Rooming in on another unit?

[Lady_Leijing, BSN]

I just want to throw this out here and see if anyone has heard of this before and what you guys think about it. I work on a Postpartum and Newborn unit where the vast majority of infants room-in with their mothers. We do have a small observation nursery, but are usually not staffed to have infants in there for long; our charge nurse has to sit in there if the baby has to stay for more than a couple of hours or if we do not have the time to stay with it ourselves. Most of the time we take care of both mom and baby as a couplet with a few notable exceptions. My question is about two of those exceptions, specifically instances where the baby is our patient, the mom isn't, and they are not on the same floor as the rest of my patients.

Example 1: Mom is discharged, but baby needs to stay another night (usually for phototherapy). The unit was full, so they move baby to pediatrics to make room for another mom that just delivered. Mom still rooms-in and does the majority of the care for the baby, but they are assigned one of our nurses who still has patients on the main unit as well. The nurse has to run down to pediatrics every 2 hours to check on the baby, but otherwise is on the main unit unless contacted by the mom or one of the peds nurses.

Example 2: Baby is healthy and can be admitted to the unit, but mom needs a magnesium drip, which requires monitoring that our unit is not equipped to handle. If the Pediatrician signs off on it, mom can room-in with baby in PCU so long as her support person can stay with her. They take care of the majority of the care for the baby, and are assigned one of our nurses to monitor baby's vital signs (and blood glucoses in some instances). This nurse also has patients on the main unit as well. The nurse has to run down to L&D every 2 hours to check on the baby, but otherwise is on the main unit unless contacted by the mom or one of the nurses.

In the latter example, I spent over an hour off the main unit to take care of the baby in PCU and teach its mom how to breastfeed. I come back and the PCU nurse had taken the baby out to the nurses station "so mom can sleep" and said that she "had thought about just giving [baby] a bottle so we don't have to wake mom up"--this momma wanted to exclusively breastfeed and I was trying my darnedest to make it happen. This nurse also incorrectly "corrected" my breastfeeding teaching while I was in the room. I had told both the family and the nurse to call me if they needed me--we carry work phones--and the family did call once, but the nurse never did, despite the fact she complained to me when I got back about how fussy the baby had been.

I don't feel this is good patient care or is safe. The babies aren't on monitors, the peds nurses aren't supposed to go in the baby's room unless its an emergency (cross-contamination risk), and I am uncertain about the level of cooperation on anything short of a crisis that I would get from our PCU nurses. I don't like having my name on the kid's chart if I don't feel like I'm available enough to monitor their condition.

Do other hospitals do this? Is this the liability issue I feel like it is or am I over-reacting?

[NICU Guy, BSN, RN]

Do other hospitals do this? Is this the liability issue I feel like it is or am I over-reacting?

You need a dedicated Nursery nurse for days when this happens or transferred officially to Peds floor and have Peds nurse care for the baby. In the first example, what is the difference between leaving the baby on the Peds floor with no Peds nurse responsible for it and leaving it in your nursery without anyone in the nursery with it? Who is responsible when something happens to the baby in between your 2 hr check-ins on the Peds floor? You or the Peds nurses?

In both examples, you are liable for a patient that is out of your unit and you only check-in on them every 2 hrs.

[Lady_Leijing, BSN]

I agree, but a lot of the nurses here act like this is "just part of the job". That's why I was wondering if it's just this hospital or if it's a more widespread thing. I check in on my patients that are off-unit more frequently if time allows, but when you have 2-3 other couplets, that's not always an option. I dislike being put in this position, but I'm not sure how to change what everyone else seems to deem okay. We've had babies whose condition changed a lot in 1-2 hours. I don't like being liable for someone I can't monitor effectively.

I'm not management, and I've only been working on this unit about 6 months, so I have little control in regards to staffing ratios or hospital policy. What is something I can do about this?

[babyNP., APRN]

The babies you describe seem like the otherwise "well babies" rather than needing true ICU care. I would ask the moderators to move this to the postpartum/OB/gyn forum since they would deal with that more. Our babies usually live in a box.

[adventure_rn, MSN, NP]

You need a dedicated Nursery nurse for days when this happens or transferred officially to Peds floor and have Peds nurse care for the baby. In the first example, what is the difference between leaving the baby on the Peds floor with no Peds nurse responsible for it and leaving it in your nursery without anyone in the nursery with it? Who is responsible when something happens to the baby in between your 2 hr check-ins on the Peds floor? You or the Peds nurses?

In both examples, you are liable for a patient that is out of your unit and you only check-in on them every 2 hrs.

Agree with Guy. I've only ever seen it the way he described: kids staying for photo or NAS get officially transferred to peds (with a peds nurse) where parents can room in and do most cares, well kids with sick moms get admitted to the nursery. A designated 'nursery nurse' has to be present for kids staying in the nursery.

Having patients on a separate floor is absolutely a terrible idea.

[Lady_Leijing, BSN]

The babies you describe seem like the otherwise "well babies" rather than needing true ICU care. I would ask the moderators to move this to the postpartum/OB/gyn forum since they would deal with that more. Our babies usually live in a box.

My mistake. I didn't read the description for the forum, just the headings. Most of the stuff in the OB/Gyn forum is geared towards the mommas, so I figured Newborns fell under "Neonatal". I suppose this topic could also potentially go under Patient Safety as well.

[traumaRUs, MSN, APRN]

Moved to OB/GYN forum

[MunoRN, RN]

OB definitely isn't my thing, I'm on the other end of these examples as we sometimes get moms in the ICU, usually for DIC, sepsis, or severe cardiomyopathies. Because of the drugs and dosages these moms are receiving they typically don't breastfeed, often they pump-and-dump if they are conscious. OB nurses do the OB specific assessments, and baby comes to visit at least a couple of times per day, even if mom is sedated and intubated.

I've never worked at a facility that required cardiac monitoring for a mom receiving OB-magnesium IV boluses or drips, I'm not sure that's really indicated. This includes tocolytic doses which are massive compared to regular floor doses.

[Lady_Leijing, BSN]

I've never worked at a facility that required cardiac monitoring for a mom receiving OB-magnesium IV boluses or drips, I'm not sure that's really indicated.

I'm not sure if this is just my hospital's policy or if it's a local thing, etc. I've only been a Postpartum/newborn nursery nurse for about 6 months. Most of my previous experience is Med-Surg. I was just told that moms on mag stay downstairs until they are off the drip here; it was implied to be a safety/monitoring thing. That's not my point though. My point is that they have me caring for an infant that is rooming in with mom while mom is not on our unit and not my patient.

Does anyone have suggestions about what I should do from a floor nurse perspective? Should I just refuse to take these assignments, or should I follow this up the hierarchy to get it changed? If I bring this up to the higher-ups, do you think anything will change?

[ashleyisawesome, BSN, RN]

We have a nursery and a nursery nurse on staff. We mostly room in, but a few moms will choose to send the babies to the nursery overnight for a few hours. We still practice couplet care. The nursery nurse will help out with assessments or feeds if we are busy, but she is mostly responsible for keeping an eye on the babies in the nursery (ie, making sure they are still alive) and admitting new babies. Any "border" babies (mom is discharge and we are just caring for the baby) are the nursery nurses responsibility.

It comes in handy for the situations you described. If mom is on another unit (usually ICU or Stepdown), we keep baby in the nursery and mom can pump and send milk until she is discharged. I've had a few exceptions where they let us bring the baby to ICU to breastfeed, but an OB nurse has to be there and bring the baby back down when it's done feeding. I don't like bringing newborns up to the ICU though, around critically ill adults who likely have something contagious. We do allow dad into the nursery to bottle/finger/syringe feed, or just hold the baby for a while if he wants.

If we have a baby who has to stay, but mom is discharged, it can either stay in the nursery or if we have rooms, mom can room in with baby (but she is not a patient and we aren't responsible for her, just her baby). This happens a lot with our NAS babies, bili babies, and kids with temp issues.

It's also useful for adoptions. Usually the birth mother does not want to room in with the baby, but it has to stay for 2 nights, so we keep it in the nursery, or the adoptive parents room in, in a separate room (if we have available rooms).

I would not be happy with your hospitals arrangement. It sounds unsafe. If they are going to have a baby on peds, either the peds nurse should take care of it (it is a pediatric patient!), or they should have a postpartum nurse on the unit and that should be her assignment, no switching back and forth between floors. What if you are on peds assessing the baby and one of your moms in PP starts hemorrhaging?

I also don't like the idea of mom/baby rooming in on a non OB floor. For one, there are really sick people in PCU/ICU. Second, those nurses don't know how to take care of a newborn. If the baby crashes, by the time you are called and make it up to the unit, it could be too late. They likely aren't looking for or would be able to recognize signs of distress in a baby until it's blue and unresponsive anyway!

I would bring these safety concerns up to your manager and propose staffing the nursery. Even if they just staff it with a nurses aide (our smaller sister hospital does this sometimes), at least it would be on the same floor and the aide could call for help easily if something goes wrong. Another idea is to send these babies to the NICU and have the NICU nurses take care of them. Another hospital in my area that doesn't have a well baby nursery does this. It is a bit of a waste of resources IMO--since the babies aren't in need of intensive care, but it sounds better than having a PP nurse split her assignments between several floors.

[not2bblue]

When you say "mom stays downstairs" do you mean the pt is still in L&D? because you say both PCU and L&D and in my experience, those are 2 VERY different units. How often are you checking in on your babies on your unit? So, if there has to be a second caregiver who can call for help then I wouldn't stress as much about scenario 2 because in reality, you are checking on your patient as frequently as you would if they were on your unit. That said, you should have someone to cover your patients when you leave and the LD nurse should have called you to take the baby out of the room and not had it at the desk. Giving the baby a bottle without permission is unacceptable. Yes, I have worked in a hospital that did that same thing. Scenario 2 makes no sense. If the baby is on peds, then why not be admitted to peds? That makes no sense at all.

[Lady_Leijing, BSN]

The PCU in that hospital is next door to the L&D. One instance the mom was in L&D, while another it was the PCU. I always let someone know if I had to leave to check on a patient, and I tried to check on all my patients at least every 2 hours.

As for why the kid wasn't a Peds patient, I don't know either. I guess transferring the kid just made too much sense!