Should CVVHD be 1:1

[kristenallene40]

Should it be required that pts on CRTs be kept at a 1:1 ratio? I have a very unstable pt on CVVHD but also have to take on another pt cause my hospital doesn't require 1:1. I think it is ridic because my other patient gets super neglected while I'm constantly monitoring and managing this guy. We have a great suport system in my unit, but it all falls back on my nursing license. I can't seem to get my nurse manager to grasp on to my argument though...

[Flying ICU RN]

CVVHD is indicated in patients who are unable to tolerate intermittent hemodialysis, usually for hemodynamic reasons, therefore by default, "unstable." The machine itself is more labor intensive than an IABP which is ironically the more acute therapy of the two. The patient's blood volume is being extracted extra corporally, therefore the primary rational for 1:1 would be safety, and secondary would be for maximum therapeutic management.

The primary reason the private sector doubles up such an assignment is for labor cost effectiveness and no other reason period. Management can double talk the issue, but there it is. I am a Government sector RN, so I (and my patients) are a bit luckier than most.

So how do you deal with this?

Keep two things in mind to determine your actions, "Standard of Care" and "The Prudent Nurse Standard." For the first ABC's, medications, TX and analysis dictate priorities. For the later, effective and very visible (think witnesses) resource utilization, (i.e. Charge Nurse, colleagues, supervisor,..etc.).

[pghfoxfan]

I always thought that CVVHD and patients on left heart assist should be one to one. I agree that not all patients on CVVHD are unstable, but DANG, the whole procedure itself takes so much time, especially when you have to increase and decrease fluids constantly to balance I&Os. Personally, I think that a unit that runs well as a team (including the charge nurse) can make any assignment doable.

[Esme12, ASN, BSN, RN]

I'm in a nicu with not much experience yet, but we had a baby on cvvh and he was 1:2 meaning 1 baby w/ 2 nurses, I think he was also very unstable, also ended up on ecmo I believe

A newborn on CVVH,intubated with ECMO.............yeah 1:2...........poor baby.....:redpinkhe

[glasgow3]

Ahhhhhhhh, the "slippery slope" of critical care staffing ratios. As a seasoned nurse, I remember when having 2 vent patients was considered a big deal......and when getting a third patient was a rarity, something that was only done if one of your others already had transfer orders.....and when a "heart recovery" got 2 nurses for the first 4 hours and 1:1 care for another four hours.......and when IABP and CRRT therapies were always staffed 1:1.

But over time, the rules change and new "concepts" are introduced by management.

Concepts such as the "stable" critical care IABP patient. They're due to have surgical revascularization in the near future and their angina has been totally refractory to medication(s), but since they aren't in full blown cardiogenic shock yet or the like they are considered to be stable----and management has decided that this stable variety of IABP patient is fair game to be paired up with a relatively stable critical care patient. Now, is this staffing change based upon something new in the literature, supporting the practice? Of course not, but hospital A across the street is now staffing that way, so we should too.

But the games don't end there. Down the road an IABP patient who has "bought" the device due to cardiogenic shock after a bad MI comes in. These used to get 1:1 care even after there was some acceptance of the "stable" IABP patient (which could be doubled). But then the criteria for a 1:1 becomes how many vasoactive drips the patient is on...just one or 2? They're stable enough according to management.....and then over time it becomes how frequently the multiple drips must be titrated to qualify as an "unstable" IABP patient.

Meanwhile, the acceptable acuity of the patient the "stable" IABP is paired with moves upwards as well.....and your colleague who used to be able to help you momentarily when your supposedly stable patient is now actively trying to die?-----Well, the powers that be have decided that 3 patients should be a manageable routine patient load for them and they are barely able to keep their head above water with their own assignment.

Now keep in mind the AACN attempted to address the "What is a 1:1 patient?" question over a decade ago using their Synergy Model. I think you'd find many current critical care nurses who would say that they routinely take care of patients who should receive 1:1 care but don't receive it.

Then again, this is an organization who can not even say that there should even be a minimum staffing ratio for critical care patients. Instead of clear leadership, they provide academic gobbledygook about matching patient needs with nurse compentencies while things get crazier and crazier at the bedside.

[TangoLima]

In our unit, CRRT is 1:1.

I routinely have 2 vents, which in some ways I prefer over someone who is on the call bell every 30 minutes.

The 1:1 vent sounds like a dream come true. Sign me up!

[matthewrn03]

CRRT and IABP and Fresh Hearts should always be 1:1. i am appalled that there are hospitals that allow you to take care of a balloon pump with another patient. maybe its because i live in california and that sh#% don't fly here, but come on! you should be constantly watching the timing on your IABP and i can't tell you how many times the CRRT machine has almost clotted off on me and thank god i was right there to stop it. You only get one license and if your facility is not 1:1 ing these patients, you are at serious risk.

The vent 1:1 is a little ridiculous as the easiest assignment on the planet is 2 vents...

[Ruby Vee, BSN]

cvvhd isn't 1:1 unless we're also opening his chest and/or doing cpr. and even then sometimes you still keep your second patient until the next shift!

[Ruby Vee, BSN]

i always thought that cvvhd and patients on left heart assist should be one to one. i agree that not all patients on cvvhd are unstable, but dang, the whole procedure itself takes so much time, especially when you have to increase and decrease fluids constantly to balance i&os. personally, i think that a unit that runs well as a team (including the charge nurse) can make any assignment doable.

an lvad gets you 1:1? what a nice fantasy! i want to know where you work!

we routinely double lvads with or without cvvhd. some of our lvads have been here for months and are classified as "chrons" rather than acutes.

[stram87]

They are usually 1:1 on our unit. Though the amount of work needed can vary greatly from shift to shift. Sometimes the CVVHD will run smoothly the entire shift and the only work needed is changing the bags up. Other times it will be alarming every 5 min related to unseen air bubbles or access pressure problems. I think that if staffing permits CVVHD patients should be 1:1 because you never know when your going to start having problems and you wont be able to leave the room.

[sockov, ADN, ASN, BSN, CNA, LVN]

wow, where do you work??

[CCL RN, RN]

CRRT and IABP are absolutely 1:1 in our ICU. Regardless of stability. 1:1

Vented patients are easy. But I've heard that those units who have them as 1:1 don't have RTs.

[NickiLaughs, ADN, BSN, RN]

I've only seen one CRRT, and that's at my new facility. He was incredibly unstable on a 1:1....but he had more drips going than I had seen on most of the fresh open hearts at my old facility. And had coded the day before.

Based on what I saw, if most CRRT's are like that, I would deem a facility out of their mind if that was placed on a 1:2