[NICU_Nurse]

I'm curious what everyone's nurset ratios are lately on your respective NICU's.

Are you 2:1? 3:1? (for Level III babies)

4:1? 5:1? 6:1? (for Level II babies)

Do you have mixed assignments, i.e., 2 vents (L.III) and 1 feeder-grower (L.II)? If you're 2:1, do you do 2 vents, or 1 vent and 1 HFNC, etc.? What about oscillators? N.O.? Post-Op?

What are your unit "boundaries"? At what point does the assignment become too heavy and require redistribution amongst staff? When do you balk? I realize it's difficult due to acuity to speculate, but examples are welcomed.

The reason I ask is that we're overwhelmed, but have been told again and again that this is "the way it was always done" and "it's not going to change" or else we're fed B.S. about "when we get enough staff for 2:1..." but "we don't know when that will be". Coming from another state with better ratios and staffing, I feel like I'm the only one who KNOWS this isn't true. Many of the staff I currently work with have been at this facility for many, many years and seem to think that what we do is the norm.

Any takers?

[TiffyRN]

Our patient population is divided into several rooms roughly by acuity. The feeder growers are assigned 3-4:1, sometimes you may have a heplocked piv for antibiotics, sometimes low flow nc, or a long term kid on 1L/min high flow. Seems like every time they have tried to sneak a kid on higher flow than that the kid winds up crashing and having to be moved back to the mid-level room.

The mid-level kids would be those with PIV's, CVL's with TPN/lipids, more aggressive resp needs such as high flow, cpap, rarely a vent. Generally if there is a vent in your group you would just have 2 babies. Rarely an umbilical line. Sometimes we would keep a baby that would seem to be a feeder grower in every other way but is still small (<1200 grams) and can't be trusted. This level babies you would have 3 to an assignment.


Then the admit room, where the sickest and smallest are. These are 2 per nurse. To qualify as a one on one, there is no set standard. Just really busy, lots of things going on. Just being on HFOV or multiple IV's doesn't qualify. I've heard of places that being post-op first 24 hrs or being on any high frequency will make the baby 1:1, not where I work.

[RainDreamer]

There are tons of threads on this topic, if you do a search you'll find a bunch.

In the unit (level III) it's usually always 2:1. If the baby is real sick, then it'll be 1:1. When we're short-staffed we can have 3 babies ..... they're more stable kids, all on room-air or maybe on nasal cannula. In the step-down nursery it's usually always 3:1 but occassionally (very rarely) it'll be 4:1.

As far as how they're mixed up, we go by the acuity scores. Each shift we give the baby an acuity score .... and that score will determine whether they're low, medium, or high acuity. A low acuity means they can be in a 3:1 assignment. So usually a medium is paired with a low. A high can be 1:1, depending on how high the score. Does that make sense? It's really a nice tool and it works very well for us and we staff accordingly.

I will not take an assignment I don't feel comfortable with. And if we have an assignment we feel is too heavy, we let the charge know and they'll either make the kid a 1:1 or they'll put a lower acuity baby with it.

I worked too hard for my license to be fed the "well that's just the way it is ..... deal with it" line of bull.

[SteveRN21]

Yeah,

We had a problem with n/p ratios last year before our new NM cracked down. We currently strictly follow DHEC guidelines, and the charge RN figures out the # of RN's based on those guidelines.

1:1 ~ Sick vent (hfov/simv) that requires a high level of care, including multiple drips, meds, marked instability, usually iNO.

2:1 ~ Vents, UA/UVC's, multiple gtts, dopa/dobut, CPAPs that require a higher level of care, roughly as stated above.

3:1 ~ stable CPAP's, NC o2, can have central lines, drips, meds. key word: STABLE.

4:1 ~ stable feeder-growers, no o2 needs, no parenteral meds.

Add in an extra 1.25 nurses for charge and a lighter transport assignment.

We went from having, like you said 2 vents plus another baby, to much better assignments of vent+feeder+admit, 2 vents, 3 feeders, 1 vent 2 feeders, 3rd+admit, etc. If there are 4 4:1 babies, they are grouped together and we help that rn out with feeds. (no admit with that one) Charge has no assignment, and the RN assigned to transport has a lighter assignment.

We have a 10-bed "intensive" area in the back of our unit, but we just opened it, and don;t have anyone back there as of yet. We're still a mixed unit.

Hope this helps

Stevern21

[danissa]

worst assignments in our unit can be in the feed/growing room, where you can be left with maybe 7-8 babes, depending on whether the parents are there, this can be a back breaking/begging for help shift! !

[PremieOne]

My unit is small only 24 beds but it can be hectic at times. In the NICU area it can be 1:1 for sick premie or unstable newborn/or micropremie that has lines and is on oscillator. Also post-op infants that have had "Duct Busters" from CHOP to ligate PDA, laser eye surgery that were on vents, and those with neurosurgery. It is 2:1 for vented infants or 1 vented and 1 CPAP or HFNC. If we are short the ANM will pitch in and help. In PCU with the feeders and growers - may be on HFNC, or NC it is 3:1 or 4:1. Infants in isolation and NAS infants are cared for by staff in PCU land. The unit is all RNs with one PCA that occationally will help po feed infants.

[sparkyRN]

There's ideal and then there's reality.
Ours is a level 3 referral, 80 bed unit-usually 20 ICU, 40-50 level 2/special care babies.
We often carry 3:1 and even occas. 4:1 in ICU, and 5-7:1 in level 2. We'd love to maintain a 2:1, 3:1, and 4:1 standard bu there just are not enough nurses available. The nursing shortage is a real problem for us because we're in a large medical community so lots of competition for the same small group of applicants.
You just have to make do, support each other, don't let nurses become "black clouds" in your unit. They will drive people away faster than any bad assignment will. Step up and be a preceptor to the new hires and remain a mentor to them when they are on their own. That's how we've managed to survive for years. We are nurses for our babies first, for each other second and for ourselves last.

[NICU_Nurse]

Well, I am just trying to figure out if it's *me* who's being unreasonable, you know? Was I just spoiled from a hospital with excellent staffing, or is this really not safe?

Can I bounce some theoretical scenarios off of you guys? I'm just trying to determine when too much is too much.

1- 1st admission with an oscillator

2- 1st admision with 2 vents (could be stable, could be unstable)

3- On Delivery Call with 3-4 babies (mixed assignment, say, 1 vent, 2 HFNC's, 1 feeder-grower)

4- 2 Level III's (HFNC), 2 Level II's (HFNC), 1 12 hour old HFNC 26 wkr on Dopa and rec'g blood

5- Same scenario as above, but no Dopa and no blood- does this make a difference?

6- 3 vents on one assignment (does it make a difference? Are 2 vents plus one other baby more reasonable?)

I know this is highly variable. I appreciate you all answering!

Also, would anyone be willing to share their acuity calculators or ratio policies? I'd like to see how others are figuring this out.

[RainDreamer]

Everytime I read these types of threads I think about how LUCKY I am to work where I do!

So no, I don't think you're being unreasonable. I think I would feel the same way if I were to go to a place like that after working in a place that staffs pretty well. And being in AZ, we have a HUGE HUGE nursing shortage. But somehow we always have safe assignments.

Originally Posted by NICU_Nurse

1- 1st admission with an oscillator

If it's a stable oscillator, then yes. Being on an oscillator doesn't necessarily make them high acuity. On our acuity sheets, I think being on oscillator or jet gives them 40 points, which is the most points you can get for each category. But some of those kids on oscillators just have bad BPD, but they'll be on full feeds, with no lines, and no meds ..... so their acuity is actually pretty low, and if that's the case they might have that nurse take first admit.

2- 1st admision with 2 vents (could be stable, could be unstable)

Doubtful that would happen on our unit. That would NEVER happen if there was an unstable vent in the assignment. And even with 2 stable vents, it's doubtful you'd be 1st admit. Usually if you're 1st admit you'll have 2 "easy" babies ..... either they'll be on room air or nasal cannula (maybe CPAP). And once you know you're getting an admit, then they'll move one of those kids to someone else's assignment. So usually we never have 2 other kids + an admit. And if it's a critical admit, then both of your other kids will be moved to other people's assignments.

3- On Delivery Call with 3-4 babies (mixed assignment, say, 1 vent, 2 HFNC's, 1 feeder-grower)

NEVER. We have a high risk nurse that goes on all deliveries, and she never has an assignment unless we're critically short-staffed. I've only been working in this unit for 8 months and I've only seen the high risk nurse take an assignment (1-2 easy babies) once or twice.

4- 2 Level III's (HFNC), 2 Level II's (HFNC), 1 12 hour old HFNC 26 wkr on Dopa and rec'g blood

5 babies?!?! Did I read that right? NO WAY! And if someone actually agrees to take that assignment they are absolutely INSANE! Yeah I understand that's 5 kids on nasal prongs, but sheeesh .... 3 of them are still considered Level III status for a REASON, because they need to be closely monitored. How can you closely monitor them while you have 4 other babies?! That is NUTS!

5- Same scenario as above, but no Dopa and no blood- does this make a difference?

Doesn't make a difference at all. We can have up to 4 babies in the Level II, step-down unit, but I wouldn't even agree to taking 5 of those. And I've never seen it done in our unit. 4 is the max, and that's in the step-down unit. FIVE babies is too much for an ICU.

6- 3 vents on one assignment (does it make a difference? Are 2 vents plus one other baby more reasonable?)

We'd rarely ever see this. In our Level III we usually always have 2. Sometimes we'll have 3 but they're usually all on room air or nasal cannula. I've had a 3 baby assignment before with 1 on room air, 1 on nasal cannula, and 1 on CPAP ..... and that was when we were over our census and short-staffed. I never see 3 vents in one assignment, or even 2 vents with 1 more on room air.

I know this is highly variable. I appreciate you all answering!

Also, would anyone be willing to share their acuity calculators or ratio policies? I'd like to see how others are figuring this out.

I don't have a copy of our acuity sheets. But they tweeked it a lot to make sure the scores we were getting were actually correlating with how busy the kids actually were. It's pretty accurate. We score them based on a number of things ...... type of vent (SIMV, HFOV, HFJV, NC, CPAP, etc), stable or unstable, number of lines (PIVs, UVC, UAC, PAL, Broviac, PICC, etc), number of meds (PO or IV) and how many in a certain time period, labs/gasses and how many in a certain time period, drips and how many, feedings (NG or PO) and how long it takes to nipple feed, etc. They also get more points if they are a fussy/unconsolable baby, if they're a new admission, if they're post-op, ECMO, if they're <1500 grams, if they're <1000 grams, etc. There are others that I can't remember, but that's the gist of it.

[nell]

Wow, one of the premises for the nurse-patient ratios here in CA is that having reasonable ratios actually ameliorates the nursing shortage. We will occasionally have a short shift due to sick calls, but for the most part we have adequate staff. Many of our nurses fled from another area hospital that stretches the ratios to the legal limit.

CA law allows up to 2 level III kids/nurse and up to 4 level II kids/nurse.

• We rarely pair a vented or recently extubated kid with another and if we have to, it is the least hands-on baby in the unit. We don’t have many “stable vents” – if they are “stable”, we are weaning them with the potential of making them unstable.
• Vented with any drip is a 1:1.
• 2 NCPAPs with lines is a maxed out assignment.
• Usual feeder-grower assignment is 3 kids, 2 if they have anything else going on (As & Bs, procedures) there would only be a 4th kid if there was no choice and it would be on nights (when there are fewer parents to deal with) or for only part of a shift i.e. a discharge.
• If we are expecting a 32-35 weeker, the admit nurse may have another patient; if the kid is <32, he/she most likely will only have the admit. R/O sepsis admits will go into a formerly 2 baby assignment or the charge nurse will take it.

Some times all he** breaks loose, but most of our staff pitch in and even the well-baby nursery will help if we are in a bind. We can often get someone to come in or our manager will come in if needed.

We are a 16 bed mixed level II-III. We do HFOV but no ECMO, Nitric or any but the most minor surgeries. We do have a very demanding parent population.

How can you all safely care for your patients with the kind of loads you have? Do you have unplanned extubations? Lose lines? High levels of NEC? Infections? Med errors?

nell - grateful for where I work.