Definition of Hemodynamically unstable...

Specialties MICU

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Hello all,

My unit is re-doing our 1:1 criteria (new director). The director wants us to help with this and there's been debate over an exact definition of hemodynamically unstable. Some bring info from the SCCM, some AACN, ASA, etc. She's doing this for our all of our units as well which adds some barriers as we have a Trauma, Shock, Medical, Cardiac ICU and each of those patient populations can come with their own definitions of instability that don't necessarily transfer over to another population. Has anyone gone through this type of remodeling or does anyone know of a source for a pretty inclusive definition of hemodynamically unstable?

(we suggested that we should just gather the info, meet with out medical director and come up with one that we can all agree on but apparently that's not going to happen...it's been rather frustrating to say the least haha).

Thanks for any help or suggestions.

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I don't really have any sources for you, just an opintion. Just about any patient in the ICU is going to be "unstable" or "critical" in some way, unless they're waiting to transfer to the floor. In terms of staffing, IMO, a "hemodynamically unstable" patient is one who requires frequent to constant intervention to sustain life. This is the patient whose BP won't stay up (or down) and is requiring frequent fluid/products/meds to maintain it, who is persistently acidotic or having worsening acidosis and is requiring interventions for that, who is on hourly pertitoneal dialysis (common in my pedi ICU, not sure about adults) or on ECMO. Things like that I think should just about always warrant a 1:1 assignment.

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Instability would be anybody who is requiring frequent interventions to maintain HR, BP, or oxygenation. Multiple vasoactive gtts that are requiring titrations more frequently than q30-60minutes would be considered *unstable* for the purposes of staffing. All of our IABP, CRRT, Rotoprone are 1:1 for staffing purposes.

Do you use an acuity tool to help with staffing?

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Fresh post op open hearts, any patient who comes straight out of surgery during the recovery period, impellas, most IABP, patients in behavioral restraints, one legacy pt, and any crashing patient such as a trauma or GIB who needs the rapid infuser for example or a patient who codes frequently throughout the shift.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Resources? Here are some...document for 1:1 criteria

Criteria for 1:1 Nurse-Patient Ratio

...Establishing Criteria for 1:1 Staffing Ratios

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Specializes in Critical Care.

It's always interesting to see how much standards have changed over just a short period of time. The year 2000 AACN criteria for a 1:1 is now what you need just to be considered an ICU patient, and many of this patients that supposedly should have been 1:1 in 2000 are now 1:4 or even 1:6 in some cases.

If anyone's wondering why the Nursing shortage never materialized, it's not because they didn't accurately predict the acuity of patients or the number of Nurses, it's that they never thought we'd just radically change our standards. They were right that there would be significantly more 1:1 and 1:2 criteria patients, they just didn't realize we'd just put them all on 1:3-1:6 units.

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Specializes in SICU.
It's always interesting to see how much standards have changed over just a short period of time. The year 2000 AACN criteria for a 1:1 is now what you need just to be considered an ICU patient, and many of this patients that supposedly should have been 1:1 in 2000 are now 1:4 or even 1:6 in some cases.

If anyone's wondering why the Nursing shortage never materialized, it's not because they didn't accurately predict the acuity of patients or the number of Nurses, it's that they never thought we'd just radically change our standards. They were right that there would be significantly more 1:1 and 1:2 criteria patients, they just didn't realize we'd just put them all on 1:3-1:6 units.

Smart. I never thought of this.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
It's always interesting to see how much standards have changed over just a short period of time. The year 2000 AACN criteria for a 1:1 is now what you need just to be considered an ICU patient, and many of this patients that supposedly should have been 1:1 in 2000 are now 1:4 or even 1:6 in some cases.

If anyone's wondering why the Nursing shortage never materialized, it's not because they didn't accurately predict the acuity of patients or the number of Nurses, it's that they never thought we'd just radically change our standards. They were right that there would be significantly more 1:1 and 1:2 criteria patients, they just didn't realize we'd just put them all on 1:3-1:6 units.

I know right...but you have to start somewhere in the negotiations and I'll be honest I am not a fan of the AACN for many reasons......but since they are out there start with the optimal and negotiate to acceptable.....I think 1:3 in ICU in MOST cases flat out wrong. For even if one or two are up for transfer that means you are next up for that critical admit....someone going to suffer and it will be the nurse who is blamed.

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Prior to our director our 1:1 assignments were made up in conjunction with the clinical supervisor or team leaders and the doctors. Agreeably this means some "softer" patients may be made 1:1 but if there's even talks that a patient should be it's worth considering. We have the acuity tool our director put out that we use now but it never went through any committee or approval before she wheeled it out. Under the current one a patient needs to be on 4 gtts being titrated frequently to meet 1:1 status basically (for standard ICU purposes, CABG post-ops, certain procedures etc are still 1:1). Under this acuity though we've had a patient on a rotoprone and CRRT that was 2:1 which is kind of scary and ridiculous. Back to the hemodynamically unstable...that's what she's trying to have us come up with a definition as it's a term used in her acuity that isn't clearly defined in lots of cases (other then 4gtts being titrated but I think that's setting the bar a bit high personally). She won't really budge unless we have a source saying it can mean less then that and that's the trouble I'm running into is many different places/organizations use the term but don't clearly define it (it is hard to define and varies from patient to patient so I can see why) but it leaves us in a bind with this staffing acuity that's just way out of whack. We had a nurse a month ago with a rotoproned patient who required to be taken off and bagged multiple times with a donor patient who required very frequent interventions. Well thanks all for the help.

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Prior to our director our 1:1 assignments were made up in conjunction with the clinical supervisor or team leaders and the doctors. Agreeably this means some "softer" patients may be made 1:1 but if there's even talks that a patient should be it's worth considering. We have the acuity tool our director put out that we use now but it never went through any committee or approval before she wheeled it out. Under the current one a patient needs to be on 4 gtts being titrated frequently to meet 1:1 status basically (for standard ICU purposes CABG post-ops, certain procedures etc are still 1:1). Under this acuity though we've had a patient on a rotoprone and CRRT that was 2:1 which is kind of scary and ridiculous. Back to the hemodynamically unstable...that's what she's trying to have us come up with a definition as it's a term used in her acuity that isn't clearly defined in lots of cases (other then 4gtts being titrated but I think that's setting the bar a bit high personally). She won't really budge unless we have a source saying it can mean less then that and that's the trouble I'm running into is many different places/organizations use the term but don't clearly define it (it is hard to define and varies from patient to patient so I can see why) but it leaves us in a bind with this staffing acuity that's just way out of whack. We had a nurse a month ago with a rotoproned patient who required to be taken off and bagged multiple times with a donor patient who required very frequent interventions. Well thanks all for the help.[/quote']

It sounds as if your new director is trying to save on payroll and budget expenditures rather than be realistic on what an unstable patient really means. Sounds like your acuity tool is a waste of time and energy. Is it a tool that has been validated or is it a home created variety of a tool?

4 twit rated gts as the definition of hemodynamically instability is beyond words. They can be on one gtt and be unstable or be on 7-8gtts and be stable. # of gts does NOT define instability. Their response and their frequency of nursing intervention is what determines their stability for staffing purposes.

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Specializes in Dialysis.

Allowing hospital management to set standards and criteria for 1:1 would be like letting the fox determine how secure the chicken house should be. This is a clear conflict of interest and the public needs to be educated to this fact. The law should determine safe staffing.

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Specializes in Med-Surg Nursing.

When I first started in the Level II Trauma/Surgical/Cardiac ICU. Anyone on an IABP was to be 1:1. Anyone on CVVH was 1:1, FRESH post-op Open hearts were 1:1 the first 12-16hrs. NOT anymore. My last shift there, I had a pt with BOTH an IABP AND on CVVHD!! they were doubling up ballon pump pts and CVVHD pts.

Sometimes, I'd have THREE pt's with one on a balloon pump!! One night my IABP pt rolled OUT of bed! Why? because I was settling my THIRD patient, a fresh MI who was life flighted to our facility from an outlying hospital...the IABP pt was down the hall where I couldn't keep my eye on him...that was common. Hey, I'm human, I can't be in two places at once...luckily balloon pump guy was ok. Im glad I don't have to deal with that kind of stress anymore!

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