Saturday, October 20, 2018


There are days I love my job, some when I hate what being an ER nurse has become.  I would love it if I could still do nursing 1970's style.  20 uninterrupted minutes for each of my patients at a time, helping them understand all their meds, treatments, and an in-depth plan that we will work out together for the length of their stay, complete with meal times, snacks, back rubs, bed baths, etc.  It would be lovely to chat with them about their family,  jobs,  previous experience in hospitals, belief systems, hobbies, how they love to take long walks on moonlit beaches.  For the most part, though, it is a race against time, and I waste a good bit of  it apologizing for what isn't being done rapidly enough to suit them.  Priorities?  Constantly changing.  Minute to minute, actually.  A nurse's priorities are manipulated by everyone EXCEPT nurses.

Although I don't work in Massachusetts, several friends and family have asked my opinion on their proposed upcoming ballot question regarding  nurse:patient staffing  ratios.  Let me walk you through my thought process on that issue, and share this exhausted bedside nurse's perspective.

My tale begins shortly after receiving nurse to nurse report from the off-going day shift.  I was responsible for four patients in the critical care zone (strokes, heart attacks, trauma) one more than is prescribed, although there is no mandate here.  It is assumed that if one nurse is busy with something truly critical, the other will pick up the "slack".  I hit the ground running.

There are three providers, all of whom have promised patients that "the nurse will be right in".  As you can imagine, I can't be in four places at once.

(In real time, now) I am answering the call light of one of my patients who is demanding instantaneous service who has to go to the bathroom.  I can simply take off the cardiac monitor leads and disconnect the IV as he is ambulatory.

I return to my desk and computer, where I must log in and acknowledge all orders and do all of my charting.  At my work station,  I find the family members of 2 elderly patients standing at my desk.  One wants water and warm blankets for their father, the other has a mother who needs to go to the bathroom "right now".  Neither of those patients are mine.  I explain that I or their nurse will attend to them as soon as possible.  The emergent toileter relative argues that the need is immediate, so I have to take care of that patient (belonging to my zone partner who is busy with a combative suicidal overdose) before I even begin to attend to the needs of my own patients.  It is a weak, dizzy, and demented nursing home patient, and the relative is useless (as they usually are), so I hunt down another equally busy nurse to assist with transfer of the patient from the bed to the commode, which I also have to hunt down.  In addition, she is caked with stool that has to be cleaned before returning her to bed.  Naturally, the relative also wants water, warm blankets and a turkey sandwich which I ignore for now place low on the priority list of tasks.  My ambulatory patient, now back in bed,  is also now ringing for meds and to have the IV restarted.

It has been 25 minutes since three physicians have promised things to patients that I have yet to provide.

Back to my desk to print med orders for 3 of my patients.  This is a policy, also a safety issue.   I must take the printed sheets to the bedside for confirmation of identifiers and allergies.  Every med.  Every patient.  Every time.  Antibiotics and anti emetics for 2 of them.  IV fluids and pain meds for one.  Before I get the orders printed I am interrupted once again by emergent-toileter-relative-who-is-not-my-patient at my desk to demand the warm blankets and water.  I say shortly that I will send in her nurse.  I hate when people stand at my desk, it's just rude.    Unless your relative is coding, standing at the desk is like jumping the queue.  Use the fucking call light.

Here is a short list of what I must do now:
Wait behind 2 other nurses to get meds out of the Pyxis, one of which is an orientee and is being coached by her preceptor so even the commonly used meds take awhile to find.  After a couple of minutes it is my turn.  I must input my password, use my fingerprint ID, find the patient name, then pull saline, tubing, antibiotic, second tubing for the antibiotic, small admixture bag with adapter, and anti nausea meds for both patients which entails knowing what they are called in the Pyxis.  A one liter bag of saline I know is listed under "Sodium chloride", with a drop down list for how big a bag you want.  I have to hit the screen on average about 4-5 times for EVERY ITEM  I need after typing in some key letters, then wait for the door or drawer to open, then the individual lid containing only the desired medicine.  I pull out what was ordered, close the lid and drawer.  Fortunately the antibiotic and anti emetic is exactly the same for both patients and this ain't my first rodeo, so I have what I need relatively quickly.  I also get the pain med and more IV fluid for the ambulatory patient.  One of the newer nurses has a question about how to administer a medication that she has never used, so I instruct her on how it's done.  Remember that.  I am taking time out of patient care to provide information to a less seasoned nurse.  This will always be a priority for me, you cannot burn the newbs, lives literally depend on it.  I grab a couple of syringes and blunt needles to draw up the anti- emetics and drop one "set" of meds by my computer, taking my orders into the other patient's room.

35 minutes have elapsed.  Nobody has what was ordered yet.

The first patient complains about the wait, I apologize insincerely, eyeball the monitor and general condition of the patient, (note that he doesn't look that uncomfortable) while simultaneously  mixing the antibiotic.  I confirm identifiers (name, DOB) and allergies.  I hang the IV fluids.  I inject the anti emetic over 2 minutes, and during this time I assess the patient:  skin color, and temperature, vital signs, pain level, get a quick and dirty on the onset of illness.  I try to make eye contact and sound sincere but I'm pretty business-like.  There is already an IV pump in the room and I spike the antibiotic that I have already mixed, hang it, priming the tubing and feeding it through the pump.  I set the pump for one hour.  I make sure the patient has a call light and have one foot out the door to run to my next task.  The family wants to know how soon admission to comfy floor bed will happen (hours) and what time is dinner (you have abdominal pain.  Never).

47 minutes elapsed.  I repeat the procedures on the 2nd patient, but must find an available pump first which takes a few minutes. I have to retrieve a visitor from the waiting room, as all must be escorted in our ER (topic for another day).  Emergent-toileter-relative-who-is-not-my-patient glares at me from her helicoptering position at the door.  I am moving too fast to flag down.

I am back at my desk now about 57 minutes in and I haven't even laid eyes on the 4th patient.  I have done nothing but toilet a patient who isn't mine, clean up shit, give meds and fluids.  I have done nothing, really, to educate my patients or make them more comfortable, or even make them feel like I care about their problems.  Tasks, tasks, tasks.

 I discover that CT has called, along with ultrasound, for the shortness of breath and leg swelling which is patient number 4.  I explain that the doc wanted to wait on the lab test before sending for the CT.  I hunt down the physician to see if it's ok to send to to ultrasound.  First I check to see if the patient has a patent IV: yep.  Quick assessment, check the monitor and VS, then disconnect and transport the patient myself to ultrasound because there is never anyone available to transport since our last transporter, the 4th this year, quit after 2 months on the job.

I return to my desk once again.  One of the physicians wants to know if meds were given:  yes, not charted.  She thought so, was just wondering if there had been any response.  No idea.  Haven't been in the room, but haven't heard any puking and they asked about dinner, so all good from my perspective.

All of this has taken place in about 1 hour and 10 minutes into my shift.  I have charted nothing, my zone partner is nowhere to be found, and my boss wants to know if any of my patients have orders for admission to the floor and can be transported (nope) or discharged (hell no),  or can be moved out of a room for an ambulance arriving with chest pains.  That means that now any remaining  tasks care to be provided to any other patients will be put on hold while I take the next 20 minutes with this new patient.  Move family of patient in ultrasound to hallway amidst grumbles, move in new stretcher, accept ambulance report, then triage/assess/undress/EKG/place on monitor/start IV and draw labs on the chest pain patient who is from a nursing home.  This patient turns out to be an elderly 90 year old, non-verbal and demented, also combative, and therefore non-participatory in his care.  He has  2,000 meds and has never been at our facility, so they all have to be entered into the computer.  I say screw it, and merely attach the list to the chart with a sticky note to the provider that I will get to the meds when I can (our pharmacist who loves to do that shit).   It is Friday afternoon and nursing homes are well known for the tactic of sending their difficult patients to the ER at this time with vague complaints or  "chest pain".  My 20 minute intake takes about 45 minutes to an hour due to incontinence, possible fever and sepsis, while dodging swinging fists and verbal abuse.

I feel I have been a bad zone partner and not been able to help with the combative overdose, but fortunately the paramedic (bless him) has been in with her the whole time.  Her other 2 patients are fortunately awaiting admission, so need little in terms of assessment and treatment at this time (except for the soul-sucking emergent-toileter whose family member continues to glare and ask for stupid things like jello).  I carry on.  In the meantime, two of my patients are on the call bell "just" wanting updates on their admission progress (hours, you are stalled in the ER as there are no available beds on the floors), "just" some warm blankets, "just a quick question",  and at 4:15 in the afternoon to inquire if a sleeping pill will be ordered when they are admitted.  Dunno, and right now I don't care.  Not my job and not up to me, ask the hospitalist.

Less than 2 hours into my shift and I have had limited contact with my patients.  This doesn't feel good for any of us.  Its "adequate" at best.  To me it was crappy care.

Our administrative clip board commandos walked out at the end of the day knowing the department was about to implode, but leaving us with "adequate staffing".

"Adequate staffing" did not add additional personnel for the additional 12 patients in hallway beds.  There were two LNA's, one of whom was designated to sit and watch the suicidal patients in the overflow hallway beds.  The other was being ridden like a cheap pony.  There was one paramedic who was occupied.  The EKG department calls it a day at 4 PM and we have to do our own.  Just one less resource and an additional task.

If we had 4 extra nurses we would have been golden, even with non-stop ambulances and an overcrowded waiting room (5 hour wait).

With 3,  it would have meant a world of difference.

One or two even would have helped.  An extra paramedic.  A couple of LNA's.  Our secretaries were thoroughly in the weeds.

At this point I completely understood why Massachusetts nurses put this on the ballot, born of utter frustration.  More nurses, better care.

Hospital executives don't care and won't spend the money on nursing unless compelled to do so.

If I lived in Massachusetts I would vote yes.


Oldfoolrn said...

My hat's off to you for mastering contemporary nursing. The big business folks that have taken over health care have a fetish for tracking all their inventory so we have things like bar codes and complex dispensing devices linked to electronic doo dads. Electronics are great if you are landing a 747 in a white out; not so great if you need a med right away. It's misguided thinking of the highest order to have thousands of dollars in electronics to control a 50 cent amp of epinephrine. (That stuff was dirt cheap before Heather Bresch from Mylan boosted the price by a million percent.)

It would be a big improvement to have stock meds and supplies readily available. The root problem here is a gross surplus of nurse office sitters and business minded bean counters.

Aesop said...

CA calling.
1) I started in the pre-ratio days.
On but one memorable night in Busiest ER On The Planet (no, really!), I was the third nurse in triage.
My assignment:
Everyone coming in on ambulances too weak/fragile/fall-prone to put in a chair.
Everyone seen, treated, admitted, but not needing a monitored bed, so pulled out so we could hot-stack new patients in their old rooms, and the pre-admitees moved to the hallways.
All the traumas downgraded from trauma monitoring, and in the back hallway.
The fresh chest pains who needed to be moved to the EKG tech booth, then back to the triaged-but-no-bed-open pit.
Move the admits to the floor after calling report, when beds become available: no tech. 18 floors.
Get food/water/urinals/bedpans/blankets/pain meds/barf basins for any and all of the above.
Discharge anyone seen, treated, and released in my flock.
Total body count tonight, just for me: 79.
Seventy. Nine.
I shit you not.

As I received report from day shift, thinking he was kidding me, and then finding out he was serious, I did some napkin math: at 5 minutes apiece for vitals, that's 12 an hour. 6 + hours to get from A to Z, and start with A again.
"Yeah, that sounds about right." he confirms.
He only tells me the highlights on the 10 sickest ones. The other 69 are either unknown, stable, or GOK: God Only Knows.
I look at his vital signs updates. In our 1-2 hour standard-of-care ER, they are listed every q6+ hours.
In the pre-EMR world, I spend over an hour just finding the charts, locating the bodies that match the charts, and writing down a list of the names on everyone's favorite ER scratch paper, a brown paper hand towel. (*Bookmark this note.)

I locate a portable vital sign machine, and except for full-arrest traumas, it takes the entire staff, including Trauma and ER Chief Attendings, about 3 minutes to realize I have the right of way at all times, owing to my demeanor, size, and attitude, and they'd better GTFO of my path, or be run over like the extra in the chariot race in Ben Hur.

Vital signs - urinal - blanket - pain med - vital signs - jello - straw - blanket - vital signs - bedpan - water - report - transport - vital signs - accucheck - snack - vital signs.
Lather, rinse, repeat, 200X.

Come 7AM, I have six patients left. No one died, everyone got to the floor/a room/discharged/whatever.

Last year, going through my papers, I found the paper towel, with all 79 names. It went home in my cargo pocket, and I was hoping JCAHO would stop and ask me about the place.

As if. They took one look at the place after 5PM, pronounced "Privacy issues must be challenging for you." and were never seen in the ER again.

Aesop said...

2) A few years later, CA (i.e. nurses in CA) put nursing ratios on the ballot. It sailed passed voter acclaim, over the fear-mongering b.s. of penny-pinching corporate sh*tweasels.
For ER:
Normal: 4:1
Critical 2:1
Super-critical trainwreck 1:1
If I have one ICU player, I can have 2 normals as well, for 3 total

And obviously, if TSHTF, and there's a train wreck, plane crash, 7.0 earthquake, you're gonna get what you get, and suck it up.

It's still too much sometimes, but is on helluva lot better than nothing.

And any place busy, you're getting patients shoved up your butt as fast as you D/C the last one, with about 60 seconds to strip and flip the gurney, shpritz it with cootie-cide, and slap a fresh sheet on it.
I've taken up my ICU player, only to return to two fresh untouched normies or another ICU player before I even get back with the empty bed.

That's everywhere, all the time.

Ratios? Hell yeah!
Next stop: mandatory ancillary staff: EMTs/CNAs, etc.
If I and another nurse split a tech, that tech, for 1/4 to 1/3 of my hourly rate, doubles my output and productivity and ,can do all the stupid stuff you don't need a license to do: vitals, blankets, water, code brown-yellow/ transport to x-ray/CT/U/S, the M/S floor, doing EKGs, D/C'ing IVs on patients for D/C, running samples to the lab, etc.

Paying me $40/hr to spend twenty minutes looking for a fricking tube system transport container to tube my samples to the lab is cost-ineffective b.s., and keeps me from doing patient care. And I spend three hours out of twelve a night doing that. SO I point out regularly to manglement that they're paying me $120/shift to play hide-and-seek with $40 worth of plastic, while lawsuits are waiting because I couldn't care for $50K patients. (Whereupon, they look at me as if I've grown another head.)

We could have enough techs to speed throughput for a thirty-something bed ER, for the price of one additional nurse, and there'd only be 1200 ambulance company EMTs who'd leap at a chance for 12 hour shifts instead of 24, benefits, and a chance for tuition reimbursement to become RNs/PAs/MDs, so of course fully staffing techs is not a staffing priority, because they could fix it in about 5 seconds, forever, and have a 100-person float pool to ensure we'd never be short techs, even with 10 psychs needing sitters.

But they'd have to pay money for that, while simultaneously cutting wait times, admit times, and sending patient satisfaction scores to the moon, so, not a priority for the clipboard commandos and the Good Idea Fairies who haven't been at a bedside since the Johnson Administration. (I'm not sure whether it was Lyndon's or Andrew's.)

I feel ya, sister.
MA should vote "Yes". So should the other 48 states.

Joost said...

Hi, just wanted to let you know that we quoted your post in a piece in which we highlighted the heartbreaking experiences of short staffing, and examined the outcome of Massachusetts nurse-to-patient ratios ballot initiative:

We used a quote from your post as the concluding note about the daunting challenges ahead...