Nursing Thoughts

Code Blog has a post briefly discussing staffing ratios and how she is now the official “break nurse” on the unit. I am for any law, rule, regulation that would limit the number of patients a single nurse must care for in any given situation. Here in Arizona there is only one regulation concerning staffing ratios. It addresses staffing ratios in intensive care units. Each nurse can have a maximum of three critical patients. For me that’s one patient too many, but it is a start.

So what happens when all the hospital beds are full and there is no room to admit new patients? Welcome to the ER. Most of the hospitals here in the valley of the smog sun don’t have holding (observation) units where they can warehouse patients. The ER’s become full with admitted patients waiting for beds in the hospital proper. Because hospitals are afraid of losing even a nickel they won’t transfer a patient to a hospital that does have beds. I have cared for and discharged ICU patients from the ER. Often patients spend two to three days in the ER waiting for a bed in the hospital. I would propose this is unhealthy for the patient on a number of levels. ER’s are busy and noisy places.

I think it was Geena at Code Blog who recently posted about the noise levels on the floor, it’s even worse in the ER. People screaming and yelling, the patients make noise also. How healthy and stressful can it be to keep a patient who is deathly ill awake for three days while they await admission? Couple this with the number of patients an ER nurse must care for and the situation becomes dangerous. While it is against the law for an ICU nurse to have more than three patients, there is no grandfather clause that extends to ER nurses. I have personally been responsible for caring for as many as five ICU patients in the ER on more than multiple occasions at 16 of the 17 hospitals at which I have worked. If it’s unsafe for the ICU nurse to have three critical patients, why is it safe for the ER nurse to have five critical patients?

While doing some consulting work at a local hospital I asked an ER nurse how many patients they were holding in the ER for admission? She responded that they had ER nurses scattered throughout the hospital and were holding 78 patients for admission. This problem was one of the prime motivators for me to go back to school and get out of bedside nursing. But what of the nurses left at the bedside? Some hospitals are trying to gain Magnet status and this is making the ER situation even worse. They advertise no more than four patients to any given nurse on med-surg and three patients to any given nurse in tele. Any excess patients are absorbed by the ER staff. This overloads the ER staff and makes a marginal situation unsafe. It’s great the hospitals are addressing the staffing issue, but it’s not safe to expect the ER nurses to shoulder all the excess patients.

There is another aspect to this that will probably only be understood by ER nurses. ER nurses are not floor nurses. We don’t do the same things floor nurses do. We don’t approach patients with the same mindset as floor nurses. We work in the ER precisely because we are not floor nurses. Most of us just don’t want to work that hard. In the ER you have time to take care of each patient as you get to them. There are times when things must be done on a schedule but usually not. We are not used to passing 7 AM meds, or doing bed-baths at 4:30 AM. Those skills are not even a part of our vocabulary. We are not used to flow sheets and MAR’s and the thousand other differences between floor nursing and ER nursing. We are not better nurses than floor nurses we are just different.

I have worked in the ICU and find it particularly boring. Plus, I don’t want to see the same patient for twelve hours at a time. I can handle any given patient for about 1 ½ hours, then I have had my fill and want to move on to another situation. In the ER we might suction a trach as needed, but it is rare that we would change an ostomy bag or give foot care. Most ER nurses I have met detest feet and anything ending in ostomy. It’s not good or bad, that’s just the way it is. One new hospital has opened and another is scheduled to open next year, but with the expanding population they won’t make a dent in the overall number of beds available in the valley.

Is there anything that can be done to help this situation? Probably not. I have personally turned down offers of fifty dollars an hour to come and work shifts. We are approximately 8,000 nurses short in the Phoenix area alone. Most of the nurses I know already work more than one job. I currently have three, and only one of those is a bedside nursing position, and then only because I teach RN students.

The board of nursing recently released its study of the problem. I go to several institutions here in the valley and I have asked almost every nurse I have come into contact with if they received anything form the board of nursing asking for their input on this problem. Not one nurse I have talked with has been contacted. I have no idea who was on the Blue Ribbon Panel, but I would bet it was the same incompetent nurse exec’s who cause the problem in the first place. One thing that would help is to pay us better and stop messing with the health benefits. Last I checked we are in the same geographic billing region as California but we make much less money than California nurses. I actually overheard the CEO of one of the local hospitals respond to the Nurse Exec “fuckem if they don’t like it, they can go work somewhere else” when the subject of nursing pay was broached. The hospitals here whine about having to pay nurses a living wage and how they can’t afford it, then turn around and bill Medicare at the same rate as California hospitals. This while paying the nurses here 10 to 15 dollars an hour less than our neighbors. It’s not my fault if your hospital contracted at a reduced rate with the HMO’s and you are losing money. Fire the management and hire someone who knows what they are doing.

Hire more nurses to care for patients. If nurses were not overloaded every single shift they work they might consider working more shifts. But if you beat up someone for three 12 hour shifts they are not coming back for a fourth to get beat up again. If they have a reasonable work load for those 12 hour shifts, picking up an extra shift is no problem. Get rid of mandatory overtime. No explanation needed. Stop ridiculous staffing practices. I know someone who sat in on the managers meeting at the largest tertiary hospital here in the valley. The nurse exec leading the meeting told the managers to pick a number between 1 and 20. The manager closest to the number got the staff that day. Limit the number of patients that can be held in the ER. The other day we held 18 patients that left two beds to see ER patients. The state would not allow us to go on divert because we had exceeded the time limit for being on divert. What sense does it make to open the ER to ambulance traffic when there are twenty people waiting in the lobby and only two beds?

Allow hospitals to put out a “closed to new patients” sign. We are not MASH units with the only available medical facility. Provide ambulance service to take the patient to the next hospital if necessary. If you can wait in the lobby for 12 hours to be seen chances are you can wait twelve hours to see your own doctor. Require hospitals holding patients in the ER to contact other hospitals and transfer them to open beds.

Penalize welfare cheats for using the ER as primary care venues. If you drag your snotling to the ER for a simple problem you get to pay the bill yourself. Link the social programs so that inappropriate use of the ER can be deducted from their monthly welfare check. I don’t believe health care is a “right” entitled to all by god or the constitution. If you are healthy enough to procreate then you are healthy enough to go work and take care of yourself.

The other side of this is corporations who take advantage of the welfare system. Walmart is a prime problem in this area. The worlds largest employer pays their employees so poorly and does not provide medical benefits that most employees qualify for welfare programs. This cost shifting to the taxpayers is a prime reason I don’t shop at Walmart. Pay your employees a decent wage and provide health insurance that pays for more than $1,000 in a year.

Reduce the co-pay to specialists and increase the reimbursement to family practice/internal medicine. If FP actually were paid for what they do they might not refer so many patients out and be able to see the panel of patients they have already. No one wants to see 27 to 35 patients in an eight hour day. It’s a disservice to the patients to run them through like cattle.

Force insurance companies to reimburse PA, NP and Physicians at the same rate for the same diagnosis. What is different when I diagnose an earache as opposed to the physician. The patient still has an earache and is being treated. Why should I accept 65% of what the doctor accepts? Is my overhead any less? Change Medicare laws to allow equal reimbursement for equal diagnoses. If reimbursement were paid based on diagnoses rather than degree, then more NP’s would open clinics. We desperately need more FP offices here in Arizona but with physicians controlling the purse strings of the HMO’s, it’s not likely to change.

Patients head to the ER because they can’t get in to see their provider. We could reduce our ER visits by 30 a day if more providers were available.

A nurse is a nurse is a nurse, I have heard management proclaim. Sorry, that’s just not true anymore. Equipment and procedures vary greatly by unit and you can’t just plop any old nurse down in a unit and expect them to be safe. Most nurses become competent in one or two disciplines, and familiar with others but not necessarily competent. I work fine in ER, ICU, PEDS ICU or PEDS med-surg. I’m a total disaster on an adult med-surg floor. There are too many patients and I am not used to all the stuff you have to do at specific times. I don’t ever want to work that hard again.

Don’t pay med-surg nurses less than ER or ICU because they are not in a “specialty” area. I disagree with the designation of ER and ICU as specialty areas. Med-surg is just as much a specialty area as ICU. There is a completely different set of problems to overcome and situations to handle. No, the equipment is not as technical, but the patients are not any less complex on a human level.

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