Preaching to the Choir

Okay, caveat to general readers: probably only nurses will truly get this post, and understand why I'm so excited and starry-eyed about my new job.

(I can only liken it to happiness and sense of fraternity I assume Trekkies feel at conventions, when discussing dialects of Klingon).

Any way, so I can't gush enough about my new unit. The building, which is entirely devoted to cardiovascular procedures, and contains its own EP, cardiac cath labs and ORs, is only a year and a half old and is absolutely beautiful. I was describing my unit as "huge" to a nurse friend of mine, who thought I was talking about "bed-number." This unit has only four more beds than my old unit, (twenty eight beds total) but is literally at least twice the size of Old Unit--plus only 6 of the beds are cohorted doubles, whereas on my old floor, only four of the twenty four beds were private rooms, usually reserved for "train wrecks" and contact precaution patients. (The same friend said, 'So what's their contact precaution policy?" And I was like, "No idea. None of our patients were MRSA/VRE/C-diff.")

One of the first things I noticed is the lack of noise due to the general systematic approach that my old hospital seems to have missed entirely--namely that we are inhabitants of an industrialized, technologically advanced society in the twenty-first century. For example, at New Hospital, the nurses carry cell phones, so instead of having 50 people trying to call the central nursing stations, they just call the nurses, which cuts down on at least 50% of the noise and confusion of a unit in one fell swoop. (Despite having an intercom system on my Old Unit, we had a unit clerk who consistently just yelled down the hallway at nurses, without bothering to find out if those nurses were actually on the floor, in a room, or even working at all that day.)

There are two nursing stations on New Unit, with plenty of spaces to chart, and about 8 additional computer stations spread out systematically in each of the four hallways. I never once had to give up my seat to anyone, which on day shift at Old Hospital, happened at least thirty times a day.

They have remote telemetry monitors who constantly watch telemetry, and if they see an arrythmia or suspect someone has taken off their leads and/or coded, you get an instant cell phone call, so no matter where you are in the unit, you never have to worry about what the hell might be going on in rapid-afib guy's room, or whatever.

When I went to pull tele strips in the a.m., I asked where we put the strips--in the medical chart or in the nursing notes, and I got a quizically polite look from my preceptor, who said, "Oh honey, we don't do any of that. The tele monitors come 'round and do that for us, and keep the tele strips in this book [shows book kept by monitors]." Bug-eyed, I said, "So you mean, I don't have to measure my tele strip?!"

It wasn't even 7 a.m. and already and I was already ecstatically happy.

I kept waiting for the noise, and the people, and the general chaos of day shift to happen--and it never did. The unit remained as quiet and orderly at 6 a.m. as it did at any other time of the day. No crazy confused patients screamed all shift long nor did bed alarms go off constantly (because every one on the floor was alert and oriented!). The hospital is a teaching facility, but I never saw random interns and residents lounging around at the nursing station doing post-conference at nurse's change of shift, when uh, we need our nursing station, assholes.

Nurses actually do daily rounds with the PA and a CV surgeon, who was a nice, normal human being who said hello to other human beings without acting like some kind of snotty stuck up prig.

I suppose the one significant difference was that people did their jobs. Ergo, I didn't spend my day babysitting every one (including my patients) to make sure their jobs were done.

Techs drew labs and started IVs, and there was none of this constant tugging on my sleeve asking for "help" which half the time is just "I'm too fucking lazy to do my job." If I needed something from them, I asked, but otherwise, people did their jobs. I kept wondering where the hell all the nurses were, when I realized that, just like me, they were in patient rooms, doing real nursing. We had time to teach, ambulate our patients, and I made three beds up just to have something to do with myself.

I never had to call lab to beg for a STAT lab, endlessly page the one poor IV nurse covering the entire hospital for one lousy infiltrated IV, call dietary to bring something up, beg housekeeping to come and clean a bed, ask a PA to put in orders, or call an attending to clarify orders. I just checked the chart for orders, which were appropriately placed, and scanned them to pharmacy, and they came up from Miracle Pharmacy, without having to call them five times.

Speaking of proper staffing:

One of the most amazing things to me is that they have a constant, stable staff of PAs who are dedicated to our floor. No more of this, "Where's PA Y? Did she leave the floor already? What's her pager number?" that happened twenty times a day at Old Hospital.

The crowning jewel came at 7p.m., when I asked, vaguely petrified, "So, uh, what happens when the PAs go home? Who do we call for emergencies and orders?" Again, my preceptor, who must have thought I practiced nursing in a barn or Soviet-era prison system before coming to her unit, said, "Oh, well, the PAs go home at 7p, and while we have two on days, we go down to just have one PA on the floor from 7p-7a. ICU has one overnight, and we have one."

I nearly fell over.

"You mean to tell me we have a dedicated PA at night?! On our floor?! You mean there's no house officer?" I asked increduously, with the Slack Jaw Yokel sign flashing in bright neon-technicolor above my head. "Oh yes," she replied confidently, "It's so nice. And if you have an emergency, and they're off the floor, they'll come right up."

I envisioned my Old Hospital where fellow nurses and myself had suffered literally hours to days worth of paging PAs, attendings, and house officers, begging for someone to come up and give a shit that the patient was bleeding out their ass, in metabolic acidosis, respiratory distress, V-tach, or whatever, only to have them say, "We'll just watch that lethal arrhythmia/whatever."

[At New Hospital, they actually have established, clinical pathways to follow, so even though taking care of postop day one CABG patients sounds like I'm being thrown to the wolves, actually, it's not, because they have it written out for you: this is what nursing/medical goals are for day one, two, three and four (discharge). I asked my friend what the hell kind of clinical pathways we had at Old Hospital, and she laughed and said, "I think we had just one: Do nothing and blame the nurse."]

PAs at Old Hospital work bankers hours, and while they were very nice and mostly very on the ball, they were also completely overworked, had huge patient loads spread over the entire hospital, and were rotated in the middle of the week to another assignment, which meant you never knew who was going to be covering your patient, because it changed from day-to-day. When they left at 5 p.m., you were stuck with a nonexistent house officer, who wouldn't return your pages until at least 6 p.m., due to some metaphysical vortex that occurred during their change of shift. Same thing between 7a.m. and 8:30a.m.--the house officer was going off duty, and couldn't be bothered to come up unless your patient was in serious trouble, which was such an elastic term at HSR that it meant "coding."

Then at night, you'd be playing Who's Patient Is It Any way with multiple house officers, and playing Pager Tag with half of them, because you never knew if the assigned beeper for your floor was working, flushed down the toilet, or turned off. Sometimes I'd have to call three different HOs, all of which pointed the finger at another HO and claimed either not to be covering the floor, or the patient, or whatever. Meanwhile, seconds, minutes, and hours ticked by while the patient needing "whatever" got absolutely nothing.

Another thing that just seemed to make more logistical sense is that nurses work two shifts--period, a day and a night shift. So there's none of this, Jamie is working 7a-7p, but Nurse X is working 7a-11a, and Nurse Y is working 11a-11p, and yet another nurse is working 11a-3p, so now Jamie and three other people have to give up half of their assignment to accomadate nurse Y and Z leaving and coming on, and then at 3p, 7p and 11p have the potential to give up and change assignments, float, or whatever staffing decided to do with you, their personal troll/slave.

The time saved in giving multiple reports alone is worth the simplification of shifts. Around 3 p.m. yesterday, I started getting a funny feeling in my stomach, known as the "change of shift shit-about-to-hit-the-fan" sixth sense, when I made another discovery, which is that there is no such monster on New Unit.

Further, I thought I was going to have a religious ecstatic moment when I was informed that unit policy was to take an hour lunch break.

I had run off the floor to gobble down my lunch in fifteen minutes, and then raced back outside to my preceptor, who said mildly, "That was a quick lunch!" Half an hour later, she said, "Well, you can take your other half an hour now; we'll go to lunch now."

I really must have appeared slow-on-the-uptake, because then she said, "We take an hour lunch here, dear." In fact, she must have thought I was mentally retarded, or something, by that point, because I had to have her explain how an hour break (unheard of at Old Hospital, where the policy was half an hour, maybe, if you could afford it) was possible. She said the unit decided they would like to take their two fifteen minute paid breaks, and add them to the half hour unpaid lunch break, because "we really do need an hour of uniterrupted time to take a rest."

Compare this to the managerial tactics at my Old Hospital, where the hospital policy was to discipline you for being so busy you couldn't take a break, or got interrupted by a desating, hypotensive demented patient and forgot to clock back in from lunch because you had to go restrain him, bump up his oxygen, and suction him, but not before you spent forty five minutes trying to find the PA (also at lunch) to write the orders to do all that crap.

In fact, on New Unit, the nurse manager not only wears scrubs, but routinely stays until 7p.m. with her day staff. She's actually out on the floor for a large portion of the shift, helping out the charge nurse or whomever, and her office door is always wide open except when physically not there. The charge nurse doesn't take patients so she can coordinate staffing, and acts as a resource nurse to help her nurses. And day shift still takes only four patients, which was becoming the standard at Old Hospital Unit, but really at the end of the day it would be more like six to seven patients by the time I was done discharging, admitting, and shuffling around my assignment so that the new shift could have patients to take.

(Incidentally, I feel like calling up my old unit manager and leaving a simple "Ha ha." on her voice mail, as per the thug kid's standard response to misfortune on The Simpsons. )