Higher patient load, higher acuity, and adverse events

[snsbelcher]

I work in a 30 bed Progressive care unit with 10 of our beds being licensed for ICU patients. Our administration has been proposing increasing our nurse to patient ratios from 1:3 to 1:4 or even 1:5 at night and on weekends. As of now, we are lucky to have 8 RN's and 2 CNA's on days and 7 RN's and 1 CNA that doubles as our clerk at night. We share an RT with 3 other 30 bed units at this time, and sometimes a physician can be more than 30 minutes away from the bedside due to ER needs and other floor needs. Our patient population's include but aren't limited to CHF exacerbation, COPD exacerbation, Acute SIRS patient's, Acute GI bleeds, HTN crisis with drip titration (Nitro, Nicardipine, Esmolo), patient's in acute NSTEMI pre and post cath, POD 1 open hearts, we are the overflow for the Neuro and Burn ICU, we get many surgical complications DOS or POD 1 patient's with o2 general requirements up to 60% FIO2 and to 100% for up to 8 hours or even continuous BIPAP, vascular emergencies on heparin or argatroban pre and post op,LTC vent patients (with stable trach), we see many drug and ETOH overdose patient's that "Bare close monitoring," acute and chronic liver and renal failure patients, and our bread and butter seem to be insulin drips (acute DKA and HHNKA). We also routinely have at least 1-2 cardizem or dopamine drips on the floor at any given time. All of our patient's are on Tele, but we do not have a monitor tech, so we are responsible for also being aware of the monitors at all times. Our charge Nurse position is being phased out, and even they are taking 3-4 patients every shift at this time. Has anyone seen any resent research regarding increased CAUTI, CLAB, SSI, VAPS, falls, readmissions, or sentinel events related to increasing patient ratios and increased acuity? I'd like to be able to review and discuss this literature with our administration to help support our adverse feelings about proceeding with the ratio increase.

[Been there,done that, ASN, RN]

"I'd like to be able to review and discuss this literature with our administration to help support our adverse feelings about proceeding with the ratio increase."

Skip it. You and your colleagues cannot do this alone.

Your administration is keenly aware of the issues involving safe staffing ratios.

They have chosen to ignore it ... as long as they can get away with cutting labor costs to boost the corporate bottom line.

Research your state's nursing unions efforts to implement legislative reform towards safe ratios.

In the meantime.. get outta Dodge. That corporate plan will not change any time soon.

[Lev, MSN, RN, NP]

Agree with above. Bringing your research to their attention will not do a thing. In fact, they may label you as a "troublemaker." It's all about the about the money. Those ratios sound unsafe given the acuity of your PCU. Start looking for a new job before your license is put at risk.

[thenightnurse456]

Sounds like a recipe for disaster that ends with the nurse getting blamed.

[ProgressiveActivist, BSN, RN]

I think we need to start a letter writing campaign to the president of aacn.

Another avenue to take would be a petition at change.org

There are 500000 CCRNs in the US.

The public would listen to us.

UOTE=Been there,done that;7950359]"I'd like to be able to review and discuss this literature with our administration to help support our adverse feelings about proceeding with the ratio increase."

Skip it. You and your colleagues cannot do this alone.

Your administration is keenly aware of the issues involving safe staffing ratios.

They have chosen to ignore it ... as long as they can get away with cutting labor costs to boost the corporate bottom line.

Research your state's nursing unions efforts to implement legislative reform towards safe ratios.

In the meantime.. get outta Dodge. That corporate plan will not change any time soon.

[TimeFlies]

And in nursing school we learned that we can all protect ourselves by carefully documenting the things we did in caring for the patient. Problem with that is that I don't have time to do an in depth documentation of everything I did in a too low staffing situation when I have to to deal with a too sick patient for that staffing. I do my best to get my patients the very best care possible . Administration will not like or allow documentation that reads anything like " 10:00 charge nurse Jane Smith notified" or things like "called Doctor Brown's paging service back for the third time about this issue at 1200".

The administration does what it does because of the economic realities of the times. Maybe because they can get away with it, maybe because they'd have to close if they didn't constantly press the limits of what nursing can do. One of today's realities is that a nurse is easily replaceable if she or he makes waves. I think its come down do just do the best you can given the situation, stay individually insured, and document what you can when you need to if you can. If that makes sense.

[iluvivt, BSN, RN]

I also agree bringing your literature and/or studies indicating that mortality rates increase as licensed personnel rates go down is not going to change anything. It will most likely label you as an unhappy,disgruntled, trouble-making employee who is resistant to change and is unable to adjust to change or work well within a team to get the work done! They are hell bent on making the changes and pushing nursing to its limits to line their pockets. You need strength in numbers and the only way to do that is through through a nursing union that will push for mandated ratios as we have in California. That was a long and hard fight! Your numbers still sound doable to me but you must be highly organized,have great teamwork, and support staff to assist such as CNAs ,transporters,respiratory and IV therapy if able to get it. The change will most likely happen and you will have to learn to cope or leave. I understand as this has just happened to our team and it is a big mess and I foresee it will change back and in the meantime we and our patients have gone through the doors of hell. The only other way I have seen the pendulum swing back to safer rations is when three things happen: There are bad outcomes that can be directly related to overworked staff,when The Joint Commission adds something to their goals that must be met and when CMS changes how they will pay for something and they need more staff to make that happen.

[gcupid]

I also agree bringing your literature and/or studies indicating that mortality rates increase as licensed personnel rates go down is not going to change anything. It will most likely label you as an unhappy,disgruntled, trouble-making employee who is resistant to change and is unable to adjust to change or work well within a team to get the work done! They are hell bent on making the changes and pushing nursing to its limits to line their pockets. You need strength in numbers and the only way to do that is through through a nursing union that will push for mandated ratios as we have in California. That was a long and hard fight! Your numbers still sound doable to me but you must be highly organized,have great teamwork, and support staff to assist such as CNAs ,transporters,respiratory and IV therapy if able to get it. The change will most likely happen and you will have to learn to cope or leave. I understand as this has just happened to our team and it is a big mess and I foresee it will change back and in the meantime we and our patients have gone through the doors of hell. The only other way I have seen the pendulum swing back to safer rations is when three things happen: There are bad outcomes that can be directly related to overworked staff,when The Joint Commission adds something to their goals that must be met and when CMS changes how they will pay for something and they need more staff to make that happen.

So maybe that is finally it!!!! Lets go after joint commission and CMS...If joint commission affects bottom line and becomes too aggressive I am pretty sure that hospitals would probably not even bother with the accreditation and would work toward another accreditation process that would spring forth as popular and not as costly. So add CMS guidelines for reimbursement to the list of organizations that nurses must seek attention from in order to get things changed for the better.

[snsbelcher]

Administration isn't increasing their bottom line with these ratios. Actually, we had a 470% increase in hai's in May. We went from zero clabs, ssi's, and caudi's last year on our unit to 4 in one month! I have a hard time believing that it is more expensive to staff more nurses than it is to pay for these infections. My manager has also asked that we all do our own research, and bring ideas to the table, so I'm not concerned with being labeled as a trouble maker. Thanks for your replies though.

[toomuchbaloney]

And in nursing school we learned that we can all protect ourselves by carefully documenting the things we did in caring for the patient. Problem with that is that I don't have time to do an in depth documentation of everything I did in a too low staffing situation when I have to to deal with a too sick patient for that staffing. I do my best to get my patients the very best care possible . Administration will not like or allow documentation that reads anything like " 10:00 charge nurse Jane Smith notified" or things like "called Doctor Brown's paging service back for the third time about this issue at 1200".

The administration does what it does because of the economic realities of the times. Maybe because they can get away with it, maybe because they'd have to close if they didn't constantly press the limits of what nursing can do. One of today's realities is that a nurse is easily replaceable if she or he makes waves. I think its come down do just do the best you can given the situation, stay individually insured, and document what you can when you need to if you can. If that makes sense.

Bold and italics mine.

It doesn't really matter if administration likes that documentation. If that is what you did that is what you document regardless of the opinion of your administrator. Your documentation is intended to reflect what you did, what you saw, heard, and witnessed. Your documentation is your friend if something untoward happens during your shift or to the patient you were caring for. When you are deposed and must reflect back upon your actions during the shift, you will be thankful that you indicated that it was the third time you had paged Dr. Slow to Respond, otherwise you might not remember that important detail.

[TimeFlies]

Bold and italics mine. It doesn't really matter if administration likes that documentation. If that is what you did that is what you document regardless of the opinion of your administrator. Your documentation is intended to reflect what you did, what you saw, heard, and witnessed. Your documentation is your friend if something untoward happens during your shift or to the patient you were caring for. When you are deposed and must reflect back upon your actions during the shift, you will be thankful that you indicated that it was the third time you had paged Dr. Slow to Respond, otherwise you might not remember that important detail.

I agree, and have documented in the majority of those cases - but I did it knowing that it was going to get me in trouble with our manager. The manager has expressed that that kind of documentation makes the facility look bad. The reason I documented it anyway was exactly the one you mention: I was reporting what happened in case of a lawsuit. I'd make the same choice again in those particular cases, but it did cost me: my manager gave me an official reprimand and 30 days to "improve my charting". Her examples were printed copies of my charting where she'd marked highlits on my notes that were of the nature "(date, clock time xxxx) call # 3 to Dr. SlowToRespond" in her reprimand, and specifically noted that was what had to change if I wanted my job 30 days later. She told me it drew attention to a liability, and it did. I wish the doc had called back. I wish I hadn't felt I had to document that I'd had to make repeated calls, but the patient condition called for them. So now I'm working elsewhere. Just know that a job search may be the result of doing the right thing.

[nurseprnRN, BSN, RN]

After you report your findings as encouraged by your nurse manager (who, by the way, sounds as if she isn't too damn happy about these proposed changes either), your other alternative is to see if you can get their new staffing ratios in writing and then take that AND your findings on increased infections AND some samples of the increasingly-abundant literature on increased infections, mortality, and morbidity with worse nurse : patient ratios to someone who will listen.

And that, my friend, would be the health/consumer affairs reporters at your biggest metropolitan newspaper and your local TV and radio outlets. Before you say one word, tell them you are reporting anonymously.