icu/don

The lactulose was almost the color of the stuff coming out of the patient in the cartoon.

Had one of these moments today when one of our primary nurses called me to her room to verify an increase in a Fentanyl drip. I slowly opened the door a crack to reach the keyboard, when I realized that I was getting mooned by her patient. The primary nurse was scurrying around the room while three wound care nurses held her patient on his side with his whole backside exposed to my view. The fourth wound care nurse was busy attempting to prepare a HUGE peri-rectal/scrotal absess (caused by gas gangrene) for a new wound vac dressing. If I would not have known where the poor guy's wound was, I don't think I would have realized that I was getting mooned. This was only rivaled by the sight about a week and a half ago of the same patient when there was a rectal tube going somewhere into that wound. Just prior to getting a sigmoid colostomy, I was assisting the primary nurse with a 1 liter Lactulose enema. Due to the fact that there was no longer any spincter the enema was not flowing down the rectal tube very well. After 300cc was instilled, I suggested that we call it good and clamp the rectal tube. Instead the gung ho nurse suggested that I squeeze the tube from the syringe to the body to help get it in. While I was pushing the lactulose down the tube the nurse had the bright idea to attempt putting another syringe of Lactulose in the tube. Needless to say, she pushed the syringe to hard coming disconnected and spraying Lactulose all over the room as well as into my face. Better end my story right there.

I have been waiting for a thread like this for a long time. Sounds like the OP is saying that the emperor has no clothes and quite a few are shocked and insist that they always see clothes on the emperor. Where do I start? When I worked long term care and switched to an EMAR, my nurses all of the sudden had panic attacks because the medication turned red when it was overdue. With the traditional paper MAR, placing initials in the box signified that the 0800 medication had been given between 0700 and 0900 (1 hour either way). The five years prior to the EMAR, I didn't see one nurse circle the initialed box and indicate on the back of the MAR that the medication was actually given at 0905 or 0930 and give the reason why. Every nurse "lied" by placing their initial in the box when meds were given after 0900. The EMAR only reminded them of the fact that they had been "lieing" for years. The only time they would ever consider marking the med pass as late would be if a surveyor was watching. Now an ICU scenario: We were audited by JACHO and found deficient on Blood Transfusion V.S. Whoever interpreted our policy decided that we had only 1 minute before and after for the post 15 minute V.S. There was a few minutes longer allowance on the 1 hour post starting. This created a huge mess for nurses and auditors. The direction from the top was to implement a paper that would be issued with the Blood unit so that all the VS's could be charted on that separate paper. (The reasoning here being that nurses would approximate the time blood started at the neorificest 15 minutes and would then write the subsequent VS times in when the unit was started.) They knew that nurses would then fill in the numbers in the pre-filled time slots whenever the VSs were actually taken. The ICU rebelled because our VS are all automatic with pressures cycle every 15 minutes on the quarter hour mark. We were failing the audits because we might start the blood at 0905 but our VS were charted at 0900 and 0915 so we didn't follow policy. Plus we also validate our monitor VS into the electronic chart. The solution here was for blood to only be started on the quarter hour marks (00, 15, 30, or 45). This made our numbers look pretty to the auditors but it wasn't very realistic. It was soon learned that we could scan in the blood in a row of EPIC that was already passed, so if the blood bank called at 0955, and I received the unit at 1001, I could back chart to 1000 instead of having to wait 14 minutes to double check and start the blood. With lots of work and oversight from management, we finally got our accuracy up high enough to pass the next survey. This doesn't even begin to talk about "blood to vein" time as being the actual time that VS should start. Luckily JACHO didn't concentrate on that whole scenario. Also when the department of health comes out to investigate Hospital Aquired Pressure Ulcers, the facility better have documented those every 2 hour turns or else. Don't know how much leeway the surveyors give on turn times. How many turns that were every 2 1/2 hours before the hospital owns the pressure ulcer? So, yes, I guess I would have to say that I have lied in my charting. In my practice, I have not found the EHR to be practical for real time charting. If charting was really in real time reflecting actual practice, management and surveyors would have a bit of a rude shock. Government doesn't reimburse enough to truly provide the care that is required by the regulations.

No, California does not have nursing ratios for nursing homes. Actually the ratios got written into the law, but are not enforceable because of budgetary restraints. The binding staffing in California is hours per patient day. You take all of the direct care RNs, LVN's and CNAs for a 24 hour period and divide by the number of residents. This has to equal 3.2 hours per resident. The state was sued because they did not come up with staffing ratios as required by law. After being sued they attempted to set ratios based on the 3.2 hours per patient day and this is what they came up with for 8 hour shifts: Day shift: Licensed nurse to resident 20:1 & CNA to resident 9:1 Evening shift: Licensed nurse to resident 25:1 & CNA 10:1 Noc shift: 30:1 & CNA 15:1 As you can imagine this would have been a nightmare for our 33 bed facility. It also didn't take into account any 12 hour shifts or overlapping shifts.

Here is a link to an article that might be helpful: http://digital.olivesoftware.com/Olive/ODE/TheModestoBee/LandingPage/LandingPage.aspx?href=TURCLzIwMTMvMDgvMTQ.&pageno=MQ..&entity=QXIwMDExMg..&view=ZW50aXR5 1. Modesto, CA 2. 15 years 3. ICU 4. $57.08 day shift 5. $1/hr weekend; $5/hr nights 6. Non-Union Note about article in link: Modesto is listed as #2 in nation per cost of living. My observation is that this is largely due to the Kaiser facility in Modesto which as I understand pays the same wages to all their facilities whether they are SF Bay or Central Valley like Modesto. Plus the other hospital in town is Union so this would increase the rate above as well.

look at a current copy of title 22 in california. the ratios for snfs are in the law but they can't be enforced because of budget issues. it would cost the state way too much to implement because medicaid is supposed to reimburse based on cost. this is what is in title 22: the department has determined that the ratios specified in the table below are required to meet the 3.2 nursing hppd minimum standard. licensed nurse (day shift-1:20)(pm shift-1:25) (noc shift-1:30) cna (day shift-1: 9)(pm shift-1:10) (noc shift-1:15) these ratios are based on three controlled variables: (1) the ratios must provide 3.2 nursing hppd; (2) skilled nursing facilities should never provide less than 1 ln for every 30 residents and should never provide less than 1 cna for every 15 residents; and, (3) more care is required during the day and evening shifts than the night shifts. this means that my 33 bed facility would need 1 licensed nurse for 30 residents at night and another licensed nurse for the other 3 residents. the nurses would still not get a lunch break because then the other nurse would have 33 residents for the half 1/2 hour lunch break. (skilled nursing ... should never provide less than 1 ln for every 30 residents). i would also need 2 cnas for 30 residents and another cna for the other 3 residents on night shift! i would need to double licensed nurses on the day and evening shifts as well to provide for that coverage. as it is now, we add all direct care hours for the 24 hour period (licensed nurses, c.n.a.s, & mds nurse) and divided by the average daily census. this must equal 3.2 or greater.

I think I agree with you. but... What is the purpose of the different training? Why not omit the LVN/LPN training and have one licensed nurse? The individual nurse will then develop skills based on the job requirements, their individual learning ability, individual skills, on the job training etc. What I learned in school only seems to be a basic foundation. What I needed to function as an ICU nurse taking care of immediate post-op CABG, Intra-aortic balloon pumps, and Continuous Renal Replacement Therapy was all a result of intense hospital based classroom and orientation/mentoring. Sorry to diverge from the original post. I am sure this issue has been hashed out many times in these forums, but I just recently began participating rather than just reading the weekly emails.

I know of a ADON in California who is an LVN but acting DON. The actual DON of this facility is actually the DON of the hospital district so I don't think she (RN/DON) has any part in the actual day to day operation/oversight of the SNF. This doesn't seem to make the state surveyors any difference because I am positive that they are aware of the set up. The facility is strictly long term and would not have any IV therapy or rehab. From my observation, it appears that she does a fine job in keeping everything together including a deficiency free survey. In my limited observation the difference between LVN and RN is very minor. To me the difference lies in the individual nurses experience and personal motivation to learn. I know LVNs that have much better assessment skills, knowledge base, etc. than some RN's that I have worked with in LTC.

In my facility we (meaning DSD,DON, MDS nurse) put pain assessment on the MAR q shift for anybody on a "pain management program" (meaning everybody on routine pain medicine). If the resident does not receive routine pain medicine, pain is only specifically addressed when a full set of vital signs is taken (pain is 5th vital in CA). I am almost afraid to ask my nurses exactly how they asses this pain every shift. I suspect I might get this response, "The resident didn't ask for a pain pill so I marked a '0'." I guess I should ask the nurses because it would be better for me to ask than a surveyor. Of course, anyone asking for a pain pill get a pre and post pain assessment.

Well, as my name implies, I am both an ICU nurse and a DON. 8 years ago I left a full time ICU position for my current DON job. I stayed on per diem at the hospital and still work there 2 shifts a month. I had about 5 years ICU experience before I went per diem. The only way this works is because I am not placed on the schedule at the hospital, but can always call up and sign up for a Saturday shift. I tell my fellow ICU nurses that I go there to relax. I just take care of my two patients and don't have to worry about all the management garbage. After 8 years as a DON, I have asked my employer to find a replacement for me. If this doesn't happen, I will give them a resignation. So my advice is too make sure you know what is expected of the DON before taking the position. What kind of "on call" time is there? What other hats will you wear? What kind of support will you have?

Found out about it through: http://home.earthlink.net/~codern2/. This site contains multiple interesting medical/nursing sites. Site focuses on ER nursing.

Culture shock is right!! As my sign in implies, I work as an ICU nurse per diem and DON full time +. I happened to work in my current facility as a CNA for 5years while going to school, so in a way I knew what I was getting into. I would never be a DON in another facility. My job is much easier than most because we are a small facility that only does Medicaid. Since I don't have to worry about rehab/medicare, our resident turnover is low. This allows us to jump through most of the hoops that the regulations require. (You can never be totally compliant.) Even with the many advantages at our facility, my 2 years as DON has felt like an exercise in crisis management. I have never felt like I was adequately "on top of things" to really focus on desired Quality Improvement. Enough rambling. If you are really wanting a change from ER, taking a position as ADON will give you an idea of what is involved in LTC. When I get to my breaking point as DON, I will return to my first love in ICU.

Wow!! I guess I am pretty spoiled. Our General ICU of 35 beds is split into three units with a charge nurse for 11-12 pts. The charge nurse does not take any pts. except in an extreme crunch. Sometimes we have up to 3 nurse aides when totally full. Now to the 1:1 business. Any pt. with one of the following automatically becomes a 1:1: IABP, ICP/drain, CVVH, or CABG (min 12hrs.). A good share of our trauma pts will be a 1:1 usually until the next shift arrives. We do have a sheet of paper that we use to justify 1:1 patients, but it has pretty much fallen by the wayside. The charge nurses pretty much decide when a pt. requires 1:1 status. This is fairly abused though. I think if our charge nurses heard your story, they would be sure not to abuse the system for fear of things changing for the worse. Alot of times pts. will be made 1:1's to cushion the staffing. The charge nurse knows that the pt. is in between criteria so if a bed is really needed the pt can be removed from 1:1 status for an admission. Alot of times a nurse with a 1:1 pt. will pick up another established pt. while the other nurse gets the admission. I have actually seen several pts. in the 4 years I have been here that were assigned 2 nurses for several shifts.

I think alot of our confusion in this discussion is that we each have different definitions of "futile care." As an ICU nurse, running a full code on a patient that has already been in the unit for weeks, is on pressure control ventilation, is on CVVH (continuous dialysis), is on Epi and Levophed drips, and is in liver failure constitutes "futile care." In many cases that I have seen by the time the pts. heart actually stops there are very few drugs/interventions we can give because we have already been resuscitating the pt. for weeks. In some cases in ICU, I really feel that running a code and/or continuing treatment is like doing an appendectomy to cure an earache. I blame alot of this on the doctors for not adequately educating the families involved. (The patient has been out of the decision making process for a long time.) As nurses in our facility, we have been warned by management that we are being too agressive in trying to convince families to become DNR's. Of course they received complaints from the surgeons who think can keep every pt. alive forever. As far as the original article on "futile care," it sounded a little scary even to a seasoned ICU nurse. As a nurse, I would refuse to participate in an extubation that was definately not wanted by the family members. I would attempt education, but I would feel the need to abide by the family wishes. I would only be able to follow a "futile care" policy as long as the decisions reached lined up with my experience and my personal ethics. I would then have to disregard my patients and families viewpoints and call their position ridiculous. This is no way to operate. The writer of the original article sure does slant things their way with the statement that Ryan "is a living four-year old child." In my mind that leaves alot unsaid. In other words, maybe the family has now been trained in the technology needed to care for him at home. It says nothing of quality of life.