siegolindoRN

I'd like to remind everyone that nursing is one of the few professions where, depending on what unit you work, only requires you to work 13 shifts a MONTH, only firemen have better schedules than we do.

Mount Sinai Health System uses the "Split Flow" patient flow improvement process. It utilizes separating ESI 1/2 and high level 3 (abd pain with co-morbidities) into acute areas and ESI low 3 (abd pain NO comorbidities), 4 and 5 into an evaluation area. It also places 2 triage nurses in walk in however they were not used in the traditonal sense. Triage was split into an A and B, A encompassed 5 data points (2 for ID surveillance) and B included v/s, domestic violence, SI, etc questions. Everyone that came in got a triage A but only during "full" times was B utilized or when the RN could not identify an appropriate ESI given the CC. The "meat" of triage hx, allergies, etc were left to primary nurse to complete. I will say that when flow was steady it worked well but buckled when we had bolus' of 3 or more patients at any single time. We regularly saw close to 200 visits per day and constantly had issues with missed v/s, allergy banding, testing etc. On days with visits approaching 250 or better, it was just painful all around. Although neither regulatory agencies nor insurance providers have set time stamps for most ED visits,(outside of CVA/MI), ED administrations have self imposed "goals" of limiting the time from complaint to evaluation by provider (MD, DO, PA, NP). These systems of bedside triage are spawning from those decisions and it places an unnecessary burden on the clinical staff, causing low moral, dissatisfaction, high turnover, low retention and inadequate orientation (to name a few).

Those are the days where teamwork is paramount for both safety of the patients and the nurses. As many have mentioned, manage up for assistance, don't assume you will be helped by maintaining silence. Don't just involve the nursing side but also the physician group as well. AmzyRN, your situation is an "all hands on deck" event!

its a multifactorial thing; on one end you have clinical practice, patient expectations, usage deals through supply chain, etc and on the other, the financial impact. Both are influenced by the medical director and/or senior administration. An IV bag is separate charge from the line its connected to (single lumen PVL) and the time for said infusion to complete (3 charges total). I have worked at EDs where nurses documented against a charge ticket and others where it was built into the EMR. Its difficult to argue fraud, as many clinicians can attest too, since most people don't do a very good job at keeping themselves hydrated per medical standards.

that sad part in the battle between ADN and BSN is that someone entering nursing as a second career with a previous bachelors education will be forced to spend more money in getting another bachelors degree (depending on year graduated may/may not have credits transferred) in order to have a better chance in this competitive market. The scholars in our professions can sometimes lose sight of reality when creating policy.

I have kept a per diem gig since my first year post nursing school. The rates are higher than staff but lower than any overtime. Most places have stipulations regarding how many shifts, weekends, holidays etc per month that need to be "picked up". Since you have experience in multiple ICU specialties, i would choose adult trauma or surgery to keep your skills sharp in the adult world. Choosing a hospital depends on what you are looking for, ie complex case mix, travel time and even culture. The best thing about per diem, you can resign without penalty if it doesn't work out and pick up another gig elsewhere (theres no need to have it on your resume if its less than a year). Alternatively, you can work for an agency, as a per diem, and get credentialed at multiple sites, essentially guaranteeing you the extra work you desire. Personally I prefer per diem over overtime as I feel saturated when i'm working too much on the same unit with the same coworkers and/or patient population. I am currently working per diem in an ED of a soon to be level 1 Peds Trauma center and I love the differences vs my full time adult ED position. You will find something as OR, ICU and ED per diem nursing gigs are the most frequently posted on job boards. Good luck!

As far as I know, only NYC HHC hires ASN prepared nurses along with most SNF or LTC organizations. I believe NYS (mostly psych) will take ASN and so does the VA (openings in the city are rare). The private sector, Montefiore, Mount SInai, NYP, Northwell, NYU, Sloan, HSS, Bronx Lebanon, St Barnabas will not hire ASN unless you have the right qualifications and experience. You are correct that without a connection, the job hunt will be difficult. I would suggest entering an organization in a non nursing capacity (for finances), enroll in a bachelors program and "upgrade" to an RN position once your bachelors is completed. Organizations give preference to employees when it comes to new positions vs outside candidates.

Where were your coworkers in all of this???? They should have divided up your assignment so that you could've gone home. I can understand why a DON would refuse report when they are in charge of the house and couldn't possibly perform bedside care. I consistently advise nurses that if they are not feeling well while on the job, they should report to Employee Health or the ED in order to obtain documentation to validate their claims. That information they would use in their favor in the event management decides to hand down a discipline. As to whether or not she committed abandonment, I would say so. Walking out of the job without a proper transfer of care, regardless of leaderships knowledge, could be seen as abandonment. Proper hand off would be to another competent nurse on the same unit or one floated from a similar unit. The BON of any state is comprised of RNs and if the responses on this thread are on either side of the fence, then the same could happen under review. Not worth the trouble, next time, take the potential discipline then risk smudging your license.

Pain can directly influencing BP, HR, and RR, amongst other things, so it should be monitored closely. When asking for pain ratings, I always add a comment to either validate or invalidate what my patients are reporting, its how I meet the need for documentation while keeping close to the actual clinical presentation. Opioid addiction is a public health crisis with its roots in all forms of healthcare and unless the States or Feds come up with viable solution to curtail over prescription, it will continue. I have my biases like any other ED RN when dealing with "seekers" however one must not lose sight of the fact that although its a growing problem, most of the population doesn't fall under this category.

KindaBack, Ill admit, "anything" wasn't the best word to use as those other items I would agree are not our responsibility (not as primary RNs at least). What is in our scope is addressing the potential mental/behavioral health issues that a patient would have when the safety of their child is in question, when alternatives are either delayed or do not exist, for that child to be placed somewhere safe while the patient is receiving care. In your meth situation, how long did it take from the time CPS was alerted to their actual handling of the child? During that time, what measures were taken to safeguard the child? Where any policies created as a result?

A nurse can delegate a support staff member to watch a patient, they need not wait on a supervisor to make that decision. Charge nurses on various units can also coordinate the use of support staff in coordination with the supervisor. At the end of the day, whether you like it or not, disagree or agree, anything tied to your patient becomes your responsibility. Every situation has a fix, sometimes it requires thinking out of the box. I once had an elderly patient I kept within the central nursing station, next to me and delegated non clinical tasks to her (shuffling blank papers, arranging staplers) in order to keep her mind from thinking of walking out (dementia).

I have experienced this many times in my ED career, sometimes we were able to get family come in, sometimes we have called ACS, sometimes the NYPD. The one common denominator all the situations had, a sitter (support staff) is placed with the child(s) until whatever arrangements are made, materialize (obviously involve leadership early). A floor cannot refuse a patient admission based solely on a sick relative having children with them; other factors, such as private room availability, destination floor, service, etc have to be taken into account. In all instances, the sitter will travel with patient to destination unit. Regardless of the liabilities involved (whether believed or actual), the organization must make every effort possible to make reasonable arrangements. Failure to safeguard a minor carries far more legal troubles than the act of accommodating for the situation. If it happens often enough, then a policy and procedure must be created.

The practice of flushing the line, or changing blood tubing, in between transfusions comes from the need to monitor for transfusion reactions (policies are created for the broadest applicability). The obvious difference in standard administration vs during hemorrhage is the time frame in which the patient needs the blood product administered. There is data on pubmed regarding transfusion reactions in the trauma population from several studies that did not tie patient death with hemolytic reaction in patients who received uncross matched blood (they did develop the antibodies against the foreign product). The belief is that trauma taxes the immune system thus preventing the reaction traditionally seen in the normal product replacement scenario. You can use this evidence to aid in changing practice. Best of luck!!

Get your year in first, then transfer to another unit. If after your second year, you still feel the organization is not up to your standards, then leave. If you quit after only a few months of work, you will find it extremely difficult for anyone to give you a second chance. Nowadays, with electronic applications, algorithms are set to automatically refer/disqualify applicants based on set parameters, you couldn't even plead your case with a nurse manager without going through an HR recruiter. I have knowledge of organizations that give the HR recruiter more influence than the hiring manager. stick it through!

1a)Full Time Equivalent (FTE) is equal to 1950 hours per year, some places work out complex algorithms so nurse's work 12 or 13 shifts in a month (11.5 flex). How you are scheduled can depend upon the payroll solutions the nursing department uses (ex, some places force nurses to work 3 shifts/week, others will allow more shifts in the week, policy may also drive this action as well) 1b)On call is paid at a specific rate and changes upon activation of nurse (usually increases) 2a) Floating is a hot topic, any credible facility will ensure any floating that occurs happens with similar units to avoid patient harm. I worked at a facility that floated ED Rns , didn't stay there long. lol 2b) no compensation for floating 3a) In a non union environment a nurse can reach out to HR and file a formal complaint if they feel a violation of code of conduct has occurred. (quick way to place a target on your back, unfortunately) 4a) new grads will be paid the starting salary for the position, experienced nurses (NYS) get "experience pay" on top of the starting pay. This is one of many contributing factors reflecting the range of salaries in the profession. I often counsel nurses on the benefits of looking at an overall package rather than focusing on salary only. ex, NYU Medical centers pays a 7% differential for float nurses and offers 6% employer contribution in 403(highest in nyc) and Lenox Hill has a program for weekend only nurses who are paid full salary and only work Saturday and Sundays and some smaller hospitals offer experience pay up to 30 years of service.