ICU Ratios in the US

[ShaunES]

Hey,

I'm in ICU here in Australia, and I've noticed that you guys in the states seem to have 1:2, even with stuff like vents and CRRT.

I'm just wondering about the practical aspects of this; what happens when one of your patients tries to rip something out? Are they all in four point restraints (I've seen a lady nearly self-extubate with a foot!)? Do you just keep them sedated? Are they right next to each other?

In my unit, we have 1:1 for 99% of patients; even the people going to the ward usually are 1:1. Vents are 1:1, no negotation. CRRT 1:1, etc etc.

We keep everything we need bedside, and aren't meant to leave the beside; for breaks we sit between two patients, during which time absolutely nothing can happen to either of them; no physio etc

The only 1:2 is our post-op HDU, and even then we have enough staffing for at least two of them to turn into 1:1's.

Just wondering what your thoughts are on 1:2, do you ever feel like your other patient could get into trouble without you watching?

Anyway, if you have any questions as to how our ICU runs please let me know!

(Also I understand some of you don't have 24/7 medical coverage? How the hell does that work?)

[CNL2B]

What's a HDU?

It is pretty standard in the US that ICU patients are 1:2 these days. There is a post right now on the home page that asks this question as well that you might want to look at (re: ICU staffing and what makes a 1:1.) Most hospitals have some sort of patient acuity decision making tree or something to determine who gets 1:1 care, and generally it is only the unstable patients.

It is not impossible to take care of two ventilated patients with sedation on board and wrist restraints. It happens all the time. We do occasionally have self-extubations (but doesn't everybody?) Some patients tolerate the vent better than others and don't need chemical or physical restraints, as I'm sure you know -- it somewhat depends on the patient.

I don't know how you are set up, either, but most ICUs in the US are set up with either glass doors or open bays where you can visualize the patients from most areas on the unit. This helps us keep tabs on everything as well. If you actually have a room with a door with an ICU patient in it, I could see that it wouldn't work very well to have another one down the hall. We also have a central monitoring station and we can set our monitors in patient rooms up to view another patient if we need to.

As far as MD coverage, I would say most hospitals have either a resident or a hospitalist in house for emergencies at all times, overnight, etc. There are some small rural hospitals that do not and you actually have to call someone in if you need something. I don't feel that is really safe, but yes, that happens too.

[sunnycalifRN]

Yes, 1:2 in our unit is standard. 2 stable vent patients is quite doable. As much as possible, the 2 patients are in adjacent rooms so you can see both from one vantage point. And, usually, one patient gets more attention than the other, whether due to hemodynamic instability, agitation, stooling or demanding family. The "hell" assignment is when both patients are very "heavy"!! That's when you hope that you've got a helpful "neighbor" nurse.

If the patient is extremely agitated and cannot be chemically restrained for whatever reason, we'll get a "sitter" to stay at the bedside.

[aCRNAhopeful]

Vents really are never an excuse for 1:1 in my unit. It does happen that they will be 1:1 if staffing allows but if thats the most invasive thing they have they are 1:2. Patient like open hearts, baloon pumps, and CRRT will be 1:1 in my hosp.

[Hoozdo, ADN]

Two intubated, sedated patients, next door to one another, with no family

present is a delightful assignment in my eyes. I can actually get done with

all the patient care and charting and get out on time!

[hockeynpolo]

1:2 is pretty standard for me too (Texas).

[HollyHobby]

I worked for a long time on a unit where 1:3 was standard. Normally, two of my three would be vented, but sometimes all three were. We also did not have a lot of ancillary staff (no aides, no phlebotomists, no 12-lead techs, no transporters, and the x-ray tech was solo so the nurse had to assist, and oftentimes we didn't have a unit secretary either). Charge nurse took a full assignment too.

The only patients who were 1:1 were fresh postop hearts- for the first 4 hours only. If you had a patient with CRRT or a gunshot to the head on a continuous EEG and pentobarb drip, you would only get two patients. Even if one of your patients was actively coding, you would still get two patients.

For some of our patients, we could call the in-house resident, but generally we had to call doctors at home. The docs were pretty hostile as a rule, up to and including physical battery in a few cases. Verbal abuse was the norm.

It was a scary place to work and I'm so very glad I'm not there anymore. At the place I work now, I would never have three vented patients.

[meschell]

My hospital (Indiana) is 1:2. The only 1:1 pt's are CRRT and first day open hearts. Open heart are then 1:2 on the second day post-op.

[Darkfield]

I'm very concerned about HollyHobby and her verbal abuse from the docs. That whole post was disturbing.

I work at a teaching hospital, and there are residents there 24/7. (They vary in skill...) They are supposed to call in the fellow or attending if there is something they can't handle. There is almost always one doc right there on the floor, but they sneak out sometimes. Saturdays are the worst because we usually have a 2nd year doc and a brand new intern, both on a 24-hr call, and the interns aren't very useful. So that leaves 1 doc for a 16 bed icu...it can be troublesome.

With staffing, it is always 1:2, and I'd rather have 2 vented, sedated patients than 2 awake and floor-ready pts. We do 1:1 with very unstable pts, those on CVVH (CRRT) or the oscillating vent. Or if someone is just unstable and we don't know how its going to go. Ideally, we should be able to single two patients every shift.

Interesting to hear how it works in Australia.

[pedicurn, LPN, RN]

I've worked MICU in Australia ...in my experience vents were always 1:1.

We didn't have RTs though ....the nurse maintains ventilation and sorts transport stuff etc. Docs order ventilation settings

HDU (High Dependency Unit) usually 2:1. These p'ts often have arterial lines, BIPAP, Dopamine infusion, trache

[RNperdiem, RN]

2:1 is possible when there are Respiratory Therapists to handle all vent needs, they will even do all the trach care.

Wrist restraints are often necessary along with the right amount of sedation.

A vented patient off sedation is either being evaluated by the neurosurgeons or going to be extubated soon.

The CRRT patients are usually 1:1, and even then, the dialysis nurse will set up and take down the dialysis.

My hospital uses transport nurses when you have a pair of patients. The transport nurse has a pager and will take your ICU patient to CT scan, MRI or wherever.

[nurse2033, MSN, RN]

We have a 1:2 as a guideline. We will go to 1:3 if acuity is light. Between the charge nurse and patient nurse we can discuss making a patient 1:1 is they are busy enough. CRRT is always 1:1 but we tend to work it out to what makes sense. Vented patients are in 2 point restraints if active enough to pull out a tube. Most vented patients are sedated to light or moderate sedated, whatever seems to work. If a patient pulls out an ET with their toe, maybe they deserve to have it out! lol