Monday, 13 July 2009

Admissions and Transfers: NIGHTMARE

I wrote some bits and pieces about what happens when we get an admission and transfer in and old post.

Let me expand on that even more.

We are taking admissions and transfers when we already have way more patients than we can possibly get around too.

They are arriving on my ward when it is convenient for the sending ward to send them. I get a "ball park figure" for when my new patient(s) may arrive. He may come in 5 minutes or 5 hours. That is all I know. I don't know when they are coming. Therefore I cannot organise my time around my other patients to accommodate the new ones.

But that is a mute point. I cannot organise anything. I am trying to accomplish anything I can in the 30-90 second periods of time I have between interruptions. The entire shift is like this. We may be working our assess off, but we are only ever ever hitting on the very top priority things. We are getting the tip of the iceberg chipped away but nothing else.

The patients have this idea that if the nurse is not at their bedside as and when they want her, that she is not caring for them. They have no idea how much goes on behind the scenes, or behind the nurses station really, to keep their ass safe and alive throughout the duration of my shift.

Admissions are sent unexpectedly at mealtimes, during handover, change of shift, when my MI patient has another heart attack stopping me from getting to the cancer patient with the pain medication she has been crying for during the last hour. Unless you are retarded you will understand that the heart attack patient is first priority in this scenario with 02, ecg's, stat orders and organisation for possible transfer to the coronary care unit etc.

If I skim the surface with heart attack man and do the bare minimum to keep him (and my nursing registration) safe from harm then I can get to the cancer patient needing pain killers in 45 minutes. That is 45 minutes if I ignore the other patients crying out for me. IF I don't ignore them, it will be hours before I get to the cancer patient with her pain killers. Setting up her narcotics, checking them for safety and administering them between all the other interruptions takes another 15 minutes.

Where am I now? Oh yes, the admission. And the other patients crying for help and everything else. I go to the admission, walking past multiple voices begging me for help with everything from getting a drink to getting a commode . My new admission and his daughter look at me sharply. "We have been on this ward for nearly an hour and YOU have not bothered to come and check on my father". The other patients are still crying and I really need to check back on my cancer patient to make sure that she is tolerating the narcotics okay and still breathing. They may not be infusing properly because of a kink in the line and she may weep in agony until I get back to her. They might infuse to fast or be too much and she might die. And I will be blamed. Your grandma and ten other people's lovely grandma's are sat weeping in their own urine right now. Right. Back to my admission and his pissed off daughter.

The admission itself is a lot of work and that right there is the crux of this blog post. When these patients come to us they are a fucking mess secondary to a lovely stay on what I term "the sending ward". These wards are called acute medical admission units, short stay medical units, medical admission units, medical assessment units. It is all the same thing really. From here on in I will refer to these places as sending unit hell, or SUH.

They come to us filthy. They come to us in pain with no prescribed pain medication. They send them up with insulin infusing IV. It was ordered to stop 10 hours ago, 10 hours before they were sent to the ward. But it is still infusing without any dextrose etc. The patient has a BM of 1.5. They come up dehydrated with orders for IV fluids prescribed hours ago, yet not started. No venflon is in place. Half the paper work is missing. Trying to figure out what is going on with these people is a mission in itself which can take a lot of time. When these people come, and they come with no warning, I need to leave my other patients and do a bit of assessing and research. Otherwise all hell breaks loose. Most of them are elderly people, who need someone there at all times to ensure that they are clean, hydrated and that their dignity is maintained. If I spend any more than 30 seconds at a time with any one person then all hell will really break loose and I just won't get to see some people.

Sometimes SUH will handover that the patient had bloods done. They were not done. Or that sando k was started yesterday for a low potassium. It was never ordered or given. Last bloods were 36 hours ago and the potassium was 2.1. If I don't contact the medics and let them know that this stuff is going on then they cannot sort it out and treat the patient. It is the nurses legal responsibility to field this crap. SUH tell us that the patient is for an urgent OGD, and that the test was ordered. It was never ordered. Now I have to chase up a doctor to order this test. The patient has been sitting and waiting for this test, and has been starved. The test department doesn't even know he exists. The medic is overwhelmed and cannot get to the ward to order this test for awhile. But the patient again has a dropping HB. Not good. Lots of phone calls and paperwork to sort this nightmare out. And you can bet your ass that it is indeed my problem, with my ass on the line.

They send patients up with the wrong notes, without wristbands, and dump them in the middle of the ward. They send them up as they are taking their last breaths. They have sent septic patients with a low white cell count secondary to chemo without warning, and the porters have dumped him in a dirty bed that has only recently been vacated and not yet cleaned. They did this while I was down the hall in another patients room hanging blood. It was 10 minutes before I saw. I just had to hang that overdue blood then the hca was going to finish ups and our first mission after that was to clean that room. But they couldn't hold off for 10 minutes. They dumped him. Its not like we have any kind of domestic support.

They send them up with dressings and ulcers but no documentation as to how long they have been present and when the dressings were last changed. It is very doubtful that I will have the dressings I need in stock and pharmacy is closed. If this is a Friday it will be Monday before I get those dressings. They send them up without telling us that they are diabetic, or that they are allergic to wheat.

Why does this happen? The nurses in SUH don't have an easy time of it, by any means.. First of all, they have A&E on the phone every 5 seconds demanding that they move people out NOW. Secondly, there are twits with clipboards and magnets constantly up there ass screaming about targets and getting patients moved NOW. With all that going on, it is very doubtful that they ever see their patients for very long and get to sort things out before transfer to the wards. Targets Targets Targets.

They send up confused and wandering fall risk patients without warning, when I and the other staff are already outnumbered by confused, wandering fall risk patients who need one to one supervision. This is often happening while I am trying to help your gran with her tablets, which will then end up on the floor as I go running to hear what that "thump" was. It is the sound of a body hitting the floor. Third time this shift, same person, and a big fat piece of paperwork for me. Those have to be filled in whenever someone falls. No, I do not leave them unsupervised because I want them to fall. You are crazy for even suggesting that.

Then send up violent alcohol detox patients, before I even get the the falling and sick ones. The families come onto the wards with the new admissions and demand to speak to the receiving nurse the second the patient arrives onto the ward. But I am in the middle of a 100 things and people are dying and they are falling and they are shouting out. The family member makes a snotty comment about how "that nurse cannot be bothered speaking to us because gran is old, and they don't care about old people".

The powers that be tell the ward nurses to stop complaining about the screwed up transfers that we are getting. "They have done all the admissions work in SUH, you only need to settle the patients onto the ward".

Um Right.


Nurse Ratchet said...

Welcome back Nurse Anne! Glad to see the bastards didn't get you down enough to stop blogging.

I sympathise with you - I really do. Being one of those clipboard wielding folk, and yes, scrreaming about targets (as I am being screamed at by those above me..and so it continues) I really do see your point. I'm not making myself out to be Florence bloody Nightingale here - but who exactly are these managers of yours that send patients to your understaffed, busy, acute ward without checking whether they're ready/fit/suitable to go? I can't help the admissions unit sending their patients all in one go, HOURS after I've given them the bed, but I sure as hell read the notes, look at the patient and decide whether the receiving ward can cope. That's my job. That's why, despite our bosses thinking that we could manage beds from an office - we can't. We need to walk the wards, see how busy they are, know how many staff they've got on, and make clinical judgements on whether the patient is better off staying where they are than moving. When it gets hideous in A&E, and we're holding ambulances full of sick people in the car park because there's just no space, then I have to say the bar gets lowered, but that is trying to even out the chaos. The point of the patients turning up not cared for is a good one - it happens all to often, and frankly it can't always be blamed on the admissions unit being busy. Sometimes it's just plain bad nursing care, and it's the ward staff who have to pick up the pieces.
Before we had admissions units the patients went directly from A&E to the wards, and I remember it being even worse then....what is the answer? It's not all target driven, we are busier than we have ever been, with less people who want to nurse,and less nurses who have good leadership to encourage them to nurse properly.

Nurse Anne said...

Granted some of it is down to bad apple nurses. But most of it is down to people being rushed without resources. I get seriously pissed off at the SUH nurses. But everytime they have tried to get me to work down there I have found a way out of it. No way Jose.

I also understand that when there are ambulances in the carpark holding patients that it absolutely means that they need to ship people out of a&e and suh FAST regardless of what is happening on the wards.

I always thought that the a&e targets were a bad idea. IF they wanted to sort out waiting times they should have put money into beds, staff, resources and step down long term care for medically stable healthy elderly patients waiting months for a nursing home placement because they cannot take care of their own basic care. Our wards (medical, surgical, specialty etc) are full of these people and they are very demanding and so are their families. And it causes acutely ill patients to be harmed.

To me, that would have been a much better investment to sort out the bed situation then to sit in a&e with a fucking clipboard.

Nurse Anne said...

I meant your bosses are the ones who sit in a&e with a clipboard screaming at the staff when there are no beds etc. I didn't mean you. I wish you worked at my hospital. Some of our bed managers are great and other totally hate us.

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