Patient ratios progressive care units

[kaylasmommy]

I work on a progressive care unit which had a pt:RN ratio of 3:1 when I started 3 years ago and now we are moving to 4:1 ratios now. The facility/mgmt has stated that 4:1 is the national standard for progressive care units now.

They have decided to off-set this increase in patient loads by increasing the number of CNAs on the floor. So now each CNA also only has 4 patients.

The problem I am seeing is that the nurses are way over worked, stressed out, skipping lunch etc. while the CNAs walk around complaining about how bored they are.

On our unit all patients are on cardiac monitoring, (which we monitor ourselves, no tech, and alarms hooked to a pager) we do some titratable gtts (cardizem, nitro, heparin and insulin). We have some respiratory patients including chronic and/or stable ventilators, rescue bipap, and hi flow 02. We also have pre and post cardiac catheterization pts, and also post open heart (usually day 2) when they still have external pacer wires, chest tubes, insulin gtts, etc. Needless to say, the assignments are busy and adding an extra patient seems unmanageable.

The union was of very little assistance with this transition. It seems to me that patient safety and satisfaction are at risk here. I'm just wondering what others find in similar units.

[Vespertinas]

Just read our actual policy which states that max RN:pt ratio for any IMC patient is 1:3. So if you even have one IMC patient, you can only have 2 more patients whether they are IMC status or floor.

[KbmRN, ADN]

On days we have 4-5 and the acuity is very similar to the OP's. On nights we have 6 max which can get hectic at times. Our CNA's on days and nights are a joke. They go missing for hours and no one hold them accountable. Mgmt knows.

[Nurse Kyles, BSN, RN]

I work on a split cardiology/PCU unit with 15 beds of each. Our PCU has open heart patients as soon as 1st day post op. Drips like cardizem, amio, nitro, dopamine, integrilin, angiomax. We run Lots of heparin gtts and a moderate amount of insulin gtts, but those gtts can be ran on the cardiology floor too. We have heart cath patients & pull (way too many) sheaths. We have a criteria policy we follow for PCU. Certain gtts are not allowed & invasive ventilation isn't either. Acuity varies from day to day.

We have a strict 3:1 ratio in PCU on all shifts. If an RN even has 1 PCU patient they can not have more than 2 other floor patients. The cardiology ratios are 4-5:1 on days & PMs & up to 6:1 on NOC shift.

After reading all the PCU ratios you guys are saying, I am feeling much more grateful! 3:1 is good! Sometimes we like to whine since the competing hospital in my city has a max of 2:1 in intermediate care. Oh & they don't have to pull sheaths in their IC either.

[JRDeeRN]

we are 3:1 dealing with vascular, heart, lung and endocrine (thyroidectomy) patients. as well as overflow ER patients... i honestly dont see how I could manage a 4:1 ratio with the work list i have with my patients. i was running around all day it seemed like today. barely enough time to eat lunch much less making sure every patient felt like they received the care they needed. luckily my unit is a very team oriented unit so that helps.

[tiffanyleigh0212]

I work on a step down unit. Our floor has 42 pts with a ratio of 1:4 or 1:5. We are the only floor besides the icus that can take a vent pt. If we have a vent pt it's an automatic 1:4 ratio. We also take pts on aquadex, it is also a 1:4 ratio. Then you have all your standard cardiac stuff. Heart caths, ablations, cabgs, stemis, nstemis, chf, drips, bipaps, trachs, chest tubes, etc. Our charge nurse takes 2 pts, so theyre not always able to help either. We have 1 cna for the entire floor and monitor our own teles. We're extremely understaffed and are required 3 12's one week and then 4 12's the next week, then back to 3. In the past month we have had a total of 8 nurses leave between day shift and night shift. I'm just about at my point of looking for a new job as well.

I'm curious to know how the pay is set in other hospitals. Do all of your rns make relatively the same base pay, or does it differ depending on acuity of pts? Ours is standard, so while were coding pts, other nurses are on other floors literally watching movies and making the same amount of money.

[Proverbs 16:3]

I work in a PCU in one teaching hospital and the ratio is 5-6, mostly 6. A lot of times, dayshift come in to 1:6 ratio. They've been trying to make it 5 at all times but it's not been working. It's so stressful, can't even take a break to eat or pee, just busy, busy, busy. The turnover is atrocious and I sucked it up for years. I started floating to the PCU at a large academic medical center and their ratio is 1:3max, phlebotomy comes around q2-3hrs to draw labs, much less stress and it's just wonderful. Obviously, I'm working less at my old job and I wonder why i'm still there each week I go there. Yes, my other job pays about $3 more than the regular staffers at my new place make but I've come to a point where I'd take less money if that eliminates the stress. The good part is I actually get time and half plus at the newer place since i'm float.

As others have said, all PCUs are not created equal. I say find a place where you can learn without the stress of task-focused care.

[MatrixRn]

After reading this I feel like I was really robbed. The last time I worked on a Step down we had a day ratio of 1:6 and nights of 1:8. If one of the night nurses called out we had a ratio of 1:12, with one or two techs. We ran most of the drips I see above, heparin, lasix, cardizem and insulin. We also took the occasional vent. But almost always had at least a few trachs, bipaps etc on the floor.

[dandk1997RN, MSN, RN]

I work intermediate cardiac care (a level below prog and above med surg) and we only get 4-5 on days, 5-6 on evenings, and 5-7 on nights. 4 on prog seems like too much to me, but I honestly don't know how many our prog nurses are taking. Now I feel like I should go ask them.

The techs are great when the pts' needs are things like toileting and food and tissues etc, but they are useless (no offense, it's just outside their scope of practice) when it comes to the drips/vents/etc you are describing- ours aren't even allowed to silence an IV alarm even if I am in the room and aware. TurnforthenurseRN's post describes my floor pretty well, but we don't do insulin gtts -ever- or titrated pressors. They can only go to ICU or CCU (but we do get other titratable drips.) We get bipap pts (no vents,) but they usually have a 1:1 sit. We don't get post-CABG pts, but we do get tons of post-cath and EP pts.

It sounds like there is a lot of crossover in the different descriptions of what we get on our units, and the staffing ratios are all over the place. But it does sound like the few differences between what I get and what you get are enough to make an extra patient seem like a bad idea. Best of luck to you!

[octbabe28]

I work on a PCU that is supposed to be primarily an open heart step-down unit. We get all the open heart pts that come out of the recovery unit (with all their drips, pressors, insulin, chest tubes, pacers etc.) as well as other cardio-thoracic surgery pts (thoracotomies, VATS, etc), post cath pts, CEAs, anyone on an insulin gtt (we're one of only 2 floors other than ICU that can have insulin gtts), and anyone who gets admitted from the ER that the MD checks "admit to telemetry". Our pt load is 1:4-5 on days and 1:5-6 on nights. It's always busy and it gets tough when your pt load is pretty acute. I agree w/ what others have said...4 pts is busy, but manageable...adding that 1 extra pt, though, makes it 10 times worse!

[brewtus]

We currently taking 4-5 pts, having that one extra to make 5 just throws you over the edge. If team leaders would room by acuity if might be better, but you can get a day 1 open heart then a post cath that still needs a sheath pull and then drips with the others. Needless to say, it makes it one very hard day to try to give the care you want too. Famlies aren't happy cause they feel like your not in there, pts upset cause it took you more than 5 mins to get to them, and then the lovely 2 pts decide to code back to back.....I like what I do, but everyday my license is on the line. I am moving on with a different career path, and leaving the hospital all together. CEO's and upper manangement don't care anymore, its all about numbers and we are all replaceable.

[anh06005, MSN, APRN, NP]

I worked on a cardiac/step-down unit (not technically termed "progressive care" but the same thing) for about 18 months after graduation. We got as many anginas as we could, outpatient heart cath or pacemaker and/or generator change, drips w/ titration (amio, cardizem, nitro, heparin, insulin, dopamine, dobutamine, occasionally a lidocaine, etc.), thoracic surgeries with fresh chest tubes, bad lung patients on high O2, nonrebreathers, or bipap, cardioversions (inpatient or outpatient). We had a high turnover rate because the if an angina patient's 2nd troponin came back negative chances are they'd go home. If the heart cath was clean they'd go home. Those coming in outpatient would usually go home. The outpatient ones in particular might mean you have THREE patients in a single bed in a single shift (first patient goes home early, get outpatient generator change who goes home that evening, and you get another admit). At first when I was working day shift (on orientation) was at 1:4 which was busy, but doable. Went to nights when I got off orientation and it was 1:5. Still doable since night shift isn't quite as hectic (mostly) and docs aren't writing orders to pull this and start that. When I FINALLY got back to days they had increased ratio to 1:5. CHAOS. How can a single nurse give blood here, assist with a cardioversion here, do q 15 minute post-cath checks here, all while monitoring a dopamine drip with a BP of 70/40?

Then to make matters worse our hospital combined a regular med-surg floor onto our cardiac/step-down floor. These nurses had to learn to be comfortable with the cardiac monitoring, reading telemetries, cardiac drips, fresh chest tubes, vascular surgeries, etc. SOOOOO while they acclimated the original cardiac nurses got essentially all of the more complex patients....at a ratio of 1:5. I want to say with this about half of the nurses transferred elsewhere or quit, myself included (yay for home health!). If I remember correctly not long after many of us left they decided to put the ratio back to 1:4 "if staffing permitted." Had they done that before running me completely RAGGED and making me dread my job I might would have stayed.......

Oh and we don't have med nurses or admit/discharge nurses. We did everything. Our aides were usually ran ragged too and ultimately the patient care falls to the licensed nurse so guess who did plenty of turning and butt wiping?? Lol!

[Yesenia PL]

Well I am a PCT in a Hospital in Orlando Florida I work in a PCU floor. The floor has 40 rooms each single occupied when we are short on staff there's only one Tech s/he will have the whole floor and s/he will only be responsible to do in the bath of all the total patients after midnight and patients were not completed by the morning shift before midnight.  when we have two Techs our paper says that we have 13 patients which we have to take Vital Signs every  4 hours Arch(suga level) at 9 p.m. and at 2 a.m. for those who are higher than 200 and then somewhere in the middle of that I had to complete all the bath the we're not done by the morning shift and be responsible for total patient after midnight we have alot of nursing  home patients in out floor all the time.. not to mention answering call lights take people's snacks or water help them to the bathroom a turn off lights when the nurses leave them on so I was just trying to find out how does it work on other hospitals cuz I thought that was a little too much cuz in the paper it may say that I have 13 patients but in reality I have 20 and my partner the other CNAs will have the other 20 cuz not that many of our nurses will help us in the floor and I really think that's a very safety issue I was trying to look up some policies from my hospital but I haven't find them yet.