Nurse: Patient Ratios

[aei09a]

I have been an RN for 2 years, and recently started a new job in a Critical setting. I am a part of a 24 bed Medical CCU. It is a very fast paced unit where we have high acuity patients such as Sepsis, induced hypothermia pts, CVVHD, and Intubated, ect. The typical nurse:Pt ratio is 1:1 or 1:2 which I believe is normal.

The question I have though, is occasionally nurses on my unit will be trippled if it is later in the shift (no one ever starts out trippled). After working for 4 months this still has not happened to me, but it makes me uneasy.

I understand the management's persepctive, as well as the nurses perspective on that issue, it must be very difficult to staff this place, when at some times half the floor may be 1:1 ratio. (therefore 2 pt's is considered being trippled) and I always help out others when they get 3 pt.s

Is this normal?

Unfortunately, I can't think of a way to get around this problem, it's not like other nurses can float to the ICU like they can on the floor (which was often an option when I was a floor nurse). Should I look for another job? Perhaps I can wait a year to not look so bad.... has anyone else faced this issue and if so, have any suggestions I could bring to my boss? Ultimately I would like to remain here and see if there is a good idea our unit could try. I would appreciate any suggestions, thank you my fellow nurses!!

[HazelLPN, LPN]

If a pt was on 1:3 care, they were ready to go up to the floor and we would try to ship them out as soon as possible. If a nurse had to take three patients, one would be the pt who was waiting to go upstairs and that nurse would either have back up from the charge nurse (who never took a pt assignment except for covering an LPNs patients..which was very little work as LPNs have a very broad scope of practice and manage 95% of the patient on their own) or the RN taking three patients would have a UAP with them (usually these folks were in nursing school). It was rare for a nurse to have three patients for more than a few hours...half a shift at max. The only time I remember having three patients for an entire shift was when we had three kiddos (this was in PICU) waiting to go to the ID floor that was getting slammed with sick bronchiolitics...I think they had 13 admissions in 12 hours. At the end of the shift, we ended up transferring all three kids from the PICU AND sending a nurse to help out the ID floor which was severly understaffed after all of those admits.

If the nurse taking three patients is given the most stable ones ( that could be cared for on the floor) and has back up from the charge nurse and one of these will go upstairs soon, this shouldn't be a huge issue. However, I would be concerned if one was expected to take three patients which should really be getting 1:2 care.

Best to you in your new role in the ICU,

Mrs H.

[MomRN0913]

Generally 1:2. 1:1 for sick patients.

We also go 1:1 for patients who are particularly needy, "VIP", patients who have a lot of road trips that day, very restless or too tasky. We 1:1 *all* patients who need isolation - contact or otherwise, all post-transplant patients and all patients who are transitioning to comfort care to be able to best manage symptoms and support the family. All patients with devices like IABP or CVVHD are singled. Patients who are crashing hard or who have needed the Level 1 in the past 24 hours get 2 nurses assigned to them.

We never, ever, ever, ever have more than 2 patients, regardless of acuity. We also staff 2 charges nurses to the unit at all times who do not have assignments. We have 1 nurse who is dedicated to doing the admission paperwork, orienting families to an ICU environment and helping to manage manipulative or needy family members that may be obstructing our ability to work. On top of that, we have float nurses who are extra RNs without an assignment that cover an assigned 3 nurses to help do turns, baths, road trips, transfers, codes, whatever... they also make sure we get our breaks. 2, 20 min. breaks in the first 6 hours of the shift, 1 hour long lunch break and at least 2 more 15 minute breaks before we leave.

Needless to staff, our staffing is phenomenal.

I would like to know what hospital this is, as I would like to pack all my stuff up and go work there:)

[g!RN]

Generally 1:2. 1:1 for sick patients.

We also go 1:1 for patients who are particularly needy, "VIP", patients who have a lot of road trips that day, very restless or too tasky. We 1:1 *all* patients who need isolation - contact or otherwise, all post-transplant patients and all patients who are transitioning to comfort care to be able to best manage symptoms and support the family. All patients with devices like IABP or CVVHD are singled. Patients who are crashing hard or who have needed the Level 1 in the past 24 hours get 2 nurses assigned to them.

We never, ever, ever, ever have more than 2 patients, regardless of acuity. We also staff 2 charges nurses to the unit at all times who do not have assignments. We have 1 nurse who is dedicated to doing the admission paperwork, orienting families to an ICU environment and helping to manage manipulative or needy family members that may be obstructing our ability to work. On top of that, we have float nurses who are extra RNs without an assignment that cover an assigned 3 nurses to help do turns, baths, road trips, transfers, codes, whatever... they also make sure we get our breaks. 2, 20 min. breaks in the first 6 hours of the shift, 1 hour long lunch break and at least 2 more 15 minute breaks before we leave.

Needless to staff, our staffing is phenomenal.

What hospital is this?, I think I am going to pack up my entire life and transfer there...lol

What is your retention rate?

[henryburdick]

Where do you work?

[jelly221,RN]

I'm with everyone else- nursenotmaid, where do you work? I'm already in SoCal and I want to go to wherever you are!!!

[Chisca, RN]

If you really want to fight this you will need the help of your coworkers, a willingness to measure and document acuity, and a lot of luck. There are acuity systems to measure the workload of nurses but most institutions resist this because once you start measuring you will find just how understaffed you really are. Start accumulating data and educating your fellow nurses on the importance of acuity in determining staffing patterns. You will need to show a pattern of understaffing and not just one or two instances of being short staffed.

The commenters from California are benefiting from the political power nurses have in that state courtesy of the California Nurses Association. If management refuses to discuss acuity go to the local media. Contact your state representatives and educate them on acuity and the importance of patient safety. Educate patients and their families on why staffing by acuity is so important to safe care. Safety is something that everyone can agree on.

SFAR - Société Française d'Anesthésie et de Réanimation

I like the TISS system developed by Washington University in St Louis. One nurse can safely care for a total of 45 TISS points. This system also has been validated and peer reviewed. If your hospital claims to measure acuity ask what system they use and what peer review has it undergone. I have worked at many hospitals that claim to staff by acuity but rely on in house systems that have never been used outside the institution that developed them.