ICU nurses, Is 3:1 patient to nurse ratio a common occurence or am I just tripping?

[Scrubs911]

*I posted this in the new grads section but I also want to hear from the experienced nurses*

Hi. I'm a relatively new nurse in a general ICU (we get a variety of patients). Considering the shortage of jobs for new nurses, I'm very grateful I found a job in an area of nursing that I find interesting albeit challenging. When I interviewed for the job, I was told that the Patient:Nurse ration was 2:1, and very rarely would a nurse have 3 patients. Well as it turned out, 3:1 is the norm on the unit (we're chronically understaffed) as I've seen more nurses tripled than doubled on any given day. Is that the norm in ICUs? Or is it just because we're a general ICU? I personally think it's dangerous because there is no way a nurse can be in 3 rooms at a time, and inevitably, one or more patients receive less than optimum care, especially if one of the three patients is more critical than the others. I worry about liability should something go wrong on the nurses' watch (more like the absence of it). Should I be concerned about this or is this the way things are in most ICUs?

PS: It's insane that nursing units across the country are so understaffed (putting more stress and workload on the nurses especially the more experienced ones) while thousands of nurses, new and old, remain without work.

[christyness, BSN]

Pts on my unit are 1:1 if they are very unstable, on an oscillator vent, or receiving CVVH. Otherwise, they are 2:1, never 3. If they are well enough to be 3:1, they go to the IMC.

[IndiCRNA]

As a rapid response nurse you're probably arriving to a code after the more chaotic period has passed and everyone has decided what they're going to take care of during the code. Like dodongo said, usually it's just the first couple minutes when everyone is caught off guard that are helter skelter. Even for ICU nurses that do it all the time. It's unexpected, your adrenaline is going and you want to make damn sure that everyone hears you and gets what you need.

I work at the same hopsital and PMFB. I would guess he is already on sceen in about half of the codes. many times there are indications before the code that some thing is going wrong and the RRT RN is already on the case. He is right, our codes are calm and well run, no yelling or excitment is allowed. Even our tele nurses have to go to Sim Man lab and run code senerios. About the only time we have yelling and excitment at a code is if a code is called in a non clinical area, like the cafeteria. Pretty normal to hear low key off topic conversations going on during a code since there isn't much stress or excitment. Our code team has worked very hard training staff to respond appropiatly. There is usally a mock code some place in the hospital every shift. By the time a med-surg RN faces her first code on her own patient she has already gone through dozens of Sim Man simulations, ACLS, several mock codes, and attended a real code or two during her stint on the code team (madatory for new hires).

[tothc2]

I work at the same hopsital and PMFB. I would guess he is already on sceen in about half of the codes. many times there are indications before the code that some thing is going wrong and the RRT RN is already on the case. He is right, our codes are calm and well run, no yelling or excitment is allowed. Even our tele nurses have to go to Sim Man lab and run code senerios. About the only time we have yelling and excitment at a code is if a code is called in a non clinical area, like the cafeteria. Pretty normal to hear low key off topic conversations going on during a code since there isn't much stress or excitment. Our code team has worked very hard training staff to respond appropiatly. There is usally a mock code some place in the hospital every shift. By the time a med-surg RN faces her first code on her own patient she has already gone through dozens of Sim Man simulations, ACLS, several mock codes, and attended a real code or two during her stint on the code team (madatory for new hires).

Your med surg RNs take ACLS? And all nurses go to codes and simulations? You have to have meant something else here. Unless you are at an extremely small hospital. Even then, where's the money coming from for all of this? And maybe he can anticipate a code on a med surg floor if they go from one extreme to the next over a period of time. But in the ICU? There would have to be a rapid response nurse just hanging out in each of the ICUs in the hospital because there are MANY if not all patients on the verge of a code. Your hospital has a lot of resources and money.

[IndiCRNA]

Your med surg RNs take ACLS?

Naturaly.

And all nurses go to codes and simulations? You have to have meant something else here. Unless you are at an extremely small hospital.

Yes all new nurses, as part of the nurse residency, will spend time on the code team with an "orientee" badge on. All will go through the Sim Man lab initialy and then anually for refresher. Our hospital is fairly small, but at 580 beds I don't consider it extremely small.

ven then, where's the money coming from for all of this?

Dunno. Our hispital, like every one I have experienced, is always crying poor mouth and budget cuts, yet seems to have plenty of money to waste on silly ideas.

And maybe he can anticipate a code on a med surg floor if they go from one extreme to the next over a period of time. But in the ICU?

Yes but it's the ICUs. Those nurses are highly experienced and trained and take care of things themselves. Usually I just place a tube (if needed) and bug out. They have had everything well in hand.

Due to the nature of our ICU patient population and our superb step down unit (means only the sickest of the sick are still in ICU or whould have been moved to the step down) codes are not ususual and the ICU staff well versed in dealing with them. As I have heard PMFB say when training nurses "Hey it's not YOU who is dead, why get all excited?".

Your hospital has a lot of resources and money.

Most hospitals do, despite their claims to the oppisit. I would bet than many nurses here have heard their hospital say there is no money for raises for nurses this year, only to see the hospital waste money doing something silly or stupid.

[tothc2]

Naturaly.Yes all new nurses, as part of the nurse residency, will spend time on the code team with an "orientee" badge on. All will go through the Sim Man lab initialy and then anually for refresher. Our hospital is fairly small, but at 580 beds I don't consider it extremely small. Dunno. Our hispital, like every one I have experienced, is always crying poor mouth and budget cuts, yet seems to have plenty of money to waste on silly ideas. Yes but it's the ICUs. Those nurses are highly experienced and trained and take care of things themselves. Usually I just place a tube (if needed) and bug out. They have had everything well in hand.Due to the nature of our ICU patient population and our superb step down unit (means only the sickest of the sick are still in ICU or whould have been moved to the step down) codes are not ususual and the ICU staff well versed in dealing with them. As I have heard PMFB say when training nurses "Hey it's not YOU who is dead, why get all excited?". Most hospitals do, despite their claims to the oppisit. I would bet than many nurses here have heard their hospital say there is no money for raises for nurses this year, only to see the hospital waste money doing something silly or stupid.

You say "naturally" like this is the norm. But it is not... All ICU nurses should have ACLS, the majority of step down RNs should, but I have never heard of med surg RNs having or being required to have ACLS. This is very strange and very much not the norm. At my hospital between the MICU, SICU, STICU, TICU, NICU, MSICU, CCU, CVICU, etc and all of their respective step downs, how there would be enough classes, money or time left for med surg nurses to get ACLS certification is beyond me. And if I were a med surg nurses not planning on going into critical care I wouldn't waste my time or money. And yes hospitals have a ton of money, but I'm saying when have they ever invested it into their nursing staff (to send all of them to sims, acls and code observations). Which from your post I see we agree on.

[gaonsi]

You HAVE to know the concentration of anything you give. You just have to know. Would you give an unlabeled syringe of what pharmacy called epinephrine during a code? I wouldn't. I would want to know how much epinephrine I am giving with this syringe. If an unlabeled bag came from pharmacy I would go mix my own bag (or if you're busy with compressions have someone else mix it for you). Just because a physician tells you to do something doesn't mean you do it. Sometimes they get a little carried away during a code and get ahead of themselves too.

Also - especially if it was a liter bag that came up. I've never seen epi in a liter bag. Red flag. I'll give you the benefit of the doubt though. Codes can be crazy and everyone is shouting and doing things and sometimes you don't know what you've got in your hands at first.

But aren't codes the most exciting thing about your job? I loooooove them. So fun.

Thank you for bringing that up tactfully! I was thinking the same exact thing. I hope this is a 1 in a million type situation. Just because its a code, it doesn't mean nurses can be careless. Even in the chaos of a code, we label our meds and use our drug mixing guide. Code carts have a bunch of different meds, so just because its a code, you don't double check our meds?! Scary ish. Epi wide open?! Scary.

[PMFB-RN, RN]

You say "naturally" like this is the norm. But it is not... All ICU nurses should have ACLS, the majority of step down RNs should, but I have never heard of med surg RNs having or being required to have ACLS. This is very strange and very much not the norm.

*** I remeber when med-surg nurses didn't have to be ACLS. However I have worked as full time staff in three larger hospitals in the last 6 years, and more hospitals on a casual or part time basis and all sent med-surg RNs to ACLS. All I can say is that it must be regional. This is the upper midwest and the hospitals I have worked in were/are in Wisconsin and Minnesota (only one in MN, my current one).

Our current hospital (IndiCRNA & mine) is a very good hospital. Union and non Magnet. We are treated and paid very well. Lots of long time nurses here and few opening.

[PMFB-RN, RN]

Most hospitals do, despite their claims to the oppisit. I would bet than many nurses here have heard their hospital say there is no money for raises for nurses this year, only to see the hospital waste money doing something silly or stupid.

*** Case in point. One hospital I worked at a few years ago told us money was tight and there would be no cost of living raise for staff. At the same time they started their "Journy to Magnet" and even hired a nurse with an MSN to facilitate getting Magnet certified. I don't remeber how much they spend to get certified but it was a lot. That combined with the heavy handed tactics used to get the nurses to respond appropiatly to survayers questions caused moral to plumet. In the end they got their certification and we didn't get our raises

[*LadyNurse*]

You say "naturally" like this is the norm. But it is not... All ICU nurses should have ACLS, the majority of step down RNs should, but I have never heard of med surg RNs having or being required to have ACLS. This is very strange and very much not the norm.

Really?

Honestly I never put much thought into it because as a new nurse (8 years ago) starting on a Med-Surg floor, I was required to have ACLS (as were all RNs) and all employees of the hospital had BLS training.

[Dodongo, APRN, NP]

Hmmmm. Interesting to hear this. I only have experience in the northeast and mid Atlantic regions. Med surg nurses are welcome to get acls but they will be paying for it themselves. CCRNs, and to a lesser extent PCRNs, are required to have acls and the hospital/unit will pay for it. I guess theoretically it sounds nice for all RNs to have acls but they would so very rarely use it I doubt how useful it would really be. My hospital is a laaaarge academic teaching hospital with a toooon of ICUs and step downs. True codes on the floors are very rare. A condition C is really all med surg nurses would be dealing with. The step downs have a much higher chance and then of course the ICUs deal with them all the time.

[PMFB-RN, RN]

Hmmmm. Interesting to hear this. I only have experience in the northeast and mid Atlantic regions. Med surg nurses are welcome to get acls but they will be paying for it themselves. CCRNs, and to a lesser extent PCRNs, are required to have acls and the hospital/unit will pay for it. I guess theoretically it sounds nice for all RNs to have acls but they would so very rarely use it I doubt how useful it would really be. My hospital is a laaaarge academic teaching hospital with a toooon of ICUs and step downs. True codes on the floors are very rare. A condition C is really all med surg nurses would be dealing with. The step downs have a much higher chance and then of course the ICUs deal with them all the time.

*** Not all RNs have to have ACLS in our hospital. Just acute care RNs. There are lots of nurses in psych, rehab, clinics and similar units that do not have ACLS. For us it's ICU RNs (obviously), step down RNs, and medsurg RNs. Also of courses units like IR, ER cath lab etc would be ALCS. All of our med-surg units are tele units. We are also a teaching hospital with scads of interns and residents hanging around duirng the day, many fewer at night.

It really isn't very expensive to train people to ACLS. Any nures who needs the initial 2 day class does it during orientation. Re-cert is online (I highly recommend it) Either the nurse manager gives them the 5 hours required to do the online recert during work hours, or nurses do it from home and get 5 hours OT pay when they hand the printed completion certificate to their NM. All of our RRT RNs are ACLS instuctors and can do the hands on skill check any time when the nurses has a few min free.

[Dodongo, APRN, NP]

*** Not all RNs have to have ACLS in our hospital. Just acute care RNs. There are lots of nurses in psych, rehab, clinics and similar units that do not have ACLS. For us it's ICU RNs (obviously), step down RNs, and medsurg RNs. Also of courses units like IR, ER cath lab etc would be ALCS. All of our med-surg units are tele units. We are also a teaching hospital with scads of interns and residents hanging around duirng the day, many fewer at night. It really isn't very expensive to train people to ACLS. Any nures who needs the initial 2 day class does it during orientation. Re-cert is online (I highly recommend it) Either the nurse manager gives them the 5 hours required to do the online recert during work hours, or nurses do it from home and get 5 hours OT pay when they hand the printed completion certificate to their NM. All of our RRT RNs are ACLS instuctors and can do the hands on skill check any time when the nurses has a few min free.

I guess my line of thinking is this - most med surg nurses don't experience code situations often enough for this to matter. The majority hardly use BLS enough to know how to properly do compressions or even use a zoll. I just don't see the point for them having ACLS as they won't use it often enough to remember it or utilize it properly. If a med surg nurse finds a pulseless pt, for example, they'll hopefully start CPR, call a code and within minutes the code team will be there to take over. I'm not saying there's anything wrong at all with your nurses having ACLS. But if you don't use something at least sometimes, you aren't going to be able to utilize it properly after even just a few months. I could maybe see med surg nurses having ACLS at a hospital without appropriate step downs available.