murphyle

370/day in a 39-bed shop?! That's not just efficiency, that's magic. You must have amazingly fast inpatient admissions, or be seeing a lot of fast-track traffic, to make that work. How do you keep up that kind of throughput?

45-bed adult acute care/10-bed adult minor care/10-bed pediatric acute care, seeing 280-330 patients/day: An acute care team, of which we run four, consists of one physician (plus or minus a resident or a PA/NP), three RNs, one tech, one secretary and one "tech aide" (these folks handle vitals, transport, patient comfort, and stocking). Up to 15 "active" patients can be slated to a team. We occasionally alter the ratio upward if a team is full of low-acuity hold traffic, and frequently cut the ratio down if it's all Priority II and post-resus. We also typically staff at least two float nurses and a float tech at all hours, and try to staff a fourth nurse and occasionally a second tech per team during peak hours to cover Resus and manage the heavy players. Minor Care gets two PAs, two nurses and a tech; Peds runs two pediatric NPs, three nurses and two techs, with the whole thing supervised by one physician. Those two units are side-by-side, so staff typically float between the two if traffic in one zone is low. Tech aides typically handle psych sits if we can't get house sitters (and with our volumes, the house is usually pretty good about finding us sit coverage). On top of all that you have anywhere from 2-4 nurses and a like number of techs and tech aides at Triage, another nurse and a tech in the Ambulance Bay, and two nurse clinicians running the show (one out at Triage and one in the back). We also get ancillary support from Respiratory (one RT staffed for the department 24/7, two during peak hours) and Pharmacy (EC pharmacist on duty 0700-1600 Mon-Sat). I agree with the OP that his/her staffing mix seems very lean for the volume and acuity described, and would likewise suggest that the issue of perceived poor performance stems more from departmental short staffing than his/her speed of work. However, I'm a little surprised to hear that other shops are running with 1:3 ratios and staff feel that that's struggling. When we've up-staffed to that degree in the past, we typically see a lot of slack staff and no real improvement in patient care metrics.

Anecdotal evidence suggests that warming lidocaine decreases burning and stinging associated with local infiltration. I have not seen any papers proving this one way or another. We typically do not warm our lido beforehand, except in the context of rolling the vial in your hand for a few moments prior to drawing the dose. The drug is stored at controlled room temperature in our automated dispensing cabinets. I would be curious to know if there is any degradation of the drug associated with medium- to long-term storage in a fluid warmer.

IV starts are a "delegatable task" in our shop, and many of our EC techs are frankly brilliant at it. Indeed, we typically assign our orienting nurses to work with an experienced tech for half a shift or so to develop their IV competencies. We do reserve EJ starts to nurses who've completed a competency training program and been "checked off" by one of our physicians.

We do have a quite robust plan for viral hemorrhagic fevers in place in my department, covering identification at Triage, a chain of notification, rooming requirements and visitor policies. If anything, it might err on the side of overkill (it calls for airborne isolation to be instituted and staff to wear Level C suits with PAPRs when treating known or suspected Ebola patients). Then again, given the eternal battle we all face to get people to wash their hands, they might just be using the Level C requirement as a forcing function... I'm far more worried about enterovirus D68, frankly. The respiratory season here is already ramping up big time, and these kids are sick. In years past, pediatric respiratory complaints usually followed an 80/20 rule (80% well kids with worried parents vs. 20% legitimately sick kids). This year, it's more like 60% sick kids, and far more of them than one would typically expect for mid-September, even accounting for the usual back-to-school spate of URI and gastro. Nobody's confirmed any actual cases of D68 in this state yet, but I don't think we have all that long to wait - and that's one bug for which we don't yet have a plan in place. Implications... unpleasant.

We've been waging this battle in my shop for the last 4.5 years that I've been in practice, and likely for a lot longer before that. Our physicians have repeatedly stated that they no longer agree with routine Foleys for pelvic ultrasound, we certainly don't like placing them because we incur trouble for violating the CAUTI protocol, and our radiologists have stated they don't care one way or the other as long as the image quality is decent. However, all our hands are tied by a certain non-trivial number of sonographers who will not perform any pelvic or abdominal ultrasound for any reason without a Foley. I've even had my ECP write a physician-to-nurse order "Do NOT place Foley for ultrasound, please send patient for exam when bladder full" and had the sonographer refuse to do the exam. (They also adhere to the rather quaint practice ADeks mentioned of refusing to do exams without a quantitative HCG result in hand, but that's another story.) This issue has gone to the respective chiefs and directors of all parties involved (physicians, nurses and radiology technologists) at least three times that I know of, has come out with the same resolution every time (no Foley for pelvic U/S unless truly emergent), and yet we still have problems. At this point, I'm not sure if it's a lack-of-education issue or just plain stubbornness. For those of you who have working no-Foley practices, how did you get all your stakeholders on-board?

45-bed department, midsize community hospital: An acute care team consists of one MD, three RNs, one tech and one secretary for up to 15 patients. ECGs are done by dedicated staff from Heart & Vascular Services (one always stationed at Triage, the other floats). One RT floats the department for nebs, ABG sticks and vent management. Techs can draw labs, start lines and insert Foleys. RNs do everything else. (Typically you and your tech will agree at the start of the shift what you want him/her to do for you - e.g. "I'll start my own lines if you can get my vitals" or some other such arrangement).

So let me make sure I understand this: you got into it with a charge nurse, then made an error and didn't document it, for which you've already had a verbal counseling and are being threatened with Warning A, and now you're slacking at work, complaining about the "unfairness" of your assignments, and developing an absenteeism problem? And all this in an eight-month period? In my shop you'd never have gotten off orientation. I've seen nothing in your post that demonstrates that you have the maturity or the skills to work trauma/resus of any description, let alone Level I. You need to be able to demonstrate that you can come to work on time every time, do the work as you're ordered, and work effectively with fellow nurses as well as management. Based on what you've stated, I wouldn't train you for trauma either. Why would I spend the money and the resources, when you're already a net liability (forcing the department to use pull staff or work short every time you call in is a huge patient safety risk as well as a cost issue) and not likely to be here in six months or a year? You need to sit down and have a good hard look at whether this is the right specialty or even the right profession for you. If you're insistent upon staying, then I'd request a meeting with the charge, your nurse manager and HR (plus or minus a union rep, if your shop is unionized). Make it very clear that you know you've screwed up royally and work with your managers to develop a performance improvement plan. Be prepared to keep your head down and eat low-rank assignments for however long as that plan entails. You will need to accept that you're going to be on the short end of the stick for a very long time while you repair all the damage you've done yourself. If that isn't something you can do, then get out before you're fired. In this day and age, a termination for cause (in any career) means you'll never work again. Good luck. I hope it works out for you.

Head-to-toe assessment, LDA (Line/Drain/Airway) documentation, SIRS screen, Braden and safety assessment are all done q shift, plus any changes. Strips (at a minimum two ECG leads and your alarm limits, as well as anything else with a waveform - art line, PA line, et al) have to be printed, mounted, analyzed and signed q shift. Diagnosis-related notes also have to be written q shift. Neuro and neurovascular are done q4h unless ordered otherwise. VS, I&O, vent settings, positioning and glucose check q1h unless ordered otherwise. (By policy you can go to q2h on your glucoses if your patient has had target-range glucoses and no titration required on their insulin for four hours or more.) If your patient is in soft wrist cuffs for a vent, that has to be checked q1h; leathers are vanishingly rare here, but if your patient does have them it's q15min. On fresh post-ops, we do initial head-to-toe within 15 minutes of arrival, and VS and I&O q15min x4 sets, then q30min x4 sets, then q1h thereafter. Hemodynamic profiling off the Swan is done on arrival, then q2h and PRN.

You do? Interesting. Policy here is that any Swanned patient has to stay on SBR, due to concerns about accidental migration of the catheter (either RV whip or PA occlusion).

I'm in a cardiovascular surgical ICU, so every post-op heart comes back with a Swan. We have rather a love/hate relationship with them; they're great for accurate hemodynamics, but as long as the Swan stays in, the patient has to stay in bed, which makes us look bad on early mobility goal measures. Hence, we're seeing a few of our docs and midlevels start pushing for Vigileo FloTrac on patients whom they want mobilized but still want hemodynamic monitoring. Therein lies the rub. My issue with FloTrac, and by extension most of the minimally invasive devices (whether they run off a radial A-line or a bioimpedance method) has to do with the accuracy of the system under one of the reps' biggest selling points - namely that such systems claim to provide hemodynamic profiling that doesn't require the patient to be vented and bedbound. For an intubated, vented, bedbound patient on a pile of drips (i.e. your average MICU player), Swan and FloTrac are probably going to come up with pretty similar numbers, and FloTrac might well be the better choice. However, once your patent is extubated and starting to get mobile, the FloTrac becomes less and less reliable, to the point where it eventually starts giving you voodoo numbers. If you have a patient who still needs hemodynamic profiling at that point (worried about low CO/CI r/t hx systolic failure or hx cardiogenic shock, need to titrate inotropes, whatever), the machine starts turning from a friend into a frenemy. FloTrac's accuracy also suffers if your patient is arrhythmic for whatever reason (A-fib, higher order AV blocks, other sinus and supraventricular arrhythmias, etc). As a result, I've seen nurses, midlevels and physicians all trying to manage patients - and erring badly - as a result of inaccurate FloTrac data. In a case of serendipity, I had an extensive discussion with our local Edwards Lifesciences rep yesterday about just this issue. According to her, there's a next generation system coming out Real Soon Now that aims to address all those issues and more. Personally, I won't be holding my breath.

Feline, your resume looks an awful lot like mine! I am also a 3-year emergency veteran, who just transferred to CV-SICU a few weeks ago. The only differences were that I came from a Level II center, and already had my CEN and CCRN when I applied. :-) Like you, I preferentially worked Resus and ICU holds, and had a fairly extensive body of work as an emergency critical care specialist to back up my application. I was not asked about drips in my interview at all; rather, it was expected that one wouldn't be applying if one didn't at least know the basics there. Instead, they wanted to know about my familiarity with invasive hemodynamics (Swan-Ganz, Vigileo FloTrac, IABP, etc) and vents. I also heavily emphasized my interest in critical care and preference of Resus and Priority I/II assignments during the interview, which I think may have been the deciding factor. Juan's comment quite closely reflects the experience I had interviewing, and I think he offers some excellent advice. Good luck to you!

Reply to Airwayguru: Neither. I wear Aviator Scrubs - Classic shirt, ER pants. They're comfy, last forever, and are the source of one of my two department nicknames, "Pockets."

For me, this question should read "What's in your pockets", plural, as I'm quite well known for the plethora of them on my scrubs. That said, on to the tally... Left sleeve #1 and 2: Pen and penlight. Left chest: Surgical site marker, misc personals (chap stick, artificial tears, etc). Belt clip: Stethoscope, mobile phone w/ apps. Left hip: Leatherman multi-tool. (Amazingly handy for fixing gronked-on clamps, busted electronic gear, etc...) Right hip: Wallet, loose change. Left thigh #1: Carpuject adaptor. Left thigh #2: Department SpectraLink. Left thigh #3: Rolls of tape (1 silk, 1 paper - nothing quite so annoying as "I'm allergic to tape!!" just as you're securing that impossible-to-obtain IV...) Right thigh #1: Pocket vision card and tape measure. Right thigh #2: Trauma shears. Right thigh #3: Alcohol and Betadine swabs. Left lower leg: Misc papers.

"303's EtOH is only 378 this time, which for them is practically stone cold sober." "Your Resus coverage is the med student, the resident and (slow-moving attending). I'll light a candle for you." "He's had three liters bolus, six units of PRBCs, four of FFP, a six-pack of platelets, Levo just went up, and MedFlight was supposed to be here half an hour ago. And yes, that really is his pressure." "Patient speaks not a lick of English, is older than God and apparently too demented to use Language Line, and the family stayed just long enough to sign the consent and split."

Love it! We call our department's "breakfast club" the Atheists' Bible Study. :cheers:

It's funny that you ask this question, as I just had this conversation the other night with an SN who was shadowing me through the usual twelve hours of mayhem that constitutes an emergency shift. I come from a family of medical professionals, in particular both my parents, who are a surgeon and a surgical nurse administrator respectively. I laugh that I grew up in a hospital, but in truth it isn't a joke; since the OR started operations at 6 AM and school wasn't till 8, every day was Take Your Daughter To Work Day. We'd go to the hospital in the morning, Mom would take her break and run me to school at 7:45, and then pick me up again at 4 PM and we'd go back to the hospital till 6 or so. Likewise, Dad's call schedule dictated what we could do, where we could go, and whether or not we could participate in family events. More than once we had to leave parties, christenings and the like because of an acute appendix or whatnot. I never knew any other way of life. When I went through nursing school, I and my classmates had the same lessons drilled into our heads. (It may not be coincidence that our program director was also a former DON of surgery...) Now, as a practicing nurse in a very busy emergency center, I very rarely work less than 4x12 per week, and get called in on a fairly regular basis. Is it stressful? Sometimes. There are occasions when I'd like to go out with my friends or go on vacations, and I can't because I'm at work. Does my family understand? Absolutely; in fact, they'd be righteously furious with me if I went to a party or family get-together and declined a call from the hospital as a result. Would I change it? Probably not. I was raised to believe that when you sign on the dotted line and accept your licensure, you take on an obligation to care for every patient that's out there. Your own life, and that of your family, must become a secondary or tertiary concern; your primary responsibility is to your patients. If you can't make that commitment... this may not be the career for you. I'm aware that mine may not be a popular viewpoint or opinion, but that's how I learned, and that's how I manage my practice. As always, your mileage may vary. :)

I think I've done pretty much all of the things people have mentioned here, and they all work pretty well. I'm also quite fortunate to have a family full of people "on the job," so I frequently try to debrief when I get home, good night or bad. Usually a bad night calls for a run or a workout. I go to a Crossfit gym not too far from my home, and if I've had an absolute garbage night at work I'll request a WOD with sledgehammers or ball slams. (For the non-initiated, a WOD is a Workout of the Day, which can be done as a set number of exercises or an AMRAP - As Many Rounds As Possible in a set time. Any given WOD can involve weight lifting, cardio of the run or rowing variety, martial arts, jumping on boxes, lifting and flipping tractor tires, swinging kettlebells, or pretty much anything else you can think of. Some exercises involve hammering on a tire with a sledgehammer, or hoisting a medicine ball over your head and slamming it on the ground repeatedly. Wonderful stress relief!)

Major community hospital in a major metropolitan area, working the midnight shift... Giving nebs: No, Respiratory does this. Drawing own labs: Yes. Starting your own IVs: Yes. If you have a tech to help you (see #2), that's bonus. Otherwise you do it yourself. Running own blood gases: Not really. Respiratory does arterial sticks, we draw off A-lines. Either way they get tubed down to Lab for the actual testing. Cleaning own rooms: Yes, unless it was an isolation clean (MRSA, VRE, C. diff, then we call Environmental Services). Walking pt to radiology, CT etc: Yes. Again, if you have departmental transport, that's bonus. Testing urine: No. Collect it and send it to lab. Mixing meds: Sometimes. Emergent stuff (vasoactives, cardioactives) and some antibiotics we mix ourselves until Pharmacy can get us an in-house bag. Caths, NG insertions: Yes. Trach suctioning: Yes, though Respiratory does the initial oral care and deep suction on newly intubated/vented patients (part of the VAP bundle).

I have a pair of Miltex 8.5" utility shears that were recommended elsewhere on this site. Might be a little on the pricey side for shears, especially as compared to EMS and drug-rep freebies, but they cut through anything and they're practically indestructible. (I actually bought two more pairs for my parents for household use, after I caught Dad using my work pair for impromptu backyard tree pruning... ) Plus, the Day-Glo green handles make them very recognizable, which may serve as a deterrent to departmental theft. http://www.expresssurgical.com/Shopping/Products/ProductDetail/571/Bandage-and-Utility-Scissors-8-1-2-%2821-6-cm%29,-with-fluoride-coated-blades,-serrated-blade,-autoclavable.cfm

I'd agree with Altra's assessment: we're always busy, but things go in cycles. * Winter sees lots of falls (and their ugly siblings, falls on anticoagulants), respiratory crud of all descriptions, infectious disease (two big subgroups there: flu, RSV and other respiratory bugs, and rotavirus and other GI bugs), and cardiac workups (holiday hearts, snow-shoveling ACS, etc). * In spring we get a lot of asthma exacerbation and exercise-related injury (people trying to go from couch to workout warrior overnight). SNF/ECF traffic seems to spike up in spring, too - not sure why. * Summer is trauma and assault season, and Altra is absolutely right about both parental holidays being associated with home improvement mishaps. ("Honey, look what I built you for Mother's Day!" *crash*) * Fall tends to look like spring, with the added fun of party traffic. (Many of the predominant ethnic groups in this area tend to hold weddings and family reunions in fall, which are always good for at least one guest developing ACS, syncope, and/or gastro.) * Sporting events bring the business year-round. (Someone's always playing somewhere: Tigers, Lions, Pistons, Red Wings, U of M, MSU...)

Definitely ask your manager. According to AORN*, surgical personnel should wear hospital-provided, professionally laundered scrubs that are made of low-linting fabric and fit in a loose and comfortable fashion. Tight-fitting scrubs increase skin friction and contribute to increased dispersal of body "scurf" - dead skin and commensal bacteria - in the surgical environment. Home laundering and home wear of surgical scrubs are not recommended due to the risk of cross-contamination from home and surgical environments. Home washers, even those equipped with "sanitize" cycles, don't get reliably hot enough to kill OR bugs, and home washers are definitely not rated to deal with hospital-grade sanitizing agents in effective concentrations. Throwing a shot of Clorox or Oxi-Clean in the washer with your scrubs is not going to do the trick. (As a side note, you always wondered how OR scrubs get that "broken in" look and feel so quickly... ) Home laundering also poses the risk of bringing external contaminants, such as smoke or animal dander, into the perioperative environment - another big no-no. As others have said, if the hospital is providing your scrubs, they will have to provide them in your size, and that's something for your manager to address. In the meantime, if you get in a pinch, you can usually call other scrub-wearing units in the hospital (for us, that's OR/PACU, Central Processing, and Labor & Delivery) and ask them to check their inventory for plus sizes. Ask nicely and they'll be happy to tube you down a spare pair. From my own experience, I've been in your predicament on more than a few occasions, but in reverse: in my hospital, it's smaller-sized scrubs you can't find. Our inventory runs predominantly to the plus sizes (look through any scrubs locker and you'll find no S, one or two M, one or two L, and a dozen or so XL-3XL), so people will beg, borrow and steal for smalls and mediums. (We actually had to special-order 2XS scrubs and 5.5 gloves for one of our residents, who's a good bit under 5'0" - poor thing looked like a kid playing dress-up in regular smalls.) Hope this helps! * Association of periOperative Registered Nurses. (2010). Perioperative Standards and Recommended Practices. (2010 Ed.). Denver, CO: Author.

Love these! ...If you've ever straight-facedly said "Okay, you'll feel a little pinch" while putting in a 14ga EJ. ...If you've had to crash sedate a seizing, febrile infant, with the parents standing there saying "Of course we didn't give any Tylenol, we wanted you to see how high the fever was getting!" ...If you've wished you could offer a teenage patient a surgical consult to remove that ingrown mobile phone from their fingers. ...If you've spiced up the old EtOH betting pool by adding side bets on the results of urine drug screens. ...If you can correctly cite the ingredients in a B-52.

The first time I had a "stable" patient go down the drain came about eight months into my nursing career. I'd been on scads of resuscitation teams, dealt with everything from chest pain to respiratory failure to massive trauma, but I'd never had one of mine crash. The patient was a hypertensive but otherwise healthy guy, in for acute exacerbation of chronic cholecystitis, and was scheduled for cholecystectomy later that morning. I was in taking care of one of my other patients, another nurse walked in to check on this guy, when he suddenly began to complain of "stomach pain" different from the RUQ pain he'd been having. She called me in, saying "He doesn't look right"; I walked in the room to find the patient gray and diaphoretic, with a major sinus brady of 35 down from the 60s, and his BP had dropped from 140s/90s 5 min previous, to 70/30 at that point. I laid him down flat, opened his IV bag wide open and grabbed the MD... and just as she walked in, the patient's eyes rolled back and he flatlined. No joke, no error - no palpable pulses and the monitor beeping "ALARM: ASYSTOLE." I yelled "Call Resus, now!" as the doc and I ran him down the hall to the trauma bay, doing this resuscitative three-legged race in the process (one of us on either side of the stretcher, both of us doing one-armed compressions with one hand on top of the other). The guy woke up as we were pulling into the bay. Opened his eyes, looked around at the assembled team, and said "What happened, why is my chest so sore, and why are you all looking at me like that?" Of course, surgery was off the table at that point, and the patient went up to Critical Care for a cardiology workup (with a monitor and one very cautious nurse escort). The culprit turned out to be his metoprolol from home, which he'd taken a couple of hours before arrival. BP dropped, HR dropped and bang, down he went. He walked out of the hospital two days later with no cardiac or neurological sequelae at all. I figure that incident counted as my cardiac stress test for the year!

Echoing what others have said: in our system, a PSQI (Patient Safety/Quality Improvement report) can be written by anyone, at anytime, on any subject. That report automatically goes to the involved departments' managers/directors, and by policy must be addressed within 24 hours of filing. Even if that's to say "no cause for complaint found, case closed," the NM still has to review and sign off the case, and frequently that means they'll ask you for your side of the story. However, our PSQI system is completely non-punitive, and PSQIs can't be used against you in any kind of job action, nor are they admissible evidence in any kind of legal action. In that sense, no, you can't be "written up" by anyone other than your supervisor. Hope this helps!