Who has ever thought about this?

[LnDPPRN]

I currently work in float pool as a post partum RN between 4 different hospitals within the same company and all within a major metropolitan area. The biggest hospital has an OB hosptalist and a neonatologist/neonatal NP present in house at all times. The largest hospital has a level 2 EQ NICU. So if something goes horribly wrong with a baby on the post partum floor and the pediatrician is not around, you can grab a NP in a pinch. (ie, a baby stops breathing because of sepsis or a baby seizes secondary to narcotic withdrawal, etc.).

At 2 of the other hospitals, they have smaller level 2 NICUs where a neonatologist makes rounds but is not there 24/7. I am told that the neonatologist has to be able to physically get there within 30 minutes of an emergency, giving orders all along the way over the phone. But that doesn't do much good if I need an ET tube or a UVC. The remaining hospital just dropped down to level 1 status a few months ago and I so infrequently work there that I am unsure if neonatologists round there anymore. The NICU nurses that have been there are quitting.

At these "other hospitals," I am getting worried about what will happen in a true emergency without a neonatologist in house. I am unsure if the ER physician can do or is willing to do anything for us or if they are NRP certified. I could see the ER phsician refusing to come up and help due to lack of experience with newborns and that could vary from doctor to doctor. (That really did happen in a previous hospital I worked for. I heard about it in a staff meeting.) I could ask the other RNs what they would do I suppose but I am afraid they will give me bad advixe especially if it is not spelled out in a protocol.

I know that the scenario I am describing is incredibly rare and none of this has happened to me in 6 years. But I tend to think of "what if" scenarios. I think it is very bizarre to not have an in house neonatolotist even if the NICU is "slow." What do you think? Am I just being paranoid? What can I do given the situation?

[ssrn13]

You mentioned some of the NICU nurses are leaving, will you have many experienced nurses on the floor that can perform these skills? I've worked at a few smaller hospitals with level IIb NICUs where the only doctor we ever had in house 24/7 was in the ED. When needed while waiting for the ped/neo to come in, we could put in the UVC's and we always had RT available if we needed an ET tube (though we practiced intubation also during NRP cert class, and could do that if necessary). Of course, the nurse in me would agree it would be nice to have a neo or nnp in house at all times, but in slow, lower acuity nurseries I don't know if it's necessary. I think the AAP even published at one point that level III and higher nurseries were defined as having continuously available personnel. All that said, my experience in the nursery has not exceeded level II care. I'm sure there are other nurses here who would have much better insight than I.

[brownbook]

Well...you said it, you are a little paranoid.

Yes we're talking about a newborn possibly dying because expert medical help was not immediately available. But it is not cost effective to have a neonatologist, or neonatal NP, or OB hospitalitist, 24/7 in many hospitals. How can money be more important that a babies life? Good question. How can a hospital justify the cost if 8 times a year they are needed?

Realistically all you can do is be the best nurse you can be. Notice a difference in a newborn, catch a change in their condition early.

It is good to be a little paranoid in thinking and preparing for the what ifs when caring for any patient. Unfortunately you will have to rely on your, and your co-workers, "intermediate" level of skills if an infant "crumps" until the infant can be transferred or the calvary arrives.

[quazar]

It's really a matter of how confident/comfortable you feel with your own skills and your coworkers' skills and their ability to work together well as a team. At smaller hospitals with doctors not available 24/7, while the patient acuity is theoretically lower, emergencies happen and sometimes docs aren't there, and yeah, that's the norm. Having worked at small hospitals without 24/7 in house docs for a long time now, and having just LEFT to go to a bigger hospital with 24/7 coverage, I will tell you why I stayed for so long, and why I left.

The hospital I just left was full of older, more experienced nurses who worked well together and who had been working at small, community hospitals for almost their entire careers. They were awesome, awesome people. They really pulled together like nothing I'd ever seen and worked beautifully together in an emergency. We hardly needed to ask for anything; everyone just knew what had to be done and did it. So even if the poo did hit the fan, we were okay and could hold our heads above water until we got the docs there, and outcomes were good.

Things changed drastically when that small hospital was bought by a very large hospital and our patient acuity shot up and we started getting lots and lots of very sick patients in, very frequently, and the docs didn't want to change their practice of not coming in and the administration didn't want to increase staffing to deal with the increased acuity and census. Long story short: things got unsafe. So I left.

The take home message here is that yes, bad things can happen and crises can arise, but if you have a good team and a staff that is competent and works well together, you can make it through. It's totally not unusual in smaller hospitals to not have docs in house 24/7 because the acuity and census is lower (in theory). That's what makes it doable. However, if you are working with a skeleton staff and don't have appropriate staffing for what's walking in the door, though, that's when there is real cause for concern and when it's not okay to not have docs in house, and you may want to consider leaving. JMHO.