heart queen

okay, now I got ya. From the point of an ICU nurse being pulled to handle an emergent crisis while being legally responsible for patients on another unit... is why I've stated this WON"T work... you're point exactly. A bit slow on the uptake here. so let me help you validate your point. As I've stated with my knowledge of my pervious hospital... the RRT does NOT, NOT have a pt. assignment, shared in the budget by the ICU's, fractioned in the units with the "code". So in this situation... the ONLY situation that an RRT should be utilized will work. my assumption is that some lunk-head manager has come across one piece of literature and has been given the go ahead to trial this with out the budget to ensure it's success. Regardless of ICU or ER nurse, there are critical patients going without care while you're butt is somewhere else, treating a patient that most likely will come to you... or in your scenerio... worse... goto step down... where you've now been tied up for an hour and have to pass off care to ANOTHER nurse.. So in you're situation, as I've stated from the beginning... this is NOT the theory behing the RRT, you're facility is half arsing it and screwing up the patient care. gather all the literature you can... log your time away from patients as well as all the chaos going on in the unit you left... as well as basic care that was negligent. I'm not flip flppping my response because you're ICU too, I'm recognizing the inability for this plan to work with the restraints they've tied you with. as always, ya've got my support, this stinks like last weeks garbage.

having interviewed and trained new nurses, my primary concern would be the patient population.... what good is 6 months in a CCU, when you crave a varirty of patients, also not how long,,, but what classes does the orientation include... hemodynamics? vents? Hoe long before you will be asked to take charge (don't laugh...I was put in charge of a new group 60 or less days off orientation). What is your learning preference? Do you learn best from one strict set of rules then formulate your own game plan, or do you prefer to be exposed to many differing points of view... ask for your preference in one or many preceptors. If you require more orientation than the facility plan allows... how do they handle this? punitive... or leisurley? How soon off orientation will you be required to float, and what type of orientation will be provided for those different units? How soon do they expect you to be up and running? It takes 6 months for a new grad, a good facillity will back classes, clinicals,,, then orientation, than resource to almost 9 months... one you should run from says 30 days. It really takes 18 months for you to feel confident.. not nervous on the way in to work... is there a mentor program to help with your transition... and who will be there to help guide you with clinical questions after orientation... how many years do they have in? If one half the people I trained asked these questions... about 40% wouldn't have taken the job... those that did, in my facility had an excellent orientation... followed by chaos. We always had turn over... and your experienced person... person... was now training a newbie... and did their best to help you.... Not scaring you at all.... let the buyer beware... watch what you ask for... you may get it... so know what you're getting into.. ps... managers love to have interviewie's ask questions.... REALLY... so let them talk... and listen, I hope this is what you're looking for.... again, NOT trying to scare you off... just be aware ofthe pitfalls... you'll be able to spot a desperate facility quickly let us know... and snatch it if it's a good deal.... starting out... it's NOT about the money... that WILL come.

we too use the sage tooth brushes, which are more expensive than the green swabs. It comes in a kit, with a peroxide mix, that you break and the brush/swab is now wet. Per manufacturer recommendations, this is used to clean the mouth Q4 hrs. it is not only a tongue, but a tooth scrub wit a closed sealed suction that doesn't get drty in the bed, floor ect. our VAP's have decreased 14% with only the oral kit and a refutable 35% with the addition of the hill rom pulmonary rotation /percussion beds. Think of all your yankours laying on the floor This kit has a sheath that protects it from that. Utilize your clinical ladder folk to do an inhouse study if your manager hems and haws about the cost, but the literature is pretty sound from my look up's, it's the personall's lack of compliance, or faked compliance which sques the studies. our team taped 24 hrs. worth of supplies to the wall, mouth care was documented Q4hrs, yet there were remaining supplies.... an easy way to figure compliance ratios.

perhaps I only inflamed your idea of an RRT, and did a poor job of trying to prove their benefit?? I'm sorry if I did. My friend, from a former hospital I worked now has a RRT in place... who's budget DOES allow this nurse to be all that... previously the busy ER staff went to codes... just the same theory as ICU staff. A nurse can't function collaboratively... when their legally responsible for a patient is on another unit... so their loyalties and needs are split... which is where the quick fix... leading to ego's rearing can happen! They, like you are then spread too thin. There is NO dumping on a RRT... it's what they do... period... when crisis is over, on down time... their skills are utilized in appropriate areas to justify the cost to this position...they are fractioned from the budget from each ICU's and clock thier time on work sheets to prove the off hour needs of a free ICU hand even if it's being the transport nurse to cat scan. No one is doubting your ability and expertise to relate to the MD the crisis. Think of how much valuable time is spent with one crumping patient... while you have 5-10 or more others. This is the point of the RRT (and no I don't work for your facility, seceretly trying to talk you into this). No one is trying to step on your toes....which are very capable ones at that. You have a HR of 150, a RR of 30 with an spo2 of 86 a BP of 90/60 in a post surgical hip with CAD. Is it pneumonia? Is it PAT, SVT, AFIB, WPW? Is the respiratory compromise causing the increased HR and lower BP? or is the CAD causing the rapid HR and the RR is an intolerance of it?. You're there to focus on mobility, warding off infection and pain controll, not manage a crisis ... and you need to be okay with this.... you don't have to do it all to provide the excellent care that you do!. The RRT with your help can assist the MD in either treating it as respiratory or cardiac..... what if you need to start pushing IV meds STAT in a non code... warding off code situation? The RRT can help the MD determine beta verse calcium channel blockers... has time to look up K and mag levels... draw abg's, read ekg's.... maybe stabalize the patient to go to tele instead of taking the last ICU bed... when another pt. is crumping on another unit who may need the bed more. The reason I see your point, which you may not believe is that the wife of my friend that works that ICU with the RRT... works the floors. We've shared many breakfast post events where her night went to pot wih 8 patients and the one crumping set her two plus hours behind. That is what this should be about.... the patients NOT receiving care on your unit when You're tied up! Not that you aren't capable. my goodness, you have a management that really wants to help you in this crisis and take some of the load off you to better care for the OTHER patients. This is not a dig about your abililty... it is about the time alloted to you, period. I hope that I have tried to say, in way to many words... that you ARE capable... and you don't need the RRT.... but your remaining pt's do. This isn't about your skills (you manage a workload that I am envious of the ability to). This REALLY may be a legit solution. I understand your position, please at least evaluate that this might work... I too am worried about the mannerisms and scathing comments that can come from the RRT (ICU nurses)... I am one... I've made the boo-boo's... and I've seen some scars made by others, maybe even myself. But we can learn as we go and give sincere apologies when we fail and work through this... cause the patients CAN benefit.... and that's why we're (I'm there). ((not trying to sound sappy)).... It may be that you've been burnt way too many times by your ICU team... to have trust in them?..... I look foreward to talking about this more... ps, my spelling stinks if you haven't noticed. And I really DO care that you're worried about this and I'd, like many other nurses... NEVER send you on your merry way! sue

I found the articles varying, which I think acurately reflects our current recussitation/ family present practices.. I'm a critical care float, er- ccu, micu, cvicu, eieio...! My own personal practice is to being in every single family member on a unit where there is little hope and the family has no CLUE.... you want this done? Have a seat and watch. 5 minutes in... family begs you to stop. no lawsuits... they can barely live with the picture in their heads of what they wanted done. Suddeness of a previous expected good outcome turned bad... I bring the family in when we're near the end (assuming they want to be there). Let 'em see the heroic measures.. the flat line... the defib... the CPR. They can have peace knowing EVERYTHING was done. ER- the pure suddeness and crazyness is a case by case basis. We do have a family facilitator who will stand with the family and support them. long and short, I bring EVERYONE in if appropriate... the other staff really HATES that I do this. It does force everyone to act professional and it really requires a post code meeting... to have a private discussion on your issues.. not able to be aired durring the code.

I was just a the lovenox site for reference. There is NO mention as to clinical trials or to dosing with IV. http://www.lovenox.com/consumer/thrombosis/heparin1.do I'm not refuting, or arguing with the posters stating that IV is used, simply stating that the drugs own site does not provide safe IV dosing or provide a recommended IV dose with clinical proof of the risks vrs. bennies. Our facility is strictly sq, with reopro, integrillin and all the what not's... can anyone give me some clinical info as to WHY this would be preferred.... aside from quicker onset of action... but why not just the glycoproteins, heparin or thrombolysis... with the manufacturer not stating an IV use? Is there new literature out ther? PLEASE share it, so we can improve our outcomes! thanks all

My understanding of the purpose of this... is to; 1. free up the hands of a VERY busy floor nurse 2. lend an extra helping hand in assessing a pt. by a nurse more familiar with the "pt. crumping routine" 3. have that extra set of hands to hang drips, push meds.. maybe not allowed on a particular unit, look at an ekg, draw a blood gas... hook up to a portible monitor (which many floor nurses are not trained to read).. and get the whole picture to present to a doc. 4. That nurse can now call the primary doc and give an assessment (not that afloor nurse can't... but the stat nurse has additional skills to not only aid the doc on the phone in a diagnosis... but help treat emergent situations... that fllor nurses not only don't have the time for... but might not be allowed to provide.. regardless of their knowlege or skill level. ie. your pt's crumping.. you call the stat nurse, they arrive.. you give them the MAR, chart and a quick report.... you can now attend to your other UMPTEEN pt's and let that nurse handle the crisis. You check in as frequently as possible. Your sick pt. now has an ICU nurse at the bedside... you aren't two hours behind and ALLLLLL the patients continue to receive care! I would take each interaction as indepedent. A stat nurse with a crappy attitude twords you can be pulled aside post situation, or a note to their manager. Consider the learning possible if you actually have time to be in the room and assist in the process. If this plan is presented in this way.... the way it SHOULD work... with and additional plan for ego's... you'll have immediate buy in by the floor nurse staff. ps. this stat nurse CANNOT have patients in the ICU. they should be utilized for IV service, educational classes, and an ICU pair of hands during off need time. IF NOT, this is doomed for failure. try to keep an open mind as how this can REALLY free you up and give the best care possible to all the patients.

It's my practice that this is a common problem, due to the facility, especially the medical director allowing the cardiothoracic surgeons to have the final say as to who's appropriate for the cvicu bed. This created havoc for us. we, management, lead nurses and the MD's to adopt to a clinical pathway for fresh open hearts... a care map of expected outcomes over a 48 hr. period. many facilities utilize this. Your manager must buy in, then the nursing leader also the medical director, who is in CHARGE of the MD's. once in place... any patient who becomes respiratory ie long term wean (not on iabp or vad)... automatically transfers out after 72 hrs to either a respiratory ICU or the CCU. Many facilities who do more than 3 hearts with less than 10 beds move them in less time. This frees the beds for the fresh hearts. We were forced (due to lack of buy in from the doc's) to allocate a specific # of beds per surgeon. Therefore if they didn't transfer a pt. to step down or another ICU... their heart, valve or what not was.. CANCELED... period. it was then upto that particular surgeon to beg, borrow or steal a bed from another surgeon... which rarely happened. It was no longer a nursing issue. Cancel a few hearts and they get the point quickly. In addition, we set up a step down, specific to the cvicu who could take any extubated, unswanned (no iabp or vad) pt. 12 hrs. out.... we fast track our hearts, many done off pump and mid cab. The step down nurses only took 4 patients, and after morning rounds if beds were open (no heart transferes) they took overflow tele (usualy pre op hearts to slosh the bed). You MUST have the proper backing in place prior to implementing.. a standardized care map for the surgeons (which they help develop) is a must for a standard to follow. getting all involved early, buy-in early is a must! let me know what you think... ask the manager to start a committee to sole this issue. sue

has your team considered a vagal nerve stimulator?

I'm so sorry to hear of your grandbaby's death. I understand your need for answers as to why, especially with a medication error so close to her death. I only work with adults, yet this shouldn't change practice with med error reporting. Having worked in a few facilities, the practices do varry with alerting families. If I've forgotten a med and missed it, after speaking to the MD, I follow the orders, alert the patient (family) and monitor. Big errors are first treated, then discussed with risk management and a family notification plan is made. but they are still notified. Perhaps your wanting to prevent this from occuring again can lead you to meetings with the manager and pharmacist to change policy, and add education or whatever is needed. I've never been in your position so I can't honestly give a personal comment on litigation. As a working professional, I know that having made an error will scar my soul more than a jury verdict will. I hope that your search and decisions to act will bring peace to your heart.

our schedule comes out in 4 week blocks. requirements; every other weekend, your weekend doesn't change unless you make a switch for that schedule out of the four mondays and four fridays you must work four of either. This guarentees that you can get a three day weekend off. so you can either box your weekend with on friday, off sat, sun. on monday or work a three in a row, fri, sat sun.. . or sat, sun mon. then mondays and fridays are never short like regular scheduling. when switches need to be made due to 7's on one day and two's on another, it starts with the least senior.. who is switched on only one occurrence, then the next least senior for one and on up it moves. In addition every staff member has a scheduling preference form filled out for reference... so you know "bill" prefers never to be switched to a wedn. or sue can't work 3 in a row which really helps with staff satisfaction if they can't get their first choices. The four person scheduling committee two on days, two on nights was chosen by staff, who voted for the people they felt would be most fair. The manager will settle disputes, in private with the committee and only reviews the holiday schedule prior to posting... as it's always a hot topic!

I've just read the link about an intruder stabbing a RN. My facility, an inner city, poorly located one, has the poorest security I've witnessed in my career (5 facilities). I've had a hell of an event and I really need your input, please bear with me. Although I'm in an ICU, it is no different from the floors, so this is NOT ICU specific and PLEASE let's not turn this into a visitation thread, please. My ICU is not a locked unit, my first experience with this. the ER is the only area that has lock released doors. After 8pm, this is the only open enterance into the facility. Security starts and stops here, they let you in, or they don't. long story short, a young pt. with "no warning" arrives at deaths door, intubated, all systems shutting down, codes multiple times... Husband, who is suspected of poisening her (no evidence... the screen will take 72 hrs) refuses to come in, leaves the 18 yr old daughter to deal with the scene, has never come to the hospital. (only inpatient 18 hrs. ) After the umpteenth code, death is pronounced after 1am, the daughter informed and all 20 plus visitors leave and never come back to view the body once "cleaned up". So I leave the pt. there and call the daugter to alert her the Medical examiner will take the pt. once cleared, the transportation to a funeral home can be arranged. The ME is on the way to pick up pt by 6am, I leave the body as I'm catching up and have an admit on the way. Husband, daughter and two new men show up unannounced by security at 330 in the am. They just waltz right in the unit. Husband states he doesn't want to see the wife, just wants to be here. Well 15 minutes later, they're all just standing there, looking around watching the staff. hair on the back of my neck stands up (never has before in my life and I think "I'm gonna die" (out of nowhere). I tell the charge, they're acting funny, "casing the place, watching". She agrees they look suspicious and calls security. Our expert security argues with her "why don't you just ask them to leave?" we insist they come up (this is during breaks and only 4 nurses are present) Charge explaines thier drunkeness (forgot to add ealier) and strange behavior and tells 'em to get here now. So stupid me approaches the group saying "is there anything I can do, can I move you to a private room etc" (how can I get you the hell outta here) Husband shouts... "I wanna see what you're gonna do with her I'm not moving", I explain, he screams "you're not taking her to the examiner... we're creamating her"..security shows up, all hell breaks loose. The group, aside from a screaming daughter, jumped security, we called a code, 911 and an overhead "all available staff to ....... stat" (which has never been done before).... The group was subdued... they had knives, various weapons (no guns thank fricken god). City cops show up, take 'em all in. I've got 10,000 forms to fill out, restraining orders recommended on an 0n. My point here is that we would have died and been a simple thread like the one I read here. Have had two meetings with the head of security since. We have no visitation/ security policies. Someone in security let these loosers in. The unit is not locked and "THE BUDGET" is being blamed for that... everyone is covering their butts and no one wants to fix the problem that 3 drunken, worrysome looking folk just walked into the ER got past security carrying weapons and I could have died. I have already utilized the union for the meetings, threatened the federal safe workplace laws and am getting nowhere. I've now threatened legal action (which I can't afford) to ensure that simply policies of announcing any family member with photo ID, are called in to the prospective unit prior to the ER security buzzing them in to entry (to have access to the entire hospital). The administration thinks I'm nuts. (need the ID since I have a restraining order on these folk now... long story) yeah I know leave... but this is not a facility issue, but an area mindset and no other facilities differ... so lets fix the problem. How would security in your facilty acted to have prevented this situation.... Please provide this info, knowing that I will print out every example to show that what I'm suggesting is not out of the norm..... Please help me fix this, your words really may make a HUGE difference in our staffs safety. Thanks for your time. please no visitor beefs, today I feel I own the rights for it, just need your current security practices to make a difference, or share a policy as to how people get "in" at 3 am" ... please help cuz I'm fixin this mess.

Everyone's advice is so excellent. I wanted to add a slight twist. from your OP, you showed yourself to be an expert as a nursing student. transfering from expert to novice "new nurse on the floor" is really hard, not only clinically, but in so many other ways. Know this from a 9 yr. ICU nurse who took a float pool position and caught a baby from a crack head screaming she was a month pregnant and miscarrying, took off the pants, caught the baby... had my own heart attack and screamed for help like a wild banshee. I've been acoustomed to being the expert... it's a very hard transition to novice.. but it can be hell and fun too. you've got a good plan. With your history in our profession, you'll get through this bump just fine.

quoting all sides, aside. there is NO health care proxy. the hospital ethics committee needed to first appoint a law guardian and then go through the stages from hospital to law. There is no court appointed guardian as I know. In any conflict of interest in the family, a law guardian needs to be appointed, interview the family and continue in the judicial process as HER defendent..... My knowledge, correct me please, shows that this hasn't happened,(no legal guardian) yet it's so commonplace. all our theories be damned.... this is about what terri would want. Not the husband, or her parents..... period. if it can't be determined, against my personal beliefs, we need to carry on and let nature take its course along side a full medical regimine of treatment. not what I want, or would choose for her.... but by not deciding .... she has chosen, on full recusitation measures.... life support and yes feeding. I say pull the tube, but this is the process that must take place.... mind you I'm against leaving the tube in.... but unless she made it clear otherwise it is assumed that all measures to maintain life will continue. This cannot continue as a husband/ family... he said... she said war.... it seems to be done... and terri will loose albeit our attempt at either end. If guilty of wrong doing, the husband has not and will not be convicted of anything her family, god love 'em can't see that terri is gone. She is not able to substain life with oral feeding, (sure she can swallow, just not enough to keep her alive, therefore, her basic brain function of being able to substain life is gone and she requires LIFE support, in the form of feeding. hence the feeding tube to prevent deterioration which will result in death. working the ICU I see families keeping guppy breathing brain frazzled patients alive because at least the patient is still there.... the mourning, the loss does't have to come as long as the body is in the bed, no matter how little is left, and the focus from the patients right to die over the families right to not grieve, loss and morn can't be distinguished by them. I support a court appointed guardian to absolve the husband and family of their fight. If terri was able to substain life without life saving measures.... she would be fed by mouth... terri is incapable of substaining her own life. Neither the husband or parents are able to determine her wishes.... it needs to be removed from all their hands, and yes the court must dedide.

off the visiation kick as this could easily take over your post. Prior to a lawyer, have you tried a sit down with another staff member to represent you, the manager and the next up in line to discuss your concerns. "we may not see eye to eye on visitation, HOWEVER, I've proven myself in these ways..... through 5 years of service. These are my strengths... I am an excellent nurse to retain in this facility beacuse...... as well as "we seem to be at an impass as I cannot support your open visitation, however there are many units in this facility in which I would be an asset. I'm asking you to seperate our visitation differences over my skills as a nurse and give me a good reference to transfer." Also see if your education department has a skilled facilitator and utilize this person to have several meetings between you and the boss. This will allow both your views to be heard and guide the conversation twords finding common ground which very likely is a transfer which will benefit all. Your hospital system, no matter how coffee clutching has guidelines of a chain of command and human resources is your next best bet. They may offer to meet with you both as well. secondly you can file a formal grievance against your boss for suspected sabatoge of transfer. you've got alot of options to explore. don't waste 5 years of service over this... you most likely CAN resolve it. if you try ALL the things I've suggested and nothing works... you know the system, the hospital conflicts with your beliefs... and from here you then make your choice to bail.