09 November 2011

Observing Patients, Eleven at a Time

I keep having family and friends ask me what unit I work on at the hospital and what we do. As a brand-new, career-changing nurse, it's been a little hard to explain, even to myself. Now that I'm officially out of orientation and some (just some) of my naivety is gone, I figured I better know where I am and what I'm doing.

I didn't have the slightest clue as to what a hospital observation unit was when FGH hired me. I was just grateful for a job offer in a city that has one major university and several community colleges, all whom had just graduated their own gazillion nursing students who were looking for jobs in the Hattiesburg area at the same time I was. That, and I could finally move out of my parent's guest room and join my husband who had moved down to our new digs several weeks earlier.

No offense to mom and dad. It was a great time having mommy do my laundry again, but this 30-year-old was ready to move out of the proverbial basement and get on with her life.

Honestly, I was so proud of my title as "RN-Medical Oncology" back in Missouri. Caring for cancer patients? Totally worthy occupation. Outpatient Observation? It sounded weak at first, like I would be putting band-aids on boo-boos and sending my patients home with a lollipop.

Some days, I wish that's all I did.

I didn't really know what an observation unit was. I was like, do I just watch the patients and make sure they don't get worse? What are we observing for? Am I going to be bored to tears?

Today's Hospitalist explains observation units like this: "As Emergency Departments are increasingly stretched by capacity constraints and lack of specialist support, hospitals are turning to observation units, also known as clinical decision units, to fill those gaps without taking up inpatient beds. Patients admitted to observation units are expected to be evaluated and treated and rapidly improve within 24 hours."

“The setting is geared toward patients who require more management or attention than can be given in the traditional ED, but do not need the length or level of services provided in the inpatient setting,” says Russell Holman, M.D., senior vice president of Cogent Healthcare, a national hospitalist firm based in Irvine, Calif.

“Placing one patient in the observation unit frees up about three beds in the ED,” says Sandra Sieck, R.N., president of Sieck HealthCare Consulting, Mobile, Ala. "Observation units can help avoid unnecessary and costly inpatient admissions by aggressively diagnosing and treating patients’ symptoms, allowing them to go home in a timely manner."

Our unit works closely with the ER doctors - but when emergency department orders run out after eight hours, care is usually handed over to one of the on-call Hospitalists...which means a whole new set of orders to implement. In the meantime, the physicians and case managers are trying to determine - in less than 23 hours - whether the patient needs to be converted to inpatient status.

So it's very true we move at a rapid pace.

Yesterday alone, between transfers, discharges and admissions, I had 11 patients.

To give you a bigger picture, our unit is only 14 beds. I take seven, the other nurse on shift takes seven.

Seven beds. 11 patients.

Lots of coffee. And aspirin. And charting.

Our floor sees everything from sickle-cell crisis to cellulitis, COPD exacerbations to dehydration. Patients come from outside clinics for blood transfusions. We see a lot of patients with renal failure - I've gotten to know our nephrologists really well. We get a lot of funky wounds, and we also serve as a recovery floor for patients coming out of surgery.

PACU delivers us lap-chole patients, (seems like everyone and their second cousin has had their gallbladder removed lately) hernia repairs, thyroidectomies...just about any same-day surgery where the patient just needs to stay the night and be discharged in the morning. I call those my "eat solid food and drink with out throwing up, pee, walk the halls without passing out and be cleared to go home" patients. We've also had a run of PEG placements lately, and I feel like I can do tube feedings with my eyes closed.

(Which I once said to a co-worker, who told me she would hope I wouldn't. Southern people still don't get that when I say things like that, it's called sarcasm.)

A typical 12-hour patient rotation can look like this: a patient is admitted to the floor from post-surgery around noon, only to be discharged four hours later...who's room was rapidly cleaned and assigned to a new patient who arrives no less than 20 minutes after the previous patient was wheeled out the door.

Or a patient gets to the floor from the ER, and ten minutes later surgery is calling for them (no joke...this happened to me this week). To get a patient to surgery, you have to complete a whole checklist of items, have surgery consents signed - which you can't have the patient sign if they've taken narcotics (morphine, dilauded), which of course the ER gave them just ten minutes earlier - draw labs, make sure the patient has removed dentures/jewelry/glasses/clothes off/gown on, plus call surgery to give report on the patient you're sending them.

Giving report on a patient you've seen for a total of five seconds to the same-day surgery nurse who's been around the block a time or two is nuts. You better have your stuff together. Or at least make it sound like you have your stuff together.

And speaking of drawing labs, PCRMC spoiled me. We had phlebotomists who would come and do a simple stick for an H&H. Not so here. We grab our trays and tubes and trot off down the hall to play vampire.

PS: I love central lines and chest ports. The end.

It can get exhausting. Halfway through orientation I decided I didn't like the floor, it was too fast-paced and that I just couldn't get my day organized with all of the admission orders, discharge orders and general care orders going on in between. One patient coming in while another is going out...I seriously felt I was drowning trying to keep on top of everything. People wanting to be discharged want to go home NOW, not in 30 minutes...at the exact same time the PACU nurses are calling you into the room of the patient they just brought up because they need to hand off the chart and have lifting help from the stretcher to the bed. And then that new patient wants something to drink and their family is hovering and their IV is beeping and....

And people wonder why I'm still broken out in stress-related hives.

(Sarcasm again, my southern friends. But not really.)

Now that I've been on my own for two weeks, I'm realizing that I'm not as incapable as I first felt. I can do this.Yes, it's incredibly stressful. Yes, it's rapid work. But I feel like I know this floor now, I know where things are, and I know who to ask if I don't know something. I'm getting to know the doctors - most of whom are fairly approachable and easy to talk to.

I really like my co-workers and feel that we all work well together. They bring cake to celebrate birthdays, and I like cake.

This floor is growing on me. Once in awhile I still miss my cancer patients and the five-patient, steady, unchanging workload in Missouri, but honestly, this is now starting to feel like home. I don't want to bail ship and leave this unit anymore.

I get it now. I get the point and purpose of observation, and I'm proud to be an RN in the middle of it.

Oh, and my scrubs are cute too.