Saturday, February 17, 2007

Peanut Butter Panic

More drama! As if we did not already have enough with the flu season, now we have widespread peanut butter panic. The day the news story aired, we had our share. They came in groups, they came in droves, they called on the phone. Everyone wanted to know what they "should do" because they had eaten from jars of the offending lot numbers. No matter that they had no symptoms, had had no symptoms and had eaten half the jar in the past two weeks. One guy showed up in triage trying to gag himself to make himself vomit. Another guy brought himself, his wife and two kids, all of whom had been on a PB&J binge. No one sick of course, but dad had made sure to contact his attorney who advised him to be sure not to throw the jar away and to come immediately to the ED. The goal was to "collect evidence" in the form of stool samples to be analyzed for the dreaded salmonella. Somehow the triage nurse kept a straight face while she explained that there would be an extended wait, even for fast track. The hopeful father retreated to the lobby with his soon to be wealthy family, where they dined on McDonald's whilst awaiting the attention of a highly trained and educated health professional.....only in America.

Sunday, February 11, 2007

Trauma and Drama

Another Sunday mornin’ comin’ down. This one came down a little harder than most. I got and “URGENT” message on my cell from a number I recognized as coming from the ED. Getting called on a Sunday with an urgent tag on the message didn’t bode well. Before I could get the number dialed my land line rang. On the other end was my assistant supervisor telling me we had “some trauma and drama working.” Turns out one of our night shift nurses had worked Saturday night and had an MVC (motor vehicle collision) on the way home from work Sunday morning. In addition, two other nurses scheduled to work tonight (Sunday) had called in sick. So with those two, plus our trauma victim we were down three nurses out of the five originally scheduled. Not good under any circumstances.

So my concerned self and my managerial self (“good grief…what are we gonna do now?”) got in the shower, threw on some jeans, forgot about the make- up, said a prayer for our nurse with my husband and went in to work. First order of business was to see about our injured night nurse whose spouse also happens to be a nurse on our mid shift. Now I’ve known this nurse for well over 20 years. In fact I was one of his paramedic instructors when he first got in “the business.” So this is as near enough to having this happen to my brother as you can get. I entered the trauma room and helped the team as they log rolled him to change wet and bloody sheets. His head was wrapped chin to scalp in bloody kerlix and besides some bruises and bumps he otherwise looked intact but hurting pretty good. I couldn’t do too much other than get a blanket out of the warmer and put on him.

The story was he had fallen asleep at the wheel and woke up as his vehicle was heading into what we call in Texas a “bar ditch”. He tried to correct and get back up on the road and when he did, the truck rolled. Thank goodness he had sense enough to be wearing his seat belt, but the sense pretty much stopped there. He got out of the truck, walked at the scene, refused collar and backboard and arrived in the ED pale and sitting upright. He had nearly scalped himself and actually took a huge divot out of his scalp down to shiny bone. He bled like stink thanks to Plavix and natural scalp vascularity so he didn’t have much in the way of a blood pressure on arrival.

By the time I got there, our great staff had given him enough blood and FFP (plasma) to get his blood pressure where it needed to be. He’d been through cat scan until he glowed and he was almost ready to be flown by helicopter to a Level 1 trauma center. Besides the huge scalp laceration that will require a skin graft and plastic surgery, he had a contusion to the frontal lobe of the brain , contusion of the chest from the seat belt and a hairline fracture of the spinous process on the C5 vertebrae of the neck. Pretty lucky that’s all there was. I talked to him and in true ED nurse fashion, he was griping about the money he would be missing by not working tonight and worrying about the fact that we are already short staffed. I assured him that we already had tonight covered and would be just fine. His job was to take care of himself and get well, to which he replied, “I’ll be back to work next weekend.” Whatever! Only an ED nurse! How can you not love and be grateful for people like that?
The copter crew came and whisked him away in the sky. I thanked the surgeon who responded and gave hugs to the two nurses who took care of him and told them they’d done a good job….which they had. I’m sure they kept him alive.

Now on to the staffing problems for tonight. My assistant supervisor had already called everyone who was a remote possibility and left messages. Oh the blessings of caller ID!
So far we had a 12p nurse willing to work 7p instead, another night nurse willing to come in at 11p and another “possible” for 11p-7a….Still short….too short for flu season which hit us with a vengeance about a week ago. One of the nurses working a short shift today volunteered to come back and work 7p-11p and another nurse working 7a-7p today said if I could find someone to come in for her today, she would go home and come back at 7p. That also would mean I’d need to find coverage for her 7a shift tomorrow. So I called one of our 7a nurses who was off. She agreed to come in and cover for my day nurse who would come back tonight and my assistant supervisor agreed to work 7a tomorrow. Whew! I couldn’t tell you how I kept all that straight. It was quite a piece of art.

These people I am blessed and proud to call “my staff” constantly amaze me. I know they’re really not “my” staff, God’s just loaned them all to me for awhile. They go “above and beyond” on a daily basis and are especially prone to pull together when one of our own need help. Right now we have two open positions on night shift and now we are down another one for awhile. Everyone has worked and worked until I don’t know how they keep it up. I used to stress a lot about staffing, but I’ve learned over the years that the great people in our department will step up to the plate when they are needed most and somehow it all works out. That’s what teamwork mixed with a little divine intervention is all about.

Sunday, January 28, 2007

My side of the stretcher continued

So I've been awake since 0530. It's Sunday morning, not a usual work day for me as in theory, I am a Monday-Friday, 0800-1700 type. You know.. no weekends, no holidays no nights. And I'm awake this Sunday morning because I woke up thinking about work (yet again) and couldn't go back to sleep. I'm what the frontliners call a "shirt/skirt". I'm the nurse in the office. The one with the "good life" and "huge" salary. The one that wakes up at 530 on a Sunday morning and thinks about how we can "make it better." I've heard many comments about how managers just "go to meetings" and no one knows what THEY do. I hope to tell you a little about that and at the same time, blow off a little steam and in the process, take a little better care of my emotional health.
My work week usually starts at 8am Monday morning. Now one perk to this job is that I don't punch a clock, so if I get a slow start on Monday and get to work at 830, it's ok... I just stay later in the day to make up for it. The down side is that I am paid for 80 hours every 2 weeks. I am expected to put in my full 80 but if I happen to put in 90 or 120, I still get paid for 80. There is no such thing as paid OT in the manager's world. My first order of business is to be sure to greet everyone on duty by name, ask about their children, their weekend, or how their morning is going. Once that is accomplished, it's on to payroll. There are about 47 employees who report to me, and I am responsible for ensuring that everyone goes home on Friday with an accurate paycheck. So that means spending an hour or so in front of the computer checking each staff member's time card and making corrections when badges have been forgotten, clock ins and outs have not been recorded, shift trades have been made etc. That's comparing the schedule to time cards, making calls and waking up someone who worked Sunday night to find out exactly when they worked, tracking attendance, call-ins and late arrivals and writing up disciplinary actions for same.
Between this activity, I am answering the phone, new "high priority" email, and questions from anyone that may pop into my door way. My office is inside the department itself, so I am in the thick of it and have the benefit of all the sounds and smells that go with a busy Emergency Department. Toddlers screaming in protest at being held down to get stitches, the splattering of vomit on the floor from the drunk patient "sleeping it off" on a hall stretcher just outside my office door, the aroma of diesel fumes from the ambulance parked in the drive that wafts down the hall and into my office, cardiac monitor alarms signaling impending death, ambulance phones announcing yet another arrival. It's a virtual auditory and olfactory buffet. There is room enough in my office for me and one other person, and then it's an invasion of personal space. Every inch of desk an shelf space is taken up with sheets of paper or notebooks of some sort, and yes I am known for being "organized."
With payroll done, I'm ready to tackle the rest of the day. It might go something like this.....
9am :Meet with staff member who has been counseled for being late. This is an intelligent person, a professional. He can start the most difficult IV, triage with 99% accuracy, knows who is sick and who is not, can predict a given diagnosis by simply looking at a patient and hearing their chief complaint and yet he cannot get to work on time. Go figure.
915am - Answer the phone. The person on the other end of the line asks, "Are you in charge of the emergency room?", and right away the hackles on the back of my neck stand up, because I know this can't be good. So I listen to this person's complaint about how she's been having this weird pain in her side for about six months and she came to my ED last night at 2 AM and she didn't see the doctor for 3 hours. ("A person could die out there in the waiting room"). And once she did see the doctor, he was "rude" to her when she told him she was allergic to everything but Dilaudid and he "didn't do anything" for her. Although when I pull her chart, I note that she waited in the waiting room about 10 minutes, saw a doctor in 30 minutes, had complete lab work, a CAT scan (all normal), IV fluids and was given medicine for pain and nausea. Once I listen to the complaint and assure her that I will "investigate" her concerns. I am required to enter this information into our hospital complaint database and am expected to thoroughly investigate the issue.
The investigation of the “issue” may involve checking the ED log to get a snapshot of what might have been going on in the department at the time this woman showed up with her “EMERGENT” problem. Once I have the information from the log, her ED record and have reviewed it all, I track down the nurses’ on duty and get their take on the deal. I document all this in the database and refer the whole mess to the medical director. I ask him to call her back and let her know that her medical management was “appropriate”. All this takes me about an hour.

I have a meeting at 10 am and I am late because of dealing with the complaint. The meeting is with our quality director and regulatory compliance officer. They have a new standard we are required to meet and they want the ED staff to “trial” their new process. The process involves having the ED staff complete a time-consuming, detailed, and onerous form, getting signatures from the doctor and the patient, making a copy of the completed form AND faxing the form to the referral doctor once the patient is discharged. All this adds about 15 minutes of time to the patient’s total ED stay and slows down the discharge process. This in a department where we are expected to move patients in and out in a timely manner AND keep them happy and satisfied as if they had stayed at the Ritz. I look at the form and note that it contains far more information that is required by the new standard. Immediately I can see several ways it could be improved and easier to complete. I negotiate with the regulatory and quality “police” and am able to get them to agree that the ED staff will only have to “start” the form with the minimal required information. YES! A small win for ED but a win none the less.
And that isn’t even half my day gone. The rest of my responsibilities still loom over me like the Grim Reaper. There’s only one of me and my poor assistant manager who has to work 36 hours of clinical shifts per week and still manage to meet her responsibilities.

So what does a “shirt/skirt” nurse manager REALLY do? What is it that THEY spend their time with? Here’s the list….. (Including but not limited to..)
Rounds-STAFF- I am expected to meet once a month with each of the 47 staff members that report to me. That means being here at 6am, 11am, 10pm, and maybe on Saturday or Sunday to catch the weekend staff.
Rounds-Patients- I have a goal to round on patients every day just to let them meet me and know that I care enough to ensure that things are going well with them.
Rounds –Other- I am supposed to meet monthly with other managers of other departments, anyone who is my “customer”. Doctors, ambulance personnel, x-ray, lab, inpatient nursing unit.
Staff Reward/Recognition- Write thank you notes and think up new ways / gifts to appreciate those people who actually do their jobs.
Staffing/Scheduling- Getting the schedule posted every month. Making sure every one got time off as requested and that we keep the request process fair. Making sure there are enough bodies on duty every day to take care of the number of patients (semi-unpredictable) that show up at the door. Making sure that we don’t have too many bodies and sending people home when things slow down. Calling nurse B to come in to cover a shift when nurse A has called in an hour before the start of the shift because she’s been sick on her previous two days off. Shuffling bodies around when someone has made a trade and now we have too many nurses working Friday night but we are short 2 nurses on Saturday. Oh and yeah….If we are too short, below core staffing, and there is no one else to work, I get to put my big girl scrubs on and come on in to work.
Patient Complaints- see above tirade. Thankfully these seem to come in “clumps” and there’s really not that many…especially not many that directly involve nursing.
Patient Satisfaction_ monitor our “scores” on a week to week basis and try to come up with new and different ways to trim 5 minutes off of our wait time or keep people happy and occupied while they are waiting.
Fixing/Buying Stuff- making sure the ice machine works, the cardiac monitor is sent for repair, new instruments are purchased, the supply cabinet is appropriately stocked, budgeting for new stretchers, requisitioning capital equipment, searching for the vital sign monitor that’s “been missing since last week” and no one bothered to look for it or let me know.
Quality Improvement- Are we doing what we are supposed to do? How can we do it better? Audits audits audits. Rapid cycle improvement. Plan Do Study Act……ad nauseum.
Staff Evaluations- these are supposed to be done every six months. Right…my assistant manager and I do well to get them done on time once a year.
Staff Competency- We don’t have a department educator so guess who gets to come up with ways to document that staff members are competent to do their jobs every year? That would be me.
Staff Licenses/Certifications- Checking that everyone that is supposed to have a license or certification actually has one that is current and unexpired and nagging people for verification of same.
Policy and Procedure- Write new ones and review and revise old ones.
Mediation/Refereeing- Serving as the crying shoulder, counselor, mentor, conflict manager of anyone who feels the need to vent
Meetings- Oh yeah….that’s all THEY do. Well that’s a lot of it. Disaster planning, decontamination training, hospital management meetings, staff meetings, charge nurse meetings, patient care meetings, nurse leadership meetings, practice council meetings, quality, safety, administrative, infection control…..the list goes on and on. Some times we actually get work done in these meetings, but most of the time I spend sticking up for the interests of the department and attending out of raw FEAR that someone will come up with some totally outrageous, unrealistic and ridiculous idea that will make the daily life of the poor ED nurse HELL.
Vision- And at the end of the day, I’m the one that is supposed to have a vision, a mission, goals and objectives for the future of my department and my staff. And it all has to be in writing and it has to be kept up to date and current with documented outcomes, data and graphs. Good grief! The truth is I DO have that vision and mission. I want my department to be the best Emergency Department there is. I want us to take care of patients as if they were our own family members and not take all day to get it done. I want us to be educated, state of the art, cutting edge. I want us to be competent, friendly, caring and compassionate professionals. I want all this and more and what I know is that most of the time we really ARE ALL THAT. And I know that it’s not me but our staff that makes this happen on a daily basis.

Saturday, January 27, 2007

My side of the stretcher

I created this blog after responding to another post on another site from a staff nurse who blogged about the dearth of "good" managers. She talked on and on about managers who sit in meetings all day and don't have a clue about what goes on in the trenches, those who implement policies without staff input, and those who wouldn't help at stretcher side for fear of breaking an acrylic nail or falling off of their 3 inch stiletto heels.

So this is "my side" of the stretcher. The one who is back there in the office working to ensure that your (our) patients get the kind of care they deserve and that you ( the ED staff) have the best possible environment to practice your art.

More later......