A Tale of Two Rehab Facilities – Being a Nurse Part II

I really really love being a nurse. I already gave a few reasons as to why I chose nursing originally, here. And the longer I’m in it the more I see that it suits many of my preferences, including my desires to:

  • Aid people in their time of need.
  • Have direct patient care – i.e., hands-on contact with patients and their families.
  • Not sit behind a desk for more than 25% of the day. This was kind of a big one since I felt like my soul was melting away at my previous desk jobs.
  • Have a lot of job flexibility. I work PRN at two jobs. It means “as needed” from the perspective of the employer. What it has actually meant in practice is that I work about 40 hours a week when I am around, but I can leave and travel a lot and not ask for PTO.
    • Downside: no benefits. So if you want to do this, figure out how much benefits will cost for you and attempt to negotiate a higher salary.
  • Learn new things all the time.
  • Have upward and lateral mobility like no other career I’ve seen. Bored?? That’s pretty much your own fault!

What I really wanted to touch on is a “good” healthcare facility versus a “bad” one. Not just for me the healthcare worker, but for you or your family member – the recipient of said good or bad healthcare.

Let’s talk about a reality most people don’t want to think about until something unfortunate happens. Whether due to an injury, accident, or a planned surgery, waking up in a hospital is not fun no matter how you slice it.

In nursing school we read the Institute of Medicine’s game-changing report published in 1999 titled “To Err is Human“. In summary, up to 98,000 people die each year because of mistakes in hospitals.

Then in 2013 the Journal of Patient Safety reported that the numbers may be much higher — between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death. YIKES.

Many of these cases can be attributed to infections and medication errors. There’s the 1 in 25 chance of obtaining a hospital acquired infection and the 1 in 3 chance of having an adverse drug event.

Now also consider the immense psycho-social aspect of being a patient: there’s the extreme loss of control from things like a devastating new diagnosis, an unplanned treatment outcome, or for most patients – navigating the medical world where strangers are making big important decisions for you while you drift along in a largely uninformed isolation. AND there’s the simple fact that people are running in and out of your room all day and all night telling you what to do and poking you with cold things or sharp things or very invasive things.

Let’s not forget the grinding, unyielding pain that so many people deal with too :(

OK! So now you’ve spent a lot of time in a hospital becoming more stabilized slash less acute – this means you don’t require as many nursing and physician interventions. BUT you aren’t well enough / strong enough / have enough assistance at home to get the fuck out of the medical world. Welcome to rehab.

Sweet, sweet rehab. A place to receive additional nursing care along with physical, occupational, and speech therapy. Some people seem to have a great time and love it and write nice little cards to the staff sent along with a crate of donuts. And other people seem to hate every minute of it and yell a lot and complain to everyone that will listen. And I can understand why. Let’s find out how two of these places work!

Rehab A is well staffed with a nurse to patient ratio hovering around 1:10, with 2 certified nursing assistants (CNA’s) for the 10 patients. Let’s assume both rehabs have equally competent employees because, well, that’s my situation. I could end the conversation right here because having adequate staffing in these types of places seems to be the vital component to you the patient receiving an appropriate amount of care.

Rehab B is poorly staffed with a nurse to patient ratio that usually sits at 1:20. And there are 2 CNA’s for the 20 patients. WITH THE SAME PATIENT ACUITY. Meaning on average the patients require the same amount of care in the two facilities.

Have fun passing a shit ton of meds, hanging IV’s, calling doctors/911 because a patient is seizing with a blood sugar of 40, cleaning wounds, drawing labs, doing 10 head-to-toe assessments, inserting catheters because loads of people retain urine, doing 2-3 admissions a night, giving 2 rounds of insulin to about a third of the patients because everyone has diabetes, calling pharmacy over and over because your patient’s pain meds aren’t in and they are literally screaming down the hall, and then documenting every single thing you do except for the time you hid in the soiled utility closet so no one could see all the tears.

The CNA’s too have a very difficult job. Performing activities of daily living for 10 people in a shift is hard labor. This includes transferring very large patients frequently, toileting patients (and some have accidents multiple times in a shift), helping to clean and change patients, feeding them if needed…basically all the things you can easily take for granted in everyday life. And frequently multiple call lights go off at the same time for patients needing to go the bathroom and since the CNA can’t be everywhere at once this sets them up to be yelled at all the time!

Suffice to say, people get burnt out and call out a lot. Which makes staffing even worse.

So this is my perspective: having less staff means being set up for failure. First, in the small ways: not being able to follow through on patients’ simple requests at times because there is just not enough time in the day. Yes, I try to delegate as much as possible but the CNA’s are running around all the time with enough on their plates, and the next nurse has it just as bad.

Second, in the big ways. And yes I mean patient safety. Just as an example, at the beginning of my shift a patient was barely responsive to pain stimuli. After checking her blood sugar – low at 50 – we gave her two units of glucagon, a hormone that helps increase glucose in the blood and is injected into the muscle for fast absorption. Her blood sugar eventually came back up into the mid 100’s. The doctor on call wanted to keep her at the facility and have her blood sugar checked every two hours. I checked it around 7:00 PM and it was still in the mid 100’s. About 45 minutes later her daughter yelled out that she was having a seizure. After the seizure ended and after making sure she was OK I checked her blood sugar and it was 45. Awesome.

So I called the paramedics and she was taken to the hospital. It’s been a while since that happened but I still think about it. If her daughter wasn’t there I may have not known it was happening and she could have died alone in her bed. There are just too many patients to be able to appropriately monitor some of them.

A commentary published by the Agency for Healthcare Research and Quality talks about the pressure on these nursing facilities to manage sicker patients, which has recently increased substantially because of hospital penalties for high 30-day readmission rates. Accepting sicker patients when you aren’t equipped to manage them = more risks to patient safety. There’s increased fall risk, medication errors, infection control problems, risk for pressure ulcers, etc.

So back to you or your loved one as a patient in Rehab B. It really sucks if you call to go to the bathroom – needing to go urgently and not being able to do it yourself – and you have to wait 20 minutes for someone to help you. It really sucks if you are  uncomfortable in bed and unable to move yourself but you have to wait 20 minutes before two people can come to move you. It really sucks if you want your medicine because you’re in pain or you want to go to bed but there are five other people that asked before you. Yes these might not seem like the biggest problems in the world. But when you’re in pain or alone in a place that isn’t your home or you’ve just experienced a life-altering medical ailment that you are trying to recover from, all of these little things can feel much more immense. And let’s not forget, it would REALLY suck if you acquired a new infection, developed a pressure ulcer, or were the recipient of a medication error because the staff couldn’t properly care for you.

What can you do? Aside from asking what therapies you will receive and what the nurse staffing looks like and how often the physician will be meeting with you…one of the better ways I’ve seen to ensure proper care is to have friends and family visit often. Yes, that might not be feasible. But [sadly] the patients with more family involved, the ones who can question more and ask for more, tend to receive more! Funny how that works. The squeaky wheel gets the grease.

The end.

 

 

 

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