Starting in a CCU LTAC from a SNF wound unit

[SusieN RN]

Hi everyone. I thought this would be the best place to make this post. I graduated in January 2009 from the associates RN program at Northampton Community College (wanted the BSN, but I was in my 20s and paying for most of my college education on my own). As a new nurse, job searching was terrible both as a GN and an RN. I wanted to do hospital nursing, with my intent being starting out in med/surg and then progressing to ICU or ED nursing, however because of how difficult finding a job was for a new nurse, I settled for working in a Skilled Nursing Facility. I worked on a general ortho/rehab floor with a patient to nurse ratio of 18 patients to 1 nurse and 2 CNAs for about one year. I was offered a position at the facility's wound unit the following year, took it and became wound care certified. The patient to nurse ratio remained the same: 18 to 1 nurse and 2 CNAs. The floor nurse is responsible for all wound care, med passing, admissions, etc and the acuity on the floor has been progressively increasing. I've worked with IV therapy, PICCs, chest tubes, VACs, burns and a variety of chronic and complex wounds. I decided about two years into the work there, I felt my wound care certification and experience would assist me in getting into hospital work, but this had no real success. Even with becoming ACLS certified on my own time and being recently accepted into Penn State University's online RN to BSN program, I was still not considered for hospital positions. I've found through some hospital RNs that DONs in hospitals have a pre-conceived idea about SNF nurses that they "Pass pills in a nursing home and will be stuck there". I finally nailed a job at a CCU/ICU/Telemetry LTAC called Kindred Healthcare. The facility was previously owned by Triumph and was recently bought by Kindred. The patient to nurse ratio is typically 4 patients to 1 nurse with a max patient load of 6 to 1. It is known to be a rather difficult place to work, but I'm up for the challenge in order to learn and gain more experience in order to get to the place I want to be as an RN. I am also staying per diem at my previous employer in order to not burn any bridges with them (I am quite thankful for the wound care experience I received there) and have a little extra income since I'm putting myself through Penn State. I start my first semester at Penn State for my RN to BSN in January (my goal is to receive my PhD and teach nursing. I really enjoy mentoring nursing students).

So, that's what I'm up to. I'm excited and nervous about handling it all. Opinions?

[Guttercat, ASN, RN]

Get out now!

(just kidding). :)

[JenniferSews]

Sounds like the path my coworkers and I are on, for better or worse. SNF or LTC is worse than new grad in my city! You learned lots of great time management skills in the SNF, and I bet you'll do fine. Hang in there, and best of luck!

[deemalt, BSN, RN]

Worked at another "chain" LTAC as a new grad. Great place to work if you ultimately want to do ICU or even ED. You will see everything and every possible intervention (vents, feeding tubes, TPN, tele, you name it. Tons of wound care so you will likely be a go to person for this. I would use it to your advantage. LTAC is tough but you will learn tons. Just be prepared to usually be at your max patient level. If you can work at an LTAC you can work anywhere.

[DixieRedHead, ASN, RN]

I certainly hope that by the time you attain your PhD in nursing you will have more respect for those who work in LTC that to say that you "settled".

I am an RN with 20 years experience. I have worked almost everywhere you can work in a hospital. I can read a rhythm strip in 4 seconds, and I can read and EKG in 5.

I have take ACLS, PALS, CCRN, and I can stick an IJ in a decapitated monkey.

I now work in LTC and I didn't settle. Thanks

[Esme12, ASN, BSN, RN]

You may find this thread interesting.....https://allnurses.com/massachusetts-nurses/kindred-boston-area-529664-page2.html

LTAC's are a unique combination of very sick patients in a LTC setting. These people are the SICKEST of the sick AND they have had complicated hospital course. A 4:1 ratio may not seem like very much but in an ICU setting like kindred.....at time a nightmare. Almost always the ICU patients at Kindred are the failure to weans so you will have 4 vented patients. Most will have multiple lines including PA Catheter's/Swan , including pressors and IV's.

These patients are the ICU patients that remain critically ill but have run out of "paid days" on insurance/medicare. You have settled for nothing and I will tell you, you will see a ton of stuff.......everyone else's failure to discharge home. Open hearts with complicated post op courses, trauma's with Halo traction, many unique disease process with complicated recoveries, open wounds, chest tubes, vac dressings, wound irrigation's. You will give TPN, blood, do labs...your IV skill will make you valuable to them. These patients are mostly full codes and every attempt is made to get them home.....but withe a fraction of the nursing staff in an acute care setting.

Hospital administrators need to pull their heads out of their butts and find out what and LTAC really is.....other that the place where they dump the financial drain out of their system. I have to humbly admit I was one of them at tone time. I knew the patients were sick but I actually went there as a supervisor to have a "slower pace":uhoh3: I was sorely mistaken. The particular Kindred I work for had a reputation too for being as tough place to work.....they are strictly FOR PROFIT and they are strict about profit. As the super, I spend a ton of time clinically, in the UNIT(more than other supers) because I felt bad for the staff.

You will gain a TON of experience and at least they do have great orientations. I wish you every bit of good fortune and luck in your new journey. If you have any other questions about and LTAC....PM me.:heartbeat

[CapeCodMermaid, RN]

I certainly hope that by the time you attain your PhD in nursing you will have more respect for those who work in LTC that to say that you "settled".

I am an RN with 20 years experience. I have worked almost everywhere you can work in a hospital. I can read a rhythm strip in 4 seconds, and I can read and EKG in 5.

I have take ACLS, PALS, CCRN, and I can stick an IJ in a decapitated monkey.

I now work in LTC and I didn't settle. Thanks

:yeah:

PS. Kindred...ugh

[Esme12, ASN, BSN, RN]

:yeah:

PS. Kindred...ugh

I know, right???

[SusieN RN]

Thanks for the replies. I know Kindred is going to be a tough place to work due to it's rumored reputation, however I'm doing it for the experience. And those offended by me "settling", I meant no disrespect towards LTC. It's been by far a challenging nursing job and I have learned a great deal. I "settled" in the respect that I wanted to obtain hospital experience, which was not available as a new grad in the middle of a recession. It's an extrmely tough job, especially as LTC is turning into rehab for sub-acute patients. I am EXTREMELY offended at hospital DONs that may state "all you do is pass pills in a nursing home". It's much more sub-actute care than long-term at many facilies now. As with LTACs, in my experience, SNFs tend to also be the places where hospitals dump individuals who run out of insurance/medicare days. Often times I do have admissions that get sent back to the hospital within 24 to 48 hours due to medical instability that they were dischared with because they ran out of insurance/medicare days. My facility is currently attempting to push a "hospital-like environment" in order to appeal to a larger patient population and reduce hospital readmissions rather than LTC. Unfortunately, staffing and equiptment has remained the same. No or broken vital signs equiptment in the facility has caused me to buy all my own vital signs supplies. I carry a tool set to jimmy IV pumps to work. I've become wound care certified, learned time management, stress management and to expect anything and be prepared. I spoke with a previous supervisor (whom I had as a very new nurse), and now DON where I work, who was a critical care RN before working in LTC "This is one of the hardest jobs you will ever do. It's a good foundation even though it's not exactly what you wanted to do out of school". Apologies for anyone I offended. It was not intended.

[Esme12, ASN, BSN, RN]

Thanks for the replies. I know Kindred is going to be a tough place to work due to it's rumored reputation, however I'm doing it for the experience. And those offended by me "settling", I meant no disrespect towards LTC. It's been by far a challenging nursing job and I have learned a great deal. I "settled" in the respect that I wanted to obtain hospital experience, which was not available as a new grad in the middle of a recession. It's an extremely tough job, especially as LTC is turning into rehab for sub-acute patients. I am EXTREMELY offended at hospital DONs that may state "all you do is pass pills in a nursing home". It's much more sub-acute care than long-term at many families now.

As with LTAC, in my experience, SNFs tend to also be the places where hospitals dump individuals who run out of insurance/medicare days. Often times I do have admissions that get sent back to the hospital within 24 to 48 hours due to medical instability that they were discharged with because they ran out of insurance/medicare days. My facility is currently attempting to push a "hospital-like environment" in order to appeal to a larger patient population and reduce hospital readmissions rather than LTC. Unfortunately, staffing and equipment has remained the same.

No or broken vital signs equipment in the facility has caused me to buy all my own vital signs supplies. I carry a tool set to jimmy IV pumps to work. I've become wound care certified, learned time management, stress management and to expect anything and be prepared. I spoke with a previous supervisor (whom I had as a very new nurse), and now DON where I work, who was a critical care RN before working in LTC "This is one of the hardest jobs you will ever do. It's a good foundation even though it's not exactly what you wanted to do out of school". Apologies for anyone I offended. It was not intended.

I know about Kindred. A LTAC is licensed as an ACUTE CARE FACILITY, they can do minor surgical procedures. If there is an ICU you will be taking care of patients that were dumped out of their hospital beds just because the money ran out. Same drugs, same lines, same vents, same arrhythmias. These people are NOT always DNR's and the goal is to wean them to get them to a SNF. You will be taking care of patients that just the day before were 1:1's or 1:2's at the most....you will have 4:1.

I have found that unless you have worked at a LTAC (especially Kindred) there is a complete misconception about what the job is and how sick these people are. These are the the sickest of the sick that ran out of money but remain very sick. I was stunned at how sick these people are.......little does anyone realize this is an acute care environment but they get reimbursed less. This translates to......you will take care of these same patients with less.....less staff, less equipment, less resources and less backup.

You will be giving blood, drawing blood, treating arrhythmias, titrating drips, intubation , extubation, doing bedside trachea and bedside line insertions as well as bedside peg tubes. You will do this with 4 to 6 patients a piece. I admired these nurses immensely.

You will learn a TON!!!! BUT........Put your seatbelt on it's going to be a bumpy ride.....

[poopprincess]

I work in LTAC, not Kindred, but my place is pretty much exactly the same. Our TCU (vent pts.) don't have the A-lines and such though. Those are in our ICU. However, LTAC is def. a great place to learn but you will work your butt off. Almost of the pts. are total care, turn Q2h, Peg tubes, feeds, TPN, post-op complications, CABG or abdominal surgery, ICH, staples/suture removals, ostomies, central lines, PICC lines, trach care. Vent weaning is what most of them are there for. There is halo traction, infections, tele, tons of wound care-complex wounds, wound vacs, renal failure and much more. We do draw our own labs, and many of these pts. are renal, so once you get it down, you are good to go. I have learned not only how to stick someone, but how to feel for a vein that I can't see and still get it. I'm no pro, but I'm making progress and can sometimes get a hard-stick. These pts. are SICK. People tend to underestimate just how sick they really are. Also, there is not a Dr. in our building at night, so nurses run the codes. There are protocols and the charge will call and inform the MD on call of what is going on, but they are not physically there. They will come in later if there is a code, or if a pt. needs a procedure done (bleeding trachs). Really, Esme just nailed it in her description.

The respiratory thereapy team is great and they are a wonderful source of info. I ask them a gazillion questions all of the time. As a matter of fact, I get to take care of the sicker pts. because I actively seek out new info and prove I can handle it. I am a new grad and this the only nursing job that I have ever had. I wanted to quit in the beginning, but I am glad I stuck it out. I wouldn't leave for a med-surg position in the hospital, but I would for ED or ICU.

Your wound care experience should serve you well in this position. There is a lot to learn and you will be busy. The ratio is by no means an easy one. We also get 4:1 vents or 6:1 if med-surg. The med-surg pts. are sometimes harder than the ventilated ones because they are more demanding. They usually started in the ICU/TCU and were moved once their acuity lessoned. They tend to get lonely and become quite needy. Also chronic pain is an isssue with many of them. There is also hospice or unexpected deaths. I will tell you that sometimes the death is bothersome because they pts. are there for a long time so you really get to know them and their families. It's not always easy to shake it off if it's someone you knew well who was progressing and then BAM. Anyways-GOOD LUCK to you! CONGRATS. Take advantage of the situation and learn all you can. Everyday is pretty much resume building. I actually have grown to like it, I do want a full time position elsewhere, but even if I get one, I'll stay here PRN. You see it all.