[Northernlights]

I'm curious about how other small hospitals staff when census goes through the roof.
I'm an ER nurse in a 25 bed hospital that has a 24-hr ER. The hospital does OB, med-surg and takes a few rehab type patients (swing bed or transitional care). My concern is not the ER, but the med-surg area. This past weekend I was turning patients over to the floor nurses who already had 7 or 8 patients. I felt awful knowing they were in over their heads, but we were backed up in ER and couldn't keep them.
My question is, how do other small hospitals deal with large shifts in patient census. We don't seem to have a contingency plan. When we talk to our director, she says staffing is based on average census, which is averaged over a year's time and is 12 patients. However when we are at top census, our patient number is 25. And we seem to be hitting our top numbers much more often lately. We have never refused admissions due to nursing staff availability, but I wonder if we should sometimes. (Our next available hospital is 60 miles away).

[sgent]

Wow... not a great situation.

You need to talk to the administrator and point out that having a patient in the med/surg is not the same as a swing bed in terms of nursing needs, and even though the *average* might be 12, you have to develop a plan to fix this issue.

As for suggestions, I would try to find every licensed nurse within 30 miles, and ask if they would accept an on call situation for emergencies -- this isn't ideal, but nothing is. These people could be nurses working for physicians, in home health, etc.

At some point, preferably one listed in the protocols, you need to either transfer existing patients to the larger hospital , or close the ER. I would definately push for a policy decision to be made now, by the director, rather than waiting until your over your head.

[obliviousRN]

We have had to close to admits before. Just told the MD's we were unable to provide safe staffing for the pts and they would have to be shipped out. It's rare, but it happens. Of course when the CFO realizes we are sending money out, he is more willing to approve the hiring of more nurses.

[OITnurse82]

the fluctuation of census is a big challenge in a little place. I work in a 49 bed or so hospital in WA state on an island.
We have a 24 hr ER and are public, so access to care is a big issue. We have 4-6 maternity beds but only do about 200 deliveries each year, 6 ICU beds and 38 med- surg beds. When we hit 25+ med surg client census we are pretty tight for staffing.
We have on-call, perdiem staff that are required to work one weekend a month. We put out calls and also have a "try me" list for staff wanting additional hours and a volunteer calendar for staff who want to be off on "low census" which makes it much easier when that happens.We also are trying really hard not to divert patients to other facilities and tend to take patients on a case by case basis when it happens. Staff will often work over into half the next 8 hour shift to cover- splitting shifts can help stretch staff. We also have a formula that our supervisors use to staff according to number and we always have primary CCU and OB staff in house even if the unit closes. Our ratio is 4 for a primary Rn on days, 4-6 for an RN- Lpn team and it goes up to a max of 7-8 on nocs. We also have a list of community members who are willing to sit with patients who need "sitters"and we will staff more for high acuity when possible.
We have had ER staff "hold "patients until we can get patients discharged and docs tend to write their transfer to tele orders quicker when we tell them the ICU is full- who can we bump if someone more acute comes in??
It certainly can consume much time and effort seeking staff and working out coverage of all areas. Crosstraining is also a help.
This is some of the brainstorming going on at our hospital. Trying to stay afloat financially made administration consider being"a critical access " designated facility but that seemed and oxymoron since we would have been limited to 25 beds and it seemed more likely that we would have to divert members of our community. Taxpayers wouldnt like to be sent away! So we keep plugging away...

[catalyst]

First I say a small hospital is a very wild animal and good luck. I am a manager and find this type of situation hard to manage, it is a eal balancing act. A well seasoned staff could probably handle your situation fairly well, especially if a CNA or Unit Clerk could be called in to assist with the admission chaos. This could be a disaster for a young nursing staff. We call agency for fluctuations if "home staff" are not able to keep up. We have a house supervisor who will take up the slack or reassign a nurse from a slow-low acuity area. Placing people on call is a very good solution as well. If this situation is a rare thing, you might think of activating your disaster call list for back-up. Just last week my 28 bed med/surg unit went from 9 patients to 17 patients in 14 hours. I was able to float two nurses in, one did assessments and the other took a patient load. The trick is to realize that we are in the business of making decisions and helping the sick, so prioritizing the needs of the unit (all the patients in mind) usually allow for a safe outcome.

I would follow the chain of command if your really concerned. A manager who only staff's a unit based on yearly numbers is makeing poor judgement. Seasons and trends should be taken into account. The usual staffing guidelines on medical surgical unit is about 8 hours of care per patient per day, but should be adjusted up or down based on acuity. Staffing decesions are usally made by taking allowed hours of care per day (8) times the number of patients. Now divide up the hours of care based on the activity performed on each shift. usually heavy on days while the unit is busy, lighter on nights when the patients are asleep. Say you allow 4.5 hours for days and 3.5 for nights (12 hr shifts). Staffing example for 20 patients: 20 x 4.5 =90. now take 90 and divide by 12 (12 hr shift) for a total of 7.5, which is the amount of staff you should be allowed to take care of 20 patients on that shift. Usually divided between manager, rn, lvn, cna, and unit clerks.
Anyway, just staffing the same way reguardless of patient volume and acuity is not appropriate. I hope this help.

[CRNA Someday]

I work at a Level IV CAH in rural Eastern Washington. Per CA guidelines, we can only have 25 beds (not including OB, observation or post-surgery patients). Our facility has about 15 long term swing-beds (like a nursing home) so we're only allowed to have 10 other in-patients in acute. However, we have also had 3 OB/mother-baby couplets and several observation patients at the same time. The LTC side is handled by one nurse. Acute has two nurses, charge and second nurse. The charge nurse also covers the ER, so if the ER is busy, the second nurse (ME!!) must handle all of the floor patients. Unfortunately, I am a baby (only 8 months of being an RN) and sometimes I get SOOO overwhelmed! Theoretically, we have nurse managers during the week and on-call staff on the weekends to help, but nobody will sign for call (we already work 3 to 5 12-hr shifts per week). Luckily, our census hovers around 6-8 patients (we've had NO patients before - I felt useless) and the ER is usually steady, but not overwhelming.

On the up-side, I have been forced to hone my organizational and nursing skills at warp-speed to keep up. IF I ever move to town and work at a large hospital, I know I will be able to keep up!

Alison, RN

[schroeders_piano]

I work in a CAH with 25 beds. Our staffing pretty much stays the same. On nights we have 3 nurses. 1 works ER, 1 (usually a LPN) does meds, and 1 team leads. This works out well most nights. Our census usually hovers around 10-12. There are times of high census when ER is busy all night and med/surg has 20 patients. It is not the most ideal situation but it can be done. There is also times when the med/surg team leader goes to ER to help. If we know we are going to have a high census, we try to get a 2nd team leader to come in for at least a few hours to help open charts and get through the first part of the shift. My hospital has a great bunch of nurses that try to watch out for each other and help out when they can.

Schroeder

[Hopalong]

Our M/S unit staffing seems to be a little better than most of those already described. Our unit manager tries to staff for the busy times as we usually have constant turnover. We our usually staffed for 5-6 patients each, but if the census falls we have an option we call AWOP (absent without pay) where you can take the day/night off w/o it being counted against attendance record and have the option of using PTO to pay for tome off. It works fairly well. We also have a list of nurses within 30 minutes of hospital to call first in the event of a true disaster.

[alphaetomega]

Hi all... I am a nurse manager for a small CAH 11 acute beds 1 L&D 2 ER our max staffing is 3 RN's and 1 CNA. We rotate turns through the ER and divide up the other patients. The problem we are experiencing right now is 3 RN's moving on to other jobs w/i the hosp. (good for them bad for us), CNA moving to days. So total pt count at max is 13 if we have a mom and babe. Then of course there is the ER/ doc clinic and all those small rural RN's know what I mean by that. (prob. lg city RN's get same crap) We can have 5-6 pt's come through at a time 1 or 2 true ER or urgent care needs the other one's have a temp for last 8 years or something and decide 2am is the time to get that checked out. So the board is willing to offer extra incentive even though we have great group of people that have been graciously signing up for OT. Any suggestions there? What have your hospitals offered for extra days? I thought about maybe even OT pay with comp time on top because we do the same thing for low census (LWA =low work activity) but people currently have to use PTO if they want paid for these hours. Give them earned comp time and it's extra time off they are getting paid for??? Does that sound enticing to anyone? feedback greatly appreciated! Life isn't about how many moments we take a breath, but how many moments take our breath away. - Anonymous

[GooeyRN]

I also work in a small CAH hospital with the next hospital 40 miles away. One nurse for ICU, one for the ER, One for OB and 1-2 for med/surg. Med/Surg is where I work and it is an 18 bed unit w/ a few swing bed patients. Even if there are 18 patients on m/s we don't get any help. No overtime allowed, ever, for any reason, period. Even if the census starts out at 8 and is at 18 within 4 hours. Sorry. Not allowed. Don't even think of calling in the part-timers either. The administrator loves when we are short staffed and have call offs. Saves $. Something we do Im not so sure its legal w/ CAH is we put patients in the hallway in geri-chairs when all the beds are full instead of sending them elsewhere. Or we put M/S patients in the ICU if there are beds available. M/S gets the ICU patients if ICU is full. That is really scarey since these pts should be 1:1 and now they have to share their nurse w/ sometimes 10+patients. Every summer its layoff time when the census is low. The ones that get laid off are the ones that have very good attendance. Administration wants to keep the ones that call out or volunteer low census so they can save even more. The more that can be done w/ the least amount of staff is the answer to the problem where I work. Yes, I would love to leave but the weather is really bad here in the winter and don't want to drive the 40 miles to the next hospital, (its really rural and in the mountains) which is in the next state and would require another license.