BEING A CHARGE NURSE

There are three roles for Charge nursing, what are they and what do they do?

RAAPID : Attend RAAPID calls, thaw DHM when LC unavailable/assist bedside staff as needed
Admitting NC/ANC: attend codes/admissions/initiate kardexes & start PNOBs
Scheduling NC/ANC: assignment management of current shift, assignment creation of following shift, communication with both POC manager and PSS regarding staffing needs and changes

What are the sequence of admitting, RAAPID and scheduling ?

Admit
RAAPID
Scheduling

What does a day shift as a NC look like?

Handover
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Listen to taped report
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Staff check in once done report
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If RAAPID DHM
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0900 Huddle in Team Room
(potential admission, whose transferring out)

• Identify admit team roles (Team lead, head of bed, emergency lines, documentation)

• Identify any learning needs or skill acquisition (Intubations, Lines, etc.)

• Update whiteboard behind charge desk post huddle

• Transfer Considerations:

  • If staffing does not allow for an LAT nurse, there is an LAT list in the excel document of staff who can do transfers

  • Check if bedside nurse can take babies on transfers

  • Will need to communicate with FC and other charges to determine best plan

  • Also consider: pod coverage, timing of breaks, 8h vs 12h staff if out of town transfer
    |

Rounds
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1345 – POC Huddle (Scheduling NC/ANC)
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1400 – Flow Huddle (Scheduling NC/ANC)
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Social Rounds – Wednesdays at 1400
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1400-1500 – DHM (If RAAPID)
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1600-1700 – Break check in (any NC/ANC)
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1730-1800 – Staffing (Scheduling NC/ANC)
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1800-1830 (All NCs/ANCs)
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1845 – Check In and Narcotic Count (Admit and RAAPID NC/ANC)

What do we do during rounds as a NC?

1. If you’re RAPID, you do seated rounds in team room

2. Admitting team starts in A pod then B,C,D

3. The 3rd team starts in B pod, then C, D, & A

4. Start handover note for each baby during rounds

5. If bedside nurse is on break, use previous handover note

6. If baby qualifies for transfer - find out prefer sites and ensure conversation is started with family and staffs)

7. Identify if any patients require a CORE review

What do you do right after rounds?

• Update the assignment sheet and FC with disposition timing and preferred site.

• Communicate with the scheduling NC so they are prepared for the 1345h huddle – some NC teams will do a mini huddle after rounds, this can differ from team to team, but info must be communicated either way

What do you do in POC Huddle (Scheduling NC/ANC)?

• How many staff are you working with and how many staff would be ideal

• Staffing numbers for 1500, nights, and following day shift

• Check auxiliary staff coverage (FC, unit clerks, service workers)

• Identified babies eligible for transfer, their preferred site, respiratory support

• Have updated plans for all babies identified at morning handover for transfer regardless of team color

What happens during Flow Huddle (Scheduling NC/ANC)?

It is lead by the flow coordinator

• We present the info for FMC using “Calgary Zone NICU 1400 Capacity Call Report” Sheet kept on flow coordinator’s Sharepoint drive

  • Current census

  • Confirmed discharges/Transfers waiting to leave

  • Confirmed admits/Transfers waiting to arrive

• Anticipated census

• Next day discharges

• Staffing levels: whether we are at/below/above baseline, and whether that is sufficient (baseline is 24 staff whether it is what we need or not)

• The flow coordinator will present the following information

  • Number of potential deliveries in the next 12 hours

What happens during Social Rounds – Wednesdays at 1400?

• Attended by NC, social work, psychology and sometimes spiritual care

• Identify any families on your team who require a consult or are being followed already

• Discuss any concerns you may have regarding visiting, coping, mental status, supports, etc.

What does the DHM/RAAPID NC does?

• Check to see if all DHM slips are in

• Thaw required amount of DHM at A Pod Counter

• Aliquot and put away DHM

• DHM slips get stapled together and place clipped to black file folder by the unit clerk printer (above the assignment sheet)

What do they do for staffing ? - 1730-1800 – Staffing (Scheduling NC/ANC)

• Send SLACK messages for vacation or cancel staff if needed

• Call out for staff via PSS or send SLACK (ideally you will have done this earlier in the day if needed)

• Save assignment sheets to historical folder

• Print out assignment sheets for next shift

What happens during the last hour for NCs? (Day shifts)

• Verify handover notes are completed and signed

• Tape report

  • Ideally <1 min per patient unless acutely ill

  • Admit NC/ANC talks about some of MOB history if relevant for new admits, DO NOT go through all of KARDEX AND handover sheet (will be repetitive)

• 1845 – Check In and Narcotic Count (Admit and RAAPID NC/ANC)

  • Check all staff are present for next shift

  • Narcotic count to be done with 2 people on different shifts, can delegate as needed

What does a night shift look like?

Handover with outgoing charge (1900-1915)
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1915-2015 – listen to taped report
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Admit/RAAPID NC/ANC checks in with staff once done report
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Glucometer/TCB QC’s
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Scheduling NC/ANC makes plan for 2300 if needed and starts on day shift schedule if time permits
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2100 – Sign Out Rounds
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2315 – Print out flowsheet for next day
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2300-0100 – Start handover notes and update kardexes
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0530-0600 – Staffing (Scheduling NC/ANC)
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0600-0630 (All NCs/ANCs)
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0645 – Check In and Narcotic Count (Admit and RAAPID NC)

What does the two charge nurses at night’s responsibilities?

one nurse

• Admit charge would also respond to RAAPID calls and is responsible for updating the kardexes and starting handover notes for two teams.
  
  second nurse

• The other charge nurse would be responsible for their team and scheduling. If the same charge nurses are on several shifts in a row, then they can alternate roles.

Who does the glucometer / TCB QC’s?

Usually transport but charge does them when they are out

What is peculiar about scheduling for night shifts?

• Make sure that if you need call outs for the next day to call scheduling before 2300

• Send SLACKs as needed

What happens when you check narcotics ? and what do you do if medication is expiring?

Check expiry date !!

• Fill out “Floorstock/Narcotic Medication Order Form” and request replacement for any drug expiring in the next 72 hours

• Clip all previous shifts Narcotic sheets and order forms together to the narcotic cupboard for pharmacy to pick up in the morning

• Ensure the “manager/delegate signature” filled out on each page at the bottom

What should you keep in mind when creating assignments ?

1. Be aware of staff restrictions

2. Double up assignment (stable vent, babies >29 weeks in critical window but are stable)

3. Babies on isolation paired up with RA

4. Consider what the whole unit looks like and how heavy pods may be (especially A pod) before moving babies to level 2

5. Don’t forget primary list and Previous shift/day assignments for continuity of care

6. Learning/Orientation Needs…(eg side by sides, check orientation calendar and update it too)

What about Sick/PL/Cancellation Calls <72 hours?

1. Note their names, date and how many shifts they are taking off

2. Transfer the call back to the absence line (4-3062)

3. Call PSS and notify them of absence and indicate if replacement is needed (ST vs OT)

4. Personal leaves:

   • If you receive a PL request during regular business hours, all PL requests get directed to the POC manager for approval

   • If a PL is requested to charge (after business hours 07-17) and you have adequate staffing - grant it and proceed to OT as needed

     • If staffing is short, you can request the individual to call at 0530/1730 prior to the shift for approval or denial of PL – this gives you time to find replacement (at OT if needed)

   • PL’s can be denied by charge if we are proceeding to mandating and we deem staffing levels unsafe

What about if we are over staffed?

1. Check short notice vacation calendar in the excel document

2. Can send SLACK message at 0530/1730 to offer vacation

   • Offering vacation for day shift: 07-1500 portion is granted right away, staff need to call back at 1300-1330h to have the 15-1900 portion of the vacation granted or denied

   • Offering vacation for night shift: 19-2300 portion of the vacation is granted right away, staff need to call back at 21-2130 to have the 23-07 portion of the vacation granted or denied

3. Try to have staff cancelled by 0545/1745

4. When cancelling OT: part-time OT is cancelled before full-time OT (regardless of order of booking).

5. 
   

What are some important shift coding?

• Add “AHN” next to any NC or TRN

• Add “Charge” next to ANC

• Shift cancellation:

  • CANE = cancelled by employee

  • CANU = cancelled by the unit

• Personal leave:

  • PL indicated for the first 8h (07-1515 or 19-0315)

  • For the remainder of the shift determine with the staff what they would like to use ex: stat bank, float bank. Staff need to use banked hours and cannot be marked as unpaid LOA.

• Absence line:

  • All absence calls should be sent back to the absence line. The extension is 4-3062 and is also on the master phone list at the charge desk with the managers phone numbers

• Vacation:

  • indicate “VAC” and if they received vacation for the entire shift or just a partial day

• Out of town transfers:

  • Ambulance pay—Nurses will input this into WFM themselves

• Staff with a student

  • Preceptor pay—Nurses will input this into WFM themselves

• Extensions

  • Please write the shift extension time (ex: [phone]) and whether it is at ST or OT

What would you go over in Handover?

1. Staffing
   - Unit census
   - Number of nurses on shift
   - Number of charge nurses and number of transport nurses on for the shift
   - Review absences for the shift
   - Review measures to get staff if short
   - If offered vacation/cancelled: order of vacation granted and if the casual staff wanted to be called back
   - Auxiliary/Support staff coverage for the day

2. Shift Highlights
   - “Hotspots” on the unit (critical assignments, areas of focus for educators and charge to check in on)
   - Admits during your shift (where and what they are, if any debriefs were needed)
   - Transfers out during your shift
   - Current admit spots and potential admits

3. Upcoming shifts
   - Number of bedside nurses scheduled – 07 & 1500 for days, 19 & 2300 for nights
   - Vacation requests on short notice calendar

4. If handing over to a new team make sure to mention

   • Any pertinent new admissions (microprems, acutely ill babies, etc.)

   • Any acute changes to previously admitted babies (work ups, re-intubations, etc.)

   • Relevant social situations

Transfers

• Review which patients will be eligible for transfer the next day

• Night shift NC: review status of all patients that are marked “Ready” and “Almost Ready” for transfer prior to giving handover and let the flow coordinator know if any status changes occurred that would prevent the transfer from occurring
  
  

What are some things managers must know?

• Deaths

• Adverse Events (see below)

• Concerned or inappropriate families

• Staff to staff conflict

• Changes to staff schedules

• No show staff (1^st call NCs then hand off to POC manager)

• Breaches of AHS code of conduct

• Staff injury/Staff leaving during shift

• PL denial

• No need to report: short notice cancellations, bereavement, PLs, sick time

What are the NC roles in code blue?

• Primary role of the charge nurse in code blue deliveries is documentation

  • Review resus record

  • Some code blue deliveries will require code reconciliation in connect care. Use the CC tip sheets to see what the requirements are

• The secondary role of the charge nurse in code blue deliveries is preparation of epinephrine, fluids boluses and acquiring supplies from the crash cart for the team as required

  • Ensure that you are aware of the dosages of epinephrine and how to quickly draw them up in a code situation. 

  • Try to familiarize yourself with the contents and location of contents (see Appendix C) within the crash cart. The binder on top of each crash cart has lists of items broken down by each drawer. If a crash cart needs to be restocked, this is a good opportunity to look through the cart to familiarize yourself with it. 

• Try to attend all admissions on the unit, ensure there is someone for each role (RN1, RN2, etc)

• Ensure admit time out is completed by a medical team member

• Admitting NC/ANC is responsible for initiating the Kardex and entering the history portion. 

• Notify medical team, RTs, other clinicians and transport nurses ASAP if setting up for a code blue delivery (Refer to the process sheet located in the Nurse Clinician Drive: 4- Clinician resources à Clinician Resources à Paging and Communication or refer to cheat sheet on charge desk computer)

• Plan a pre-brief to review roles and plan of care with MDT if able

  • This is especially important for complex deliveries or anticipated complications 

• Not all Neos will carry a code pager on them during their admit day, this is good to check with them if you are anticipating a code blue 

• Remember to return the portable monitor to either D pod or L&D once the baby is settled on the unit, make sure spO2 and ECG cables remain on monitor

What does case room set up look like?

• All infants less than 32 weeks require caseroom setup and code blue at delivery

• Congenital Diaphragmatic Hernia

• Gastroschisis/ Omphalocele

• Myelomeningocele

• Hydrops

• Off unit deliveries

• Complex genetic conditions/congenital abnormalities 

Deliveries/Admissions the Neonatologist is expected to attend:

• Admissions <26 weeks

• Congenital Diaphragmatic Hernia 

• Gastroschisis/Myelomeningocele

• Suspected or confirmed pulmonary hypoplasia

• Complex congenital heart disease

• Conditions where significant difficulties are anticipated at delivery (hydrops)

Policies with information related on who should attend and what equipment is required at delivery:

• Congenital Diaphragmatic Hernia 2-C-11

• Esophageal Atresia/Tracheoesophageal Fistula Management 2-T-7

• Gastroschisis Management 2-G-3

• Hydrops Management 2-H-7

What does the Caseroom Setup look like?

• Stethoscope

• Thermometer

• Golden Hour Timer

• Leads, SpO2 probe, posey

• Neohelp bag

• Diaper

• Measuring tape

• 6 and 8 Fr Suction Catheters 

• Monitor (D pod or from U51 crash cart) 

• Bar on side of bed***

What is the admitting NC role?

Admitting NC Role:

• 0900 Huddle

• Tour of L+D and review of crash cart/elevator key locations

  • Tour of unit 52 nursery location

  • Tour of ED 

• Review portable monitor locations

• Review resus record and documentation expectations

• Review code medications and familiarize yourself with crash cart contents 

• Microprem caseroom setup (Ideally you will get an opportunity to do this, if not review or practice with your NC buddy)

• Attend a code blue delivery (Ideally you will get an opportunity to attend a code blue delivery, however you can review the steps with your NC buddy or ask the RTs to bring you to some code greens to get familiar with L&D)

• Review code reconciliation in connect care 

• Review emergency algorithms ex: emergency airway activation, mass hemorrhage protocol, etc.