The Making and Life of a Registered Nurse in the Era of COVID-19: Chapter Thirteen–My Life in a Long-Term Acute Care Hospital

If you are treated with a chronic critical illness, you may need long-term acute care (LTAC) after you leave the hospital. The LTAC facility gives you the specialized care you need when you are too sick to go to a skilled nursing or rehab facility.

What is difference between LTAC and SNF?

Typically a SNF will offer a more residential experience, whereas an LTACH will focus on more rigorous clinical care and observation. In the case of the Goldwater North LTACH renovation, one of our current projects in New York, there are 111 (of 201) patients on ventilators.

What are the 5 levels of medical care?

1.1 Primary care.

1.2 Secondary care.

1.3 Tertiary care.

1.4 Quaternary care.

1.5 Home and community care.

1.6 Ratings.

The previous information was provided by a Google search, and is public domain.

This chapter picks up where the last chapter leaves off. When I left my last job which was at a full hospital Intensive Care Unit, I was experiencing burnout and the early signs of Post-Traumatic Stress Disorder or PTSD. I will discuss my experiences with PTSD in the following chapter.

After I left my last job in early December of 2021, I gave myself a couple of weeks before considering my future career options. I had several initial goals for my new career. I wanted to work in a less stressful environment for one. I decided that I would do my best not to work in an acute hospital ICU again, at least that is till COVID-19 had became endemic and was no longer killing people. I had frankly seen enough death to last two life times.

Second, it was that I hoped I could find a day job, so I could get back to a normal lifestyle and to be able to sleep with my wife again. Right now, my sleep schedule is so erratic that even on my days off, I don’t have a normal sleep pattern and only sleep three to four hours at a time. I also was thinking of a shorter work day. I firmly believe that a 12-hour shift is just too long to work. I think that it was a precedent that should have never been started. I know the reason was to give more continuity of care to the patients with fewer staff changes being made in a patient’s day, but at what cost? I feel after 10 hours, you no longer are at your peak efficiency, and are more prone to make mistakes. I am sure that is why the med passes are smaller at the end of each twelve hour shift to cut down on possible mistakes. However, mistakes can still be made. Also the amount of attention given to the patients tends to taper off as the staff member becomes more fatigued. So is the patient truly getting the best of care with 12-hour shifts? I know that less time is given to shift reports with only two nurses working in a 24-hour period of time. It is also nice to be able to work just three shifts a week. But in actuality most nurses especially the younger ones work more than 3 shifts a week which now puts them way over the typical 40-hour work week. I think that four 10-hour shifts should have been implemented with liberal overlaps. This could have worked because the use of CNA’s could have been virtually eliminated with primary nursing care only. The quality of care would have been improved substantially. Bed baths and intensive levels of care could be scheduled at the time of the overlap which would have been a total of six hours a day. Med passes could be shared so there would be less risks of mistakes. Fewer meds given by one nurse means fewer chances for mistakes, less hours of work means less fatigue. Working four ten- hour shifts still gives the employee three days off. By them getting a 40-hour pay check, there will be less reason for the nurse or other care professional to pick up extra shifts and thereby reducing burnout and stress levels. A shorter work day will give the medical staff more downtime and time for sleep and time to spend with their families and possibly share meals together. I feel that the 12-hour work day is bad for families, in general.

When I started looking for work I considered day surgery clinics, however, the pay for these clinics was far less than the hospitals mainly because I am at the top of the pay scale based on years worked and the level of care I provide in the ICU. The surgery centers have less need for those skill levels so the number of job opportunities were fewer. I also have no training or interest in working in the OR in any facility. I gradually came to the realization that a Long Term Acute Care facility or LTAC was my best option. When I researched that option I was pleasantly surprised. The pay I was offered was quite competitive with my previous salary with a lot less stress. However, I would still be working 12-hours a day and I would be working nights. I was offered a $15,000 sign-on bonus for two years of work. So, that certainly sweetened the pot some. I had also came to the conclusion that I was running out of acceptable options in Las Vegas. It was either an LTAC or move. My wife certainly was against the moving part.

Right after I was hired for the ICU night position, I was offered the position of house supervisor for days. I thought I had won the lottery until I found out that I would also be the charge nurse as well. That certainly put a damper on things. I said I would give it a try if my new boss really needed me at the position more than in the ICU. I worked my first two weeks in the night to get my feet wet. I had done House Supervisor and charge nurse before but only when I knew the facility and had worked there for some time. This was the first time I walked into an unknown facility and took on a managerial position from the start. I was still having my doubts after I finished my first two weeks of rotation. When I worked my first day shift, it was like being hit with a freight train. But I gave it three more shifts. By then I had come to the realization that this is not what I wanted. I had quit my other job because I wanted to have a less stressful work environment. Now I was working under an environment that was even more stressful. No, thank you! I told my boss that I did not want the position and wanted to go back to the original plan. He was a little resistant and unhappy at first, however, the next day he was OK with my decision. I had my letter of resignation already to give him, if it was necessary. So I have made the move back to ICU nights. It is less than optimal but it was the best compromise I could make. My salary was comparable, the work was less stressful and the staff are friendlier, and above all else, I did not have to relocate. Unfortunately, the work schedule is less flexible and I am still working nights and 12-hour shifts. One really big positive is that I am not taking care of COVID patients anymore. Since the acuity is lower and the patient population is more stable, this translates to fewer patient deaths, that is another big win for me. Everything in life is about compromise, I guess, you can’t have everything.

The portion you just read is word for word from my second book. Several months have gone by now and I am more settled in with my new job. However, my health continues to decline. My weight is becoming a problem for me and is definitely affecting my health. The task of getting on my knees or squatting down to empty my patient’s foley bag is becoming an increasingly difficult undertaking for me. It is becoming painful for me to go on walks with my wife as my hips are hurting more because of the increased body weight I am carrying. I am also finding that I am getting short of breath when walking. I informed my boss of these issues I was having and the plan I had for rectifying it. I was quite surprised when he was supportive of the actions I was planning on taking. Unfortunately, I don’t have enough PTO or personal time off to cover the time I need to take off and I am not protected by Family and Medical Leave Act or FMLA because I have not worked at this job for a year. The Act provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires that their group health benefits be maintained during the leave. My boss said that he would definitely keep my job open for me when I came back from my surgery. I had offered to do light duty, but he said that it was not a good idea since my surgery was going to involve a lot of life changes. I have also been able to pick up extra shifts prior to my surgery date, so money is now no longer an issue. I found myself again being pleasantly surprised by their willingness to work with me.

Now that I have that out of the way, I would like to discuss my new job a little more. As I have stated I am working at an LTAC not an acute hospital. We do not have an ER, so we do not take direct admits or walk-ins. We get all of our patients from acute facilities where the length of stay in acute hospitals is usually measured in days, while in the LTAC, it is measured in weeks and months. Many of our patients have been intubated emergently during their stay at the acute care facility. Due to poor overall health, they are usually not able to get extubated in a timely manner. They, therefore, require a tracheostomy to be inserted for breathing and a peg tube to be inserted for long term feedings. These two devices give the patient more time to gain strength and eventually be weaned off of the ventilator. Since the care we provide is no longer acute the cost is less to the patient and insurance. We also provide long term wound care, on site hemodialysis treatments and rehabilitation and strength training. These activities are all geared with the eventual outcome being a discharge to home.

Our facility is smaller, so thusly are our resources. We rely on outside lab services for one. We also don’t have a 24-hour pharmacy on the premises. We do, however, have an overnight medical doctor on premises to provide for emergent care needs such as codes or rapid responses or RRT’s.

Since our facility is smaller, so is our staff. When people call- in sick, we definitely feel the pinch because we just don’t have a large enough staff pool to pull from. Agency staffing can only provide so much help especially if the call-in is a late one. When we are fully-staffed, the work load is not an issue and that especially holds true for the ICU department. The normal workload is far less than what I am used to. This gives me more time to spend with my patients which is a definite plus. While the software we use is a bit primitive, the charting once you get used to it is easier than when compared to my previous hospital. No place is perfect and as always life is a compromise. I am quite happy with the driving distance as I only live four miles from work. Therefore, in a pinch I could ride my mountain bike to work, that is once I get in better shape.

There are a lot of things that we could improve on and progress is achingly slow. We are currently experiencing a major shake up in management, so hopefully some positive changes will be the result. As long as things don’t get worse, I can see myself working out the remaining years of my nursing career at this location. I just wish we had a little more flexibility with our schedules. My wife and I like going on road trips, and four days off is just not enough time to go too far from home.