Attention ICU/CCU nurses

Gardengal · Nov 15, 2002

In my ICU we are typically 2:1 or a few 1:1 assignments. We have a unit secretary and nursing assistant 24/7 barring call offs. The only times we have 3:1 is during breaks, lunch or nurse off the floor for patient transport times. we try very hard to have a charge nurse without a patient assignment so the breaks and transports and changing acuity can be covered more easily.

There was an occasion about a year ago when the hospital was so full we were gridlocked and I had 3 patients to be transferred to the floor but there was no general floor bed movement so I did have a 3 pt assignment. It was understood though that if we got a bed for one of those patients, we could not take another until the next shift. My charge nurse had picked up a patient to accomodate one of patients who was coding. As I am the unit manager and discuss staffing regularly I do not forsee that a 3 patient assignment would occur on a routine basis because the acuity is too high. I do view acuity however, and if there were not any 'road trips' I think we could probably manage maybe one 1:3 patient assignment on rare days. This would certainly be the exception. I can not envision trying this on a routine basis. Not feasible with my high acuity patient population.

If I had another time when patients got'stuck'in ICU because of floor beds though I can see how it might happen again. If I worked in a hospital with less high acuity referral patients being flown in it might be a different story.

JMP · Nov 15, 2002

Never 3-1...... and never 2-1 for that matter.

But I am in Canada and I understand things are different.

The only time I have ever been doubled (2-1) was on the rare occassion that we where short staffed and they where extremely stable pts.

And even then it would not be for a full shift.

I work in a high acuity ICU.

BadBird, BSN, RN · Nov 15, 2002

Working agency I quit working in one facility that was insisting on trialing 4:l on nights, that would give me 3 vents and a active GI bleed, I said NO WAY !!! called my agency and told them I would report off to the supervisor and leave, admin. backed down, I only had 3 vents, 2 unstable and 1 stable. That was the last time I worked for that particular facility. I find that the smaller community hospitals have some strange hold on their nurses where the nurses are afraid to drive into a city to work,because of this strange hold the nurses complain but just accept what rolls their way. I work in city hospitals and the norm is 2:l, and very high acuity is l:l

christianRN · Nov 15, 2002

at times we have 1:3, but the # of times I've had to take 3 pts is decreasing since our unit is staffed better. so I don't see us progressively moving toward staffing 1:3 on purpose. We always have a secretary and/or one or more aides, depending on census.

J. Tigana · Nov 15, 2002

In England, at least in the hospitals were I work, we double only on rare occassions. No nurse would ever triple as this would be very unsafe for the patients. Our level of pay is, however, roughly equivalent to that in Canada and much less than that in America. This fact may explain something to you. Although I'm not justifying putting patients lives or at least health at risk. My point is nurses in England would not tolerate a nurse patient ratio of greater than 1:1 in an intensive care unit except on rare occassions. 1:3 no way!!!

whipping girl in 07, RN · Nov 15, 2002

Thanks for your replies. I know I have heard other nurses say that their CCU/ICUs have a 1:3 nurse to patient ratio. Any other comments?

Tweety, BSN, RN · Nov 15, 2002

I occasionally float to neuro ICU. But from doing house supervision relief I know about critical care ratios. Crashing critical patients that require frequent monitoring, drips, etc. are 1:1. Post tpa neuro patients are 1:1, (I'm not sure about tpa cardiac patients, but I don't think so), organ donors are 1:1.

We are horibbly short staffed and have mandatory on call of 12 hours a month, plus bonuses for people willing to do ovetime. But despite that sometimes the nurses must go 3:1. This usually happens when a noncritical patient crashes and is upgraded in the middle of the shift, or a post-code patient must come to the unit.

3:1 assignments must be stable critical patients if there is such a thing. It's not routinely done, but sometimes it happens. Unfortunately our hospital has had an increase in the number of critical patients (i.e. staying in the e.r., overflow units opening up) and a decrease in the number of critical care nurses and tripled assignments are more common than they were 10 years ago.

It's a dangerous trend.

Jenny P · Nov 15, 2002

I work in a busy 22 bed CV-ICU unit.

My unit staffs 1:1 for immediate post-op pts., pts. on vents or multiple gtts, and also for IABP's, CRRTs, etc. We staff 1:2 for STABLE OHS "fast track" pts. (after initial recovery, usually on the night shift; these pts. are well enough to be out of our unit by 10AM the morning after surgery).

If a pt. is very unstable (say on IABP, heartmate, NO2, multiple gtts, PLUS CRRT, etc.), we usually try to staff them as a 2:1.

We recently had one nurse who had 3 pts., but they were actually tele pts. and there were no beds elsewhere in the hospital; that nurse was to treat the pts. like tele pts. and let them sleep and do vitals only twice that night!

The idea of 3 ventilated pts. makes my blood run cold! Even if they were stable, the chance of infections, complications, accidental extubations, etc. scares me.

BTW, we rarely ever use restraints, and we have a very low nosocomial infection rate in out unit. We also had a traveler last spring who said that we don't have nearly the number of codes that her previous hospitals had had in spite of the fact that we have the same types of pts. She thought that having better staffing made the difference-- and so do I!

We have secretaries on days and eves only, and 1 aide all but Sunday night (Sundays usually have a lower census and the aide is utilized for transports and turns and re-stocking the unit supplies), and our charge nurse NEVER has a pt. assignment.

whipping girl in 07, RN · Nov 15, 2002

Wow, Jenny, your unit sounds better staffed than mine! Our charge nurse always takes a full assignment and we have a secretary from 7a-7p only. Our unit is divided into two halves, 10 beds on each side, but we only have 16 beds open. We usually try to have 8 patients on each side. On weekdays we have a secretary for each side if census is high enough (or if there isn't a shortage in the hospital; then we only have one).

Our biggest problem lately is that administration says we have to take as many patients as we can staff for the next shift. So if we have 9 nurses scheduled for day shift (and no hearts on the schedule that we know about), the nursing supervisor has the authority to admit up to 18 patients on night shift (after the hearts from that day are extubated they go to 1:2 ratio, freeing up a bed or two or more depending on how many hearts we had that day). If a unit is "over" in house, they will pull a nurse to us, give them the "easiest" assignment and then open up a nurse to "task" for admitability (help everyone else, including three floors in the hospital, until they get one or two admits). The problem with this is that they are pulling nurses will little to no ICU experience and in essence, we have to watch their patients, too. The last time that happened when I was working, the pull nurse would sit at the desk and wouldn't even answer the phone and had a patient on dopamine that was being titrated for BP. I happened to pass the room and noticed his pressure was in the 70s. I told her and she came and looked at the monitor and said, no, look it's 92. Except she was looking at the SpO2, not the BP. She had not even been oriented to our monitors and didn't know what she was looking for. I ended up having to keep an eye on that patient in addition to my 2 sedated vent patients and help her titrate the dopamine. Then the "task" nurse admitted two patients, one that was a post code and the other that had been going downhill and they started coding about five minutes after she rolled into the unit. To top it off, another heart had been added on to the surgery schedule that no one was aware of, so when we changed shifts that day, we had 18 patients and needed 10 nurses, but we only had 8 scheduled. We couldn't even start report till after 7 because they couldn't figure out how to do the assignments two nurses short. At the time our census was supposed to be a max of 14.

VickyRN, MSN, DNP, RN · Nov 15, 2002

In the high acuity CICU (level III) in which I used to work, never greater than 1:2 for the regular ICU patients, but this also included IABP patients, pts on drips out to WAZOO, CRRT... You get the picture. All of those very sick patients SHOULD HAVE BEEN 1:1 IMHO.

whipping girl in 07, RN · Nov 15, 2002

Yes, Vicky, I agree. We have a form to fill out to make a pt 1:1 (fresh CABs and IABPs are automatically). If the pt meets certain criteria (vent, hemodynamically unstable on a certain number of gtts, actively titrating multiple gtts, tranfusing multiple blood products, undergoing ultrafiltration, etc.), they get a certain number of points for each problem. If it adds up to a certain number, the patient is supposed to be 1:1. It's just too bad that sometimes it"s the trauma we get in the middle of the night when there's not enough nurses to make the patient a 1:1 unless someone else takes 3 pts.