October, 2006 Archive

October 10, 2006, 1:28 pm

Unbounded Enthusiasm For Grand Rounds!

ahhhhh

Whoa!

Now I like my Tuesday morning coffee with my Grand Rounds, but this guy looks like he had three too many add-shots in his espresso!

Too much of a good thing, perhaps?

You can never have too much of a good thing at the weekly meeeting of the medical blogosphere known as “Grand Rounds“.

This week our host is Dr. Jon Mikel of Unbounded Medicine and he has a beautifully clean, concise edition of the ‘Rounds up on the site.

Great job, Dr. Jon!

Emergiblog is proud to be a part of this week’s compilation.

Next week’s host is….

Me!

So, bring it on, folks!

I’ve got Grand Rounds on Tuesday and Change of Shift two days later so if you’re a-writin’ it, I’m a-wantin’ it!

Don’t make me come and get it…!

Read »

October 8, 2006, 10:46 pm

When Will It STOP?

sign

Neat sign!

Of course, I’m 51% Nurse,

20% Simple Human,

And 29% Rock Goddess.

Not too many people realize that.

What?

Why are you laughing?

******************************

Living as I do in the San Francisco Bay Area, one would think that I would see the occasional sports figure or rock singer, either on the street or in an ER.

Nope.

I can honestly say I have never taken care of anyone famous.

Ever.

Not even someone famous’s sister’s friend’s cousin once removed.

Oh, I’ve missed ’em by half-an-hour.

I think they’re avoiding me.

So, I make this public plea: if you are a famous rock star and you EVER need an ER, email me so that I can arrange to be your nurse.

I promise I won’t blog about it.

Trust me.

Really.

******************************

I try really hard to keep a good attitude at work.

I try to see the benefits of new policies, work with changes and hold opinions until I actually see how things pan out.

(Any co-workers reading this will choke at that last sentence. Let’s just say I’m not shy about verbalizing….anything.)

But sometimes you just feel like enough is enough, that you are already working at the maximum level of efficiency you can muster.

Then you get hit with something new.

Again.

And you know a line has been crossed.

*****

So what is so awful it has me wondering how I’ll be able to function?

A new piece of paper.

No, let’s be honest; it’s a different piece of paper.

*****

We all know about the medication reconcilliation forms. First, we had to do it on admitted patients.

We did.

Then they expanded it to every patient who arrives in the ER.

We did.

Then they told us that we had to fill in every single piece of information including dose, schedule and last dose taken.

We have.

*****

At the same time, we were told that verbal reporting to the medical/surgical units would be replaced by a written, faxed report.

A report that would not be part of the chart. Just a way of giving the admitting nurse a time-saving way to take report and have a written note of the patient’s history in front of her.

I did not object to this. If I was the admitting nurse on the floor, I would love a faxed report, as I would not have to break away from patient care to take a verbal report.

It was/is extra work in the ER, especially if you are writing a thorough report; essentially it is double-charting as we have to put down the most recent set of vitals, the medical history, medications given and lab results pertinent to patient care. But, as it is a rather open-ended document, it gives you a lot of lee-way on how you choose to write the report.

But we did it.

Then they said we had to send written reports to Intensive Care and the Mental Health Unit, two units where verbal communication is preferrable. Critical patient status changes quickly and it is easier to describe patient affect and behaviour verbally for the psych nurses.

But we did it.

*****

Now it has been decided that we must have a “house-wide” written report.

The report proposed is so detailed it looks like a flow-sheet of an entire shift. It is truly a case of double charting, as after the “trial” period, the plan is to make it part of the permanent chart, signed by both the sending and receiving nurse.

When will it stop?

*****

I’ve had it.

The emergency department already carries an inordinate amount of responsibility when it comes to initiating required paperwork.

Let me be more specific. ER NURSES carry an inordinate amount of responsibility for required paperwork.

  • We are already doing what should be the responsibility of the admitting physician, and that is filling out the medication reconcilliation form.
  • We are already filling out a paper report in addition to the medication form and the “regular” nurses notes.
    • Those “regular” nurses notes are the legal record and had better be court-ready.
    • I can’t tell you how often I’ve heard stories of how a set of nursing notes has stopped a lawsuit.
    • The hospital administration should be bending over backwards to allow us the staffing and the ability to chart appropriately, not adding so much paperwork that that the patients begin to suffer. It would behoove the physicians to back that up; when our charting is concise, they benefit in the long run.
    • The written report does everything for the receiving nurse and puts the entire onus for re-charting on the sending (ER) nurse.

Every additional piece of paper they add to the already voluminous amount we are required to fill out in detail:

  • Takes a nurse away from the bedside
  • Makes it harder to provide accurate, complete nursing care
  • Makes it harder to do the actual legal charting we are required to do.
  • Increases the wait time for patient admissions, as the patient can’t go up until the report is faxed and the medication form is complete.
    • Add another 2-3 patients to the ER assignment, and it isn’t easy to get to that paperwork. The patients wait.
    • ER nurses have no control over their assignment. They can receive a critical patient or have a patient go bad at any time. The paperwork must be done. The patient waits.

And guess what happens when a patient has to wait? For anything?

PATIENT SATISFACTION SCORES DROP.

Some units live and die by those scores.

*****

I love paperwork. I really do! I love charting; it’s an art form.

I’ve never been militant in my life. I’ve never refused to do anything when it came to paperwork.

But I have reached my maximum ability to provide the care and attention my patients deserve and do all the increasing amounts paperwork required by my hospital.

And they require the nurses to do it.

*****

Despite what you have read above, I work in a wonderful ER.

No patients in the hallway ever. Experienced nurses. Fantastic doctors. The expectation is that we will give excellent care and we are proud of it.

Patients ask for my facility by name. Some drive hours to get home when sick so they can come to my hospital.

I really do enjoy patients, whether they be homeless, drug seekers, having chest pain, dealing with a migraine, status post emesis x1 or rushed in by parents with a fever x 30 minutes.

They’re my patients.

I love my job.

It’s getting harder to do that job to the best of my ability because the amount of paperwork is on the verge of oppressive.

What the hell am I supposed to do?

Read »

1:10 am

When A Patient Threatens To Shoot You

No funny photo goes with this particular post.

In a comment to one of my “The Answer Nurse” posts, I received this disturbing question:

Question:

What is the correct response when a patient states “Something has to be done about this headache or I will come back with a gun and start shooting.”?

Recent events have made me think that this question needed to be handled with gravitas and responded to in a serious manner.

The following is just my opinion on what should be done, based on the scenario posted in the question. If you are ever in this situation, follow whatever your hospital policy dictates or whatever you have to do to save lives.

This is not to be taken as advice – simply what I would do if it were me.

ABOVE ALL ELSE, TAKE THE PATIENT SERIOUSLY!

  • IMMEDIATELY notify your local police or sheriff’s department that an ACTUAL THREAT has been made. While awaiting a response:
  • Inform hospital administration/nursing supervisor at once. Tell the ER doctor immediately.
  • Utilize your hospital security to ascertain that your patient does not have a weapon in his posession at that time. Whether your hospital security carry weapons or walkie-talkies, you need to get them down there.
  • Let the verbal terrorist think he/she is about ready to get the biggest dose of any narcotic they want on the face of the earth and that your sole reason for living is to cater to their every whim so that they do not leave your sight
  • DO NOT
    • Place the patient in the waiting room
    • Place the patient in a multi-bed ward
  • Do
    • Stay calm
    • Room the patient immediately if possible. Discharge/move other patients.
    • If possible, register the patient as fast as possible at the bedside to get as much information as you can
    • If the police don’t show up Code 3 (and they should), actually medicate the patient if you can with as much as you can get the doctor to ethically order. In other words, “do something about their headache”.
    • Be alert to sudden changes in affect, signs of agitation or escalation:
      • pacing
      • cussing
      • more threats
  • You may be the only witness to that verbal threat
    • What the patient says to you can be charted in quotes, verbatim and becomes a legal part of the medical record.
    • Chart accordingly. The chances that what you write will be used in court are high. Especially in this day-and-age.

We have lost colleagues to ER shootings in the past.

For those of us who do not live in high-crime areas, we can be like “sitting ducks” in our work environment.

Get busy and get your department as safe as possible by:

  • limiting the access to your department by making entry to the patient area difficult
    • use a door code
    • use a badge-swiping system
  • Be especially aware of doors with access from the rest of the hosptial.

I don’t even want to think of this.

But better to think about it now before they are playing those “five funeral songs” you put in your last blog meme.

Again, this is just my opinion of what I would do if faced with this situation. Your milage may vary.

Make sure you have a policy/action plan in place.

And pray you never need it.

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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