to describe the lack of clarity in their cognitive processes. at times, this seems similar to "depersonalization or derealization" in which a person's sense of self and place are altered. sensory hyperacuities: some patients experience a heightened sensitivity to sound or to light, particularly in the early phases of neurologic lyme disease. in the more severe cases, patients need to wear sunglasses indoors or earplugs to diminish sensory stimulation. spatial or geographic orientation problems: for example, patients may bump into the door jambs; go to place an object on a table only to see it fall to the floor due to a misjudgement of spatial distance; get lost in a familiar place. problems with speech & fluency: stuttering, reversing words (e.g., stating "tomorrow" when one means "yesterday") less common neurologic syndromes: partial complex seizures, multiple-sclerosis like illness, dementia-like illness, guillain-barre syndrome, strokes, tullio phenomenon. psychiatric symptoms in adults: irritability, poor frustration tolerance and mood swings are common. less commonly: panic, obsessive/compulsive behaviors, or other anxiety states. rarely: mania, paranoia (these usually occur among patients with encephalitis). neuropsychiatric problems in children: headaches, disturbances of behavior or mood, fatigue (falling asleep in class), problems with auditory and visual attention (with some children mistakenly being diagnosed as having attention deficit disorder) fluctuating symptoms: worse on some days, remarkably better on others, without clear cause.cognitive aspects in adults: attention problems: easy distractibility; difficulty handling multiple tasks at the same time; trouble sustaining attention on tasks and completing tasks; trouble following the course of conversations or the text of a book. memory problems: retrieval difficulties are common in which patients may have a hard time recalling what they know; patients may forget conversations or children may forget that they've done homework assignments. at other times, patients experience a problem with the "working memory": as if the material can't be kept on board long enough. patients may find themselves keeping multiple lists, but then they lose track of where they put their lists. slower processing speed: patients may find it takes them longer to respond to questions or to complete tasks. reaction time and thinking feel sluggish. verbal fluency problems: the ability to engage in normal conversations is impaired by the inability to retrieve the right word for the moment or the ability to "name" well-known people or objects. patients may experience word substitutions or "paraphasias". a patient trying to refer to a "microwave" might, for example, say "radiator". or, trying to refer to "amazon.com" the patient might say, "aol". or, trying to refer to "fireworks", the patient might say "skylights". patients may also experience an impairment in speech production, such that they stutter, particularly at times of sensory overload.psychiatric aspects in adults irritability and moodiness are common. these tend to be most severe in neurologic lyme disease before treatment, during the first few days or weeks of treatment, and during resurgences or relapses of active lyme disease. antibiotic therapy can be very helpful at these times. symptoms that persist despite appropriate antibiotic therapy should be treated with psychiatric medications. it is very important for patients to take advantage of all opportunities for therapeutic benefit. these include consultation with a psychiatrist for both medication and therapy. psychotherapy with a psychiatrist, psychologist, or social worker can be very helpful to help the individual cope with the effects of a serious illness. family and couples therapy can also be vitally important, particularly when family members are confused by the changed behavior or personality of the patient. psychiatric medication can be very helpful to combat mood and sleep disturbances, to enhance attention, to decrease central nervous system hyperacuities, to decrease excessive worry and fear, and to contribute to overall good health by countering the negative impact of neuropsychiatric disorders on the immune system. mood lability: spontaneous swings of mood; spontaneous tearfulness. at times, patients with these symptoms may appear to have a bipolar ii disorder. irritability: an inability to tolerate normal frustrations, with quick bursts of anger. patients may seem to have undergone a personality change in that previously mild-mannered individuals may now become quite difficult. panic attacks: tachycardia, flushing, chest pain, , numbness and tingling, shortness of breath, choking feeling with the sensation of loss of control and/or of fear of death. needs to be distinguished from tachyarrhythmias. panic attacks unrelated to lyme disease are usually 10-20 minutes in duration. lyme-related panic attacks may last for an hour or more. less commonly: manic or psychotic episodes (during encephalitic phase), paranoia, tics, obsessive/compulsive symptoms (may trigger a milder pre- existing condition or bring on symptoms de novo)neuropsychiatric problems in children as noted among adults, when lyme disease is treated early in children, few children develop long term problems. when lyme disease is not treated until later in the course of the illness, the clinical manifestations may be more neuropsychiatric and the response to treatment less robust. in a large series of children with lyme disease referred to a pediatric neurologist (belman et al), headaches were the most commonly reported symptom. the second most common symptom were disturbances of behavior and mood. mri abnormalities may be seen in some children following lyme infection, located predominantly in the deep white matter, which is consistent with reports of mri lesions seen in adults with neuroborreliosis. these findings are similar to the mri findings of children with parainfectious or postinfectious acute disseminated encephalomyelitis.children in particular may appear to have "pseudo-tumor cerebri" because of an elevated opening pressure at lumbar puncture. complex partial seizures may also occur more commonly among children with neurologic lyme disease than among adults.like adults, these children may appear to have chronic fatigue syndrome due to an extraordinary capacity for prolonged sleep at night and need for naps during the day. cognitive. in a study by adams et al, children with relatively early manifestations of lyme disease appropriately treated with antibiotics were found to have an excellent prognosis for short-term and long-term (4 years) unimpaired cognitive functioning. in contrast, a study by bloom et al reported on an evaluation of 86 children for possible late manifestations of lyme disease, 12 of whom had neurocognitive symptoms thought to be related to lyme infection. of these 12, 5 had past or present b. burgdorferi infection in serum and csf and had developed neurocognitive symptoms either at the time of onset of lyme infection or months after classic manifestations of the disease. the most prevalent neurocognitive symptoms were behavioral changes, forgetfulness, declining school performance, headache and fatigue. two of these children had developed complex partial seizures. a comprehensive neuropsychological battery revealed that these children had normal intellectual functioning, but particular deficits related to auditory or visual sequential processing. these deficits, as well as many other symptoms, gradually improved following ceftriaxone therapy, although two of the children continued to have auditory sequential processing deficits. a controlled study by dr. tager at our lyme disease research program, reported at the 1999 viii international lyme disease conference in munich germany, revealed that chronic lyme disease in children may be accompanied by cognitive and psychiatric disturbances, resulting in significant impairment in psychosocial and academic functioning. the most prominent cognitive problems involved the domains of attention and learning specifically related to perceptual/organizational abilities, visual scanning, and sequential tracking. psychiatric.two studies from different institutions found that children with lyme disease may develop late problems with visual and auditory attention. these children may be mistakenly diagnosed as having primary attention deficit disorder as opposed to attentional deficits secondary to a systemic infection. other findings in children include new onset phobias (e.g., fear of the dark, separation anxiety), depression, listlessness and irritability, oppositional behavior,obsessive-compulsive behaviors, and/or tourettes disorder. http://www.columbia-lyme.org/flatp/lymeoverview.html

Can I add the pt on an opiate DT, refusing meds, with psychotic delusions, with a Super Low BP (don't remember exact #'s) but with a HR of 122? :uhoh21:

Everybody needs a Compliance/Integrity Officer! AKA: Incidence analysis slooth. Policy and procedure overlord. Persistantly caught between a rock and a hard place middle-man. Director's are tired of the heat? Behavioral must make sure I's are dotted and T's are crossed so the hospital can be properly reimbursed and is billing for services that are rendered and necessary. For Behavioral, this seems to be monumental task. From what our Integrity/Compliance Officer has said, he's not a real popular guy. :chuckle He ought to have "If you didn't chart it, it didn't happen" tatooed across his head. He said Behavioral Health is the latest to have a big red target painted on it's rear by the gov'mnt. Hellooooooo Medicare! New positions available! Here are a couple similiar job descriptions I found on a quick google, not specific to Behavioral Health, but a tad more descriptive: - Plans, organizes and directs a quality assurance program within a State general hospital; sets up operating units for prospective review, concurrent review and retrospective review functions relating to admission request, pre-admission clinical testing, admission necessity certification, length of stay review, discharge planning, evaluation of utilization review, continuing criteria development and education. - Renders decisions on unusual problems that involve policy interpretations or consults with medical staffs and hospital direct for advice on problems requiring medical and/or procedural knowledge. - Continuously evaluates procedures to provide more efficient methods; revises reporting forms to provide for more complete and condensed data; consults with proper committees in the distribution and filing of information. - Establishes safeguards to preserve the confidentiality of information from the patient medical records or other sources of patient information, assists authorized personnel in the implementation and use of quality assurance data and reports. - Consults with the medical staff and hospital administrators on revisions of reports, seeks cooperation of medical staff in recording and completing medical records of patients to adequately document data necessary for quality assurance evaluations. - Reviews the data on a non-routine basis, contacts attending physicians or refers to physician reviewer when necessary; assists authorized non-hospital organizations such as Federal, State, professional regulating groups and third-party payers in determining hospital compliance with their respective regulations and standards. Coordinates at the administrative level with admissions, credit offices, medical records department, social services, and professionals including physicians, nurses, dietitians and therapists in the interchange of necessary information in carrying out the quality assurance program. --------------------------------------------------------------------------------- Distinguishing Features of the Work Assists in planning, organizing, and directing the Quality Assurance Program of which the two main components are Medical Audit and Utilization Review within a State general hospital. The work includes responsibility for supervision of the utilization review activity conducted on the units, assuring standardization of procedures to be followed in the abstracting and recording of data, assists in developing and coordinating efforts of professional committees toward development and revision of patient care audit and utilization review criteria. Other responsibilities include teaching computer terminal operation and maintenance necessary to complete utilization review functions. Decisions as to program administration are made in accordance with the Director. This person is immediately responsible to the Director of the Quality Assurance Program. Examples of duties characteristic of positions in this class: 1. Assist the Director in managing, planning, and organizing the Quality Assurance Program within a State general hospital for the purpose of accomplishing goals and objective for both medical audit and utilization review. 2. Reviews utilization review data on a routine basis and designs reports from existing data to obtain statistics or verify certified action. Ex: would include evaluation of diagnosis, types of services, rendered, why certain test on patients are delayed. 3. Implements an employee evaluation procedure based on the Management by Objectives Program. 4. Coordinates orientation for all new employees by training new employees, writes outline for orientation, selection of team leaders. 5. Renders decisions on utilization of computerized reports and problems involving maintenance and operation of terminal. 6. Conducts staff meetings on weekly basis for the purpose of upgrading skills. 7. Continuously evaluates utilization review procedures to provide more effective and efficient methods of carrying out the function. 8. Coordinates responsibilities of team leaders and conducts weekly meetings for the purposeof insuring standardization of utilization review procedures. 9. Supervises themaintenance and updating of files on review data and statistics on the efficiency of the utilization review system. Ex: would include monthly reports on admission diagnosis, financial classification, profile on attending physicians, etc. 10. Makes recommendations to the Director based on experience in implementation of the utilization review process. 11. Coordinates in-service programs based on identified needs. All comes down to the $$$$.And if you don't do your job, yikes!!! The Victoria Behavioral Health Services, a Community Mental Health Center located in Miami, Florida, received reimbursement for partial hospitalization services provided to Medicare beneficiaries. The audit showed that the center did not meet the certification requirements established under Sections 1916©94) of the Public Health Service Act and 1861 of the Social Security Act. Further, we found that none of the 20 medicare beneficiaries in our sample were eligible for partial hospitalization benefits and that $1,196,664 of the $1,959,296 paid for services provided to the 20 beneficiaries in our sample were unnecessary, unreasonable and unallowable under Medicare coverage and reimbursement criteria. We also found that the center claimed reimbursement for unreasonable and unallowable administrative costs, including related party costs that had not been properly disclosed. Based on the audit, we recommended that the entire $4,510,161 paid to the center during their participation in the Medicare program be disallowed. Medicare payments to the center were suspended with notice and the findings were referred for possible criminal prosecution. Did I digress? oops, sorry bout that. Good luck.

Aloe, Thanks for your responses. :) I have since talked to a variety of people, on all levels of the management ladder. To sum it up: That's just the way it is, we don't like it, we hope it will get better, this is a temporary low for us, expect 16 pt's a shift, hands are tied. I'm starting a few projects, gathering info from peers, and research on the issue at large. Maybe try to get active in the local association. I am going to try to inform my supervisor in writing when I think a shift is particularly unsafe. Trying to figure out the best way to do it, i.e. non-threatening, yet CYA. I don't want to cause trouble or grief OR get labeled either. Here's to "keep keepin' on"! ~Daze

OK, so reading through this thread, I'm hearing short staffing is a widespread and often "accepted" practice, albeit unsafe for pt.'s and staff. I'm a new RN (2nd career -- I'm 38) and in my 3rd week of acute inpatient unit orientation, 2nd (evening) shift. I'm seeing 2 RN's with 10-16+ pts on average with 3-4 PC (Patient Coordinators/techs) shared on a unit. Dayshift is slightly better, might have 3 RN's. 1 RN on 3rd shift with 2-3 PC's. Roaming HUC's .... not sure how they work that out. Here was last night: My first night of orientation to the detox / bipolar etc unit (It has a name, I don't know it, um hum). We walk in to a scant report, 17 discharges (many pt's require FAST discharge or they are just left, i.e. transport won't wait more than 10 minutes), 2 pt's needed to go to ER (transport to another facility), not even sure how many holds, and multiple admits ... I was so busy doing discharges I never had time to see the total census. (I'd never done a discharge before this shift.) So much not finished by the previous shift ... orders out the wazoo, tests needed, more orders needed. It was a madhouse. Oh, and it's ALL paper. I have yet to touch a computer since I've started. My preceptor wanted to get the dc's out of the way .... hmmm .... so it was 3 hours before I saw my first pt. Yeah, then they gave me 7 or so pt's. I know little about detox, but I'm doing CIWA eval on one alcohol detox with chronic pain and PTSD, and after much confusion another CIWA ordered for an opiate detox .... this person was off the charts anxious and angry. Huh?!? A methamp detox with multiple open skin lesions and chronic pain protocols and blood pressure issues .... no BP meds ordered, even though pt reported she took BP meds 2x/day (this is day 3 for her ..... hello?). A bipolar who was set to d/c, who broke down and said she'd kill herself if she had to leave .... call the doc, dc the dc. Another detox with a possible bowel obstruction -- sent to ER .... never even had the chance to check in with him, but heck he was in so much pain he couldn't talk anyway. Couldn't have done an NG tube or any type of emergency intervention for this patient. Yikes. A Bipolar non-compliant diabetic with new skin lesions, also on chronic pain protocols. A couple other borderline's that were Med seeking staff-spliters with various medical issues. One with boundary issues who should have been on constant observations and who frankly scared me. The 2 RN's took the rest ... roughly 12 pts each give or take (who knows with that turnover). I'm not sure how many PC's we had. (!!!!) Again, this is my first night on this unit. I don't even know the unit capacity. I don't have access to the med rooms yet. I have to trust that my meds are passed and c/o pain are given their prns. Check back ... yeah, sure. At one point, we had a swarm of pt's around the nrs station (with PC's sitting nearby). Pt's boring holes into our heads, watching us working furiously. I just HAD it. Went out and told them we were working hard for them but they needed to stop staring at us, get out of the hall and into the dayroom or their rooms... NOW. Where is the structure? OK. Stop. Breathe. My question is .... WHAT can I DO about this? Who do I talk to? Would talking to anyone help? The nsg supervisors are well aware of the situation, as are the managers. And I'm NEW. But this is about as unsafe an environment as I can imagine. I want to work there. I want psych. I don't think running would help. So how can I be part of a SOLUTION? (oh, and keep my license and not kill anyone.) Please, if all you have to say to me is "welcome to nursing", don't bother. I'm looking for serious positive proactive responses if at all possible, please. Whew. Thanks in advance for any insight.