cmarn

Remember Bayada has both Home Health visit offices and in home nursing care for peds and vent patients. They are two separate home health practices. That being said, the "visit" side encourages full time employees to see apx 6 patients/points a day. As with any home health agency, your schedule can change, but you plan out your visits and turn in your schedule the Thursday prior to your work week. Bayada is a major HH agency that maintains a small company feel. In other words, you feel important, your voice can be heard...etc. Good luck...hope this helps.

Murphyle Great response! I do think that a lot of this will come with time. I've also realized that I spend a lot of time resisting the system in my mind because I can see its faults. That probably keeps me from thinking clearly at times so I need to let it go for now. I feel like I spend a lot of time trying to figure out who has the chart, does my patient have new orders, has the doc been in...etc. It is a huge communication issue. We all carry hospital issued cells so I'm not sure why it is so difficult. We have face to face report from ED to floor so I am not sure why we don't do that when a patient is brought from triage. Some people will put a patient in and assess them. Others drop them off and disappear. I just feel lost a lot of the time. Quick example of useless chaos.... Had 2 critical paitents/1 treat and street. I'm in with one of the new rescues(critical, very critical) working her up, starting an IV, drawing labs, etc. My phone rings and its the front desk saying "room 8 is calling out..(the non critical)" I tell her to let charge know I can't go right now. Five minutes later...my phone rings and it's charge "room 8 is calling out"..So, I take a sec and check on room 8. He wants to know when he is going to be discharged! Go to the desk and let them know again that I'm with a critical patient and room 8 doesn't have any orders yet. Back to my new critical patient...Phone rings again. Room 8....Are you serious??? I step out and room 8 says...when am I going home. I explain that I am with a critical patient and he needs to limit use of the call bell to emergencies. Now, in my mind the charge knew about my rescue (she's the one that told me the patient was coming to my room), the front desk knew I was busy. Where is the teamwork? I've just gotta find the right recipe for prioritizing and time management. I felt like I wasted a lot of time with a non critical patient and that I didn't have the support I needed from coworkers. I'll figure this out eventually. Maybe one day I'll be able to give someone else advice :)

Today was more of the same but I am just learning to have thick skin and stay ahead of the game. I had 4 rooms and a hallway assignment. Was taking out an IV to discharge a patient and got a phone call that I had a new rescue. Explained I would be just a minute. DC'd my patient quickly and went to the rescue. Now, that wouldn't be a problem but one of the aids I work with went up front and saw 3 to 4 nurses munching on goodies and told them my rooms were slammed. No one lifted a finger. I mentioned this to the charge nurse. Honestly, if there is a chart in the rack, I always help if I'm available so I just don't get complacency? Things that made today better... I communicated with the docs on a regular basis to anticipate what was around the bend. Focused on my critical patients and didn't spend us much time checking on patients who were just waiting for results. Had admission paperwork ready ahead of time. It helped me. The bottom line is I have to stop looking for what others "should" do and just keep truckin'

Thanks for the responses so far. Helpful. I've always thought of myself as very resourceful and efficient, but this has been a challenge. Our triage is a bit different. Not a lot is initiated there. If we have beds, especially CP patients, they are brought back and we start the protocol. It takes a bit longer that way and we are often trying to talk over registration to get our initial info... Regarding admissions, I am hoping to get a better handle on this. Even some of the nurses who have been there a while seem perplexed. I think what happens is that we complete every order on the chart...the doctor pulls all of his charts that he has been waiting on labs, studies, etc and decides whether or not to admit several patients at once. He then sticks it in the secretary's rack to order the bed...the secretary puts the chart in the done rack....Sometimes a bed is assigned within a few minutes...all without me knowing. I'm going to work with the assumption...everyone's an admission today and see how it goes :)

Hi folks! I am a 6yr nurse who recently transitioned to the ER. I am a perfectionist, like to have a plan, and believe communication is an essential part of medical care. (some of you are probably laughing...knowing where I am headed with this). I am hoping that some of you have some helpful tips. My biggest concerns are: Communication 1. When I am with an acute patient providing care, other patients are being put in my rooms, my name being put in the computer as the patient's nurse, and no assessment is done. I am not told that I have a new patient. Now...I know it's my responsibilty to keep track of these things BUT sometimes if I am with chest pain protocol, a tough IV, etc. it could be a while before I can check my other rooms. I have started making notes on these charts stating "assessment completed upon my knowledge of patient placement in room". 2. Admissions. Patients are being admitted and assigned rooms and I am never told. There is a lot to do to prep the patient for the floor and we take them up ourselves. I just feel like I need to be made aware and other nurses who might not be as busy could put meds in the computer, update vitals, etc. Again, I try to keep up but if I'm busy it might be a while. 3. Teamwork. If I am slammed and a chart is put in the rack with orders...why do other nurses sit at the desk talking and snacking? I don't understand. Shouldn't the charge nurse encourage others to help if another nurse is busy? It would be ideal if the charge or secretary could page us when we have new orders/admissions. Also, how to get the CNA's to help with updating vitals, getting urine specimens, EKGs, etc. 4. Organization. I could just use some general tips in how to be more efficient with my time...save a few steps. Are there things I can do to feel like I have a better handle on all of my rooms at once? Thanks for helping!

Agreed. Again, such a tough issue and both sides struggle. Often in the ER we are caring for one acute MI or stroke while 2 of our other patients have unknowingly been admitted. Once we figure out they are admitted and call to verify the room is ready (but when we get there...it isn't) we have 30 minutes to have the patient to the floor. Guess what? My thirty minutes was up before I knew the patient was going upstairs! Those who get faxed or verbal report...would you be available, the room clean, people available to transfer the patient if the nurse accompanied the patient? That is what our facility does and it ties up the ER staff for 30 to 40 minutes while critical patients are left unattended. The rooms and staff are rarely ever ready and we announced our arrival. I respect the work on the floor. I just think we both have to see their are two sides. I make a point to complete every order from the ER doc prior to coming to the floor. Once the hospitalist writes or calls in orders for the admission, he/she indicates "now" orders and I do those as well. Everything else is non acute and can be done in time on the floor. Where does the ER nurses responsibilty end? We are flying folks out, doing CPR (on that "unexpected patient in the room that wasn't ready), taking care of babies, adults, geriatrics, hanging drips, bathing the homeless guy before he gets to the floor, calling security for the delusional druggie, etc. It isn't that we don't want to help....we stablilize patients and transfer them for floor care. That's what we do. Our patients don't wait for bed assignments. They fill the rooms, hallways and waiting rooms.

Every single shift on the floor is like a day getting slammed in the ER? Really? For many reasons I have to disagree. Both are tough for very different reasons. Kudos to all nurses :)

I see where you are coming from. Let me give a bit of the flip side. I think it's tough for both the floor and ER nurse.. In our facility we call the floor to let them know we are on the way and let them know what's needed in the room ahead of time. We accompany the patient to the floor. In fact, if it is a remote tele or tele patient, the nurse and CNA take the patient to the floor. We also put the patient's complete med list in the computer prior to taking the patient. Here's our battle... I have 3 to 5 emergency patients. I put in the med list (which can take a lot of time...) I call the floor. I get to the floor and no one is available right away. The room isn't ready. I empty the room by myself, wait for transfer help. Get equipment for the room. Repeatedly page someone to take report. Sometimes I am on the floor for thirty minutes. During this 30 minutes I have other patients downstairs that might need to be admitted, may be critical, and probably have a new patient in the room I just emptied. I am not sure what the answer is to this issue? I agree that face to face report is a plus. I agree that it is best for a nurse to accompany a patient to the floor. We all know that patients can go from non-critical to critical in a heartbeat although we transfer them all over the hospital via transporters for all sorts of things. I agree that you should not be responsible for any patient you have not assessed yourself. We have that same issue. For example, my name is put in the computer as the nurse for the patient in the empty room downstairs while I am transporting a patient to the floor. I would love to know the best practice as well. Tough issue.

:redpinkheWow! I realize the original post was not intended to illicit such an opionated response; however, I do think it's a touchy subject for many. There seems to be a lack of respect on the part of both professions for one another. I think each profession has its place in the area of their specialized training. I have had personal experience working in an ER and office setting with EMTs/Paramedics. EMTs/Paramedics are trained in a very focused area of care. Thank God for them....they make split second decisions stablilizing our patients for transport to the hospital. They are accustomed to operating independently under a certain protocol. As nurses we are responsible for holistic care of patients and their families. We are trained to help stabilize patients, recognize contributing factors, long term care issues, education, working WITH physicians, coordinating care..etc. It seems like when EMTs/paramedics are introduced to care outside of the truck there is a struggle for power. I have dealt with many who do not want to take orders from nurses or physicians. They function outside of their scope of practice acting independently in an environment that is not conducive for them to do so. Once again, I appreciate their aggressive, focused care but the focus broadens after patients are stabilized and we have to be willing to appreciate that other disiplines are needed for continued care. As a nurse, I have never felt offended that repiratory therapy draws ABGs, or bags my patient in a code just because I can do these things myself. I welcome them and try to learn from their knowledge when they are willing to share. I have not met an EMT/Paramedic who exhibits this same attitude toward nurses. A few examples from the last few months.... Today: We had a code. EMTs brought patient in performing CPR. The patient was found unresponsive. We were told the patient had a pulse of 30. When the nurse asked why the patient did not have an IV, was not on the monitor, and had not had a FSBS, the EMT filed a formal complaint. I'll let you form your own opinion. (the patient's actual rate was above 100 and how did the EMTs know what the patients rhythm was?) As a Home Health Nurse I called rescue for a patient having abdominal and chest pain. The patient was bedbound and several co morbidities. He was requesting to go to the hospital. Rescue came and tried to convince the patient not to go to the hospital explaining that it was probably GERD. As nurses, paramedics, techs, etc....our job is never, NEVER to diagnose. They finally took the patient but never reported the abdominal pain to the ER. The patient was admitted to telemetry, discharged days later only to end up dying from a small bowel obstruction. Last, I worked in an office. Patient came in with chest pain. I had orders from the doctor to start saline lock, no fluids..send patient to ED. Paramedic came in took over disregarding MD orders, getting in the way of the IV start, hung fluids and delayed the patient's transport. I don't understand why anyone has to feel threatend, challenge other disciplines, or argue that we all have an area of expertise. Just because I don't want EMTs/Paramedics in the ER doesn't mean I don't think they are incredible at what they do.

Two suggestions. First, I would recommend having the KCI (or whatever company is providing the vac) rep meet you at the patient's home. They usually have a lot of really helpful suggestions and it is best if they can actually see the patient. Also, it may be helpful to get a condom cath or foley for the patient while the vac is on to lessen the moisture the patient's skin is exposed to. Hope this helps. Remember, that even if there isn't drainage the vac is providing negative pressure for wound healing. The lack of drainage may either be a poor seal or just reduced drainage. Hard to tell at this point.

Trying to come up with some ways to simplfy physician communication, especially at Start of Care. Currently our agency gets a referral from the hospital, phones the primary to verify he will sign orders, sees the patient, calls the primary back to get orders, mails the 485...etc. A lot of the doctors complain about the calls, faxes, etc. Truthfully, I have to wonder how many nurses are actually calling the doctors and getting all of the orders OR at the most are they leaving a voice mail with the nurse saying that we are seeing the patient? I would just be interested in coming up with a fax at start of care that has the complete orders for the doc to sign until we get the 485. Any thoughts? I wonder if this would be more efficient/less...take more time or less? What are others doing that works?

I agree with the previous replies. When I first started HH, I was very hard on myself. I thought I should be able to do it all. Well, the bottom line is you do have to set goals for all patients but you may have one CHF pt that teaching daily wt, diet, etc WILL keep out of the hospital. Another CHF pt may be non-compliant or just sick enough that you cannot keep home. The goals do not have to be the same for each pt. To me, our goals have to be realistic. For example, the first pts goals could be that they stay out of hospital and increase knowledge of disease process. The second pts goal might be lengthend time at home or identifying exacerbation of CHF earlier to avoid lengthy hospitalizations. You get the idea. Our CHFers will be back and forth. Don't think you aren't doing a great job!

Very helpful information! You are right about the office staff. Although it can be frustrating, I do try to remember that I wouldn't trade places for anything. We are fortunate to have 5 clinical supervisors and at least 8-10 office staff, so luckily they aren't in the postion to bear the full burden alone. The suggestion of keeping a journal was great. I have often considered documenting on the Oasis, "spoke with Jane Doe, RN who was aware of pt functional status (or whatever) and requested that pt be admitted for HH services" But the point isn't to get someone else in trouble...it is to CMA. With a journal of the calls I make and such at least I could refer to it in case a chart is questioned by MCR. HH truly is a great job. It is holistic nursing at its best. If we can be welcomed into a patients home, we can learn so much about them and what their needs are. How many people have all of us seen who were discharged from the hospital with no competent person at home to help....no heat...no food...no transportation, etc. We see it and pull all of our resources together for good pt. outcomes. Gotta love it!

I just wanted to see if all agencies have similar issues... I absolutely love Home Health. I feel like if we take time, we actually can help our patients. We have the time to sit with them in their own environment and educate them properly, monitor their conditions, troubleshoot...all things that aren't provided for in other environments. I feel strongly that we can make a difference. The issues that discourage me in my job are the following: Schedules: Our nurses who have regular visits (pay-per-visit) turn in their schedules mid-week for the following week. Many nurses have 8-12 patients on these schedules, sometimes as many as 14. Our quota is 6 per day. Now, there are nurses who want a lot of paitents because of the money, but they are finishing at the same time of day as those who have 6 patients. What this tells me is that the quanity may be preventing us from providing quality. The purpose of our visits should never be to take vital signs, chart, and leave. If we are providing a skilled need then I feel its important to take the time to educate and assess. If we aren't doing this our patients don't need our service. The nurses who don't want more than 6-7 patients have complained but are usually told that their is no one to cover their patients. Even if there is someone to cover, this nurse is still case managing a ridiculous number of patients. Usually the schedulers are scrambling the day of the service to cover visits. Not sure why if these schedules were turned in days ahead of time. We continue to do new admissions regardless of how many patients we have. I would imagine we would try to limit visits so that we can provide quality care to our patients. I would think that management would be monitoring the schedule and make necessary arrangements for this. If one nurse has too many new patients in a week I would hope they would consider her case load and reassign this patient. Mileage: Currently we are getting less than 40 cents a mile. It takes a long time for it to be increased when gas is high, but it takes no time for them to deduct... Qualifying patients: I feel strongly encouraged to accept patients that I do not feel are Home Health appropriate. Some examples: A patient who is not homebound who needs a one time foley dc. A patient from a doctor's office referral who has had HTN/diabetes for 25 years and manages their condition well but is looking for an aide.(referral says A/T disease process) A total hip who has been dc from SNF after a 2 month stay and is not taking Coumadin, no surgical wound. You get the picture. If I voice concern it is overlooked as me not wanting to do the work. And if I document honestly on the Oasis on functional status, I am asked to write notes as to why this patient is homeboud. (even though they might not be...) I am constantly hearing how "we need to meet quota" Poor referral information: When we get admissions to do in the a.m. we begin the tedious process. It usually takes 2 hours before we get our admissions and then we have to track down the patients. Some are still in the hospital, others have incorrect phone numbers and still others have no medication lists, etc. Without these things I feel it is difficult to provide quality care. How can you be sure the meds are correct if you don't have a list to compair to? Many, many, many patients are sent home from SNFs without discharge instructions, prescriptions for meds, newly dx diabetics without insulin, glucometers, syringes, etc. When we arrive we call the SNF and it takes days to reconcile for the patients. After I finally get out of the office in the morning, my admissions (in home) take at least 2 hours because of issues like this. Of course that doesn't include the paperwork in the office or follow-up doctors calls. Poor coordination Why do hospitals, SNFs, MDs give us referrals and refuse to provide timely call backs? If we are calling for orders or needing information, we are calling because we NEED it. I find that the hospital and SNF dc patients and do not feel obligated in any way to correct mistakes made on dc. We didn't give them prescriptions...sorry they are gone now! And MD offices...voice mail....no call back. We are just trying to help your patients! Office/Clinical I have heard that some offices handle this differently, so I am curious. Our nurses our in the field all day. They have to come into the office at the end of the day to fax labs, call MDs with results, get orders off their phones...I am curious if every office handles the orders and calls this way. If orders do get phoned to a nurse that works in the office it isn't called to the nurse in the field but just placed in her box. Many times Coumadin orders are phoned in office and orders are never written. That leaves the nurse calling the doc back and a very unhappy doc. I guess this is just all so frustrating because I really care about my patients and the kind of care they receive. I know our companies have to make money, but I feel there has to be a focus on the care we are documenting this patient needs. What do you think?