Tuesday, 6 November 2012


Holy Shit!  No goddamn wonder British hospitals cannot afford to hire RN's for the bedside.

David Cameron's Hourly Rounding Sheets


I had been planning to post about this years ago. Oh well. Better late then Never.

I read with astonishment David Cameron's comments on Nursing awhile back. His ignorance is incomprehensible. He clearly doesn't understand just why there is such nation wide poor nursing care in the UK. http://www.youtube.com/watch?v=fseCsrq2Lsw. Sorry I just can't be arsed with the video links.

 Mr, Cameron, NHS is nursing care is terrible because you and your hospital chief underlings are not willing to pay for RN's to staff your wards. Simple as. And no amount of hourly rounding paperwork, dignity classes and hospital training rather than university training is going to change that. General ward patients are 10x more complicated than they were in the 1970's, throughput is higher, and the pressure on the RNs is immense and constant. There are fewer RNs per patient now than there was decades ago.  Don't be fucktarded enough to by into DoH stats and shit. The population has aged and are living with chronic illnesses that wards did not deal with years ago (hint these kinds of patients just died in the past). And instead of increasing beds and RNs to keep up with it all the system has done the opposite.

I was still working in the NHS when I first read about Cameron's suggestion for hourly nursing round sheets.  These are pieces of paper located on each patient's bed.  The nurse is supposed to round on everyone of her patients every hour and sign and time the form each time.  

At the time I laughed. On my NHS ward I would often be the only nurse for 19 patients. Many of these people are so sick that they would have been in the intensive care unit with one to one nursing 15 years ago.  Now there are so many of them that they come to the wards with complicated drips, meds, orders, tubes and etc.....and they share their RN with at least 12 other patients.

I wondered how I would manage to sign those sheets and see all 19 patients within the hour. If  I spent 3 minutes with each patient it would have taken me 57 minutes to see them all once. But how would I manage all of the other things going on and still manage to see everyone and sign those sheets.

 Many of my patients were each on meds etc that took 15 minutes at least out of every hour to prepare and give.  Family members of just ONE of my patients could take up 20 minutes out of EVERY hour and many patients had families who tried to do just that. Labs, diagnostics, patients returning from theatre, chasing meds, dealing with changes in condition, doctors orders. Nurses are doing like 20 jobs per second.

Now that I am in a place that actually has hourly rounding sheets I laugh even harder at Cameron.  Not only because it is impossible even with 6 patients but because Cameron obviously stole his idea from somewhere else.

On a bad day here (blizzards, tornados, etc) I have 6 patients MAXIMUM.  If I am the designated charge Nurse for that shift then I get no patients or two patients depending on staffing and acuity. As charge I need to organise the ward and  help the RNs who each have 6.  This is why charge has a smaller assignment.

Filling in those sheets for just 6 patients is nuts.  You want to get to all 6 of them within the hour as well as dealing with all of the other things that cannot be ignored. Yet each patient (or their family) tries to keep you in the room for 20 minutes. Interruptions continue (this is a constant thing for Nurses, we usually average about 30 seconds between interruption for 12 hours).  People deteriorate, admissions come, families on the phone, pharmacy and lab want you, the insulin, heparin and cardizem drip that needs to be started and monitored, the IV antibiotics that need to be prepared by the Nurse and given all at the same time.  These things are all constant and never stop.

It takes each RN at my american hospital (and I work with fabulous ass hauling nurses) about 3 hours to get in and sign those hourly rounding sheets once for each patient. And they each have only 6 patients.

What the hell was Cameron thinking when he wanted to add these sheets to the workload of a Nurse with 20 or 30 patients?   I have never EVER seen him mention safe RN ratios at the BEDSIDE. The boy doesn't have a clue.

The problem down to a couple of issues.....Cameron is one of these morons who thinks that RNs are hospital orderlies who are there to wait on patients and have nothing else to do.  He shares that view with most people. His view of Nurses has been shaped by media such as TV, movies and books that have never in the history of their existence depicted Nurses doing what they actually do.  I've never seen a tv show depict a nurse managing a gazzillion doctors orders for 20 patients at once, dealing with lab and pharmacy to initiate a heparin drip as per doctors orders whilst being expected simultaneously to constantly assess all this stuff to notice changes in patient conditions. These shows do however show nurses acting as maids, switchboard operators and secretaries for doctors. 

The other possibility is that he has no intention of staffing those hospitals safely or he knows it is unaffordable but of course is NEVER going to communicate that to the public.  Neither will labour, the libdems, the american political shits or anyone else who wants to win an election.

I think it is a combination of the two.  As the population ages and we have people living with all these complicated treatments and disease processes like dementia, immobility, airway support, regular blood transfusions, parenteral nutrition, organ transplants, second organ transplants when they drink their way through yet another liver etc etc etc and the system knows that it needs to reduce qualified staffing costs to pay for all this stuff.  Costs are going up and basic care is going down.  And it will continue to do so.

In  1946 if you had anything that I described above you DIED. Quickly. You did not live with these things. 21st century healthcare is advanced and costly and the systems are going nuts trying to pay for it all. Their solution is to decrease qualified staffing and beds and increase throughput.  This is what they started doing about 15 years ago when they realised that the whole system would collapse if they didn't.

I hope they find another way.  I think they could, if they weren't so crooked. And I would like to tell David Cameron to eat shit.  Seriously dude:  Eat. Fucking. Shit.

Saturday, 3 November 2012

Mealtimes USA.......

........Fucking love it.

My older readers will certainly remember an old post of mine regarding hospital mealtimes in the UK.  http://militantmedicalnurse.blogspot.com/2008/03/protected-meal-times-what-fucking-joke.html

In short that post explained why patients are not assisted at mealtime in UK hospitals. It should also help readers to understand that that NHS RNs have ZERO control over this situation. 

Let's talk mealtimes USA.

Keep in mind that even though my hospital is large, number one in the region and absolutely groundbreaking that we are also non profit and  that the majority of our patients are poor, chronically ill medical patients. Around 60% of our reimbursement comes from medicare and state programs. My floor specialises in kidney patients and Americans with renal failure are covered by the government.  In other words no one dies because they cannot afford dialysis.  They kill themselves quite often by refusing to be compliant with dialysis, renal diets, medication, diabetes education and fluid restrictions but that is a whole 'nother post.

Anyway . Mealtimes. 

In the UK I was one RN to 12 to 25 patients. Some kitchen troll dumped a food cart onto the ward at 6PM and took the damn thing and all the food away 15 minutes later.  Kitchen troll didn't give a fuck if staff were able to get that food out or not.

Ahhh rather than write about it all again here is the link  again. http://militantmedicalnurse.blogspot.com/2008/03/protected-meal-times-what-fucking-joke.html

In the USA I have 6 medical patients. I also have a certified nurse's aid and a charge nurse. The charge nurse has no patient assignment (if we are short she may get two patients as well as be charge but it's still manageable). We have multiple multiple kitchen staff from 6 AM until 10PM.   In short, I have help.

The patients each have their own free phone and are able to order their meals from kitchen who brings the tray to the patient. If a patient is on a renal diet, fluid restriction, or is Nil by mouth an order would have been entered into the computer system for that and it would have been seen by the kitchen staff.  They are meticulous about monitoring for diet orders.  If a patient is too sick to order their own meal, I do it for them.

The beauty of this system is that not all of my patients are getting their tray at the same time. And with 6 patients in my assignment I am usually able to assist.  If not then the certified nurse's aid probably can. Say 3 of my patients can order their meals and feed themselves, and 1 patient is nil by mouth .  That leaves only two patients for me to feed and not at the same time.  Very manageable.

Sure, the shit hits the fan here too, and drugs, medical emergencies, admissions,  psychopath schizophrenic weirdo relatives, and stat doctors' orders slam me to death at mealtimes regularly.  Usually all at once, as such is the nature of a medical ward. But still, it is manageable.

The kitchen staff here are trained. They know not to do anything FUCKING STUPID like leave a tray in front of and in reach of a demented elderly patient. That would OBVIOUSLY cause choking and burns.  They will tell the nurse or the tech that they are bringing the tray.  Then we can get there and feed the patient while the food is hot.  If we can't get there the tray is kept warm and ready for when we can.  It is kept this way by the kitchen staff. 

In the UK the nursing staff leave trays out of reach of patients to avoid choking and burning of their elderly patients. ....unfortunately they are too short staffed to get back and feed before NHS kitchen troll takes the food away.    Three NHS staff have 35 meals to dish up and hand out in 15 minutes over there.  It's not like they can bring a tray to a patient and then stay there and feed them. If they did that, then no one else would get their tray at all!!!

So yeah, patients and families here are sometimes whiny temper tantrum throwing crackhead dilaudid addicts but hey, mealtime is great. No one goes hungry unless they are ordered by the physician to be Nil by Mouth for a test. Nothing I can do about that as a Nurse unfortunately.  Feeling hungry is preferable to dying on the operating table of aspiration because you pigged out before surgery.

Off the subject but one thing I have found comical about the United States is that the uninsured patients who are getting free care throw the biggest tantrums.  They are often very noncompliant with their free dialysis, renal diets, diabetes diet.  We are talking about people who weigh 25 stone with a blood sugar of 30, creatinine of 6, and potassium of 5.9 going nuts and putting in official complaints because the Nurse wouldn't go and get them a big mac and 36 ounce coke.

They throw things because there is no dvd player in the room, or they want the doctor to prescribe 6mg of dilaudid IV fast bolus every hour and he won't (because it might kill them on top of making them high). They bitch about the free ice cream, the comfort of the beds (they get the same beds and facilities as everyone else), the lack of HD on their TV screens and the fact that the kitchen cafe is closed between 11PM and 6 AM.   We had a patient who was an illegal immigrant from the caribbean punch a doctor in the stomach when he came to see her because she wanted " bigger apartment from rich America" i.e. a bigger hospital room..  She had a life saving (and free) OP at my hospital.

Meanwhile the working family guy who works 80 hours a week and HAS to pay $1100 dollars a month plus co-pays to insure his family plus anything that the insurance company won't pay for is nice, understanding and grateful for care.   Because he is so nice we take the good stuff out of his room to give the government assistance patients so that they don't beat us up.  You think I'm kidding?  Okay not all government assistance patients are ghetto thugs.  We are all one unplanned step away from being on state assistance, especially in this economy.  But many of them are thugs and druggies, and they are usually regulars and they are seriously entitled and abusive. They are also insanely sick usually due to life style choices.

Have had two patients with guns on them so far.  Also  I worked an extra shift in trauma just to see what it was like. All gang members. The whole unit is on lockdown bigtime with security "in case whoever put the patient in hospital comes in to finish him off".  Yeah I will stick with my kidney unit. Thanks.

Whadda country.

Anyway hope you all are well!!!

I am very sad to read about the way certain journalists are presenting the liverpool care pathway. That pathway is what I would want for myself and my family if terminally ill or quality of life was gone.  I wish we were better at palliative care in the USA. We suck at palliative care here. We have had 98 year olds begging to be allowed to die with dignity put through big operations, intubations ICU stays and months of suffering for NO reason.  So sad.

Well I suppose that's all for now. Take Care.