ICU nurses - acuity systems?

[neurotraumaRN]

Hi everyone,

Sorry this is long, but here goes....

I'm an ICU nurse wondering how everyone out there does their acuity system. The reason I ask is that I had a situation at work that I feel was very unsafe, yet management was aware of it and I don't really know where to go or what to do from here.

My first day that week I was assigned to two patients, they were doing a procedure on Patient A when I first got there and while I was getting report. About 15 minutes after report ended Patient A coded - we got him back pretty quickly but after that I was hanging multiple drips, etc, busy with all the post code activities. Finally the charge nurse starts doing the assessments for Patient B and gets her squared away, she is off to the OR so I don't have to worry about her for the moment. Patient A meanwhile is consuming every bit of my energy. He has literally 14 IV pumps going - sedation meds, 3 vasopressors, insulin, maintenance fluids, replacement fluids (losing a lot from his abd drain), K/Mag/Ca/Phos supps, abx, etc. I'm pushing bicarb and he is also getting liter after liter of fluid on the warmer. He has a swan and I'm doing Q1 hr wedge readings. He also has 4 chest tubes to keep track of and now his kidneys start shutting down, so they consult renal - they start CVVHD later that day. I'm also dealing with family since of course they are distraught that he has taken such a turn for the worse.

Luckily at this point my charge nurse decides that when Patient B comes back from the OR they are going to put her in a different room. She is also pretty sick, beginning stages of ARDS and making lots of vent changes on her. Anyway charge nurse tells me that she'll keep my other bed open but if an admit comes, that she'll care for it, so I will be one on one with Patient A. Whew. The thing about this unit is that they literally NEVER 1:1 their patients. So I get there the next day, and I am told BY THE NIGHT MANAGER my assignment is Patient A and Patient C, a stable vented patient. I say "Is Patient A more stable?" She says no. I ask why Patient A is not singled, she repeats "the assignment is Patient A and Patient C." This is where I don't know what to do. I don't think switching my assigment will help because ultimately someone will have that assignment, and at least I already know Patient A. Plus I have had him for a few days now and have bonded with his family, etc. So I get report and the night shift nurse had that same assignment, tells me basically "yeah it sucks, but they don't 1:1 people here."

My question is WHY THE HECK NOT? Both the day and night managers were aware of this patient's acuity and he is still doubled. He is still a full code and he has so many hourly things to do you barely have time to finish them before the next hour is here. I am just so frustrated by the mentality that the other nurses have - they just say "well this is just how we do it here." They say "we all just help each other out." Sure, so if something happened to Patient C, you're all going to come to court with me and say "Well we all work as a team here"? That is unacceptable to me. I have been at this hospital for about 8 months now. I have 5 years of ICU experience in teaching hospitals. The hospital I used to work at would 1:1 sick patients based on an acuity system - Level I, II, III, etc. Here they don't have that. Each nurse is assigned to two patients, period, end of story. They don't have any flexibility in their staffing at all - 11 bed unit, 6 nurses each day. One to do charge and take one patient, everyone else is doubled. I know that in another unit, they double two CVVHD patients together, so I know it's not just my unit. Did I mention this is a Magnet Hospital? Ha!

What should I do? Sit down with my manager and raise my concerns again? Go to risk management? Can anyone offer any advice or words of wisdom? I just don't know how to even change things since no one seems to think it's a problem but me and a few others - most of them just accept that this is how it is.

[icu/don]

Wow!! I guess I am pretty spoiled. Our General ICU of 35 beds is split into three units with a charge nurse for 11-12 pts. The charge nurse does not take any pts. except in an extreme crunch. Sometimes we have up to 3 nurse aides when totally full.

Now to the 1:1 business. Any pt. with one of the following automatically becomes a 1:1: IABP, ICP/drain, CVVH, or CABG (min 12hrs.). A good share of our trauma pts will be a 1:1 usually until the next shift arrives.

We do have a sheet of paper that we use to justify 1:1 patients, but it has pretty much fallen by the wayside. The charge nurses pretty much decide when a pt. requires 1:1 status.

This is fairly abused though. I think if our charge nurses heard your story, they would be sure not to abuse the system for fear of things changing for the worse. Alot of times pts. will be made 1:1's to cushion the staffing. The charge nurse knows that the pt. is in between criteria so if a bed is really needed the pt can be removed from 1:1 status for an admission. Alot of times a nurse with a 1:1 pt. will pick up another established pt. while the other nurse gets the admission.

I have actually seen several pts. in the 4 years I have been here that were assigned 2 nurses for several shifts.

[Super_RN, BSN, RN]

I feel for you! Patients like that deserve for to be 1:1, not only for their sake, but for yours too!! It is a violation of patient safety to have assignments like that. I would definitely fill out an assignment despite objection form. They help to cover your butt in court when these situations come up.

[zambezi, BSN, RN]

We have an acuity system that follows:

Low: overflow patient

Medium: "Stable" critical patient- extubated first day heart "usual"drips, longer term vents, anyone pairable (most of our unit is usually a medium) and get 1:2 nursing.

High: Fresh hearts, CRRT, IABP, someone that is requiring 1:1 care of very frequent assessment for changing condition, etc...

Extreme: Someone that codes on shift, VAD, CRRT with citrate (just because it is new to us), any severe cardiogenic shock with multiple stuff going on, very unstable IABP, IABP and CRRT, chest cracking...

The charge nurse makes the designation (we have a printed list which is much more extensive than this)...our charge nurses fight pretty good to have fair staffing...sometimes it is just not possible due to no staff available. If that is the case, we will usually triple some stable medium patients (ie: a heart that is going to transfer the next day and two stable MIs or something) than double a patient that is really really busy. Typically the staff that I work with has good teamwork too so someone will step up to the plate to take the triple...OUr staffing isn't always great and we try our hardest to make safe assignments for both the patients and the staff...