unit Rules

imperial · Feb 24, 2005

Considering you asked me to explain, to you, various things, which I did, please explain to me what is the reason, or why are you asking this question. I am confused, and, would it matter anyway, that is, if you and others had nothing to hide with answers, being no one knows who you are? As I stated, I am just someone who has worked in the medical profession who is interested in knowing, answers to questions, from those who work in the field. Answers that are, in fact, truthful. Nothing is perfect in this world of delivery of care, nothing and mistakes/errors occur as well as inadeqate delivery of care due to nursing shortage. Been there done that. Again, I am just interested in knowing the 'real' aspects. Namaste Imperial

leslie :-D · Feb 24, 2005

no imperial, no one has anything to hide.

but when more than one member feels uncomfortable and suspicious in your ongoing questions, with its' own set of implications, perhaps you may want to reflect on these comments and see why we feel as we do. there's much validity to what is being felt.

leslie

jnette, ASN, EMT-I · Feb 24, 2005

So, I would pose to you, in this last post here, "What makes you so uncomfortable and why? Has something been asked that makes you feel the way you do and why? That is the question, WHY? I would have to wonder that if you 'all' get so upset with questions that my question would be "Do you have something to hide relating to what I have asked?" And, the choice of words, i.e. 'allegations'. obviously you do not understand that word. Again, any statements of what I made have been witnessed or verbally given to me.
What are you afraid of? thnk about it. Obviously there is no 'inner peace' when one is so paranoid. Namaste' p.s. for anyone reading this one certainly has to wonder why those expertised at this can't answer questions without feeling so defensive? I believe this is perhaps what happens in units when patients ask questions, techs/nurses are not educated enough to answer questions then they become defensive and patients are the ones who suffer..... This is a long standing thought within many in the field.

imperial.. there is certainly nothing to hide. I am PROUD to deliver competent care. But what you just stated above (my emphasis) just really rubs me the wrong way. You are posting things under the ASSUMPTION that dialysis staff are uneducated, unclean, uncaring, non professional, treat their patients with disrespect, want no input from them, etc., etc. etc.

And THAT is just so uncalled for. While there may well be SOME situations that could stand improvement, SOME staff members who could use a kick in the rear, SOME clinics which might not be quite up to par or what we would like.. is this not to be found in ANY capacity of healthcare, in ANY setting ?

It does appear that you are generalizing here.. painting the dialysis business and its staffmembers with a VERY broad and ugly brush. And to THAT I take offense.

Certainly, improvements can be made in EVERY setting, and within EVERY individual. That does NOT imply, however, that we who work in dialysis are in dire need of whatever it is YOU think of as improvement.

Yes, I have been to your "dialysis ethics" site that you posted a link to. And yes, again, there are some valid concerns.. but this does not mean that ALL clinincs are like these particular ones mentioned there. Far from it. Yet you make it sound as though this were the case, and "shame on us" ! :stone

As for some of the things you propose.. let me give you a little scenario and you tell me just how reasonable that appears to you, shall we?

You are adjusting a patient's blanket.. or charting at their machine, when the patient next to him/her at the adjacent machine goes into hypertensive crisis.. you glance over at his alarming machine and notice his B/P has suddenly bottomed out... 65/38.

Do you walk over to the sink, pull off your gloves (and according to you, your gown as well), begin to wash your hands thoroughly, dry them well enough to be ABLE to get on a new, clean pair... don a new gown... and THEN go over to assisit that patient ? Or do you drop what you're doing, quickly check your hands to make sure they are not soiled, or better yet, jerk off your gloves, and rush to his aid, placing him in trendelenburg and opening up the saline line to get some fluid into this patient... ?

Another scenario..

You are carrying jugs of bicarb or acid to replace those which are running low on several machines. Are you suggesting we change gowns before setting down the jugs at each of these machines?

And another...Your patient is holding her sites, and you go to take off one of your other patients.. hands washed, clean gloves. You are in the process of rinsing back said patient's blood.. but have not touched his sites, nor come into contact with any blood.. just giving him saline to rinse him back.. your first patient shouts "OMG"!!! You turn to look and she (an eighty nine yr. old already severely anemic and with parkinsons) has lost her grip on her access and the blood is spurting out of her arterial stick site. Do you say, "excuse me, let me go wash and dry my hands first and put on a clean pair of gloves.. try to plug the hole as best you can.. and oh! I also need to put on a fresh new apron first, too, while I'm at it."

Or do you turn off the bloodpump at the machine you're at, and go immediately to stop the bloodloss in this profusely bleeding elderly woman?

And remember.. all your coworkers are themselves tied up with their OWN patients at this time, so they are unavailable to you. They're not sitting behind the station filing their nails.. they are each dealing with their OWN four patients and their little crises... just as you are.

What do YOU say?

You must also keep in mind that a dialysis unit is NOT comparable to a hospital setting, in which you go into one patient's room, wash your hands, put on gloves, provide the care, turn back and wash your hands before leaving the room and going on to the next patients room at your leisure. At dialysis there is far greater urgency, no time to waste between patients.

Also note that the patients' machines themselves are no more than two feet apart.. so to change gowns between patients would mean changing gowns with each LITERAL STEP you took. When several alarms are going off at the same time, (and yes, this is nearly always the case).. one a TMP alarm, the other a conductivity alarm, as soon as you reset that one, there's the one right next to him whose arterial pressure alarm is going off and the bloodpupmp has stopped.. fix that and BINGO.. there's that darn tmp alarm on the othrer machine again... and Mr . So and So is due to come off in two minutes and I still need to draw up his heparin blocks for his catheter which has done nothing but alarm ALL morning, regardless of our attempts to flush it, cathflo it.. reposition patient time and again (between the OTHER alarming machines)......

Such is just ONE FRACTION of an hour at dialysis, imperial. Thought you might like just a bit of insight. (again.. one must actually work it to appreciate it)

As to your friends at the website "dilaysis ethics" who complain about "fabric lint" on the velcro closure of their B/P cuffs.. I would suggest they write to the company CEO and request that each patient be provided with their own personal cuff to keep with them and bring back to each tx.

I would LOVE to hear the response they get. Of course, they could also go out and purchase their own as well.

As far as washing down the cuffs between patients.. I have yet to see that be done in a hospital setting, either.

Yes, we wash down the cuffs with a 1:100 bleach solution every evening, but between shifts would mean to put on your next group of patients with sopping wet cuffs.. I'm sure they would not appreciate this.. nor would the cuffs last very long as bleach, even diluted, is very corrosive. If one becomes soiled, absolutely it is wiped down, or replaced.. but it's not like we have dozens of extra cuffs lying around to play with.

There is so much more to dialysis than just putting on your four patients and taking them off. We stay on our feet circling the room going from patient to patient non stop, because if nothing else, you're having to constantly monitor them and addresse the alarms on the machines... (patient bends arm in sleep... there goes the arterial or venous pressure alarm)... poorly running catheter?... you're lucky if you can get ANYTHING done THAT shift!... try drawing up all your patient meds inbetween attedning to the alarms... :rolleyes: ..and what if three out of four of your patients have new or lousy caths? Heaven forbid.

And so it goes...

For just ONCE.. I would like to hear SOMEONE approach the hardworking, dedicated, and caring staff who work in dialysis ( I have have taken ONE sick day in all my eight years at dialysis... ONE) with something along the line of :

"How can we make things run smoother for you? What can we do to assist you in your daily routine? How can we help you to give EVEN better care to your patients? Are you adequately staffed...would another staffmember or two give you more patient contact you so desire?

Instead of being confronted by the dialysis police.

Thank you for hearing me.

nosonew, BSN, RN · Feb 24, 2005

Jnette you ARE my hero! I think Imperial has never worked in dialysis, thus has no right to throw stones. I believe "ONE MUST walk in the shoes" before they can state such comments.

To me, Imperial sounds like a past medical professional who is now on dialysis or has a loved one on dialysis or has passed while on dialysis and is looking for anything and everything to complain about. But that is just my theory.

Oh, and Imperial, FYI, our unit DOES give each patient their own cuff. I felt this was needed more for correct cuff size than infection control. But it actually takes care of both.

jnette, ASN, EMT-I · Feb 25, 2005

Jnette you ARE my hero! I think Imperial has never worked in dialysis, thus has no right to throw stones. I believe "ONE MUST walk in the shoes" before they can state such comments.
Oh, and Imperial, FYI, our unit DOES give each patient their own cuff. I felt this was needed more for correct cuff size than infection control. But it actually takes care of both.

Hey ! Actually, I think that's a wonderful idea, and more power to ya ! But I can just hear OUR company if we were to request that.. bwaaaaaaaahaha !!!

( I might just mention that, however, just to see what response I get.. should be fun). :)

As for imperial.. your guess is as good as mine. To me, she reminds me far too much of the "bookworm" type.. very rigid, by the book, all in black and white.. full of idealistic thinking, yet so far removed from reality.

My gosh.. the entire UNITS are contaminated, for crying out loud. There is no way to have a sterile environment. Even if I don a new, clean APRON.. what about my pants legs.. or my sleeve.. what if IT were to brush up on a patient's machine? How do I know that I don't have a minute speck of blood on IT ? :rolleyes: Everything in the unit is contaminated in SOME way.

I agree... educators, too, should have to WORK the floor for a full year with NO privvies or advantages, get down and do the work just as we all do... and THEN come up with their proposals. I think their great ideas might just be a tad more slanted in the direction of "what makes sense" and "just how practical/reasonable/ doable are my ideas NOW?" :stone

I don't mind good input.. always eager to look for ways to improve. Improvements for both patients AND staff.

What I DON'T care for was imperial's "TONE". Just my humble opinion.

imperial · Feb 26, 2005

Hey ! Actually, I think that's a wonderful idea, and more power to ya ! But I can just hear OUR company if we were to request that.. bwaaaaaaaahaha !!!
( I might just mention that, however, just to see what response I get.. should be fun). :)
As for imperial.. your guess is as good as mine. To me, she reminds me far too much of the "bookworm" type.. very rigid, by the book, all in black and white.. full of idealistic thinking, yet so far removed from reality.
My gosh.. the entire UNITS are contaminated, for crying out loud. There is no way to have a sterile environment. Even if I don a new, clean APRON.. what about my pants legs.. or my sleeve.. what if IT were to brush up on a patient's machine? How do I know that I don't have a minute speck of blood on IT ? Everything in the unit is contaminated in SOME way.
I agree... educators, too, should have to WORK the floor for a full year with NO privvies or advantages, get down and do the work just as we all do... and THEN come up with their proposals. I think their great ideas might just be a tad more slanted in the direction of "what makes sense" and "just how practical/reasonable/ doable are my ideas NOW?" :stone
I don't mind good input.. always eager to look for ways to improve. Improvements for both patients AND staff.
What I DON'T care for was imperial's "TONE". Just my humble opinion.

As I sit here and wonder... I still don't know why, on a message board, one would be suspicious of questions... come on guys/gals...a few questions.. no one said the staff were horrible vultures.. and, yes, to answer your question, I am a former Surveyor and a researcher/consultant now. I hope you all don't get as defensive when your patients ask questions, or, to that matter, would question something you are doing....Ida Imperial

jnette, ASN, EMT-I · Feb 27, 2005

As I sit here and wonder... I still don't know why, on a message board, one would be suspicious of questions... come on guys/gals...a few questions.. no one said the staff were horrible vultures.. and, yes, to answer your question, I am a former Surveyor and a researcher/consultant now. I hope you all don't get as defensive when your patients ask questions, or, to that matter, would question something you are doing....Ida Imperial

There you go again... it is THIS accusatoryTONE that is bothersome... always ASSUMING the worst.. ASSUMING we would be "defensive" with our patients.. ASSUMING we are "hiding something" ... and always ASSUMING the NEGATIVE.

Sorry Ida... that's what makes one feel devalued and unappreciated. I have yet to hear you say anything GOOD or uplifting or encouraging, or even motivating. Life and work is tough enough, thank you. :stone

imperial · Feb 27, 2005

Goodness. It was 'just' a question and that is all. I have seen how hard the work is and how demanding it is. I know there are good units and I know there are downfalls but not to the staff's fault and it is usually a corporate decision.. As you mentioned about the BP cuffs. money money.

jnette, ASN, EMT-I · Feb 27, 2005

Goodness. It was 'just' a question and that is all. I have seen how hard the work is and how demanding it is. I know there are good units and I know there are downfalls but not to the staff's fault and it is usually a corporate decision.. As you mentioned about the BP cuffs. money money.

True enough.. and exactly why I feel you would be better served by inquiring directly of THEM.. the Corporate heads, the CEOS, the admin. "suits". These are the ones who write the policy and procedure manuals. These are the ones who expect ALL and give nothing. Always looks pretty on paper, though.

nosonew, BSN, RN · Feb 27, 2005

Jnette you and I seem to have many of the same philosophies regarding how we care for our patients.

Regarding the dry weights, there are SOME nephrologists our there who demand their patients are pushed to the limits...they obviously feel quantity of life is more important than quality, regardless of the patients own feelings. I don't happen to have a doc like that in my unit, and if I did, I am sure we would go head to head about this issue.

Regarding plastic, the plastic we use is intended to protect ourselves from blood splatter. If our plastic becomes soiled, it is disposed of in a red bag and a new one is put on. If we had to change them in between patients, it would be impossible, literally.

I work in a MWF unit, with 27 patients. We currently have 12 catheters. This is due to the fistula first rule (which I like, BUT), it is causing patients who DO NOT have the ability to build up their fistulas getting one anyway. And only after they fail to develop over a long period of time is a graft put in. I find this ridiculous. Anyone who has been on high doses of prednisone for many years, is on chemo, and anything that affects the circulatory system with regard to strength of the vessel, should NOT have a fistula.

Our staffing has been cut recently, although we have had an influx of new patients as well. I have careplans from last month that I still need to go over with my patients, and next week will have this months to do. It is very frustrating when I get there at 4:30 am, have a 15 minute lunch, no breaks, get to sit for a while around 4:30-5p to do my paperwork, and get to leave at around 7pm and DON'T DO ANY other paperwork than what is required for that day.

I love my job, but I am really getting tired of these types of situations. I am working on my BSN and then my Masters, and if I don't have a different FA by then, I will have to look elsewhere...

jnette, ASN, EMT-I · Feb 27, 2005

You know, Ida, we BOTH really want the same thing, and that is improved care and outcomes for our patients. We see eye to eye there.

But you won't be finding the answers from the staff.. truly, it is not in our hands, even if it is in our HEARTS.

These concerns need to be directed at the upper levels, for "floor staff" are rarely (in MY experience NEVER) asked for their input. Our staff meetings are held with our clinical manager only, who pases down the info from the regional mgr., who passes down the info from.... you get the picture, yes?

Many (if not most) of the "upper echelon" have never worked the floor and wouldn't make it through the first day.. much less a week or month. Yet these are the very ones who sit behind their desks and come up with all this pie in the sky. While their "improvements" are well intended, they must also be willing to provide us with the TOOLS to implement them.. "put up or shut up."

As staed before, it all boils down to how much $$ they are willing to invest in the care of these patients.. supplies, proper equipment,increasing the staffing levels, etc., etc. While our company certainly is on the cutting edge of leading technology.. all this means little when it trickles down to the daily routine if there are unresolved staffing issues, or old chairs which need replacing, or cuffs enough to go around, and staff having to be concerned about every red cent "wasted" during the course of the day and finding ways to cut costs. And funny, how it is always at the floor staff's expense when introducing new measures, facilities, equipment... we are due for a new facility, new chairs, and further technical improvements.. so guess what?

The annual raise percentage has just been slashed for our floor staff ! :rolleyes: BINGO !

And yet we have excelled in every area, winning all kinds of local and regional awards of excellence.. from patient outcomes to safety awards, to virtually zero staff sicktime... and this is how we are shown appreciation...???

Yes, we could probably agree on MUCH when it comes to improving patient care, but the COMPANY has to provide the means. Much of the infection control issues you spoke of could only be implemented (realistically) if there were a staff ratio of 1:1 or 1:2 nurse to patient.. and you and I BOTH know that this will NEVER happen in OUR lifetime.. if ever.

Sad.. but when $$ rules, patients AND staff suffer.

jnette, ASN, EMT-I · Feb 27, 2005

Jnette you and I seem to have many of the same philosophies regarding how we care for our patients.
Regarding the dry weights, there are SOME nephrologists our there who demand their patients are pushed to the limits...they obviously feel quantity of life is more important than quality, regardless of the patients own feelings. I don't happen to have a doc like that in my unit, and if I did, I am sure we would go head to head about this issue.
Regarding plastic, the plastic we use is intended to protect ourselves from blood splatter. If our plastic becomes soiled, it is disposed of in a red bag and a new one is put on. If we had to change them in between patients, it would be impossible, literally.
I work in a MWF unit, with 27 patients. We currently have 12 catheters. This is due to the fistula first rule (which I like, BUT), it is causing patients who DO NOT have the ability to build up their fistulas getting one anyway. And only after they fail to develop over a long period of time is a graft put in. I find this ridiculous. Anyone who has been on high doses of prednisone for many years, is on chemo, and anything that affects the circulatory system with regard to strength of the vessel, should NOT have a fistula.
Our staffing has been cut recently, although we have had an influx of new patients as well. I have careplans from last month that I still need to go over with my patients, and next week will have this months to do. It is very frustrating when I get there at 4:30 am, have a 15 minute lunch, no breaks, get to sit for a while around 4:30-5p to do my paperwork, and get to leave at around 7pm and DON'T DO ANY other paperwork than what is required for that day.
I love my job, but I am really getting tired of these types of situations. I am working on my BSN and then my Masters, and if I don't have a different FA by then, I will have to look elsewhere...

Yes, it is getting to be a bit much... I agree. We, too, are getting an unbelievable increase in patients as well as patient acuity.. many of our patients now are very limited in transfer ability, etc., all of which requires far more time and effort. These things are never considered when they question any overtime which staff aquires during the day.. and our poor Clinical Mgr. has to try to "push" us out the door in the evening just to keep her SELF out of trouble with the "suits".

Our nephrologist is fabulous.. he has full confidence in our judgement and abilities.. re dry weights and other issues.. and has gone to bat for us many a time.

Yes, I, too, have nursing notes still to be done for this month, as well as careplans... and no time during the day to do these.. so I guess I'll be staying over my usual 12-13 hours one day to tackle these.. and of course that means overtime..tsk, tsk, tsk. :rolleyes:

Dialysis COULD be wonderful.. it USED to be when I started there eight years ago.. but the patient load has doubled, (and therefor also the paper work, etc.)...but the staff numbers have stayed the same.

Someone is always demanding more for less. :stone