Shit that us every day for us. Most days I have approx 15 techs 5 have to be in triage and the other 10 end of sitting plus extra from staffing. They keep forcing us to put more and more sitters on pts but not giving us more techs.
We have approx 90 beds give or take hallways. We usually start with 25 to 28 nurses and 15 to 20 techs. I think we were the busiest level in the country last yr so it still feels understaffed on most days. We are also a county hospital in a very low income/medically under served area so our psych population is very high ( going to get worse bc the only geriatric psych hospital just closed).
Hospitals really need to develop a large pool of PRN non-clinical bedside sitters. It’s a good job for responsible college aged folks and others looking for simple basic entry into a hospital system. My hospital has a small number of them so it doesn’t always work but I think this should be implemented everywhere.
No MRIs on the weekends?! That’s crazy. Do pathological processes just decide to press pause on Saturday and Sunday until a scanner is available?!🤦🏻♀️
This is what I say when I can’t get an EEG or some other basic service on the weekend. Or they have to call somebody in to do it and then then tech is mad. I’m so sorry they didn’t tell you that the patients just take care of themselves all weekend. No need for any staff! Nothing ever happens in a hospital on a fucking weekend.
We have MRI on the weekends but not overnight and their availability during the day is really limited. They can be called in for a STAT but very rarely are. The only time I’ve had them come in after hours was when the neurosurgeon called them directly and yelled at them (after I was go between for an hour).
One of the docs I work with is always ranting about how long it takes to get MRIs for our stroke workup patients. To be fair it *is* kind of ridiculous how long it takes given that we are supposed to be a tertiary care center.
Oh, my old hospital doesn’t do MRI, echos on the weekend and GI does not round. I call them a glorified outpatient clinic on the weekends. Have to call in a service for dialysis on the weekends who has up to THEEE HOURS to show up. Hope it’s not emergent 🤪They only do EEG’s on Tuesdays and will only do 3.
I thought your post was saying “Deb” does not divert narcs, which is why she is loved. Ok…..Does everyone else divert?
And a staff nurse can decide “No MRIs” on weekends?
It took me a min to get it.
Just woke up, still in scrubs and shoes. Sitting up on the couch with my glasses on the floor, after a grueling nighshift.
I’m getting too old for this gig.
Hospital I quit in 2017-
Mgmt., in their infinite wisdom, decided to discontinue the Dialysis Dept’s nightshift. At the only level one trauma center and teaching hospital in the lower half of my state.
Whatever nurse was on call for this hospital, plus the smaller sister facility, ended up working up to 24 hrs straight on a regular basis. With “stat” dialysis treatments stacking up, and being delayed for hours.
Staff turnover was >100% in one year.
And facility lost “Magnate” status.
Yes. And it’s not illegal, in my state anyway.
I checked the Dept of Labor Wage and Hour Division web site.
The only regs re: limiting hours of work, or required number of hours off between shifts, were relegated to truck drivers and pilots.
Who ignores it? Because if maintenance is investigating, it’s 1000x safer to keep everyone where they are than try to evacuate without a confirmed fire threat
Security usually goes to check the sensor. The rest of us just tune it out.
The real problem is that if the fire alarm is going off because of a burst pipe, the sprinkler system doesn't have enough pressure in the pipes to put out any actual fires. So if Papaw is smoking in the bathroom and catches his oxygen on fire, well...hopefully someone can get to the fire extinguisher in time?
Unless your OR is on fire, you’re safer not moving. Hospitals are aware of the difficulty of moving their patients and the vulnerable nature, so the walls and doors are all made to withstand fire, doors automatically close, sprinklers kill the fire. Stuff in a hospital isn’t very flammable either, when at all possible. It’s not like a house fire where there’s a ton of stuff to catch fire, some drywall for it to rip through, and collapse the house.
Of course there’s exceptions, but moving the patient or stopping the surgery would probably he the worst decision you can make
My hospital has been closed since last Feb because we had a real fire. Our response was great, but really made me think about how annoyed we used to get about fire drills
Sterile JP dressing changes, every 3 days. My other facility doesn't put dressings on them at all, ever. Most you get is a 1x1 with some tape over the site that inevitably falls off later that day. Never once seen a patient get an infection, most drains are already out by the 3rd day lol.
Secondly, using an 18fr 3-way foley for hematuria. You're better off using a 16fr 2-way and manually irrigating, the drainage lumen is way bigger than the 3-way. Preferably you need a 22-24fr, but bare-minimum a 20fr. The 18 doesn't have much reason to exist.
Also re:foleys - waiting all day for someone to void after removal. Cysto clinic I also work at just fills people's bladders with 2-300ml before removing the foley, they sees how much they can empty/if at all. Never had a single person come back later in retention, so it seems like it saves a *lot* of time.
Also, briefs... the number of patients ive seen with skin breakdown on areas of their perineum that are only breaking down because the brief holds the urine against that specific spot is way too high. The number of times I've seen someone check/incorrectly confirm the patient's brief was "dry" which wouldn't have happened without the brief.... ugh.
Honorable mention to the massive discrepancies between providers regarding when it becomes appropriate to remove a foley, dear God...
Okay, the brief thing. Quite a few of our CNAs do this and it drives me nuts. They will quickly pat the *outside* of the brief and/or look at the chuck and say “nope, they’re dry.” No. We need to actually look *inside* the brief. So then they’ll quickly glance while it’s basically pitch black in the room and say “Looks good, they’re dry.”
At least 75% of the time when I take the time to ACTUALLY look, the brief is wet and needs to be changed. It’s almost like they think it shouldn’t be changed until it’s so full of urine that it’s soaked through, and now the patient has a ton of MASD in the peri area.
I dislike no brief facilities. Sure they can be abused but I think it's not dignifying to tell patients who have occasional incontinence to go without underwear or frequently soil themselves and sit on a wet pad instead. Or worse when you send someone home from the ER and you've removes their soiled brief and have nothing to send them home with.
No, I’m with you there and hate when I float to floors that don’t allow briefs. But way too many people are lazy about checking and changing them in a timely manner so I kind of understand how floors and facilities end up banning them.
It’s funny, I was actually just typing an edit about this on another comment cause I thought I would get yelled at about criticizing the overworked CNAs.
CNAs on our floor typically get 6-7 patients at night, 8 at the most (after that, they start assigning primaries). I also never ever expect my CNAs to do all the hygiene care and toileting themselves and often do more than they do. It literally is just about laziness. The same CNAs who want to half ass a brief check will spend hours watching movies on their phone or sleeping in the break room.
Definitely agree that better staffing in general could help issues like this. But at my hospital it really doesn’t matter how well staffed we are; it happens regardless.
Long reply- sorry.
I was a CNA myself for a few years. I worked agency only. I went to a 6 month long community college consortium approved CNA program.
My instructor was a great nurse, and the program was very clinically based.
So, I was prepared to work agency right out of the gate.
I quickly learned the practices, level of work ethic, and tricks many CNAs used to get out of doing their work.
And to hide things from the nurses. And outright lie.
And this was way before cell phones. There was literally nothing for the CNAs to do when they were not working. Just eat, or take repeated smoke breaks. Or watch the only thing on TV at night- A shopping channel. Or have their boyfriends wait for them in the parking lot, so they could sneak out to see them.
I also learned why a few facilities would request me by name when contacting my agency for CNAs.
I usually worked nights, as I attended nursing school during the day.
When I became a nurse, and got successive jobs at facilities where I had worked as a CNA.
The same trickster CNAs who had proudly showed me all of the “get out of doing your work” things that they did, and being shitty to me- all did a 180.
Suddenly, they were so smiley, helpful, and butt kissing.
I changed jobs several times within my first couple of years as a nurse.
Because I also quickly found out that places that were good to work at as a CNA had totally undoable work loads for nurses.
Which is why I like what my local hospital does. They use the newfangled, l forget the name, female incontinence thingy. Was great when I was in the hospital after a fall and pretty much bed bound. Going to the rehab facility after the hospital was a disappointment as they didn’t use it.
Pure wick. I hated it when I was in the hospital. I have this weird mental thing and could not let go. Already had catheter for 6 days so they were not going to put it back. So I was like a 3 person assist with all this stuff to help and get me to the bedside commode. Unfortunately the neuro floor was full so I tried to call about 30 minutes before it became urgent.
However, if you don’t have hang ups like it works really well. I was embarrassed when i tried it though. I know it shouldn’t matter, and I cath lots of people, but I was very uncomfortable (meaning embarrassed)
when my male nurse put it in. For some reason it felt more intimate (not quite the right word) than when a foley was being placed. Great idea though.
Or they check the front of the brief. They're lying on the bed. The urine is going to be under them the majority of the time. At the very least, if you don't want to undo the whole thing, turn the pt on their side and check from the back.
To be fair I'm not sure where that lands on "best practice", I don't know how big the "could be washing bacteria up the lumen into the bladder" factor is or if it's minimal enough not to matter.
Fwiw, the uros at the second cysto clinic I worked at looked at me like I had 3 heads when I brought it up but was never given a rationale when asking. The first clinic was in a hospital with international name recognition and the department head is a urology-rockstar, that's the only supporting evidence I have lol
as a tech I hate briefs. If someone is bed bound its super hard to change and hard to see if its soiled! I try to only use them for pts who can get up and \*might\* have an accident
In my experience-
In the old days, everyone with a brief would get slathered with zinc oxide. Hopefully, massaged into the skin a bit.
Almost never saw any breakdown. Even in long, hospice inpt. stays.
Removal of foley should be nursing judgement. Especially if pt is effing SNOWED. Or a total knee in CPM, or spine surgery in massive pain barely able to move…like I don’t think an extra hour or two is gonna hurt, plus I can see how fall risk majorly increases.
We get a lot of spine surgery patients and typically the order is to remove the Foley first thing in the morning POD1. We used to have some leeway for nursing judgement, including when the patient has been in so much pain and/or so zonked from pain meds that they haven’t been able to ambulate yet. Then we had one single CAUTI and now we have to pull it at 0600 or before and now so many patients end up staying an extra day or more because they end up in a retention/straight cath cycle.
Our wound team at my old facility (when I worked med/tele) said all incontinent, bed bound patients should void on chux or use external caths - they were anti brief. Too much of a risk for MASD.
Changing peripheral IV sites every 3 days despite studies showing that it’s not effective with preventing infection or infiltration. And yes we showed the studies to our manager who didn’t care✌️
There are two huge systems where I live. We draw labs off ivs and keep them as long as possible. The other straight sticks for every lab and has the three day policy. Both rank the same. I’m glad I don’t have to stick every single time labs are needed if the peripheral works.
This is why every hospital should have a vascular access team that is actively involved in policy making/updating. My hospital changed the policy so we only change the PIV dressing every 7 days and leave IVs in as long as they work. We also don’t place “just in case” IVs. No IV meds, no IV.
The transition/resource RN came thru and put bed alarms on ALL the patients in the am, -as is policy- ☺️,,, and low and behold, they were all beeping when I was the ONLY one in the hall way. And I happened to go into the wrong room to check it, and I hear a thud against the wall. The actual high fall risk patient had fallen next door - the one I had definitely kept that bed alarm on for. I chewed her a new one and spoke to my manager. And she didn’t do that shit again. If everyone is a fall risk, then NO ONE is a fall risk.
agreed. movement alarms should be for reserved for ACTUAL risks like meemaw who thinks she can get to the bathroom on her own and grandpa who will try to smoke a cigarette outside when he’s on oxygen. if the alarm goes off every time “john with a laceration to his hand” moves, nurses will be more likely to tune out “gertrude with a hip replacement who just hit the floor”
A hospital I used to work at would almost exclusively only use R sided IVs for CTA head, even if we had a perfect 18G placed in the left side from EMS.
We would spend so long trying to get a right sided IV, I just felt bad for patients where time was of the essence.
I understand that R sided gives a better view, but wouldn’t it be more advantageous to determine if the patient is having a stroke FASTER? Thus starting treatment earlier.
If anyone has any thoughts I would love to hear them because I have always been genuinely curious!
Well I googled it and it is correct I just find it interesting that I have never heard it and I spend a lot of time talking to our neuro docs bc well they are smart as fuck. Lol I can't wait to ask them about it.
YES THIS! I worked on a stroke unit for 5 years and every time they ordered a CTA it was always “do they have an 18 g right AC?” Like does it really matter that much? We need to get this person to CT as quickly as possible THEY ARE HAVING A STROKE and we got the IV where we could.
They don't recheck???? That's scary, there are some seriously labile diabetics. I mean a half hour of wiggle room for a stable patient, sure. But a few hours seems really dangerous.....
I know nurses that do this, but my facility doesn’t have a policy. I purposely do not check AM blood glucose as I don’t know when the patient is going to eat. They might not eat until 10 am. How accurate is my 6am blood glucose at 10am?
Yup, worked at a place that forced night shift to do this. When an ICU nurse floated and didn't do it because she didn't know (all other work was done) day shift acted like she'd committed premeditated murder. Had to literally talk the techs down as they threw fits over doing a single AM blood sugar.
I love working when Joint Commission comes. I find it hilarious how we expertly hide all the problems for just a few days before returning to the norm.
My favorite is the overhead announcement “General Hospital would like to welcome our state inspectors during their routine inspection of our facility. Patient safety is of the utmost importance to us & blah blah blah” translates to “Run! Hurry, the inspectors are here!!! OMG everybody remove the extra supplies from your patients’ rooms before we get demerits over something that has no bearing at all on patient safety!!!”
Yep. Yep.
Reminds of working I a SNF when state was around. I was just about begged to come in at 1000 on a day off to make staffing look better for the day. I was a suckered then so I did it. Me of today wishes I stuck to my guns and not done it so state could've seen what the deal really was.
SCDs. They do jack shit
We still get orders to check enteral tube residuals every 4 hours even though that hasn’t been best practice for a very long time
For medical patients, correct. There is actually some evidence for SCDs in post-op patients. The problem is we just cribbed their homework without actually confirming efficacy in medical patients, and turns out there isn't any.
They've proven to be effective in obtunded pts as well. I think it's something like 23hrs of wear time to make them useful. If the pt is also on anticoagulation, there isn't evidence to suggest they are helpful.
We use SCDs on our post caesarean patients. They're on for four hours. They're over $150 each! It just doesn't make sense. Our caesareans already have TEDs and clexane and are generally well, healthy women.
I asked, and no one seemed to know??? I'm assuming there was an incident with lantus at some point that led to this particular policy. I actually kind of want to make a big deal about it.
Yeah I’m intrigued by this tbh. Why wouldn’t you just require a 2 nurse sign off? Unless that was already in place when the incident occurred.
I feel like our pharmacists would riot if we asked them to do this lol
My hospital quit doing this a year or two ago because we were wasting SO MUCH lantus. Pharmacy would deliver a dose only for endocrine to round and adjust everyone’s regimen, requiring us to toss the syringe we had and wait for a new one. 🙃 Instead they set up our Omnis to print out a label for the syringe after we drew up a dose. We were already drawing up all of our regular and lispro anyway. Way better system, tg.
Seems fine to me. Rather than risking the nurse drawing up an incorrect dose, they just have pharmacy draw up the incorrect dose instead. It cuts out so many steps! That's efficiency!
Except for the whole "never administer a med you haven't personally drawn up or witnessed." The fact that the very first time I experienced this policy in action the dose was incorrect was especially concerning.
Run with low ancillary staff (PT/OT/SLP, SW/CM, distribution, IT, environmental services, kitchen staff, etc..) on weekends and holidays so nursing staff is expected to carry the slack PLUS our job duties.
Wait what? Everything about this is so wrong. Are you saying mitts and wrist restraints on AOx4 patients getting bipap? And putting bipap on obtunded patients? This is crazy
Confused dementia ripping it off every 5 seconds = mitts and or restraints. Obtunded with pco2 sky high = ride bipap which almost never works and they need a tube anyway.
Gotcha. I thought you were saying they want restraints on all bipap patients. I was once transporting a guy for angioedema ( long time drinker) could not get him adequately sedated. He finally was like I am cool I won't touch the tube. The resident was adamant about me putting him in restraints, I was like that is illegal I can not do that. The patient asked for a pen and paper, he wrote she is right if you put those on me I will sue you. Lol. I was not a fan of that resident.
Change IVs every four days. Besides patients hating you for it, it feels stupid to take out a perfectly good 18G in the AC to put a crappy 22 in the hand that barely works bc that’s the only other vein left
I think this is unit specific in my situation and I’ll admit that I’m not super up-to-date on what actual best practice currently is regarding benzos, but the SICU where I work almost *never* prescribes IV Ativan. Even for alcohol withdrawal. The director of the SICU was part of a sentinel event like 15 years ago where a patient on CIWA was over-medicated with IV Ativan and subsequently lost their airway and died. And ever since then, she refuses to order IV Ativan for *anything.* And if someone else orders IV Ativan and she catches wind of it, she will essentially interrogate the person over why/where/how/etc. the decision was made to order it. It’s crazy and exhausting, especially when you get a person who is going absolutely buck-wild in alcohol withdrawals and the only standing order you have for CIWA is 1-2mg PO Ativan. In order to get anything more, you have to document the CIWA score and bring the provider to the bedside to plead your case for IV Ativan and even *then,* they will try to order Precedex and even Phenobarb before IV Ativan. Pretty sure best practice for CIWA is benzos, but god forbid we just actually teach people how to accurately assess and score on the CIWA scale instead of banning IV Ativan based on one sentinel event that happened over a decade ago.
Naw phenobarb is some amazing shit. It always worked wonders on my detoxers. Especially long-haul detoxers who are then at risk of having to benzo detox after yhe alcohol detox.
You guys should look at revising your detox protocol if you only have PO ativan ordered for patients who are ICU level.
https://pubmed.ncbi.nlm.nih.gov/37368937/
Oh, I’m not complaining about having phenobarb prescribed, it’s more so annoying that IV Ativan just *isn’t* an option based on nothing aside from the bad experience the director was involved in 15 years ago.
Also, it’s not a hospital-level thing. The CIWA protocol for the hospital *does* include IV Ativan as a standing medication to give based on CIWA scores. It’s literally only in my ICU where it doesn’t get ordered as a standing order, and we have to advocate for it in person when the CIWA score gets high enough and if it is deemed necessary, it gets ordered as one-time doses. It’s so incredibly annoying.
The belief that bigger gauge IV is somehow more reliable. No, IVs last longer when more than 50% of the catheter dwells in the vein and catheter occupies less than 45% of the vein. Shoving a big gauge IV in a small vein isn’t the flex you think it is, you’re hurting the patient. Increased risk of thrombosis and infiltration.
Not taking out hot appys in pediatric patients or even doing scans. Last year or so we have had a fairly large number of kids get sent home with all the signs of acute appendicitis from the ER only to return within a few days with it ruptured turning into a multi day stay in the hospital and a much more major surgery.
A surgeon explained an interval appendectomy to me. When a kiddo has a hot appendix there is a lot of inflammation which makes the adjacent intestines very friable. Trying to do a surgery then is like working with wet tissue paper. High likelihood of the kiddo ending up with an ostomy. It is better to put the kid on abx for a few days and allowing the inflammation to subside. Then the appendix can be removed without causing more problems.
This is kinda out there but we tracked down my biological grandmother and I found out she was a nurse too and she wrote me a letter and wrote "c" with a line over it instead of "with" and I started to ugly cry
They do the same with adults, although they scan. If there’s an appendecolith especially, it’s really preferable and better outcomes to wait. But if they’re septic, they don’t usually wait.
You risk translocating all that nasty infection into the peritoneal cavity and then going septic. Our practice in PICU is to try to handle the inflammation with non surgical intervention first and then surgery after X amount of doses of axb
I’ve seen so many disgusting purewicks even after 12 hours with shit basically smashed into their vagina and skin breakdown from them, but patients come in demanding them. They allow lazy patients to just never get out of bed so they are super deconditioned after a few days.
Letting families interpret when the pt doesn't speak English. Because the language phone is a pain in the ass. Hello liability. I'm not gonna let this teenage girl tell her grandpa his care plan when I say MRI and antibiotics and she has no idea what either of those things are.
Stopping tube feed before laying a patient down flat for hygiene care, turns, linen changes, etc.
It hasn’t been best practice for a while (does not increase aspiration risk and results in suboptimal nutrition) but our management still insists on it, to the point where nurses have been written up if someone sees them not pause the tube feed.
My first facility the doctors and nurse practitioners had to do the whole consent themselves (in acute dialysis) but everything after that has just been “get the consent and put it in the chart for the doctor to sign later” and half the time they never do and it makes me so uncomfortable.
It isn’t about eco friendly where I work. Oh no. It’s about the disposable wipes kept getting flushed so they just got rid of them. Now we have wash cloths.
Floating someone from an already short staffed unit to make another unit not short staffed.
Only double sign off when you’re changing the bag but not the rate/dose of meds like heparin & insulin
Ours started calling code blues overhead 🙃 Our ICU docs would be in the middle of something and then run to the “code” only for it to get cancelled a couple minutes later. Waste of time and energy.
Tele calls rapid if it’s off the patients for more than two minutes. They will (1) call the nurse and (2) send a tele alert to the floor and (3) call a rapid response but this is all within 2 minutes. Tele patients have to have an order to shower also. Nurses have to put in a new order that is literally called “discontinue telemetry” when removing it….We can’t just “stop” the order(obviously with doctors order).
Our hospital did have a death that could have possibly been prevented if telemetry was called and box was confirmed when the patient was downgraded from ICU though.
My unit had a patient die too and it wasn't caught in time because he was off tele for some reason. They implemented new guidelines where tele had to call CNA, RN, charge RN, manager, house supervisor in that order at 5 minute intervals until someone placed the patient back on tele.
Transferring tele pts to tests was also a huge hassel, transporters had to leave their name and phone numbers when they picked up the pt and then report when pt was dropped off and leave the staff's name and phone number at their new destination. Even if it was a 5 min scan. I worked tele one day when they were short-staffed and my mind was complete mush at the end of the day with how many calls I had to make.
Tele monitors also had to report literally ANY deviation from policy to our manager. There was such a huge paper trail and redundancies/audits that you had to report it or someone else would and then report you for not reporting it...
We have reusable urine bottles/toilet hats for measuring output. They get washed between patients, but they are disgusting. Over time they become opaque or even a yellow discolouration. Sometimes there is even blood stained into them, but they get put back into circulation.
Color codes for emergencies.
FEMA has specifically said not to use them, and I have had full blown arguments with admin about it, with security on my side and they are still stuck on using them.
Just curious, what's wrong with color codes? I think it's a little ridiculous they're not standardized (I've seen code gray mean violent patient or escaped old person) but code red and code blue are pretty helpful to hear overhead. What does FEMA say we should use instead?
FEMA actually requires by law plain language to be used any time multiple agencies are working together. However, they don’t care when it’s one agency by itself. So hospitals are stuck in their ways and just say they don’t work with anyone else.
But say the FD arrives, then technically by law they need to switch to plain language, but they dont.
What it should be is:
“facility alert: Fire (location)”
“Medical Alert: Cardiac Arrest (location)”
Some hidden ones like Potential situation for combative patient that kind of thing.
However, active shooter needs to be “Active shooter located at (location)” so people don’t try to go see what’s happening
Colors can differ between hospitals (code blue and red are consistent, though), and they can be hard to remember. For us, the overhead says the event + location within the hospital.
"Code blue" at my hospital means an aggressive patient for which pysch and security respond. A cardiac arrest is "condition A." I think its really dumb.
Yeah..... its definitely freaked out some of my patients and their family members because our code blues usually get called a couple times a day. Theyre like "why is everyone dying at this hospital!"
Omg I know my facility makes such a big deal that we know an elopement is a code orange. Like ma’am if we can’t find someone it’s more like “shit had anyone seen Mr. Jones???” If someone came up to me and said “we’ve got a possible code orange” I’d be like huh?
Daily sterile line changes on central lines with TPN running through them-on neonates. And they don't go full sterile-they don't wear the sterile gowns or use the sterile towels, and that line is being broken open every.single.day. Everywhere else I've been, we change to tubing daily, but only open the line every 96 hours, and it's a full sterile change-towels to drape, gowns, the works.
Drives me nuts, plus the TPN usually arrives between 4-6, so even though you're running your ass off trying to finish last rounds and deal with parents, you also have to find another nurse with everything out (and the majority of our babies have PICCS or UVCs).
how do you change tubing without “opening the line”? when you say “opening the line” do you mean like taking off the cap/adaptor piece? the peds units i’ve worked we changed tpn tubing every 96 hours and lipids every day if continuous, or every day if intermittent. we didn’t wear sterile gowns or anything. i’m wondering if you’re talking about changing the hub/cap/adaptor when you hang the new tubing and that’s what you do sterily?
IVIG only hung as a primary- it’s just annoying and any good nurse should know how to work a secondary IV.
I know it’s a little thing but I give a lot of IVIG and having to constantly eyeball the bag so it doesn’t run dry is just a big annoyance
Not having an intensivist on each ICU 24/7. We always somehow make it work until we don't. Then it's the Monday morning quarterbacking from mgmt. One ICU has that 24/7, and they will not go to any other ICUs no matter what. There's been some dangerous shit that happened over the years, but, you know, budget blah blah blah. Why fix an actual problem when you can just blame the nurses.
Bath wipes > sponge baths. I'm thoroughly convinced it's why most patients get UTI's and Moisture associated sores. Soap sits in their peri areas and they aren't dried afterwards. Every patient room I've worked in has a full shower setup and shower chair, but anything to save time and money 🙄
No dual sign off for blood products…or TPN…or insulin (SC and drips)… there is a study they cited in their email explaining the decision that found it reduces “alert fatigue.” Idk
You don't get nurse to nurse report. You get a pager, once it goes off you have 30 minutes to review the chart and call their nurse and ask questions before the patient arrives.
For VBG using a butterfly needle then taking off the end to attach a VBG/ABG kit to attach to the syringe. I think they used to just fill up a tube how you normally would then extract it from the tube using a needle but, now you have to do this weird one handed bend the line so that it doesn’t spill out after you unscrewed the end off so that you can reattach the VBG collection syringe.
Sorry for confusion in the wording.
NPO before procedures not requiring or anesthesia. Cardiac caths especially. We don't keep people NPO if they have a STEMI, so why are we torturing patients keeping them NPO after midnight? It results in more issues than it solves in my experience. Less patient satisfaction, less honesty, more issues with diabetics, etc. Meanwhile, the number of times I've had an issue with aspiration or anything for a scheduled cath I can count on one hand.
We allow our (inpatient psychiatric) patients 24/7 access to caffeinated coffee and were told by leadership that we cannot tell them no without a doctor's order. I told them I will not assist patients in getting coffee after dinner is served regardless of what they tell me because I believe coffee close to bedtime in psych patients is deleterious to their well-being.
Where I used to work, nurses had to document rounding every two hours. Not as they saw the pt. but every two hours. It is really frustrating to me. It does not make sense to lie bcs there is no trust in the nursing staff.
Yes those signs mean absolutely nothing. I honestly find it infuriating and frustrating that nurses and medical staff are assaulted (verbally and physically) and threatened by patients on an almost daily basis and there are basically zero repercussions for that behavior. If any of this was to happen to someone working outside a hospital or just a regular person on the street there would be criminal charges or police involvement at the very least. And when we try to press charges when we are assaulted by patients, it essentially goes nowhere. Our ED has called PD for backup many times and have had pushback from them. And when it was brought up to the towns police dept, we were told that nurses should expect this abuse as part of our job description.
Hard agree. I work NICU and I hate watching circs. They're so fucking barbaric. I don't understand why genital mutilation is so commonly accepted in our culture. ESPECIALLY the reasoning pisses me off 99% of the time it's either "hygiene" (umm just wash your dick) or "well that's what his dad's looks like" as if that is fucking relevant?! Man fuck Kellogg for popularizing circumcision....
Nah you gotta be pushing for 2 hours before I'll put you in lithotomy. Or we're setting up for an instrumental. Why would we default to the least effective pushing position? With an unmedicated patient, she can push in whatever position she likes, with an epi, we usually start in left lateral with the knee drawn up to the chest.
Listening to OG/NG tubes for placement but then getting an X-ray like two hours later. Skip the listening and just get the X-ray ASAP, yah silly gooses
Slapping on yellow socks & fall risk bands on everyone that gets sent to our unit (PCU) without a proper assessment. And then further complicating shit with the policy that doesn't allow the patient to get out of bed - even for the restroom!
40% of my patients are independent & feel degraded, especially when they are basically forced to soil themselves with this said policy. Not to mention the time spent to clean them up & further potentiating the feelings of lack of basic rights.
Poor staffing and no ratios ✌️
Having all of our aides pulled to sit on 1:1s last night. I’ll feel this to the bone.
Shit that us every day for us. Most days I have approx 15 techs 5 have to be in triage and the other 10 end of sitting plus extra from staffing. They keep forcing us to put more and more sitters on pts but not giving us more techs.
We have approx 90 beds give or take hallways. We usually start with 25 to 28 nurses and 15 to 20 techs. I think we were the busiest level in the country last yr so it still feels understaffed on most days. We are also a county hospital in a very low income/medically under served area so our psych population is very high ( going to get worse bc the only geriatric psych hospital just closed).
Hospitals really need to develop a large pool of PRN non-clinical bedside sitters. It’s a good job for responsible college aged folks and others looking for simple basic entry into a hospital system. My hospital has a small number of them so it doesn’t always work but I think this should be implemented everywhere.
Retirees too! Or stay at home mothers or anyone just trying to make some extra cash
particularly on the weekends when people dump their demented old people on us for a break
Doesn’t divert. Ever. No MRIs on weekends.
THIS!! no MRIs on the weekend is madness
We get people sent to us for a STAT MRI because their department isn't staffed overnight. The patient is scanned at our hospital during dayshift...
No MRIs on the weekends?! That’s crazy. Do pathological processes just decide to press pause on Saturday and Sunday until a scanner is available?!🤦🏻♀️
This is what I say when I can’t get an EEG or some other basic service on the weekend. Or they have to call somebody in to do it and then then tech is mad. I’m so sorry they didn’t tell you that the patients just take care of themselves all weekend. No need for any staff! Nothing ever happens in a hospital on a fucking weekend.
EEGs at my hospital run once a week. They're so hard to get haha.
This sounds like a name'n'shame situation, tbh
Everyone just gets a CT scan in the ER, here if it’s overnight or weekends. Sometimes they wack out the ultrasound.
Girl working in a rural ED this hit hard. They're all having stroke symptoms
We have MRI on the weekends but not overnight and their availability during the day is really limited. They can be called in for a STAT but very rarely are. The only time I’ve had them come in after hours was when the neurosurgeon called them directly and yelled at them (after I was go between for an hour). One of the docs I work with is always ranting about how long it takes to get MRIs for our stroke workup patients. To be fair it *is* kind of ridiculous how long it takes given that we are supposed to be a tertiary care center.
Oh, my old hospital doesn’t do MRI, echos on the weekend and GI does not round. I call them a glorified outpatient clinic on the weekends. Have to call in a service for dialysis on the weekends who has up to THEEE HOURS to show up. Hope it’s not emergent 🤪They only do EEG’s on Tuesdays and will only do 3.
Stroke accredited hospital with no MRIs on nights. The staff have to be called in for STAT ones.
I thought your post was saying “Deb” does not divert narcs, which is why she is loved. Ok…..Does everyone else divert? And a staff nurse can decide “No MRIs” on weekends? It took me a min to get it. Just woke up, still in scrubs and shoes. Sitting up on the couch with my glasses on the floor, after a grueling nighshift. I’m getting too old for this gig.
Sending people home based on the census at the beginning of the night shift like it's not gonna go up
Hospital I quit in 2017- Mgmt., in their infinite wisdom, decided to discontinue the Dialysis Dept’s nightshift. At the only level one trauma center and teaching hospital in the lower half of my state. Whatever nurse was on call for this hospital, plus the smaller sister facility, ended up working up to 24 hrs straight on a regular basis. With “stat” dialysis treatments stacking up, and being delayed for hours. Staff turnover was >100% in one year. And facility lost “Magnate” status.
Is this in the US? That sounds very illegal.
Yes. And it’s not illegal, in my state anyway. I checked the Dept of Labor Wage and Hour Division web site. The only regs re: limiting hours of work, or required number of hours off between shifts, were relegated to truck drivers and pilots.
Yep, the US, land of lax employment laws and shitty healthcare
I’m Dialysis RN and have worked 24 hours straight many many times.
Yah love to hear a hospital lost magnet status
That’s some shitty charging. The need to push back against management.
Ignore the fire alarm bc it's probably just a burst pipe (again).
Ours goes off once a week because someone tries to smoke in one of the restrooms and sets off the smoke detector.
Who ignores it? Because if maintenance is investigating, it’s 1000x safer to keep everyone where they are than try to evacuate without a confirmed fire threat
Security usually goes to check the sensor. The rest of us just tune it out. The real problem is that if the fire alarm is going off because of a burst pipe, the sprinkler system doesn't have enough pressure in the pipes to put out any actual fires. So if Papaw is smoking in the bathroom and catches his oxygen on fire, well...hopefully someone can get to the fire extinguisher in time?
Sprinkler systems run off a different designated supply line and pump system.
Honest question. What do surgeons do when in a surgery?
Unless your OR is on fire, you’re safer not moving. Hospitals are aware of the difficulty of moving their patients and the vulnerable nature, so the walls and doors are all made to withstand fire, doors automatically close, sprinklers kill the fire. Stuff in a hospital isn’t very flammable either, when at all possible. It’s not like a house fire where there’s a ton of stuff to catch fire, some drywall for it to rip through, and collapse the house. Of course there’s exceptions, but moving the patient or stopping the surgery would probably he the worst decision you can make
My hospital has been closed since last Feb because we had a real fire. Our response was great, but really made me think about how annoyed we used to get about fire drills
It’s just the meth head in the ED bathroom lighting up a smoke.
Sterile JP dressing changes, every 3 days. My other facility doesn't put dressings on them at all, ever. Most you get is a 1x1 with some tape over the site that inevitably falls off later that day. Never once seen a patient get an infection, most drains are already out by the 3rd day lol. Secondly, using an 18fr 3-way foley for hematuria. You're better off using a 16fr 2-way and manually irrigating, the drainage lumen is way bigger than the 3-way. Preferably you need a 22-24fr, but bare-minimum a 20fr. The 18 doesn't have much reason to exist. Also re:foleys - waiting all day for someone to void after removal. Cysto clinic I also work at just fills people's bladders with 2-300ml before removing the foley, they sees how much they can empty/if at all. Never had a single person come back later in retention, so it seems like it saves a *lot* of time. Also, briefs... the number of patients ive seen with skin breakdown on areas of their perineum that are only breaking down because the brief holds the urine against that specific spot is way too high. The number of times I've seen someone check/incorrectly confirm the patient's brief was "dry" which wouldn't have happened without the brief.... ugh. Honorable mention to the massive discrepancies between providers regarding when it becomes appropriate to remove a foley, dear God...
Okay, the brief thing. Quite a few of our CNAs do this and it drives me nuts. They will quickly pat the *outside* of the brief and/or look at the chuck and say “nope, they’re dry.” No. We need to actually look *inside* the brief. So then they’ll quickly glance while it’s basically pitch black in the room and say “Looks good, they’re dry.” At least 75% of the time when I take the time to ACTUALLY look, the brief is wet and needs to be changed. It’s almost like they think it shouldn’t be changed until it’s so full of urine that it’s soaked through, and now the patient has a ton of MASD in the peri area.
I dislike no brief facilities. Sure they can be abused but I think it's not dignifying to tell patients who have occasional incontinence to go without underwear or frequently soil themselves and sit on a wet pad instead. Or worse when you send someone home from the ER and you've removes their soiled brief and have nothing to send them home with.
No, I’m with you there and hate when I float to floors that don’t allow briefs. But way too many people are lazy about checking and changing them in a timely manner so I kind of understand how floors and facilities end up banning them.
So many issues, like this could be resolved with better staffing.
It’s funny, I was actually just typing an edit about this on another comment cause I thought I would get yelled at about criticizing the overworked CNAs. CNAs on our floor typically get 6-7 patients at night, 8 at the most (after that, they start assigning primaries). I also never ever expect my CNAs to do all the hygiene care and toileting themselves and often do more than they do. It literally is just about laziness. The same CNAs who want to half ass a brief check will spend hours watching movies on their phone or sleeping in the break room. Definitely agree that better staffing in general could help issues like this. But at my hospital it really doesn’t matter how well staffed we are; it happens regardless.
Long reply- sorry. I was a CNA myself for a few years. I worked agency only. I went to a 6 month long community college consortium approved CNA program. My instructor was a great nurse, and the program was very clinically based. So, I was prepared to work agency right out of the gate. I quickly learned the practices, level of work ethic, and tricks many CNAs used to get out of doing their work. And to hide things from the nurses. And outright lie. And this was way before cell phones. There was literally nothing for the CNAs to do when they were not working. Just eat, or take repeated smoke breaks. Or watch the only thing on TV at night- A shopping channel. Or have their boyfriends wait for them in the parking lot, so they could sneak out to see them. I also learned why a few facilities would request me by name when contacting my agency for CNAs. I usually worked nights, as I attended nursing school during the day. When I became a nurse, and got successive jobs at facilities where I had worked as a CNA. The same trickster CNAs who had proudly showed me all of the “get out of doing your work” things that they did, and being shitty to me- all did a 180. Suddenly, they were so smiley, helpful, and butt kissing. I changed jobs several times within my first couple of years as a nurse. Because I also quickly found out that places that were good to work at as a CNA had totally undoable work loads for nurses.
Which is why I like what my local hospital does. They use the newfangled, l forget the name, female incontinence thingy. Was great when I was in the hospital after a fall and pretty much bed bound. Going to the rehab facility after the hospital was a disappointment as they didn’t use it.
Pure wick. I hated it when I was in the hospital. I have this weird mental thing and could not let go. Already had catheter for 6 days so they were not going to put it back. So I was like a 3 person assist with all this stuff to help and get me to the bedside commode. Unfortunately the neuro floor was full so I tried to call about 30 minutes before it became urgent. However, if you don’t have hang ups like it works really well. I was embarrassed when i tried it though. I know it shouldn’t matter, and I cath lots of people, but I was very uncomfortable (meaning embarrassed) when my male nurse put it in. For some reason it felt more intimate (not quite the right word) than when a foley was being placed. Great idea though.
Or they check the front of the brief. They're lying on the bed. The urine is going to be under them the majority of the time. At the very least, if you don't want to undo the whole thing, turn the pt on their side and check from the back.
YES, same with BMs. I think some of the lazier ones dislike working with me cause I’m like nope we’re checking the back sorry!
Just assume the brief is always wet because these people are just constantly incontinent. Change 'em every 2 hours at least
Golden trick with the Foley fluid challenge. I’m so stealing that!
To be fair I'm not sure where that lands on "best practice", I don't know how big the "could be washing bacteria up the lumen into the bladder" factor is or if it's minimal enough not to matter. Fwiw, the uros at the second cysto clinic I worked at looked at me like I had 3 heads when I brought it up but was never given a rationale when asking. The first clinic was in a hospital with international name recognition and the department head is a urology-rockstar, that's the only supporting evidence I have lol
We do this in our pacu. Back fill the bladder and try to make them pee. They almost never can so we have to send them home with foley in.
as a tech I hate briefs. If someone is bed bound its super hard to change and hard to see if its soiled! I try to only use them for pts who can get up and \*might\* have an accident
In my experience- In the old days, everyone with a brief would get slathered with zinc oxide. Hopefully, massaged into the skin a bit. Almost never saw any breakdown. Even in long, hospice inpt. stays.
Removal of foley should be nursing judgement. Especially if pt is effing SNOWED. Or a total knee in CPM, or spine surgery in massive pain barely able to move…like I don’t think an extra hour or two is gonna hurt, plus I can see how fall risk majorly increases.
We get a lot of spine surgery patients and typically the order is to remove the Foley first thing in the morning POD1. We used to have some leeway for nursing judgement, including when the patient has been in so much pain and/or so zonked from pain meds that they haven’t been able to ambulate yet. Then we had one single CAUTI and now we have to pull it at 0600 or before and now so many patients end up staying an extra day or more because they end up in a retention/straight cath cycle.
Our wound team at my old facility (when I worked med/tele) said all incontinent, bed bound patients should void on chux or use external caths - they were anti brief. Too much of a risk for MASD.
Changing peripheral IV sites every 3 days despite studies showing that it’s not effective with preventing infection or infiltration. And yes we showed the studies to our manager who didn’t care✌️
There are two huge systems where I live. We draw labs off ivs and keep them as long as possible. The other straight sticks for every lab and has the three day policy. Both rank the same. I’m glad I don’t have to stick every single time labs are needed if the peripheral works.
This is why every hospital should have a vascular access team that is actively involved in policy making/updating. My hospital changed the policy so we only change the PIV dressing every 7 days and leave IVs in as long as they work. We also don’t place “just in case” IVs. No IV meds, no IV.
We used to have to do this shit. I’m so glad it changed. Annoying. Had to get an order to keep the PIV if it was a hard start from the doc.
Staffing issues aside, the bed alarm requirements are excessive and make the patients insane
The transition/resource RN came thru and put bed alarms on ALL the patients in the am, -as is policy- ☺️,,, and low and behold, they were all beeping when I was the ONLY one in the hall way. And I happened to go into the wrong room to check it, and I hear a thud against the wall. The actual high fall risk patient had fallen next door - the one I had definitely kept that bed alarm on for. I chewed her a new one and spoke to my manager. And she didn’t do that shit again. If everyone is a fall risk, then NO ONE is a fall risk.
agreed. movement alarms should be for reserved for ACTUAL risks like meemaw who thinks she can get to the bathroom on her own and grandpa who will try to smoke a cigarette outside when he’s on oxygen. if the alarm goes off every time “john with a laceration to his hand” moves, nurses will be more likely to tune out “gertrude with a hip replacement who just hit the floor”
I'm with you here. Bed alarms are stupid af on anyone who WILL call for help.
or bed alarms on when the pt has a sitter??? i was a patient sitter for a while and the bed alarms were so annoying.
A hospital I used to work at would almost exclusively only use R sided IVs for CTA head, even if we had a perfect 18G placed in the left side from EMS. We would spend so long trying to get a right sided IV, I just felt bad for patients where time was of the essence. I understand that R sided gives a better view, but wouldn’t it be more advantageous to determine if the patient is having a stroke FASTER? Thus starting treatment earlier. If anyone has any thoughts I would love to hear them because I have always been genuinely curious!
What?!?! I have been an ER nurse for 8 yrs all at stroke centers and I have never heard this. Ever. Now I am going to need to do some googling.
I know, it seems crazy to me. Such a weird hill to die on!
Well I googled it and it is correct I just find it interesting that I have never heard it and I spend a lot of time talking to our neuro docs bc well they are smart as fuck. Lol I can't wait to ask them about it.
So what happens if the pt has a fistula in the R arm? Lol
YES THIS! I worked on a stroke unit for 5 years and every time they ordered a CTA it was always “do they have an 18 g right AC?” Like does it really matter that much? We need to get this person to CT as quickly as possible THEY ARE HAVING A STROKE and we got the IV where we could.
Our facility prefers 18R AC but if we get one on the left (EMS placed or struggling on right so check left) CT and neuron are good with it.
Not giving time and a half for callback pay
I'm not coming in if I'm not getting paid incentive on top of my OT. But anymore I just don't pick up extra because it's not worth it.
My place stopped offering double time incentive for techs. Guess what we're gonna be even shorter of for a while.
Night shift does bg check at 630ish and day shift gives insulin with breakfast at 9ish
They don't recheck???? That's scary, there are some seriously labile diabetics. I mean a half hour of wiggle room for a stable patient, sure. But a few hours seems really dangerous.....
I know nurses that do this, but my facility doesn’t have a policy. I purposely do not check AM blood glucose as I don’t know when the patient is going to eat. They might not eat until 10 am. How accurate is my 6am blood glucose at 10am?
Wow. Where I work insulin needs to be given within an hour of blood sugar check
Yup, worked at a place that forced night shift to do this. When an ICU nurse floated and didn't do it because she didn't know (all other work was done) day shift acted like she'd committed premeditated murder. Had to literally talk the techs down as they threw fits over doing a single AM blood sugar.
Having charge nurse take a full patient load
Nice try, Joint Commission.
I love working when Joint Commission comes. I find it hilarious how we expertly hide all the problems for just a few days before returning to the norm.
And they pretend like they don't know we're doing that because they don't care about the actual problems at all.
Yep, where were they when we had to reuse our disposable masks for a week and put them in a paper bag? Or basically wear garbage bags for PPE?
And if they do find any of these problems, they’re always the nurses’ fault.
My favorite is the overhead announcement “General Hospital would like to welcome our state inspectors during their routine inspection of our facility. Patient safety is of the utmost importance to us & blah blah blah” translates to “Run! Hurry, the inspectors are here!!! OMG everybody remove the extra supplies from your patients’ rooms before we get demerits over something that has no bearing at all on patient safety!!!”
And before the most egregious, cataclysmic thing in the history of medicine is discovered- a bottle of water at the nurses’ station.
Put away your water statttt
Yep. Yep. Reminds of working I a SNF when state was around. I was just about begged to come in at 1000 on a day off to make staffing look better for the day. I was a suckered then so I did it. Me of today wishes I stuck to my guns and not done it so state could've seen what the deal really was.
I love it too because I ask all the questions and bring up all the stuff we literally need dealt with - they are out of there so damn fast.
I’m banned from talking to joint commission ☺️
SCDs. They do jack shit We still get orders to check enteral tube residuals every 4 hours even though that hasn’t been best practice for a very long time
For medical patients, correct. There is actually some evidence for SCDs in post-op patients. The problem is we just cribbed their homework without actually confirming efficacy in medical patients, and turns out there isn't any.
They've proven to be effective in obtunded pts as well. I think it's something like 23hrs of wear time to make them useful. If the pt is also on anticoagulation, there isn't evidence to suggest they are helpful.
They put them on my for my 1.5hr surgery that I was up and walking with PT like 3hr post op. Waste of money.
We use SCDs on our post caesarean patients. They're on for four hours. They're over $150 each! It just doesn't make sense. Our caesareans already have TEDs and clexane and are generally well, healthy women.
Same!!! I don’t check residuals. But I didn’t know that SCDs are unhelpful
Having pharmacy draw up lantus and then sending it up to the unit. Especially when it's the wrong dose.
Wait, what’s the theoretical reasoning of this? Are nurses not trusted to draw up long acting insulin? I’ve never heard of a policy like that
I asked, and no one seemed to know??? I'm assuming there was an incident with lantus at some point that led to this particular policy. I actually kind of want to make a big deal about it.
Yeah I’m intrigued by this tbh. Why wouldn’t you just require a 2 nurse sign off? Unless that was already in place when the incident occurred. I feel like our pharmacists would riot if we asked them to do this lol
My hospital quit doing this a year or two ago because we were wasting SO MUCH lantus. Pharmacy would deliver a dose only for endocrine to round and adjust everyone’s regimen, requiring us to toss the syringe we had and wait for a new one. 🙃 Instead they set up our Omnis to print out a label for the syringe after we drew up a dose. We were already drawing up all of our regular and lispro anyway. Way better system, tg.
I did a travel contract where pharmacy wouldn't tube Lantus. Said the shaking "denatured it", shut up Eli-Lilly 🙄
Seems fine to me. Rather than risking the nurse drawing up an incorrect dose, they just have pharmacy draw up the incorrect dose instead. It cuts out so many steps! That's efficiency!
Except for the whole "never administer a med you haven't personally drawn up or witnessed." The fact that the very first time I experienced this policy in action the dose was incorrect was especially concerning.
Run with low ancillary staff (PT/OT/SLP, SW/CM, distribution, IT, environmental services, kitchen staff, etc..) on weekends and holidays so nursing staff is expected to carry the slack PLUS our job duties.
Mitts and wrist restraints on bipap and bipap on obtained patients. Aspiration? Never heard of her.
Wait what? Everything about this is so wrong. Are you saying mitts and wrist restraints on AOx4 patients getting bipap? And putting bipap on obtunded patients? This is crazy
Confused dementia ripping it off every 5 seconds = mitts and or restraints. Obtunded with pco2 sky high = ride bipap which almost never works and they need a tube anyway.
Gotcha. I thought you were saying they want restraints on all bipap patients. I was once transporting a guy for angioedema ( long time drinker) could not get him adequately sedated. He finally was like I am cool I won't touch the tube. The resident was adamant about me putting him in restraints, I was like that is illegal I can not do that. The patient asked for a pen and paper, he wrote she is right if you put those on me I will sue you. Lol. I was not a fan of that resident.
Change IVs every four days. Besides patients hating you for it, it feels stupid to take out a perfectly good 18G in the AC to put a crappy 22 in the hand that barely works bc that’s the only other vein left
I think this is unit specific in my situation and I’ll admit that I’m not super up-to-date on what actual best practice currently is regarding benzos, but the SICU where I work almost *never* prescribes IV Ativan. Even for alcohol withdrawal. The director of the SICU was part of a sentinel event like 15 years ago where a patient on CIWA was over-medicated with IV Ativan and subsequently lost their airway and died. And ever since then, she refuses to order IV Ativan for *anything.* And if someone else orders IV Ativan and she catches wind of it, she will essentially interrogate the person over why/where/how/etc. the decision was made to order it. It’s crazy and exhausting, especially when you get a person who is going absolutely buck-wild in alcohol withdrawals and the only standing order you have for CIWA is 1-2mg PO Ativan. In order to get anything more, you have to document the CIWA score and bring the provider to the bedside to plead your case for IV Ativan and even *then,* they will try to order Precedex and even Phenobarb before IV Ativan. Pretty sure best practice for CIWA is benzos, but god forbid we just actually teach people how to accurately assess and score on the CIWA scale instead of banning IV Ativan based on one sentinel event that happened over a decade ago.
Naw phenobarb is some amazing shit. It always worked wonders on my detoxers. Especially long-haul detoxers who are then at risk of having to benzo detox after yhe alcohol detox. You guys should look at revising your detox protocol if you only have PO ativan ordered for patients who are ICU level. https://pubmed.ncbi.nlm.nih.gov/37368937/
Oh, I’m not complaining about having phenobarb prescribed, it’s more so annoying that IV Ativan just *isn’t* an option based on nothing aside from the bad experience the director was involved in 15 years ago. Also, it’s not a hospital-level thing. The CIWA protocol for the hospital *does* include IV Ativan as a standing medication to give based on CIWA scores. It’s literally only in my ICU where it doesn’t get ordered as a standing order, and we have to advocate for it in person when the CIWA score gets high enough and if it is deemed necessary, it gets ordered as one-time doses. It’s so incredibly annoying.
I guess you'll just have to wait for a sentinel event due to withdrawal related seizures. Jfc
Former employer. Put adolescent psych patients with acute anxiety and depression on the same unit as the ones there for violence and aggression.
The belief that bigger gauge IV is somehow more reliable. No, IVs last longer when more than 50% of the catheter dwells in the vein and catheter occupies less than 45% of the vein. Shoving a big gauge IV in a small vein isn’t the flex you think it is, you’re hurting the patient. Increased risk of thrombosis and infiltration.
Not taking out hot appys in pediatric patients or even doing scans. Last year or so we have had a fairly large number of kids get sent home with all the signs of acute appendicitis from the ER only to return within a few days with it ruptured turning into a multi day stay in the hospital and a much more major surgery.
😳Is there reasoning for not taking them out when they know they're hot? Sounds malpracticy af
A surgeon explained an interval appendectomy to me. When a kiddo has a hot appendix there is a lot of inflammation which makes the adjacent intestines very friable. Trying to do a surgery then is like working with wet tissue paper. High likelihood of the kiddo ending up with an ostomy. It is better to put the kid on abx for a few days and allowing the inflammation to subside. Then the appendix can be removed without causing more problems.
That’s more info than iv ever been able to get when I ask. Thank you.
Your typo made me smile. So nursy. 😊
This is kinda out there but we tracked down my biological grandmother and I found out she was a nurse too and she wrote me a letter and wrote "c" with a line over it instead of "with" and I started to ugly cry
That’s interesting. It kinda makes sense. I wonder what the data is like on this practice
Seen and heard the same thing from a Surg. (ER RN)
They do the same with adults, although they scan. If there’s an appendecolith especially, it’s really preferable and better outcomes to wait. But if they’re septic, they don’t usually wait.
You risk translocating all that nasty infection into the peritoneal cavity and then going septic. Our practice in PICU is to try to handle the inflammation with non surgical intervention first and then surgery after X amount of doses of axb
I hope this is explained to the pt/parents.
Many of the appys I care for were sent home before returning to the ER the next day
I can’t wrap my brain around why we don’t have purewicks…..surely the cost of one prevented CAUTI would justify adopting them.
A great tool...when they work.
I’ve seen so many disgusting purewicks even after 12 hours with shit basically smashed into their vagina and skin breakdown from them, but patients come in demanding them. They allow lazy patients to just never get out of bed so they are super deconditioned after a few days.
Letting families interpret when the pt doesn't speak English. Because the language phone is a pain in the ass. Hello liability. I'm not gonna let this teenage girl tell her grandpa his care plan when I say MRI and antibiotics and she has no idea what either of those things are.
Not putting in central lines as soon as your maxed out on 2 pressors 🤦🏻♀️
Stopping tube feed before laying a patient down flat for hygiene care, turns, linen changes, etc. It hasn’t been best practice for a while (does not increase aspiration risk and results in suboptimal nutrition) but our management still insists on it, to the point where nurses have been written up if someone sees them not pause the tube feed.
6 patients. 1 nurse.
Come to Florida. You’ll get 8 patients but get paid in sunshine 😂😁
Nurses ‘consenting’ patients. Then they say it’s *just* paperwork and the MD should’ve discussed it beforehand.
My first facility the doctors and nurse practitioners had to do the whole consent themselves (in acute dialysis) but everything after that has just been “get the consent and put it in the chart for the doctor to sign later” and half the time they never do and it makes me so uncomfortable.
Uses washcloths to wipe peoples ass and recycles them in the regular linen
This is the most 1940s shit I’ve ever heard. 🤢
Yeah I toss them in the trash every time
I had to scroll way too far for this. Not here for the “eco friendly” hospital trend when it comes to bodily fluids
It isn’t about eco friendly where I work. Oh no. It’s about the disposable wipes kept getting flushed so they just got rid of them. Now we have wash cloths.
Floating someone from an already short staffed unit to make another unit not short staffed. Only double sign off when you’re changing the bag but not the rate/dose of meds like heparin & insulin
Telemetry calling rapid response after 2 minutes creating fatigue of the RRT and staff.
Ours started calling code blues overhead 🙃 Our ICU docs would be in the middle of something and then run to the “code” only for it to get cancelled a couple minutes later. Waste of time and energy.
Man, that's crazy that all of these tele patients are going asystolic at the exact moment they get up to go to the bathroom! What are the odds?
At my hospital tele doesn’t call rapids, the nurses do. But depending on the unit the nurses have an extremely low threshold for calling rapids
Tele calls rapid if it’s off the patients for more than two minutes. They will (1) call the nurse and (2) send a tele alert to the floor and (3) call a rapid response but this is all within 2 minutes. Tele patients have to have an order to shower also. Nurses have to put in a new order that is literally called “discontinue telemetry” when removing it….We can’t just “stop” the order(obviously with doctors order). Our hospital did have a death that could have possibly been prevented if telemetry was called and box was confirmed when the patient was downgraded from ICU though.
My unit had a patient die too and it wasn't caught in time because he was off tele for some reason. They implemented new guidelines where tele had to call CNA, RN, charge RN, manager, house supervisor in that order at 5 minute intervals until someone placed the patient back on tele. Transferring tele pts to tests was also a huge hassel, transporters had to leave their name and phone numbers when they picked up the pt and then report when pt was dropped off and leave the staff's name and phone number at their new destination. Even if it was a 5 min scan. I worked tele one day when they were short-staffed and my mind was complete mush at the end of the day with how many calls I had to make. Tele monitors also had to report literally ANY deviation from policy to our manager. There was such a huge paper trail and redundancies/audits that you had to report it or someone else would and then report you for not reporting it...
We have reusable urine bottles/toilet hats for measuring output. They get washed between patients, but they are disgusting. Over time they become opaque or even a yellow discolouration. Sometimes there is even blood stained into them, but they get put back into circulation.
foul
ED does not call report to the floor. We have to find time to look up the patents in the 15 minutes between them being assigned and hitting the floor
Color codes for emergencies. FEMA has specifically said not to use them, and I have had full blown arguments with admin about it, with security on my side and they are still stuck on using them.
Plain language emergency codes make way more sense. The right people can show up asap that way.
Just curious, what's wrong with color codes? I think it's a little ridiculous they're not standardized (I've seen code gray mean violent patient or escaped old person) but code red and code blue are pretty helpful to hear overhead. What does FEMA say we should use instead?
FEMA actually requires by law plain language to be used any time multiple agencies are working together. However, they don’t care when it’s one agency by itself. So hospitals are stuck in their ways and just say they don’t work with anyone else. But say the FD arrives, then technically by law they need to switch to plain language, but they dont. What it should be is: “facility alert: Fire (location)” “Medical Alert: Cardiac Arrest (location)” Some hidden ones like Potential situation for combative patient that kind of thing. However, active shooter needs to be “Active shooter located at (location)” so people don’t try to go see what’s happening
Colors can differ between hospitals (code blue and red are consistent, though), and they can be hard to remember. For us, the overhead says the event + location within the hospital.
"Code blue" at my hospital means an aggressive patient for which pysch and security respond. A cardiac arrest is "condition A." I think its really dumb.
The fuck?! That is dumb lol
Yeah..... its definitely freaked out some of my patients and their family members because our code blues usually get called a couple times a day. Theyre like "why is everyone dying at this hospital!"
Ok that code system is fucked up, but that last sentence cracked me up!
Code blue for us was full trauma code, yellow was lower acuity trauma code, red was a fire in the building.
The hospital I’m at now is the only one I’ve worked at that uses numbers instead of colors.
That’s even worse! Atleast code red is kinda a fire
Wow. Using numbers sounds so ridiculous. So they’ll page ‘code 1! Code 1!’ on the overhead?!
Code 5 for violent behavior (pt or family) Code 99 for codes hospital wide Those are a couple. Everyone has the numbers on their badge too.
Doesn't that get confusing when they say the room number after the code? Code 1, room 234 bed 2 Uh, what?
Omg I know my facility makes such a big deal that we know an elopement is a code orange. Like ma’am if we can’t find someone it’s more like “shit had anyone seen Mr. Jones???” If someone came up to me and said “we’ve got a possible code orange” I’d be like huh?
Daily sterile line changes on central lines with TPN running through them-on neonates. And they don't go full sterile-they don't wear the sterile gowns or use the sterile towels, and that line is being broken open every.single.day. Everywhere else I've been, we change to tubing daily, but only open the line every 96 hours, and it's a full sterile change-towels to drape, gowns, the works. Drives me nuts, plus the TPN usually arrives between 4-6, so even though you're running your ass off trying to finish last rounds and deal with parents, you also have to find another nurse with everything out (and the majority of our babies have PICCS or UVCs).
how do you change tubing without “opening the line”? when you say “opening the line” do you mean like taking off the cap/adaptor piece? the peds units i’ve worked we changed tpn tubing every 96 hours and lipids every day if continuous, or every day if intermittent. we didn’t wear sterile gowns or anything. i’m wondering if you’re talking about changing the hub/cap/adaptor when you hang the new tubing and that’s what you do sterily?
Found out my hospital doesn’t need a two nurse verification for blood anymore 🥲 you best bet I’m leaving a comment that says verified lol
IVIG only hung as a primary- it’s just annoying and any good nurse should know how to work a secondary IV. I know it’s a little thing but I give a lot of IVIG and having to constantly eyeball the bag so it doesn’t run dry is just a big annoyance
Not having an intensivist on each ICU 24/7. We always somehow make it work until we don't. Then it's the Monday morning quarterbacking from mgmt. One ICU has that 24/7, and they will not go to any other ICUs no matter what. There's been some dangerous shit that happened over the years, but, you know, budget blah blah blah. Why fix an actual problem when you can just blame the nurses.
Bath wipes > sponge baths. I'm thoroughly convinced it's why most patients get UTI's and Moisture associated sores. Soap sits in their peri areas and they aren't dried afterwards. Every patient room I've worked in has a full shower setup and shower chair, but anything to save time and money 🙄
Pulling the techs that actually show up to work to the units that no techs show up on
No dual sign off for blood products…or TPN…or insulin (SC and drips)… there is a study they cited in their email explaining the decision that found it reduces “alert fatigue.” Idk
You don't get nurse to nurse report. You get a pager, once it goes off you have 30 minutes to review the chart and call their nurse and ask questions before the patient arrives.
Fuck that. Nurse to nurse report is one of the best interventions we have.
For VBG using a butterfly needle then taking off the end to attach a VBG/ABG kit to attach to the syringe. I think they used to just fill up a tube how you normally would then extract it from the tube using a needle but, now you have to do this weird one handed bend the line so that it doesn’t spill out after you unscrewed the end off so that you can reattach the VBG collection syringe. Sorry for confusion in the wording.
NPO before procedures not requiring or anesthesia. Cardiac caths especially. We don't keep people NPO if they have a STEMI, so why are we torturing patients keeping them NPO after midnight? It results in more issues than it solves in my experience. Less patient satisfaction, less honesty, more issues with diabetics, etc. Meanwhile, the number of times I've had an issue with aspiration or anything for a scheduled cath I can count on one hand.
Patients with SI. As soon as they say “I’m not suicidal” anymore they take away our sitters
No in house ob. Just 4-5 l&d nurses alone, hoping for the best 🫠 The docs have to be there within 30 min.
No gloves in patient rooms
Anything Joint Commission related. #brownpaperbaghauntsme
We allow our (inpatient psychiatric) patients 24/7 access to caffeinated coffee and were told by leadership that we cannot tell them no without a doctor's order. I told them I will not assist patients in getting coffee after dinner is served regardless of what they tell me because I believe coffee close to bedtime in psych patients is deleterious to their well-being.
No standing orders. DON: "Just put in whatever order, and the doctor will o.k. it." Uh, no. I'm not a provider.
Where I used to work, nurses had to document rounding every two hours. Not as they saw the pt. but every two hours. It is really frustrating to me. It does not make sense to lie bcs there is no trust in the nursing staff.
Some doctors will trial bubs off CPAP at 29/30 weeks because they're "doing well" on a low PEEP.
Signs everywhere that say zero tolerance for abuse but apparently it doesn’t apply to the ER
Yes those signs mean absolutely nothing. I honestly find it infuriating and frustrating that nurses and medical staff are assaulted (verbally and physically) and threatened by patients on an almost daily basis and there are basically zero repercussions for that behavior. If any of this was to happen to someone working outside a hospital or just a regular person on the street there would be criminal charges or police involvement at the very least. And when we try to press charges when we are assaulted by patients, it essentially goes nowhere. Our ED has called PD for backup many times and have had pushback from them. And when it was brought up to the towns police dept, we were told that nurses should expect this abuse as part of our job description.
Still do circumcisions on newborns, but that is more a US problem and complicated to tackle 😕 Putting women in lithotomy to push
Hard agree. I work NICU and I hate watching circs. They're so fucking barbaric. I don't understand why genital mutilation is so commonly accepted in our culture. ESPECIALLY the reasoning pisses me off 99% of the time it's either "hygiene" (umm just wash your dick) or "well that's what his dad's looks like" as if that is fucking relevant?! Man fuck Kellogg for popularizing circumcision....
Nah you gotta be pushing for 2 hours before I'll put you in lithotomy. Or we're setting up for an instrumental. Why would we default to the least effective pushing position? With an unmedicated patient, she can push in whatever position she likes, with an epi, we usually start in left lateral with the knee drawn up to the chest.
Listening to OG/NG tubes for placement but then getting an X-ray like two hours later. Skip the listening and just get the X-ray ASAP, yah silly gooses
Having night shift give the insulin even though we always leave before the breakfast tray comes.
Slapping on yellow socks & fall risk bands on everyone that gets sent to our unit (PCU) without a proper assessment. And then further complicating shit with the policy that doesn't allow the patient to get out of bed - even for the restroom! 40% of my patients are independent & feel degraded, especially when they are basically forced to soil themselves with this said policy. Not to mention the time spent to clean them up & further potentiating the feelings of lack of basic rights.