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TColeman
Information on IV/PICC teams, please.

I'd like to pose a couple questions to the group, but, would be particularly interested in answers from the baltimore/washington area.  Any help would be appreciated.  We are having an increasingly hard time keeping up with the PICC/midline requests in our hospital.  We are a 2 fte team servicing a 500 bed hospital and a 200 bed nursing home(approx).  I have been asked by my director to see if i can gather information about what the other PICC teams (esp in our area) are doing.  We do not have an IV team and it seems that the calls are increasing for simple IV access.  The increase has also been seen in PICC placements because our interns no are required to place central lines, so we are seeing an increase in STAT or emergent PICC requests.  Is anyone else seeing this trend?  Again any input would be greatly appreciated.

 

1.  Do you have an IV team, and/or PICC team?  If so how many are on the team and what size hospital do you service.

 

2.  Do you routinely place PICC lines in an emergent or STAT situation. 

 

 

 

 

Janet Ahearn
I work in Western New
I work in Western New York.  We have an IV/PICC Team comprised of 14 RNs We staff 24/7. We have part time and full time..not sure what our total fte is. We start all IVs except ICU and insert all PICCS(about 60-70/month) I believe we have approx 400-500 beds. Though we used to say PICCS aren't stat, we are being called in sooner to replace CVP lines due to increased risk of infection. If we are unsuccessful with the PICC, we send them to IR. We also change PICC dsgs, declot them, access all mediports. We're busy!
cathie
our hospital utilizes 2 FT

our hospital utilizes 2 FT IV Specialists...we average 60-70/month...I discussed these numbers (which go higher each week)with our critical care MD ...his response was that the legal side has changed...if he has a failed or complicated CVC insertion and has complications, the legal community will question why a triple lumen was placed while there is a safer alternative(Piccs)..as far as stat consults....we respond that we do not provide stat services...that has been the mantra for8-9years only the new docs try that!

cathie 

 

 

swensonals
I work in Illinois, in a
I work in Illinois, in a suburb of Chicago. The hospital is approx. 450 beds. The Vascular Access Team (as we are now called, previously IV Therapy) has 22 RN's, fulltime, parttime, and resource.  We cover seven days a week, 24 hours a day from Sunday to Thursday, from 5am to 1130 pm on Fridays and Saturdays.  We are a "combination" team, doing IV's (supposed to be difficult starts only, but for some, all starts are difficult),insert PICC's, assisting MD's with CVC insertions,do  blood draws from all CVC and PICC lines, dressing changes on PICCs and CVCs, accessing ports, teaching patients about their lines, declotting lines, resources for the staff nurses on any IV related issue.  I think that's it, but there's probably more!  We are also very busy, placing about 110-120 PICCs per month(in addition to everythiing else).  We do on occasion do "stat" PICCs, especially if the patient is venously limited and their condition is rapidly getting worse (as in some ER patients and ICU patients on vesicant drips).  We do not have residents or interns, but have intensivists in ICU, some who are better than others in placing CVCs.  Depending on who is on, we get more or less PICC business. From the sounds of what you've described, you need some additional help!  Good luck--I hope you can get it.
kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Each RN can place 4 PICC lines in an eight hour day. 800-1,000 per year for an FTE

How many do you place? 

What is emergent because patients oiut of veins is emergent?  Patients out of access is emergent

 

kathy

Kathy Kokotis

Bard Access Systems

Gwen Irwin
Kathy, What are your

Kathy,

What are your refernces for a nurse placing 4 PICC lines in an eight hour day?  I know that ther are time and motion studies for an IV start neding 30 min. each IV.  But what is the reference for the number of PICCs in an 8 hour day?

 Thanks so much!

Gwen

Sharon Davis
I work in St. Louis, MO. Our
I work in St. Louis, MO. Our team is currently in transition. We recently went from a 24h/7 day a week service, doing IV's and PICC's to now our service will only be doing PICC lines (along with other services, declot's etc.)  from 7am to 9pm 7 days a week.  We are an approximately 900+ bed hospital and we do 320-335 piccs per month. We have I believe 14 or 15 people on the team. ( not sure of the exact number of FTE's, but most of the staff is full time). We do not place PICC's on a stat basis, but we do try to prioritize them.  Hope this helps and good luck. 

Sharon Davis Smith,

TColeman
Kathy, On an average, I can

Kathy,

On an average, I can place 5 PICC's a day.  The most I have placed in one day is 7.  Very tough day. 

 

Let me give you an example of a STAT PICC that I've been asked for lately.  Trauma pt comes in around 2A.M.  There is an order at 7A.M for a STAT PICC prior to surgery.  Has a 22g that is very shaky, no attempt at central line placement by MD.  Another pt in CCU, cardiomyopathy in a 19y/o who is pregnant.   Pt sat all weekend until we came in and then there is an order for a STAT PICC.  Now both of these situations are typical of what we've been seeing lately because there are very few docs that can place a central line.  With only 2 FTE's M-F, we have to prioritize.  If we place the STAT PICC, we get reamed by Case Management.  If we place the discharge, we get reamed by the units.  I am trying to gather info to present at a meeting to convince the "powers that be" to increase our staff, to think about starting up an IV team, and/or to think about a line team for traumas.  etc.  Any or all of the above. 

Thanks for all the responses!

TColeman

Sinai Hospital

Baltimore Md

T. Coleman

Sinai Hospital

Baltimore, Md.

JoseDelp
We are a combination IV/PICC

We are a combination IV/PICC team. We experience some of the same issues with physicians and STAT PICCs. We have 7.9FTEs for 254 inpatient beds. (two hospitals).WE cover 7 days a week 16h per day. PICCs are not placed as  STATs. We work with physicians to place as soon as possible but prioritize the referrals we get by the clinical condition of the patient and whether they currently have access to treat. Pending discharges get prioroty if the clinical condition of the other patients are stable and treatable. Case management pressures me to try and bring in extra staff to meet their needs at the last minute and are beginning to learn we don't have a flexible staffing matrix. We promise them to do the best we can. Our early screening criteria will sometimes have us ahead of the referrals and anticipating the need prior to case manamgement " bugging us" 

Jose Delp RN BSN

Clinical coordinator IV Team

Upper Chesapeake Health

Jose Delp RN BSN

CliClinical Nurse Manager IV Team

Upper Chesapeake Health

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

You will all see more stat PICC lines than ever before.  RN's use US and many MD's do not.  Acute care central lines are a temporary line.  Patients need IV therapy.  Malpractice is increasing on central line MD placements.  MD's get $118 to drop an Arrow TL catheter.  Patients have no veins.  Drugs are bad.  Stat PICC's are needed and will grow.

I believe PICC teams will become 24/7 in the future.

Kathy Kokotis

Bard Access Systems

Julie Mijatovich
We are a 500 plus Trauma

We are a 500 plus Trauma Level 2 center that already is 24/7.  We place 250 PICCs plus a month with 3 PICC/IV Nurses on days and evenings.  1 On night shift.  1 on 1300-2130.  We can't keep up either.

Our Hospital/Health System covers 6 facilities and we do travel also.

Management wants us to shy away from peripheral IV's, but staff and patients don't.

Management wins.  With the numbers of PICCs we place, there is nothing else we can do.

We place 250 PICC's and 1700-2100 starts every month.

Julie

Parkview Health IV Therapy, Fort Wayne, In

service
Precision Access's responce

Precision Access's responce time is guaranteed within 6 hours, unless the patient is on TPN it is 2 hours or less!  I know they frown on stat orders, but those nurses are always close by it seems, they usually arrive within an hour after I call them!

 Check them out their nationwide too: www.precisionaccess.org

Pat RN 

4E Oncology Floor

Ingalls Hospital

Harvey, IL 

ADAVIS
I am looking for information
I am looking for information on starting a PICC team. Any information will be useful
Leigh Ann Bowegeddes
I work at a 404-bed level I

I work at a 404-bed level I Trauma center in Kentucky. We are a Vascular Access Specialty Team, which is different from when we just had a PICC (PICC, Stick and Run) Team. There are four full-time RNs and one per diem (me) who works at least 36 hours/month. We cover 7 days a week, 12 hours a day, currently with 2 people most Mondays through Fridays. Every other week we teach an IV class for incoming nursing orientees, and we staff with three that day. We cover with one person Saturday and Sunday. We do all inpatient PICCs that can be advanced to SVC. For those that need fluroscopy, we send to I.R., which is relatively few. We do the difficult PIV insertions when no one on the floor can get them, though we do have some nurses in house using U/S for this. We consult on patients to help determine type of access needed, and we troubleshoot all vascular access. We do education for nurses and physicians. My teammates recently did a Grand Rounds for physicians on appropriate vascular access selection.

We triage our own referrals, and determine which should be prioritized, but we do NOT do stat PICCs.

fizerjk
We currently have seperate
We currently have seperate IV and PICC teams. There are 10 members on our PICC team for both the Adult and Pediatric Hospitals. We provide 7 day a week coverage 7a-7p, for the Adult hospital and M-F for the Children's. We provide placement of PICC's, Midline catheters, IJ small bore central catheters. A new service we started providing is the placement of femoral pheresis catheters for stem cell collection. 

Jeffery Fizer RN, BSN

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

You are 500 beds which equates to a minimum of 2,500-3,000 PICC lines per year

You need one RN to do 800 PICC lines per year based on time and motion

A PICC line equals 2 hours and a PIV = 20 minutes

do a time and motion anaysis to evaluate your labor needs for a week and see where you stand

Kathy

Kathy Kokotis

Bard Access Systems

momdogz
We have a 25 member IV

We have a 25 member IV Department (in the process of changing to Vascular Access Department).  10-12 of us place PICCs between 7am-5:30pm 7 days/week, and off hours if emergent.  If we could staff up with PICC RNs, we could place PICCs from 7am-9pm 7 days/week.  We're a 500 bed teaching facility.

We do place them emergently.  I agree with Kathy; used to be we classified PICCs as non-emergent and would tell MDs that, but it is clear that there are plenty of instances where a PICC line is the best choice for vascular access.  We no longer refuse PICCs because they're needed emergently - we triage all of them and make decisions based on a thorough evaluation on a case:cased basis.

Great thing about a PICC team placing central lines - they have loads of experience/continuity.  The residents in a teaching facility don't. 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

momdogz
I think my previous post

I think my previous post wasn't very clear.  It's not that we have 10-12 placing PICCs every day - we have anywhere from 2-4 PICC RNs on the day shift, and 2 on the first part of eves.  

The rest of the IV Department each day is doing PIV cannulation on most inpt units, dressing changes, consults, etc. etc. 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Karen Day
Karen Day's picture
this thread is very

this thread is very interesting to read as we have many of the same problems in our facility.  I agree that "Stats" have to be looked at in a professional manner - although we do see many stats ordered on patients that have waited 24 - 48 hours for the PICC team to arrive on Monday simply because no one could get a PIV in,  we do see an urgent need for some of the piccs ordered as stats (no venous access, multiple non-compatible drips etc.).  Our anestesia department used to be called upon for the difficult PIV starts, while they are still called upon, they always defer to the picc team.  It can get frustrating because we are only a 2 person team placing approximately 115 lines per month - fitting in with Kathy's data of 1FTE for every 800 - 1000 piccs annually, but we get called so frequently to do a PIV that is getting harder and harder to keep up with things.  Leigh-Anne, would you be willing to share the information(powerpoint or whatever you used to present to the staff) you used for your grand rounds for all to review and possibly do the same in our facilities.  Thanks so much

 

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Words of advice and I know you will all hate me and I will get hate mail.  Look to the future and investigate adding technicians to do PIV's.  Reserach the Minn. model.  There are multiple facilities doing this.  The team maintains control and frees up time for higher technical based procedures. This is what the future will look.  This will happen with or without our support as the model is working in Minn. 

 

Kathy Kokotis

Bard Access Systems

joelbcruz
I used to belong at a

I used to belong at a pediatric hospital as IV/CVL/PICC team member. Our team composed of 8 nurses and 2 advanced nursing assistants.  Our facility is only a 150 bed hospital. Placing a PICC is not an emergency but if the patient is going home on abx, we'll place these lines with urgency and importance.  Im in the Norfolk/Va Beach area. Our staff has been dropped to 4 FTEs due to some transferring and some got let go.  I strongly believe that your facility needs to have more staff.  Our assistants due all IV needs of the hospital while we're tied up placing PICCs.  PICC has been increasing in need versus percutaneous lines. Are you looking for more FTEs and if so could you let me know the starting salary for I'm available for hire.

Jim
Joel, I've got a question

Joel,

I've got a question for you... please contact me through PM & give me your e-mail address if you're still interested in a Vascular Access postion in Hampton Roads.

Thanks

jimcarry
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Dianne Sim RN VA-BC
Our data base (monitoring

Our data base (monitoring several indicators, on 5,000 PICC insertions performed by several well educated, experienced vascular access consultants working for my company) shows it takes 1.8 hours to place a successful PICC, 2.1 hours to attempt to place an unsuccessful PICC, so Kathy K's quote of 4 PICCs in an 8 hour shift is correct.

Dianne Sim RN, VA-BC, CEO; IV Assist, Inc.

Dianne Sim RN VA-BC
I believe the standard has

I believe the standard has been set ! In an honest attempt to decrease complications such as infection, pneumothorax, etc, it is our responsibility to ensure that PICC placement by a dedicated, expert vascular access consultant, using at least ultrasound and TLS, is available 24/7 to place the best vascular access device for your patient.

Dianne Sim RN

CEO & President,

IV Assist, Inc

Dianne Sim RN, VA-BC, CEO; IV Assist, Inc.

jordanhosp.IVT
I work with a another IV
I work with a another IV nurse as our "IV Team"..we not only place the PICCs without ultrsound(not in the budget)...but are also responsible for all the central lines in the hospital.On top of that, we run a outpatient infusion center...we are only available from 8am-4:30 pm.and many of the RNs on the floors don't know a picc from a vad...Is this the norm..?
Julianne Jabon
We have a 4 nurse PICC team,

We have a 4 nurse PICC team, and we work 9-5:30 m-f and 7a-7p on Sat & Sun.  We rotate a 7 on - 7 off work week.  We service a 230 bed hospital in South GA.  We do ultrasound guided PICC placements, and also do ultrasound PIV placements as we can.

As long as it takes to place a PICC, there is really no such thing as an emergency PICC placement, and besides if the patient is that bad, the peripheral circulation will be shutting down and almost impossible to place anyway.  The physicians will place a central line in the IJ, and we will replace it at 7 days if the patient is still with us.  We do not place PICCs in the ED, OR, PACU, but usually do everywhere else.

jenny01
Nice Blog

I recently came across your blog and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

Gerald L Naftalin, DDS

Lawrence Rojas
Any new changes/positions/situations?

I am the daily PICC team at my 150 bed hospital. I work M-F 0700-1530. I cover call 3-4 nights a week, and have one PRN that covers call opposite me. I have another PRN that will cover my daily duties as well as call as needed.  PICCs are not my/our only responsibility, our actual title is Radiology Nurse: IVs in department, Stress tests, consicious sedation, legal film copies, EVLTs (luckily, I guess, those have tapered off to almost none), etc.  And like most here, as well as PICCs, we do PIV starts too. It can get busy. Oh we will put PICCs in the ER, if the patient is going to be admitted but still needs a CT with contrast or the ED nurses couldn't get access.

The three of us just put in our 405th PICC for the year (and still have a few weeks for more)! more than any previous year. I put 300 in myself, whew sounds like a lot when I say it. an easy day is no PICCs, but the most I've put in is 6 or 7 in a day.... THAT was a BUSY day!! I read someone's post that it takes 2hrs for a PICC.... wow! I must be motoring, a non-complicated one takes me an hour with paperwork and CXR.

So any previous posts have updates?

Lawrence Rojas RN

Radiology Dept.

Garden Park Medical Center

Gulfport, MS

coffeemania
1. Our hospital has 240 beds

1. Our hospital has 240 beds including maternity floor.

Average daily census: 150.

PICC insertion per year: 1100.

Difficult PIV's per year: 2500.

Daily PICC nurse: 1, Mon-Sat

Coverage time: 12 hours/day

Sunday: On-call, 12 hours.

Team: 2 FTE's, 2 Perdiem.

2. "STAT" PICC's do exist. So we do STAT PICC's. Because the budget does not allow us to have 24/7 coverage, we have to do STAT PICC that come in over night first thing in AM. Patients do suffer if we dont do STAT PICC. I have a friend who is a PICC RN. He used to argue against STAT PICC. For him, "there is not a such thing called STAT PICC" and "the only STAT PICC is the one that shove up your ***" (his exact words!!!) One day, his mother had a severe abdominal pain with fever and vomiting and brought to a local hospital. Staffs at that hospital, including RN's, ER MD's, anesthesiologist... tried many many times to get an IV access or central line. They were unsuccessful. So they ordered STAT PICC. There was no PICC RN at night. They couldn't do a CT with contrast. So all night long she suffered. The next day the PICC nurse came in and managed to put in a PICC. But it had been more than 12 hours pass and she went into septic shock. With the PICC inserted, things started moving along for her but it took almost 3 months later she could finally come home. Needless to say, my friend got a new respect for STAT PICC. I still mocked him sometimes that "the only STAT PICC is the one for your mother".

 

 

delixson
Looking for JoelBCruz

Hi Joel,

If you are still interested in a vascular access position in the Hampton Roads area, please contact me via PM. Thanks.

Debbie Elixson, RN, CRNI

Dan Juckette
When your PICC service is

When your PICC service is good enough that none of your physicians have placed a short term CVC in 3 months or more, in order to meet the standard of care that you have established, you should provide a Stat PICC when needed. Whether your management or your team recognizes it, you are the central line Providers. I think regulators might have an issue with saying " we provide this standard of care, except after hours and on weekends." If you are an acute care facility with an ER, you need to be able to provide a central line when it's needed.

Daniel Juckette RN, CCRN, VA-BC

lynncrni
Well said Daniel. I totally

Well said Daniel. I totally agree. We must structure our services around patient needs not anything else. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

kmills
IV/PICC Team

We had a full service IV Team until August of 2010. We now have a "PICC" team that works 8-530 Monday thru Friday. The Interventional Radiology team can place them in off hours if absolutely necessary. We average 80 PICC's per month (by our PICC Team) in our 250 bed facility. It is unfortunate to have lost a full service team as their stats were phenomenol. We had only 1 questionable CLBSI in over 15 years in lines placed by the team - but even that was not enough to save them. I am happy that we have been allowed to at least have the PICC team survive.

davica
York County

 I am a nurse on an IV team in York county, PA. We have a 550 bed hospital and an IV team of about 20 nurses. We do most of the IV's in the hospital and provide backup to the areas that do their own. We assess most Iv's in the hospital once daily and provide some preventative care/maintenance to the sites as well as change the outdated or 'bad' iv's. Although having an IV team is a good thing, it creates a dependence. There are nurses who call to have the IV 'retaped' or check the pump, or other issues ANY RN should be able to manage. Yes we also get calls to areas for simple access for reasons other than failed attempts. 

During the day we have 4 nurses who assess and change IV sites, PICC dressings, ports, etc. Floor nurses care for their own CVC's. On average each section of the hospital has about 30-60 sites to assess in the am and about 30ish on evening shift. We have a picc nurse (all RN's on the team are able) who does the insertions, we rotate the assignments. If we are unable, then we send them to IR

Their is no such thing a s a stat PICC! That is a dump! Piccs are not stat and we have had to explain this to residents who do not want to place needed CVC's because of reasons other than medically contraindicated. Most residents don't know that a PICC IS a central line. We do not do Midlines at all, but will pull a PICC back to axillary if unable to advance(but not very often) Luckily we have a medical director who has not only changed the Picc criteria, but has informed med residents of the need for CVC's in 'emergent' situations. 

Our hospital changed PICC criteria last year and reduced our numbers dramatically. People were getting PICCs for reasons other than needing them--nurses like to have them, patients who ask for them. Now, they have to be getting ABX for at least a week, TPN > 5days, not had Blood cultures drawn or they need to be Negative for 48 hours. GFR needs to be >30 or they get a tunnelled cather.  No more blood draws from PICCs and a few more things.  We went from about 150-170 PICCs placed a month to about 60-80. More CVC's are placed, all in all it has improved a few issues, but has also created some as well --just like anything!

Good luck!

Cheryl

txrnmarie
For Cheryl:

R you in a pediatric hospital? How many PIV's do you place on average? I am curious as to the rational for not drawing blood from a PICC line.

Thanks

 

Marie

lynncrni
The rationale for reducing

The rationale for reducing the use of any CVAD including PICCs for blood sampling is to reduce manipulation and reduce the risk of CRBSI. All manipulations increases the risk of contamination. See the Infusion Nursing SOP #18 Infection Prevention, Practice Criteria E. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

[email protected]
Cheryl,  It sounds like you

Cheryl, 

It sounds like you have a busy program. Explain to us the rationale for not allowing blood draws through the PICCs. Have you seen a reduction in CLABSI ? I have heard similar discussion from other sources pertaining to this. Are you allowed to draw from CVC's ? Thanks in advance. 

Dave

David Bruce RN

michael2010
picc team info

we are a two fte person team in a 190 bed hospital

we place an average of 85 piccs monthly in house and another 10 OP

We also average 60 troubleshoots per month

michael2010
sorry i forgot   we are

sorry i forgot   we are geting an increase in requests from the ER but have been resisting those. 

garavano
PICC teams

We have an IV team that places over 1500 PICCs/year.  We have an OR team that places >250 PICCs/year.  We also have an out patient PICC program but I am unsure of those numbers.  We established the formal OR team Jan of 2010. (There are three of us).  We have policies in place for the docs to "book" PICC lines as an add on if that is all they need.  (we are a pediatric hospital). If a child will not tolerate bedside PICC or does not meet sedation requirements then they come to the OR.  (Personally I would like to see more placed in the OR or a procedure room rather than bedside.)  The most lines I have done in one day was 5. Our IR department only place the most difficult lines.  In addition we do all of the dressing changes, start the IV's in the pre-op area if warrented and occasionally we will help the IV team with PICC lines if they are short staffed.  Once a month the IV team, OR team, various directors meet as a task force to discuss issues etc.  The program has been well received and with recognition of services more popular. (It is alot easier to place a line in a child who is asleep...)

txrnmarie
IV Teams

I work in a pediatric hospital, level 1, licensed for 559 beds.  Our access Team is divided into a PICC Team and an IV Team. OUr PICC team consist of approx 8 nurses, and cover 7 days a week 7a - 7p. Some of the  responsibilities include PICC placement, care and maintenance of all in house PICC's, including daily rounds on all PICC dressings, occlusion management, PICC d/c and family education. Our IV Team consist of 13, full and part time, and cover 7 days a week, 24 hours a day. We esatblish PIV's hospital wide, including ER, ICU's and clinics. We follow and track infiltrates, PIV assessments as requested, Central line repairs, and difficult lab draws. A typical month for PIV  (January, for ex) was 1450 successful PIV's. We also track our success rates, and I am proud to say we have an average success rate as a team >90%. I also would like to mention that we follow the INS guidelines, and if we attempt a PIV and are unsuccessful x2, we ask for another IV team member assist. We do not attempt more than twice, per person.

cealdo
cross campus vascualr access team

We are standardizing 2 vascular access teams to provide coverage at 3 separate facilities (740 beds, 400 bed and 150 beds) and am looking for some information from similiar programs.  Would love to hear from you and get some info on staffing plans,  duties etc..thanks!

Cheryl E. Aldo, RN, BS VA-BC

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