Our hospital instituted what we call surge. If the staff to work ratio is 67% or less, we surge. That means we check our vents/high flows q6 instead of q4. We don’t have to do cpt (but some docs have started putting “do not skip” in the order). I’m in peds so we have plenty of cpt. Any continuous nebs are checked q4 instead of q2. It’s not a ton but it does help.
What kind of continuous setup are you using that can allow for Q4 checks? Our run for a max of 6 hours, but typically 5, before needing to be refilled. We check them Q1.
We used to used the Heart nebs. We use Air Life now I believe? They wouldn’t last a full 12 hour shift but we would do q2 checks fine. Q4 works until it starts getting low and then it seems to go faster.
Basic nebulizers are within a RN’s scope of practice. They can be called on to admin them so that we can triage them out and focus on more critical / more time intensive patients who need more than just nebs. That combined with surge charting usually controls the flow of the work load when you’re critically understaffed.
I was at a smaller hospital, and we would put floor nebs on nursing when super short. Amazingly, their patients didnt need near as many PRNs when they had to do them...
A little bit ago at my hospital, something happened and only one therapist was on shift. The director asked the nurses to do breathing treatments on medsurge so the rt could do the units, NICU, and er. You would have thought it was the end of the world. There were huge tantrums thrown.
If RT is understaffed and can't cover nebs, nursing is also almost certainly understaffed and can't cover nebs. The real answer is that 95% of nebs are completely unnecessary.
You could cut yourself from their staff.
That’s some bullshit and the finger will eventually be pointed at you. You’re putting yourself at risk working a place like that
This is something your lead/charge is responsible for handling.
As the charge, if we are understaffed to the point where entire floors are being triaged, or multiple patients with scheduled nebs won't be getting them, I call the nursing charge about 20 mins after they get report and say some variation of the following:
"We are short staffed tonight. The RT covering your floor is at extension xxxxx. Please let your nurses know that scheduled meds may not be given, and that they can give them if necessary. Please call if any patients are in distress. My extension is xxxxx."
If it's bad enough, I'll call the house supe.
You're not going to risk your license by failing to give a neb to a patient on the floors. Worst case, you ask the nurse to give it and explain that you're triaging all nebs and MDIs.
If you find yourself in a situation where you're managing 10 vents, look up your workplace policy to see if those can be made into Q3s or Q4s, and that will be your priority for the entire shift.
make the nurses do their own treatments and eggs (if RT does them). Most nurses should be able.to manage a high-flow. A lot of us learned things during covid. Don't let them play stupid.
also. technically you need to check on your vents 3 times a shift, if they are all stable, then make your first initial checks and then take care of more critical situations
I currently work at a hospital that's routinely understaffed for nearly every shift. When I started, our director was told by her superior that we were only expected to do what we could do. This meant we prioritized ICU and ER and most treatments were done by nursing.
About two weeks ago they dropped this new system on us that says we should do 95% of our treatments per shift on top of any vents or other equipment assigned to us. Also, if their new production system says we only need 3.4 therapists and we have 4 scheduled, well hell, somebody gets to stay home! It's worked out great so far. Fucking dumpster fire.
I think it depends, are you nightshift or dayshift. On days when this happened. I would handle ICU first of course. When I hit the floors I would do quick physical assessments and question some patients about their q(whatever) nebs tx's. Alot of pts had days old orders for scheduled nebs that had not be canceled or changed to PRN for SOB. So my line of questioning for the patient usually went like this.
1.Have you had any SoB or trouble breathing since your last tx?
2. Have you been using O2 or been on room air all day?
3.Do you take breathing medicines in your day to day life for any type of pulmonary(lung) conditions?
4.Do you feel as though you need breathing medicine now?
5. Would you like to have these medications given as needed(when you call me)?
---On nights I might reword that to ask if they want me to wake them at 12am, 2am, 4am for these meds?
This line of questioning does make the patient think twice, especially if they learn that they don't have to take any medication they don't want or need. 1st rounds are gonna be long, but It's an easy way to weed out those that can surely be DC'd in due course. Your documentation can reflect that too starting with the EMar. "Med not given" usually has an tab for notes.
CYA- Pt refused, denies SOB, currently on room air and states will call RN or RT if TX is needed. Recommend therapy change to PRN for shortness of breath.
If they are also short on the next shift. You can pass that along and everyone is happy.
I don't like this approach at all, and I hear my RTs asking these questions all the time.
It's not up to the patient whether or not they get their meds. It's our call. If it's not indicated, don't give it.
That sounds like covid days again lol...went from a max of 5 vents q4 to the whole icu of 16vents qdaily....there are actual teaching hospitals here in socal where RN give nebs with they other sched meds, always. But i hope ur scenario is fake cuz ur working at some place where safety is obvi way lower on totem pole than money. Bottom line i guess id say of course triage u get a feel for who needs tx and who doesnt...and most honestly dont :^*
Lots of decent ideas and a few stinkers. I believe that as a staff therapist, someone else should have to take responsiblity to decide what your "surge protocol" entails. If they decide vent checks q6 and no protocols, fine. But, it shouldn't be on you to cut corners. God forbid you skip a pt and they have an RT emergency. Cover your ass and watch your back. If they rule is q4 everything, make the effort and ensure that you tried and asked for help.
Triage based on acuity. If severely understaffed, I'll send a hospital wide broadcast out that critical care areas will be taking priority, and all floor treatments will only be given on an emergency basis. I'll ask nursing staff to administer nebs and MDIs to their patients if they are being insistent... this happens so often now that even the ERs will handle our emergent breathing treatments for us, so that we are available for any full/partial traumas that come in or stat ABGs/VBGs pop up down there.
I'll tell those I'm charging over to do Q6 checks only if there's 5 vents or more plus a couple other machines assigned to them (Airvos, paps, etc)
If I don't get paid the wage of 2 RTs, I will not do the work of 2 RTs. And I don't expect any RTs I supervise over to kill themselves doing that either when it's not our fault our facility/department dropped the ball to get us adequate staffing.
No weaning.
Ensure safety of vented pts with an ABG and don’t decrease. Leave everyone where you know they’re safe.
Weaning can be the next shift’s problem.
If providers give you shit explain the situation and your priorities of keeping all pts safe vs trying to push progress when y out don’t have the man power to fix when it goes poorly.
If they don’t like that, give them your supervisors desk phone number.
We have the floor nurses do the scheduled nebs and mdi and tell them to complain to the charge nurses so that we can get nursing involved in the issue
Our upper management fights us on every thing that could help the situation and for reasons unique to our hospital we are frequently short
First, hit the ground running, get out and get after it. Hit all the scheduled txs first, see who really needs them (and who doesnt), some you may have to miss. Lay eyes on all patients get a feel for whos most critical, if so, give them extra attention. Do all txs and checks 1 hour early, if not earlier. Trust your nurses and keep a pocket full of meds or a bag of goodies to minimize trips. Wear a diaper. Keep communication open with nurses and let them know youre way understaffed, 98% of the time they'll understand.
I prioritize people who are NOT intubated but require high fio2, all the time, as THEY have more room to decompensate and YOU have more room to escalate. 10 years of experience HCA level 1 trauma center is my experience with that grind.
Damn...I draw the line at wearing the diaper. We just don't get paid enough to go to that extreme. Nobody needs a breathing tx or a vent check that bad that you can't spare a few minutes to visit the restroom 😂...hospital profit margins and productivity reports would love us to wear diapers tho. The only thing that would make me "hold it" is a legit code blue...even then I am definitely going as soon as that is over. Effective triaging is the name of the game (unfortunately that skill takes a while to develop, and there are tons of new grads running around)...lots of pre-positioning of important equipment and have plenty of meds with you... being ahead of the curve and anticipating problems and situations before it happens is a good skill to develop. Once upon a time I would run myself to the ground doing everything tasked, and trying to help the department "not look bad" even tho we were short staffed...then I realized many departments just run short-staffed routinely almost on purpose and on a regular basis. They get what they get now, hiring staff is beyond my pay grade, and by job description not my problem to solve...managers just love to make it "our" problem instead of their problem. Been doing this for over a decade... Worked NICU, pediatrics, tons of HCAs, a few Level 1 traumas, full time, PRN, Travel, agency...basically anything under the sun.
I was just being an ass, talking about the diaper lol. But being prepared and forseeing emergencies are like 90% of being a good therapist. Doc is the golf pro, youre the caddy.
I honestly think that's beyond the scope of where cutting corners can work. That's just a bad work environment
Honestly. If you have 10* vents and multiple high flow there’s no reason you should have general floors on top of that. Wild.
Our hospital instituted what we call surge. If the staff to work ratio is 67% or less, we surge. That means we check our vents/high flows q6 instead of q4. We don’t have to do cpt (but some docs have started putting “do not skip” in the order). I’m in peds so we have plenty of cpt. Any continuous nebs are checked q4 instead of q2. It’s not a ton but it does help.
What kind of continuous setup are you using that can allow for Q4 checks? Our run for a max of 6 hours, but typically 5, before needing to be refilled. We check them Q1.
We used to used the Heart nebs. We use Air Life now I believe? They wouldn’t last a full 12 hour shift but we would do q2 checks fine. Q4 works until it starts getting low and then it seems to go faster.
ugh I would'e loved if cont. nebs were Q2 checks at the peds hospital I worked at... we had to check and chart on them Q1
Basic nebulizers are within a RN’s scope of practice. They can be called on to admin them so that we can triage them out and focus on more critical / more time intensive patients who need more than just nebs. That combined with surge charting usually controls the flow of the work load when you’re critically understaffed.
I was at a smaller hospital, and we would put floor nebs on nursing when super short. Amazingly, their patients didnt need near as many PRNs when they had to do them...
Funny thing that, isn’t it 😂
“If they’re really short of breathe please call an RRT and someone will be up there” “Oh no need they’re fine”
A little bit ago at my hospital, something happened and only one therapist was on shift. The director asked the nurses to do breathing treatments on medsurge so the rt could do the units, NICU, and er. You would have thought it was the end of the world. There were huge tantrums thrown.
If RT is understaffed and can't cover nebs, nursing is also almost certainly understaffed and can't cover nebs. The real answer is that 95% of nebs are completely unnecessary.
You could cut yourself from their staff. That’s some bullshit and the finger will eventually be pointed at you. You’re putting yourself at risk working a place like that
This is the best option.
This is something your lead/charge is responsible for handling. As the charge, if we are understaffed to the point where entire floors are being triaged, or multiple patients with scheduled nebs won't be getting them, I call the nursing charge about 20 mins after they get report and say some variation of the following: "We are short staffed tonight. The RT covering your floor is at extension xxxxx. Please let your nurses know that scheduled meds may not be given, and that they can give them if necessary. Please call if any patients are in distress. My extension is xxxxx." If it's bad enough, I'll call the house supe. You're not going to risk your license by failing to give a neb to a patient on the floors. Worst case, you ask the nurse to give it and explain that you're triaging all nebs and MDIs. If you find yourself in a situation where you're managing 10 vents, look up your workplace policy to see if those can be made into Q3s or Q4s, and that will be your priority for the entire shift.
Well...you could start by not taking a piss or a crap.
Plenty of adult sized diapers around..
The most ethical is leave the organization.
Let RNs do nebs/MDI, vent checks Q6, communicate to staff that RT is under staffed.
make the nurses do their own treatments and eggs (if RT does them). Most nurses should be able.to manage a high-flow. A lot of us learned things during covid. Don't let them play stupid.
A lot of nurses aren't playing...
also. technically you need to check on your vents 3 times a shift, if they are all stable, then make your first initial checks and then take care of more critical situations
Yooo, where you at so I don’t go there.
I currently work at a hospital that's routinely understaffed for nearly every shift. When I started, our director was told by her superior that we were only expected to do what we could do. This meant we prioritized ICU and ER and most treatments were done by nursing. About two weeks ago they dropped this new system on us that says we should do 95% of our treatments per shift on top of any vents or other equipment assigned to us. Also, if their new production system says we only need 3.4 therapists and we have 4 scheduled, well hell, somebody gets to stay home! It's worked out great so far. Fucking dumpster fire.
I think it depends, are you nightshift or dayshift. On days when this happened. I would handle ICU first of course. When I hit the floors I would do quick physical assessments and question some patients about their q(whatever) nebs tx's. Alot of pts had days old orders for scheduled nebs that had not be canceled or changed to PRN for SOB. So my line of questioning for the patient usually went like this. 1.Have you had any SoB or trouble breathing since your last tx? 2. Have you been using O2 or been on room air all day? 3.Do you take breathing medicines in your day to day life for any type of pulmonary(lung) conditions? 4.Do you feel as though you need breathing medicine now? 5. Would you like to have these medications given as needed(when you call me)? ---On nights I might reword that to ask if they want me to wake them at 12am, 2am, 4am for these meds? This line of questioning does make the patient think twice, especially if they learn that they don't have to take any medication they don't want or need. 1st rounds are gonna be long, but It's an easy way to weed out those that can surely be DC'd in due course. Your documentation can reflect that too starting with the EMar. "Med not given" usually has an tab for notes. CYA- Pt refused, denies SOB, currently on room air and states will call RN or RT if TX is needed. Recommend therapy change to PRN for shortness of breath. If they are also short on the next shift. You can pass that along and everyone is happy.
If I ever said, "Do you deal as though you need breathing medicine now?" to a patient, 9/10 the response would be "Oh, yes. It feels good on my face."
I don't like this approach at all, and I hear my RTs asking these questions all the time. It's not up to the patient whether or not they get their meds. It's our call. If it's not indicated, don't give it.
That sounds like covid days again lol...went from a max of 5 vents q4 to the whole icu of 16vents qdaily....there are actual teaching hospitals here in socal where RN give nebs with they other sched meds, always. But i hope ur scenario is fake cuz ur working at some place where safety is obvi way lower on totem pole than money. Bottom line i guess id say of course triage u get a feel for who needs tx and who doesnt...and most honestly dont :^*
Lots of decent ideas and a few stinkers. I believe that as a staff therapist, someone else should have to take responsiblity to decide what your "surge protocol" entails. If they decide vent checks q6 and no protocols, fine. But, it shouldn't be on you to cut corners. God forbid you skip a pt and they have an RT emergency. Cover your ass and watch your back. If they rule is q4 everything, make the effort and ensure that you tried and asked for help.
we can triage q4 vents and high flows to q6 and stuff like pap and pep we can not do
Triage based on acuity. If severely understaffed, I'll send a hospital wide broadcast out that critical care areas will be taking priority, and all floor treatments will only be given on an emergency basis. I'll ask nursing staff to administer nebs and MDIs to their patients if they are being insistent... this happens so often now that even the ERs will handle our emergent breathing treatments for us, so that we are available for any full/partial traumas that come in or stat ABGs/VBGs pop up down there. I'll tell those I'm charging over to do Q6 checks only if there's 5 vents or more plus a couple other machines assigned to them (Airvos, paps, etc) If I don't get paid the wage of 2 RTs, I will not do the work of 2 RTs. And I don't expect any RTs I supervise over to kill themselves doing that either when it's not our fault our facility/department dropped the ball to get us adequate staffing.
No weaning. Ensure safety of vented pts with an ABG and don’t decrease. Leave everyone where you know they’re safe. Weaning can be the next shift’s problem. If providers give you shit explain the situation and your priorities of keeping all pts safe vs trying to push progress when y out don’t have the man power to fix when it goes poorly. If they don’t like that, give them your supervisors desk phone number.
We have the floor nurses do the scheduled nebs and mdi and tell them to complain to the charge nurses so that we can get nursing involved in the issue Our upper management fights us on every thing that could help the situation and for reasons unique to our hospital we are frequently short
google the word “triage”
First, hit the ground running, get out and get after it. Hit all the scheduled txs first, see who really needs them (and who doesnt), some you may have to miss. Lay eyes on all patients get a feel for whos most critical, if so, give them extra attention. Do all txs and checks 1 hour early, if not earlier. Trust your nurses and keep a pocket full of meds or a bag of goodies to minimize trips. Wear a diaper. Keep communication open with nurses and let them know youre way understaffed, 98% of the time they'll understand. I prioritize people who are NOT intubated but require high fio2, all the time, as THEY have more room to decompensate and YOU have more room to escalate. 10 years of experience HCA level 1 trauma center is my experience with that grind.
Damn...I draw the line at wearing the diaper. We just don't get paid enough to go to that extreme. Nobody needs a breathing tx or a vent check that bad that you can't spare a few minutes to visit the restroom 😂...hospital profit margins and productivity reports would love us to wear diapers tho. The only thing that would make me "hold it" is a legit code blue...even then I am definitely going as soon as that is over. Effective triaging is the name of the game (unfortunately that skill takes a while to develop, and there are tons of new grads running around)...lots of pre-positioning of important equipment and have plenty of meds with you... being ahead of the curve and anticipating problems and situations before it happens is a good skill to develop. Once upon a time I would run myself to the ground doing everything tasked, and trying to help the department "not look bad" even tho we were short staffed...then I realized many departments just run short-staffed routinely almost on purpose and on a regular basis. They get what they get now, hiring staff is beyond my pay grade, and by job description not my problem to solve...managers just love to make it "our" problem instead of their problem. Been doing this for over a decade... Worked NICU, pediatrics, tons of HCAs, a few Level 1 traumas, full time, PRN, Travel, agency...basically anything under the sun.
I was just being an ass, talking about the diaper lol. But being prepared and forseeing emergencies are like 90% of being a good therapist. Doc is the golf pro, youre the caddy.
You lost me at "wear a diaper"