Saturday, 11 July 2009

More fun during "protected mealtimes"

By 2PM I had discharged 3 of my patients and transferred two others to rehab and long term care facilities.

I had 5 empty beds! I made sure that the bed manager knew this. Our patients are always breaching the targets in a&e due to lack of beds. If she knows I have beds then she can get patients out of express admissions unit/medical holding and send them to me. Then she can get patients out of a&e and into medical holding.

I was left with a mere 10 patients (25 beds on ward total, and one other nurse). The healthcare assistant and I ran around making sure the beds were cleaned. I had to walk away from some important time sensitive things to help her do the beds quickly. Usually the discharged patients are not even out the door before the transporters are dumping another into that bed. What if the staff hasn't had time to clean the bed because the new patient is coming before the old one is out the door? Well then the porter will just dump the new patient into a dirty bed and go off on his merry way. He has other places he needs to be and it isn't his problem if the nurse gets an admission with no notice. It isn't his problem if she cannot sort the discharged patient's bed out right away because Gladys in the next bay collapsed onto the floor with a massive GI bleed. The buck always stops at the nurse and the numerous support staff goes on their merry fucking way and do as they please.

If the new patient complains about getting dumped into a dirty bed or gets ill as a result the ward nurses have to take all the blame. The porter can do as he pleases. Even if the patient has been on the ward less than 10 seconds anything that happens to that patient during that 10 second period is the responsibility of the RN. And they often send up admissions that I am not expecting and dump them and walk off while I am in another patient's room and don't see.

Sometime after I declare our number of planned discharges/empty beds to the bed manager the nurse from the "sending ward" calls me on the phone and tells me about the patient they are sending to me. This is called handover. After that happens the patient may arrive on the ward 3 minutes or 5 hours later or anywhere in between. They get sent to me at the convienance of the sending nurse's unit. I have no idea when they will show up on the ward. What I do know is that they like to send them all at once either at change of shift or mealtime. I don't know why it is that way. Either they are being twats or the situation on their unit is such that they have no choice.

Sometimes there is so much going on with the patients I already have that there is no fucking way I can nip down to see the new admission as soon as I want to and need to. I do not get given an exact time as to when they are coming so I cannot plan for it really.

I want to and very much need to go and see my new admission and give him a once over and a kind word of welcome as soon as he comes onto the ward. As a matter of fact I really fucking NEED to see him. But it isn't always going to happen right away. The ward receives admissions when it is convenient for those who are sending the admissions. That means admissions are arriving when I am up to my eyeballs in other things.

No thought whatsoever is given to what is happening on the receiving ward. That means that I am often getting new patients when it is unsafe. It means that I cannot always get to them straight away. Wanting to get to them straightaway and understanding that it is crucial for me to get them straight away is not enough to make it happen. This is the case even though I am an extremely hard worker and easily able to multitask.

If I had 5p for everytime a walking wounded transfer said "well I have been here 20 minutes and not one of the staff has seen to me yet" I would be rich. How I would love to say "well they sent your ass up here when I was smack in the middle of inserting an NG tube into someone with an obstruction.

As a matter of fact it is a crime for me to leave that very unwell patient at anytime for any reason EVER especially to be down here apologising and kissing your medically stable ass. But I took a risk to come down here because I care about your welfare too. Believe me, I took a massive risk when I left him and came to you. It's because I don't trust the ward who sent you or the transporters who dumped you here not to leave you in a bad way. Once upon a time the ward who sent you handed over that they were sending me a stable patient and when the man got here he was dying. It may have taken me 20 minutes to get here. But I got here as soon as I could. I did it in the only 30 second period I had to check on you and make sure that you are actually stable as they said you were. Your welfare is important to me, even if you are a complete twat. A word of thanks rather than a stupid smart ass comment about how long you had to wait would be more appreciated. Not one thing about this situation is created by the nurses. Nor can they control one bit of it.

Back to the point of this post. I had 5 empty beds at 2 PM and the bed manager knew this at 2:05 PM. She knew that those beds were coming up and already had transfers slated to come to us.

We got the beds ready right away because we know what happens. 3PM rolled around and I had not received a phonecall from a medical holding unit nurse to give me handover on a patient that she would be sending. By 4 PM I had received a call from the holding unit nurse. She handed over two patients. I told her to send them now, before mealtime.

By 5Pm nothing. At 5:50 they called and handedover 3 more patients. At 5:55 they sent all 5 of them up together. The porter left them in the middle of the ward and walked away. I found them all when I came out from a bay where I was pulling a central line.

3 of them were confused. None had wrist bands on to ID them. The one who was supposed to be treated for dehydration with an IVI and a had low potassium according to today's blood report had NO IV. No venflon. Nothing. Nothing prescribed for his K+ of 2.2. First priority above all else right there. Had to get a venflon and get something prescribed. He wasn't taking oral anything. The last note from a doc who saw him prior to his arrival on my ward said to hang IV N. Saline with 40 mmols of K+ and monitor fluid balance closely. Well duh. But he never prescribed it onto the medication chart. In the UK nurses are not allowed to transcribe orders from the doc's notes to the drug chart. The doc has to write it on the drug chart. Yeah. And for those of you who don't know, if your potassium is that low your heart will stop.

The one that had urinary retention (according to handover) and had not passed urine in 11 hours (bladder scan that was done in medical holding showed 800mls in bladder). The sending nurse handover to me that she was going to cath the patient. This was a few hours ago. He was supposed to have a catheter inserted. There wasn't one.

So all this was happening at the same time and there were 2 nurses and 2 HCA's. It was 5:55 PM. The supper trolley comes now, and we have 20 minutes to get all the food out and served and fed to all 25 patients (and 10 feeds). I also have an hours worth of a drug round due now and people need their pain killers. I can't even get to the new patients new and read up on them to see if there have been any changes since they were handed over. This is because the notes are on the desk and that is where the visitors are queing.

I go for the notes to read up on my patients and make sure there aren't any other life threatening "surprises" left over from the sending unit and the visitors of the other patients go for my jugular." Patients are crying for nurse and suffering and there is that nurse with her face in the notes" "Don't you know that grandma cannot feed herself cannot reach her drink? Don't you horrible people care?" It's not like I can through all the notes in a few seconds. Getting all the information that I need to takes time and concentration. But the families go nuts when they see me open a chart....then mistakes happen because the nurse does not have all the info she needs to be able to function.

The domestic was stood with the supper trolley hands folded staring at me menacingly while I was getting the venflon into the low K+ guy. The other nurse did the catheter. One HCA sorted the ID and wristband situation and tried to get the new people settled into their beds. They new admits got really pissy when she moved at the speed of light and wouldn't stay or organise their belongings in the cupboard. The reason she was moving so fast is because one HCA was now trying to serve and feed all the patients on the ward by herself. Impossible for speedy gonzalez let alone 50 year old Linda. We all needed to pitch in and help. Even with all 4 of us on deck it was never going to happen, let's be honest. It was 20 past 6 before I sorted out the man with the low potassium and by that point the fucking domestic was trying to collect all the dishes in so that she could get home on time.

Now it is 20 past 6. I was trying to keep an eye on my unstable patients, figure out who actually ate and who didn't...everyone was simultaneously shouting "nurse nurse nuuuuuursssse" as I walked by and the visitors who just arrived were queing up at the nurses station to bitch at me and tell me things I already know. My drug round still wasn't started. At this point I would be lucky if I finished it by 7:30 PM. That means it is going to be another hour before I get around to everyone in pain with their medicine. IF I stop at any point to talk to visitors or answer the cries of "nurse nurse nuuursssssse" it's going to take a lot longer.

FUCK. FUCK. FUCK.

Later on we again had two empty beds by 7PM. I told them so no later than 7:05PM. They handed over patients at half past 7 and then sent them both up together at 9PM. I am off duty at 9PM but the night nurse was going to struggle handling two new admits, her initial drug round, and all the problems that were happening. Really no choice but to stay late and unpaid and sort the new admissions. You would think that transfers from medical holding would be easy to deal with because the staff in medical holding due the initial admission and paperwork and "supposedly" get treatment started. When they are coming to us, they are merely transfers not proper admissions. Therefore it should be easy and straightforward. But it is not straightforward as that and I'll explain why later.

In the meantime if there are any medical express/holding/admissions nurses and bed managers around can fucking you tell me why the hell you send them up in clumps at mealtime and change of shift?

To be continued.

106 comments:

hospital management said...

wht you are describing is a NIGHTMARE, A REAL NIGHTMARE. but then again nurses are to blame are they not? when did it happen that nurses put in I.v. cannualas? and worried about blood results? that is NOT a nurse`s job. a nurse should feed the patients, care for them, manage the ward. by saying you have cannulation skills, but telling the bed manager you have empty beds............well you create work. So what if the patients fucking K+ was 2.1: that is a medical problem, not a nursing problem.........so what he is probably in AF anyway! just focus on supporting you new staff nurses, ensuring they are not given too much work to do: in otherwise teach them time management skills like going home on time.

Nurse Anne said...

Ooh it's another hospital manager that doesnt know dick.

Sorry love but in the real world if a patient has a low potassium it is the nurses job to inform the doctor. If we do not do this then the doctor doesn't realise that he have a patient with screwed up electrolytes on the ward. If he doesn't prescribe treatment on the drug chart then I cannot get the treatment started. Then the patient dies. In this case the nurse would take the blame and legal liability. Seen it happen a million times. I have seen nurses sacked and reported to the board for just such a thing.

If I had just let it go and left a patient with a low K sit there whilst saying...oh well hopefully the doc will eventually figure out he has a man down here who needs treatment prescribed I would have taken the full blame when he arrested.

It's not possible to get out on time even with good time management skills.

WE HAVE to declare our bed state to manager via phone as soon as we know about an upcoming discharge and or as soon as a bed becomes empty. There are penalties for not doing this. Keeping the bed manager in the dark about what your bed state is gets you in the shit real quick.

We been told that it is considered an offense that justifies sacking. Once I forgot to phone the bed manager and update her about our bed status and she didn't know we had beds and people breached in a&e. Got my ass nailed to a wall for that.

So what if his K was low and so what about AF??? WTF?????

Another member of the hospital management team who doesn't understand shit and probably gets people killed.

Our new staff nurses were left alone in charge of a side from day one. IF another staff nurse is not there with them then we cannot control their workload so that they are not overwhelmed you ignorant twat.

Nurse Anne said...

sorry about the typos. I am still doing this one handed.

It should have said "doesn't realise that he has.....

Nurse Anne said...

Christ. I trained overseas in the 1990's and we were taught to cannulate. We were taught that it is the nurses job. We were taught this by nurses who trained in the 1970's who cannulate and they were also taught that it is the job of the nurse to do this. If you had the audacity to ask the doctor to cannulate a patient you would be fired. Docs don't do such things!

So I learned to cannulate. In the UK nurses are spread between too many patients to take time to cannulate. We have support workers who cannot always come right away and doctors who don't have time.

Can any US RN's help me out here? By cannulate we mean start an IV. This fucker is telling me that this isn't a nurses job. What would happen if you asked the attending to start an IV?

Nurse Anne said...

It was a fucking situation that needed to be sorted out immediately.

If he had arrested because I hadn't got the treatment prescribed by a doc or because I was waiting for someone to cannulate him (necessary for treatment to get started) YOU WOULD HAVE FUCKING SACKED ME.

Twat.

Nurse Anne said...

If I was caught abandoning a patient with an electroyte balance and not organising the things that he needed for treatment to start... in order to feed patients I would be knee deep in litigation and possibly going before the NMC.

Nurse have to do 10 things at once. Always prioritising.

Anonymous said...

Quite right Nurse Anne. Low KCL is the problem of the nurse. These electrolyte imbalances can be quickly fatal and not getting a venflon in is a hanging crime.

Hospital management. You are a total fuckwit. You would be quick enough to blame the nurses when a patient with low KCL arrests yet you try to shift the blame

You suck.

Nurse Anne said...

I think we need to do a blog post about things nurses have been hung over...things that people think are the doctors job.

Happy1 said...

Hospital management - please stick to targets, paperwork excercises and meetings about having meetings. You know NOTHING of the role of the nurse. If your loved-one sat with a low K level, and died as a result, you would sue the ass off the nurse that was sat mopping brows instead of acting upon it.

How many doctors do you think there are? Patients do not have a personal doctor, sitting waiting for blood results to return...It is the responcsiblity of the nurse to monitor outstanding results...whilst the doctors go about admitting yet more patients (all the while ensuring your precious targets are met).

You know nothing of the REAL work that goes on in a hospital, otherwise you wouldn't have made such a ridiculous comment. Ignorance on managements part is heavilty displayed here in your post, and that is exactly the root of the problems in the first place.

Anonymous said...

Do you have any idea HM about any sort of patient? I am inclined to think you are a troll.

If the U&E's are deranged you have to take immediate action. You do not have time to wait for some incompetent F1 to cannulate your patient. You do that yourself. It is NOT the job of the doctor.

The doctor will tell you how much KCL your patient needs and how quickly. This will be written up as a thing called an "order" or a "prescription". The amount will depend on the blood result.

KCL is dangerous. Infusing too much too fast will result in cardiac problems. Too little has equally bad results.

Idiot.

Anonymous said...

I have read some right stupid comments on this blog recently, but Hospital Management, you win first prize. You are right back in the 50's, times have changed. Please keep up if you wish to retain some credibilty.

Anonymous said...

Troll.

Cannot be anything else given the massive ignorance

If not a troll then should be ashamed of the huge know-nothing and outdated ideas.

uk nurse said...

Has to be a troll..Even hospital management generally aren't THAT stupid.

Nurse Anne said...

I am thinking that it is a piss take as well.

I am annoyed with myself because I don't generally lose it in the comments section.

Anonymous said...

Our discharges take so long, what with waiting for the Dr's to write the discharge letter, and the prescription, then pharmacist to come and check, then pharmacy to dispense it, then wait for transport. Dr's says that patient can go home at 10am, 6pm maybe everything is sorted for them to go. But 11am bed manager wants the patient out of their bed and in the discharge lounge or day room. Even once you've sent them to the discharge lounge it is still the ward nurses responsibility to sort everything out. So you have 4 discharges, you never really get rid of them you just get an extra 4 but sicker than the originals.

I don't cannulate, I have been asking for months to do the study day, now I've just booked it myself and will tell the manager I am going. No Dr will come to cannulate unless every nurse on the ward has tried and failed.

Nurse Anne said...

Oh yes. Discharge hell.

A little birdie once told me that they used to have hospital social workers and ward doctors to sort that stuff out.

If you are like us you don't know when the transport will actually show and if you do actually get a ball park figure time...they usually show hours earlier.

...and then the discharge drugs are not ready from pharmacy yet. So the ambulance has to leave without the patient, or I have to leave multiple unwell patients to run down to pharmacy as they are refusing to answer their phone.

Then the ambulance personnel stand there and glare at you and say stupid stupid things like "If you knew she was going home why didn't you get it sorted before now". As if that's even fucking possible. I could slap their dumb arrogant asses I really could.

We do chase the docs to write the discharge orders in the days leading up to discharge but they are usually to busy and have higher priorites. They usually leave it until the day of discharge after we have been forced to book transport. Nothing can get set into motion until we have the damn letter. If you wait until you have the discharge letter and book transport then...the patient will sit there waiting for transport another 24 hours.

Pharmacy doesn't cooperate at all. They are taking on more work than they can handle as well.

Anonymous said...

And that's just simple discharges, complicated ones, making sure the care package is set up, social services have been to assess, district nurse etc are just hell.

I used to work in a community hospital and we had a discharge co-ordinator (band 2) and was fantastic, not the clipboard carrying waste of spaces we have in the hospital.

Nurse Anne said...

It is hell and it all kicks off simultaneously when all of your patients have drugs due, docs showing up to do rounds and the domestic is standing there with the meal trolley waiting glaring at you.

Dr Machaon said...

Um, maybe it varies hospital to hospital (& I've never worked in England), but if I admitted a patient, I always checked the initial bloods myself & inserted the IV. It was absolutely considered the doctor's job - how can you fully diagnose & prescribe treatment without knowing the labs? For follow-up or routine bloods the nursing staff would usually be notified first (lab calling the ward if abnormal). IVs & charting fluids - again the doctor's job where I come from.

hospital manager (new to the job but learning fast) said...

i afree with the last post: since you cannot prescribe KCL..........what is the point of trying to insert a cannula (when you are angry and stressed to the limit). call the doctor, get him to check the renal function, prescribe the KCL and put up the I.V. IF NURSES REFUSED TO DO THIS: they could get on with nursing. but because they do the jobs of an F1 (no wonder they are crap at cannulating as they are just sitting in the doctors mess "WAITING FOR EVERY NURSE ON THE WARD TO USE UP ALL THE VEINS TRYING........AND THEN CALLING THEM). the solution is that nurses stop doing the extended roles like cannulating, prescribing, taking blood gases, worring about U/Es and things. and started to nursing. otherwise who is doing the NURSING? on my ward it is the dodgy looking rwandan nursing auxillary who came from the cheapest agency that could be found ( via call centre in india).
case in point: nurse spent all moring trying to find a monitor, and a nurse to "special" a patient on the ward who needed a magnesium infusion. My question is: why bother! this is not HDU. her concern was "patient might develop an arrhythmia". my argument is "well i dont think the ruwandan NA will notice the AF. he has just done all the obs on this side of the ward.........the dynamap thingy that does the obs was broken (it would not switch on) so he MUST have invented the obs anyway.

Nurse Anne said...

In England our patients go from accident and emergency to medical holding units until a bed becomes available on the wards.

He had been in hospital 48 hours before he was transferred to me. The low potassium was the blood result from the day he was transferred to me. It came back from the lab about 5 hours before he was transferred to me. Treatment had not been initiated yet. The doctors (or probably doctor singular) in medical holding are OVERWHELMED. That's probably why they forgot to prescribe treatment, and then forgot that they forgot to prescribe treatment.

When these patients are sent to the wards their situation is a mess.

In England the nurses have too large of a patient load to cannulate and many don't learn. We normally have support workers to do this. But these support workers take forever to arrive. If it is a tough one the doctor has to come and do it when he has time. We often have one junior doc covering the whole hospital.

Nurses like me who trained overseas can cannulate. And we do so when the need arises. Usually I am too busy and dump it onto the support worker. Then I lose my mojo with that skill.

It's been a long time since I was across the pond but as far as I know, if you asked a doctor in the USA to cannulate a patient for you he would probably slam your fucking head into a wall.

They have special "IV teams" in the US made up of nurses who are great at cannulating, in case the ward nurse gets stuck.

I didn't even know that doctors knew how to cannulate until I came back to the UK. I had always assumed that they never learned that skill because the nurses do it. In all honesty, it's a little beneath them to cannulate.

Nurse Anne said...

You still do not understand the situation HM.

and nurses never ever ever ever draw blood gases.

If that nurse had infused that without having the patient on the monitor you would have slaughtered her and you know it.

Nurse Anne said...
This comment has been removed by the author.
Nurse Anne said...

HM,

Why the hell did the nurse get left with nothing but a crappy agency assistant who was incompetent?

Happy1 said...

HM.

"....call the doctor, get him to check the renal function, prescribe the KCL and put up the I.V."

Due to 4hour targets, the doctor's priority is the multiple new patients in A&E. Once a patient is transferred out of A&E, the doctor then becomes torn between these existing (now ward) patients, and the new one's that are continuously arriving. Outstanding blood results are always repoted to the nurses.

(The doctors do attempt to filter the reviewing of results, in between initially assessing new patients).

If a nurse recieves an abnormal result, he/she is duty bound to act upon it. If a patient has an abnormal result, and is at risk of 'crashing', the nurse is duty bound to stop whatever she is doing, and act upon it. If this potentially unwell patient has no IV access, the nurse (if trained to do so), is duty bound to insert one.

There is often not time to wait for the doctor, as once a patient has 'crashed', obtaining IV access is 10 times more diffiult.


A coroner would NOT accept my statement >> "Yes i knew the patient could crash yet had no IV access, I informed the doctor, then went about mopping brows, as it's more his job than mine"


I don't think you fully understand how things work. Doctors are as overwhemed as nurses. I regularly overhear telephone conversations between doctors in A&E and ward nurses, it usually goes something like this >>> " well, i'm tied up in A&E with breaches, i cannot come...you will need to put the line in, i will be there as soon as i can"


If nurses are trained to cannulate, and they don't, and this has an adverse effect on the patient, then the nurse will be slated with the blame.

Maybe if this extended role was withdrawn from nurses, your ideal situation would be achieved? I don't think so. Doctors would become MORE overwhelmed, and patients would suffer more than they already do.

And the nurses WOULD STILL not have time to mop brows.

AND, HDU have a limited number of beds. Poorly patients (and potential ones that DO require monitoring) will always exist on wards.

You would be better off ploughing your energies into increasing staffing levels rather than critising nurses for doing the best/safest that they can, often in impossible circumstances.

Nurse Anne said...

That's true Happy.

The path labs calls critical blood results into the nurses. If I ignore them I get slaughtered.

It's my job to make the doctor aware that he has a patient with critical blood results. It is also my job to prioritize and get the patient ready to receive whatever treatment the doc prescribes.

This is called being a registered nurse. It is nothing like pretending to be a doctor.

Happy1 said...

It should also be said, that where I work (in A&E) doctors put the cannula in when they take the blood. Historically (in my department) its the doctors role.

>> >> cannulla's fail, just because one went in, doesn't mean it will stay patent and in place. Patients that go on to require multiple infusions, go on to require 2 cannula's, often in a hurry.

But as a manager, far removed from the patients, you wouldn't understand issues such as this.

In my dept, nursing care is said to be excellent the majority of the time. We are overwhelmed, but do the best we can. During particularly busy times, nursing care slips a little, patients are not fed and watered (a seemingly big issue for many A&E patients, despite only being in the building for less than 4 hours). Often pain relief can be delayed, or patients can be found very sick, as no-ones checked on them for a while. Patients may be left wet or soiled as the nurses tend to a cardiac arrest etc. We are prioritising all of the time.

The nurses have now been informed (directly from hospital management) that from now on, the nurse must insert the IV and take blood when they accept the patient into the department, as part of the initial assessment. The reason for this (as we have been informed), is to work towards preventing 4 hour breaches.

I am not happy. And I know for a fact that nursing care/close monitoring etc will suffer as a result. It could be achieved, but only with more nursing staff. The only time I will be putting cannula's in, is when the patient is sick, and the doctor is prioritised elsewhere.

Good nurses act continuously "in the best interests of the patient". I(hopefully) will ALWAYS BE ABLE to defend my actions in a court of law.

Nurse Anne said...

According the the BBC, a nurse in a place called whitby found out the hard way what happens when you attend to a commode whilst another patient is deteriorating. She was struck off.

Anonymous said...

Some nurses here to blood gases, One of the charge nurses on my ward does, as do the CSP's (clinical site practitioners) and the resus officers. But it is a specialised skill.

Happy, if everyone got a cannula whether they needed one or not I think infection control would go mad. They don't like 'just in case' cannulas.

Even if nurses did no extended skills, then we would still have to do all the medications and IV's, admissions paperwork 101 risk assessments, actions plans. feed and changed patients.

Also if we are going to only do real nursing tasks, then does that mean I can refuse to mop the floor because my patient was incontinent? Because is mopping the floor really my job?

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