Wednesday, April 23, 2014

It's All in the Timing

I hate getting up early but agreed to a 4 hour 7 AM princess shift at BWOM.  Bad idea.

At 80 minutes prior to the beginning of my shift, I arose having gotten about 5 hours of sleep after leaving my other job at midnight (1 hour late).  I had a 20 minute drive home.  I made it through 27 stop lights without getting a single red one, a personal best for me.

At 45 minutes prior to the beginning of my shift, I left my house to start my 35 minute drive to BWOM with a quick stop of coffee.  I hoped that the fact that it was lightly snowing would not interfere with my drive but forgot that I also had to stop for gas.  Damn.  No coffee.

At 5 minutes prior to the start of my shift, I arrived without coffee and grumpy, but found my 4 assigned rooms and 6 patient beds delightfully empty.  Coffee was my only plan for the next few minutes.  I checked my emergency carts and supplies while I sipped.  It wasn't Dunk's, but it was hot and black and nobody wanted to talk to me just then which suited me just fine.

At  30 minutes into my shift I got a single frequent flyer psych patient with a simple medical problem.

At 2 hours into my shift I got a different assignment and inherited a COPD patient bound for the ICU who had been there for about 6 or 7 hours.  Admissions generally take forever at this hospital, there just does not seem to be any sense of urgency.  

At one hour prior to the end of my shift the hospitalist had finally seen the patient and I was ready to get her out of the ER.  Frustrated with 2 computers that were frozen for 25 minutes and unable to get the Tech Monkey on the phone, I was unable to complete the mountain of computer entries (about 500 for one ICU admission) so I could transfer my patient to her Comfy Bed.  This sucked because I had timed it perfectly to coincide with my expected arrival time in the unit according to the Gospel of BWOM Admission Policies, Procedures, Unwritten and Implied Codes of Behavior, Safety and Floor Nurses Lunch Schedules.

The procedure is to fax the report, 10 minutes later the ER nurse would call to confirm receipt of said fax and give the receiving nurse the opportunity to ask questions or for clarification.  After 30 minutes the patient goes away.

I started this nonsense 1 hour prior to the end of my shift.  Plenty of time to get my patient transferred to the floor within 30 minutes of faxing the SBAR, right?   Figure 10 minutes to bring the patient to the floor,  return to the ER, 10 minutes to tidy the room, give report to the oncoming nurse, pee, and boogie home.  60 minutes.

NOPE.  The SBAR report that I had faxed to the floor 30 minutes prior to my expected arrival time was, as usual "not received" by the ICU nurse.  Re-faxed, which resets the 30 minute window.  This window is not in effect for 90 minutes around the change of shift at any time because the floor nurses are getting report and making rounds.  Fair enough.  Which means two hours, generally.  Also another 90 minutes during the middle of the shift for lunch.  Not that we ever get lunch in the ER.  

So 10 minutes after I re-faxed the report that I had written out I gave a FULL, DETAILED VERBAL REPORT to the ICU nurse,  regardless of the fact that the information is readily available in the computer.  This is where my extremely detailed and copies notes may found about my patient assessments, IV infusions, meds, labs, cultures, vital signs, I&O's, pretty much everything the astute nurse needs to know about the patient they are about to receive.  More wasted time and effort, documenting in 2 places and giving verbal report as well.  Brilliant system.

At 20 minutes before the end of my shift  I spent about 10 minutes looking for the pieces to the rarely used portable monitor and throw a few curses to the computer because NOW I CANNOT FINISH THE COMPUTER ENTRY THAT HAS TO BE MADE BEFORE THE PATIENT LEAVES THE DEPARTMENT.

I proclaimed loudly "Well, I can't fix this".
Boss Lady ran by enroute to another important meeting throwing a " yes you can!" over her shoulder as she raced by,  as if I merely need encouragement instead of a cudgel or someone who can actually fix the problem.  It wasn't happening as the Tech types were also at lunch.

At 10 minutes past the end of my shift,  I brought the patient to the ICU by myself, because there was nobody to help as usual.  The ICU nurse futzed about with the patient's bed weight that she couldn't quite figure out (you need to zero the bed first, honey),  fluffing, figuring out which monitor leads are mine and which are hers, chatting pleasantly with the patient, answering phones, putting on a different sheet, and blocked my egress from the room by holding me hostage with the patient still on my ER stretcher.

At 30 minutes past the end of my shift I returned to the ER  to find two more patients in my rooms, but the relieving nurse, having been 10 minutes late arriving for the day, had condescended to take responsibility for them.  Unfortunately, she had not as yet received report on my remaining patient and busied herself caring for the two new patients, one of which was a kid who needed stitches.  I could not, in good conscience, drag her away from that.

At 90 minutes past the end of my shift I left the hospital, forgetting to pee, and with a 35 minute drive home.

And the charge nurse went to lunch.