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The New Observation Unit
  #1  
Old 05-04-2018, 10:53 PM
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jedimaster91 jedimaster91 is offline
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Default The New Observation Unit

My place of employ has recently opened a chest pain observation unit to try to get emergency patients cardiac testing the same day instead of transferring them to other locations. My location is mostly an outpatient testing center in a semi-rural area, but does have an ER. As such, our resources for the really big stuff is somewhat limited.

And let me tell you what a cluster-fark this thing has been from the get-go.

-The clinical staff wasn't brought into any of the planning meetings until things were well underway. I'd gotten a few general questions from my immediate supervisor, but really they were questions Google could have answered. The first conference call I was asked to sit in on spent 45 minutes discussing what to do with patients who had positive stress tests (meaning likelihood of a heart attack was pretty high). Apparently there are at least a dozen different ways to say "It depends on how stable or unstable they are and what resources and openings we have at other locations." That's 45 minutes of my life I'll never get back.

-The next meeting I went to spent the entire time going back and forth on how to classify these patients in the computer system. "Observation" status is different from "Emergency Department" or "Inpatient" status and they're not really outpatients either. Yes, it does matter for coding and reimbursement purposes. And the ER here can only keep patients up to 23 hours. After that they have to either be discharged or admitted/transferred. But the software the nurses use doesn't have an "observation" category, or it does but it doesn't show on the tracker, or something. IT wasn't anywhere near ready and we were about a month out from the initial launch date. It later got pushed back. Twice.

-After that snoozefest someone finally asked the techs what we needed. Hilariously enough all this was going down while the regular tech was on maternity leave. But she's an Air Head on a good day so Boss Lady wanted me handling this anyway. So we discussed patient prep and the fact we need a cardiologist or a nurse practitioner to supervise stress tests. Ok, the later will have to be coordinated with the office manager for the cardiology group. We'll call her Waffle for reasons that will become apparent later. Now because we're mainly an outpatient facility, cardiology isn't staffed 24/7 like the ER and XR/CT, nor are we on call (and we'd like to keep it that way, thankuverymuch). So then the issue became how to let us know we had a chest pain patient if we'd already left for the day. Initially, the ER was going to text us, but that got shot down because that would technically put us on call. There's still no real answer. I think Air Head calls the ER on her way in just in case we need to order radiotracers. I petitioned to have a standing set the pharmacy would send us every day, but I got overruled "due to cost."

-Let's talk about Waffle. Oh, Waffle, you make my job so much harder than it needs to be. She is supposed to send out a weekly schedule of who is coming to supervise stress. It's rarely on time and often incorrect. She is also supposed to tell the docs/nurses when there is an obs patient they need to come out for. Either she forgets to tell them when we do have a patient, or still sends them out when we don't. And it's still a tossup whether the person who actually comes is the person on the schedule. There has been some talk about switching up the days we do only cardiac studies since Waffle said she couldn't send anyone out on Thursday afternoons for afternoon outpatients. But we had a late obs patient this week on Thursday and she didn't have a problem sending the nurse back. So.....why is one ok, but not the other? This isn't the first issue she's changed her answer on either.

-Not directly related, but there is some feuding going on between the cardiologists. It's gotten to the point where the one who sends us most of our patients (let's call him Dad1) refuses to let anyone read his exams except for Dad2. And the other side of the conflict, Husband and Wife, are looking for any dirt they can throw. I have no idea what happened that started this, but it's spilling over to the techs now. We're getting caught in the middle and it's awkward. Personally, I don't have any issues with Husband and Wife (though Husband is kind of an odd duck, but at least he's nice to us), but I've worked with Dad1 and Dad2 longer. So if push comes to shove, I'm siding with Dad1 and Dad2.
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  #2  
Old 05-05-2018, 11:52 AM
Mental_Mouse Mental_Mouse is offline
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So, let's see if I've got all the points here:
* They want to be able to lay hands on cardio staff 24/7, without actually paying for on-call staff, let alone continuous staffing.
* And radiotracers available, without actually keeping them in stock.
* Meanwhile, the computer systems are so closely bound to your current work that they won't allow you to hold a patient for observation, and nobody bothered to check with IT about this.
* And meanwhile, the cardio office has a office manager who can't seem to keep track of her staff or the patients, and also doctors who are ratcheting up to war with each other.

Dare I wonder how much the patients will be paying for getting diagnostic work via the ER? (See also these Vox articles about ER costs.)
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Old 05-05-2018, 03:21 PM
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jedimaster91 jedimaster91 is offline
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Pretty much, yeah.

Due to licensure and regulations, we can't stock the radiotracers ourselves; they have to come from a central pharmacy (thanks USP797). The tracers are technically pharmaceuticals so they fall under those regulations, but the radioactive component puts them under our scope of practice to be able make them ourselves. Some outlying areas have been able to get around it by arguing scope of practice and showing they can comply with USP797.

And no cardiologist is going to come supervise a stress test in the middle of the night. They'd laugh at you for even suggesting it. Personally I wouldn't mind if they put us on call just to be able to let us know, hey you have a patient for tomorrow and not have to actually come in for anything but they're not going to do that.
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Old 08-30-2018, 01:39 AM
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Patients who come into the chest pain unit Friday afternoon through Sunday night that fit the criteria to get a stress test from us get discharged with instructions to come see the cardiologist Monday morning (or the next business day if Monday is a holiday and we're off). The charge nurse then sends an email to the cardiology team so we know to keep an eye out for another patient.

Lately there have been...issues.

A couple weeks ago we didn't get the email we were supposed to and ended up with not one, but two surprise patients. On top of an already busy day. The next week we got the email, but it was for the wrong patient. And there was a second patient we didn't know anything about. Fun times.
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Old 08-30-2018, 02:35 AM
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EricKei EricKei is offline
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(Assuming the US) ...At least with on-call, they have to PAY you all for being in that status (at your full normal rate, IIRC), whether you get called in or not.
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Old 08-30-2018, 12:12 PM
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They do have to pay for on call, but it was $4/hr when I was still taking call. Minimum of 2 hours at time and a half of we got called in though.
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  #7  
Old 09-07-2018, 03:35 PM
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Oh boy was yesterday fun.

Guy comes in for chest pain, gets ordered for treadmill stress. Well, he's not real steady, so maybe chemical stress would be better. No big deal; we switch stuff like that all the time. Can't use Drug1 because he's actively wheezing. Don't have access to Drug2 (and haven't for years because we didn't have a nurse to give it). Nurse Practitioner gives the guy the choice of try to walk, cancel the exam, or transfer to another facility that does have access to Drug2. Guy says he'll try to walk.

Good news, he's older, so his target heart rate we need to get is lower. Bad news, Guy is suuuuuuuper unsteady. More bad news, his EKG is wonky. He's basically hovering between first and second degree AV block (a delay in the top and bottom chambers of the heart talking to each other) with some extra beats (both PACs and PVCs) sprinkled in for good measure. In short, I don't wanna stress this guy. The chances of Bad Things(tm) happening is more than I'm comfortable with. But such things are not up to me. Nurse Practitioner and Burly Nurse are on either side of this guy holding him up on the treadmill and he's walking like a cat with booties on. I'm hooked up with my syringe getting ready to do my thing and also have my other arm wrapped around Guy's waist.

Well, the inevitable happened: Guy took a bad step and stumbled. Burly Nurse saved the day by catching him before he fell completely and out of the corner of my eye, I see the EKG go bananas. It looked uncomfortably like Torsades in the moment, which is a VERY Bad Thing, but turned out to be an unsustained run of V-Tach. Still a Bad Thing, but not Quite As Bad as I first thought. So what might have happened is Guy's heart rate shot up, which caused him to start passing out, which caused the stumble and near fall. Or the stumble and near fall caused his heart rate to shoot up. Chicken or egg, it doesn't really matter. But it did get his heart rate up to where we needed it to be and we were able to finish the test. Thankfully, there were no further issues.

I have a feeling now that Burly Nurse is here, we'll be getting access to Drug2 in the very near future. Which I'm not super stoked about because I hate Drug2 (it takes forever to work and makes people feel really crappy for a long time), but such is life. Sometimes we need it.
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  #8  
Old 09-08-2018, 11:33 PM
TheSHAD0W TheSHAD0W is offline
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Uhhh... IMO you should've followed your first inclination and refused to perform the stress test. I don't think even the chemical stress would've been safe.
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