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solneeshka BSN, RN

PACU, Surgery, Acute Medicine
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solneeshka has 11 years experience as a BSN, RN and specializes in PACU, Surgery, Acute Medicine.

solneeshka's Latest Activity

  1. solneeshka

    Block Time Utilization?

    Any ASC managers out there, or any other folks who would happen to know, care to share how you arranged block times for your surgeons, and more than that, how you calculated room utilization rates? I'm managing an ASC that is a department of a large hospital, and leadership uses the same utilization calculations for us as they do for the main campus. But scheduling works differently, and our availability is not the same. I'd like to propose different calculations but I'm not entirely sure what would be appropriate. It would help to have an idea of standards in the industry out there. We are orthopedics but responses from any specialty area would be helpful. Thanks!
  2. solneeshka

    Cleveland Clinic EVAR graft question

    I'm a nurse. I'm involved in negotiating prices for our implants. I know what they cost; we use them and I can see very easily what we pay for them. My question was is in regard to a specific other facility, who I'm told uses a different pricing model than we do, hoping to learn more about how they developed that model. Clinical care isnt isn't the only role that nurses can have. We do all sorts of things, and can add significant value to traditionally non-nursing functions when we step into those roles in the context of healthcare. Vendor contract negotiations, for example. Vendors can't BS me in the way they might be able to BS an accountant (which I also am, BTW) because I've been in the OR with the surgeons who use these items, and I have the relationships with the surgeons to ask them if something is really worth paying a premium over something else. It is one of our surgeons who told me about the pricing model at Cleveland Clinic, which is why I logged on and asked the question. There are nurses who are not involved in direst clinical care who use allnurses. If they were smart, there would be non-nurses in the healthcare industry who would also use allnurses. If someone on the board happens to have the info in my original question, that's what I'm looking for. If not, no worries.
  3. solneeshka

    Cleveland Clinic EVAR graft question

    Sorry, I wasn't clear. I'm not looking reimbursement information or or total cost of stay info or anything like that. I know that no one can give out the prices that they pay for the actual grafts. Just looking for the process that they (or, more likely, their supply chain) followed to come up with whatever the prices are that they are willing to pay for the grafts. Different hospital systems use different methods to set pricing, and even within their own system will use different processes for different kinds of products, particularly high-dollar physician preference items (like EVAR grafts).
  4. solneeshka

    Cleveland Clinic EVAR graft question

    Anyone out there from Cleveland Clinic who would be willing to field some questions about how you arrived at EVAR/TEVAR endograft pricing? I know you can't share the prices and wouldn't ask you to, just would like insight as to the process of how you arrived at pricing.
  5. solneeshka

    What to do if you disagree with the care of another nurse's pt?

    It's posts like this one that make me glad I work at a gigantic teaching facility. The place is crawling with residents, and on the medicine floors, crawling with hospitalists, even at night. Everything (usually) moves fast; you call for help, it starts coming out of the woodwork. (Unless the team gets lost on the way to the call, because we are that huge - it happened to me on the very first code I ever called - funny in hindsight, not at the time!) We have the number for our RRT posted in patient rooms, so *anyone* can call, even a family member. It does not get overused at all. I would say there are more overhead pages for codes than for RRT. But we all know about it, it's a great ace up your sleeve. OP, I don't remember now if you did suggest rapid response to the other nurse, but if not, there is nothing at all wrong with doing that, even if that nurse is more experienced and you are new. If it were me I would think, "Would I call RRT if this were my patient?" If so, then I would be strong with the language: "Why don't I call a rapid response for you? Here, you go back in with the patient, I'll make the call." Just because another nurse is more experienced than you are doesn't mean he or she doesn't sometimes second-guess themselves. Maybe it was on her mind and just knowing it was on your mind, too, would have been enough for her to go ahead and do it. And yes, as some have noted there are no guarantees that calling a rapid response would have improved her outcome, but the whole point of having a rapid response program is to increase the chances of improving a patient's outcome, so probably, it would have! At least the patient would have sooner been on the radar screen of those who give a higher level of care. You were thinking along the right lines, and the next time it comes up, you'll have a better idea of how you'd like to handle it. That's called "gaining experience."
  6. solneeshka

    12 hour shifts and young kids

    A lot depends on whether or not you have another adult living in the household. Are you married? If so, does your husband pick up the slack? If so, then your kids will be like a bazillion other kids all across America who don't have full time stay-at-home mothers (that is, just fine). If you are the only adult in the household and have to make other child care arrangements (my situation), it can be tricky. My son has survived, but we've been at the mercy of the willingness of various family members to help out. It would be one thing for my son to be at home without me but with his father until 8:00 pm when I get home; it's another thing for him to be at my aunt's house until 8:00 pm, then I need to get him home and that's when we're just starting our evening routine. Not the end of the world, we've been okay. This may be a short-term situation for you, you never know when something part-time might open up, and if you already have your foot in the door, you'll be better positioned to move into a part-time role. You both will survive!
  7. solneeshka

    Hypoglycemia Mystery Theater

    The BMP glucose was "
  8. solneeshka

    I'm tired of screwing up at work

    In our facility, incident reports for lab specimens are automatically done by the lab. When it happened, I also e-mailed my manager to let her know what had happened (so I could provide the information while I still remembered it). This situation is a little bit different in that what I did (leave the neo running to meet a MAP goal) was in fact what the service wanted to have happen. I think what TakeTwoAspirin is getting at is that the way our system works leaves big possibilities that what ends up being done is *not* what the service wanted to have happen.
  9. solneeshka

    Hypoglycemia Mystery Theater

    All nurses! Put on your sleuthing caps because I cannot figure this one out and it's driving me crazy. Had a pt last night who had a carotid stent placed yesterday afternoon. He had come out of the OR on neo with a MAP goal of 80-90 and still had the neo going. He has DM, day RN had not done the 17:00 accucheck by 19:00, so after report she did it. He was 219 and she slid him according to his scale, 2 units of novolog. We kind of laughed about how little that was, but if that's the scale, that's the scale. By then, he had already had a couple of sodas (diet) and some jello. He was complaining to me that he was hungry and his nutrition orders had advanced so he could have real food. It was about 20:30 by this time so I told him I would do his HS check before he ate and then I'd get him something to eat. He said he usually didn't slide himself at night, he just took his lantus, which was not on his orders. I explained all this to the NP, she said if that's what he does at home, let's do it here, skip the HS novolog and she added his home lantus to his MAR (31 units). I got him a turkey sandwich with mayo, a salad with French dressing, and another jello. He also drank 4 sodas over the next couple of hours (they were all diet). At some point after he ate, I gave him his lantus (probably 21:30 or so). He had napped all day so of course he didn't want to go to sleep. He stayed up until well after 03:00 reading and watching movies on his kindle. Finally around 03:00, he had to pee (had great urine output all night), so I got him the urinal and then helped him move from the recliner to his bed. They were almost right next to each other, but he wasn't shaky or anything, he moved just fine. All night I had been trying to wean him off the neo with mixed results. Not long after he went to bed, his BP started to rise so I turned it off. It actually started getting really high (mapping in the 100's, SBP 160s bumping up into the 180s sometimes). The NP and I noticed how now we seemed to have the opposite problem, but at least he didn't need the neo anymore and he'd be able to go home in the morning. I went in pretty frequently (maybe every half an hour) to have him reposition the arm with the art-line, just to make sure we were getting a good reading because he moved around a lot in his sleep. Also cycled the cuff enough to be confident the art-line was correlating. Around 05:30, I noticed blood all over his non-art-line arm and realized he had pulled out one of his PIVs. I cleaned it up and noticed it was all wet underneath, which I took to be from fluids that were no longer running into his arm. I cleaned his arm up, dried it off, and placed a dressing (although it really had already clotted off by then). While I was in the bay, I noticed that his heart tracing was looking goofy. He had been bradycardic all night with bundle branch block, and really didn't deviate all night. But now I can only call it irregular and funny looking, BBB but odd. I called the NP who was in the SICU at the time, she said she'd be down in a minute to look at it, but in the meantime, draw a BMP on him. (She had not ordered PM labs because he'd just had them drawn when he arrived around 15:00 and everything looked good, we were expecting him to go home in the morning.) When I was drawing them from the art-line, I noticed that that arm felt wet, too. Then I noticed that all of him felt wet. Then I realized he really hadn't woken up much during all of this. I grabbed the accucheck and (are you ready for this)...14! Another nurse repeated it, again 14. I didn't even know it could register that low. We pushed an amp of D50 and I hung a 250mL bag of D10, we rechecked and he was 209. A resident had shown up coincidentally during this and called up for a SICU bed, asked us to get him up there asap. By then, the pt was already oriented. I explained to him what had happened and he just kind of nodded his head knowingly. (His HA1C had come back at about 8 and a half, so this was probably not his first hypoglycemic rodeo - just not well controlled.) After the accuchecks but before the dextrose, his BP dropped fast, down to systolic 80s. After the D50, it was very nice, systolic 130s, mapping in the 80s, and his heart tracing was nice and steady (BBB, but even). Wait, I did turn the neo back on when I saw that low BP, I forgot about that. That might explain the improvement in BP, but not in the tracing. After I got back from dropping him off in the SICU, I looked up the BMP I had sent earlier. His K went from 4.2 at 15:00 to 3.2 at 05:50. These are all the data points I can think of that might be relevant. So what the hey happened?!?!? How does someone with a BG of 219 who gets 2 units of novolog and 31 of lantus, and is eating like a cow, drop to 14?!?!
  10. solneeshka

    I'm tired of screwing up at work

    I so need to do this...
  11. solneeshka

    I'm tired of screwing up at work

    You know, I have not thought previously about possibly not needing an order for a drip started in the OR. If that's the standard in our facility (and I will need to find out!), then I guess all of my angst has been for nothing. We in PACU chart in the same system that anesthesia charts in, so the meds admin In the OR and the meds admin in PACU is all on the same page, one seamless flow. It would definitely show that anesthesia started the drip. And I made several notes about my call to the MD and discussions with the charge nurse, I even made notes in there about the MAP goal that was on order in the *other* system and how we were doing at various times. Hooray! I think that if I'm not totally saved I at least have a defense, and I don't hate myself or think I'm an idiot anymore! Thank you, fine people of allnurses! And I promise to report the scenario through our risk management system.
  12. solneeshka

    I'm tired of screwing up at work

    Agreed! Thank you for the replies!
  13. solneeshka

    How do you do it? Advice/Tips

    We nurses spend too much time nursing the charts and not enough time nursing our patients. Sigh...
  14. solneeshka

    Interest in Nursing is wavering

    I seem to recall things settling in for me at about four months. For most of that time, I felt like I was always running around crazy and I almost never left on time. By four months, though, things just seemed to get better. I can't say exactly why, I can't say I felt more competent, but I just started having more time on the shift and started leaving on time pretty much all the time. I can only chalk that up to more experience. I did also change my practice to focus more on charting up front. That was hard. I felt terrible doing any charting when I knew there were all of these tasks sitting in front of me. But by even popping in parts of my assessments when I passed pm meds, that made it go a whole lot faster when I finished up charting later. I can't say why. The amount of work was the same and the total amount of charting was the same, but I saved a lot of time if I just sucked it up and charted my assessments early on. Try some things out, you will find what works for you!
  15. solneeshka

    I'm tired of screwing up at work

    The neo was actually started in the OR, but you have the idea, it was obviously something the service wanted, and they didn't need a written order at the time it was initiated because it was in the OR, but they should have provided (and I should have ensured they provided) a proper written order once they were out of the confines of the OR environment and it was to be left running. I kept him in the PACU for a few hours (3 hours, during which time the RN in the bays next to mine had a patient code, so there was some time lost there helping her) trying to wean him off before deciding it was not going to happen anytime soon. I thought the MD would say to send him to our short-stay post-op ICU (which is where I usually work - I was floated today). When I called the MD and told him we were unable to wean so we couldn't send him to the vascular obs unit at he was slated for, he said that wasn't true, the chief of the service "e-mailed everyone" two weeks ago that they could take pts on drips, so I said great, wish I knew that three hours ago. My charge called the obs unit to confirm, we found out he was partly right; they would take a pt on neo but at no more than 50 mcg/min (he was at 67 at the time and shortly after I had to bump him to 75). Shortly after, I reported off because my shift was ending. When I called tonight to see what the status was, I was so sure that he would already have been transferred to the short-stay post-op ICU that I called there first. When he wasn't there I thought well maybe they did get it down. I didn't know the number for the obs unit, plusi figured ey wouldnt have the skinny on what i wanted to know anyway, so I called PACU and was very surprised that he was still there. Those three hand-offs were probably the reason; probably no one had the time to initiate getting him in the right place before they had to hand him off again. What's so funny is that his then-current nurse was so busy she could barely talk to me, I'm thinking, why do you still even have this guy? They have two nurses and two pts upstairs, ship his arse up there and get him out of your hair! BTW, we have a lot of staggered shifts in our PACU, so some people leave at 7:30, some 8:30, some 9:30, some 10:30. I know when I reported off, my charge had already left and someone else was in charge (we consolidate all of our areas around 7:00 - it's really pretty massive, 80 cases is a slow day for us). I thought one gal was going to be his RN, started to report, New Charge busted in and said, no report to Other Gal, we'll have him out of here by 8:30 (Other Gal got off at 8:30). I'm thinking she must not realize we've tried to wean and can't so I started to explain and she cut me off, "I know, I know, Day Charge told me all about it." Which, to me, says that she didn't think there was any weaning issue at all but rather I'm a slow nurse because I'm floating and I just wanted to hang onto a patient so I couldn't get a new one, and The Real PACU nurses would take care of business and get him to the floor. It's true that I'm slower than those who actually work there, but who isn't when they float? And I'm always very helpful to my fellow RNs while I'm there. I guess I have the mild satisfaction of knowing she was proven wrong, if she was saying what I think she meant. She's normally very nice, that was an exceptionally catty thing for her to say, so I don't know if she was having a bad day or if I misinterpreted. I feel a hundred times better. Thanks for reading my many words and using your few to talk me off the ledge :-)
  16. solneeshka

    I am still considered as a "New Graduate"?

    If you have only passed the NCLEX but have not actually worked as a nurse yet, then yes, you should apply to new grad job postings. Those postings are intended for nurses who don't yet have experience.