Spotlight on Long-Term Acute-Care Nursing

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By Debra Wood, RN, contributor

Bridging the transition from intensive care to home, nurses in long-term acute-care hospitals draw on their critical-care skills while building professional relationships with patients and families.

“I get to do all the things I love about critical care, but I also have follow through,” said Lisa McEwen, RN, director of clinical services at Select Specialty Hospital of Greensburg, Pennsylvania.

Most LTAC patients transfer from an intensive-care unit and are receiving ventilator assistance. Some have large open wounds or other acute problems. They may be on inotropic agents and in need of careful monitoring. LTAC patients, age 18 on up, stay an average of 25 days or longer.

“We see a lot of different diagnoses and patients,” said Natalie Jones, RN, BSN, unit operations manager of the DeKalb Medical Center LTAC unit, Decatur, Georgia. “Sometimes you think your patients are not getting better. It takes quite a bit of time to get them weaned, but you can see results after working with them for so long.”

As part of an interdisciplinary team, LTAC nurses aggressively wean patients off their ventilators and drips. Patients get up, even while on the vent.

“We are the pretty much the last stop as far as trying to get them off the respirator,” said Laura Ray, RN, a nurse at Kindred Hospital - Louisville for the past 10 years. “They have been months in the hospital by the time they get to us. They are frustrated and at the end of their ropes.”

LTAC nurses agree that the most challenging aspect of care is managing multiple, long-term, complex medical conditions, multiple system failures and patient anxiety.

“We may not see a diagnosis again for several months,” Mary Beth Bell, RN, MN, CEN, CCNS, at DeKalb LTAC. “The staff has to really be on their toes.”

The majority of LTAC patients go home or to a rehabilitation or long-term care facility.

“We have a chance to maximize their potential,” said McEwen, who takes great pride in the “miracles” that take place on her unit, such as the patient who arrives in a fetal position and on a vent and, eventually, walks out the door.

“We have patients come back to visit,” Ray said. “Most patients are very appreciative of everything we have done for them, and that’s the biggest reward of all.”

In addition to caring for their patients, LTAC nurses also spend considerable time with family members. Loved ones may feel frustrated by the patient’s perceived lack of progress. They also may have to travel quite a distance to visit their loved ones and be unfamiliar with LTACs.

“We do a lot of being a sounding board for the families, allowing them to ventilate frustrations and being emotionally supportive,” Ray said.

DeKalb community education specialists visit potential patients and family members at the transferring facility to dispel fears and ensure the hospital would be a good match for the patient’s needs. In addition, DeKalb provides a nonclinical patient ambassador to every patient to assist with orientation and follow up on any concerns raised by the patient or family.

LTAC nurse staffing depends on patient acuity, ranging from one-on-one with a patient who had recently coded to five- or six-to-one when caring for relatively stabile ventilator patients.

“It’s hard work, with all the equipment—the wound vacs, the ventilators,” Bell said. “It’s not an easy job, but it is very rewarding.”

Most LTACs hire experienced nurses, primarily in critical care. LTAC nurses work more autonomously than typical in critical care. Unlike in an ICU, the physician is on call, not in the unit.

“Your satisfaction from your job comes from within yourself most of the time,” said Ray explaining that management recognizes accomplishments but nurses do not receive immediate gratification of quickly fixing patients’ problems. “You have to work independently, have a lot of critical thinking skills and be able work in a pressured environment and maintain the control. And I love it.”

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