patient ratios?

  1. We recently had a meeting at work and one of the nurses brought up the fact that there are actual guidelines for patient/nurse ratios in mother/baby and that if our assignment is higher than set guidelines, we can personally be sued if there were a problem. I guess the point is that the staffing should be 3 -4 mother/baby couplets, max. And if one patient is high-risk (mag patient, hemorrhage or AP, etc) then there should be no more than 3 couplets, including the high risk patient.
    I know that there is a lot of under-staffing in nursing in general, that is no surprise. What surprises me is that we are liable if our assignment is too heavy and there is an incident. We can't refuse our assignments, because then we will have no nurses. We are not unioninzed although there are whispers now about possibly considering it.
    What to do about this? We can't force management to hire more nurses, although I wish we could.
    I know maternity has one the highest risks for lawsuits but is it that way in other specialties? Has anyone ever had a problem where a nurse was held liable in the case of too-high patient load? How does your hospital handle it?
    RIght now we have approximately 300 - 400 births/month, with 29 postpartum beds. I am not sure how many nurses, but there are usually 5 - 7 on per shift, includes nursery nurse. (Sometimes we borrow one from labor floor, sometimes we just shut down the nursery) Usually one or two techs, and a secretary about half the time. We all have to take call time too, which I didn't realize is not standard practice for other floors.
    I am starting to wonder if working here is a risk to my license. We are a great group, teamwork is huge, we have a great local reputation for our maternity care, and we haven't had any incidents that I know of. I just wonder if its safe for my license here. The other night I had an ap with kidney stones and pain issues, a mag patient on hourly checks and her baby, a relatively new admit from a couple hours before me and her baby, and I admitted another couplet as well. I was busy and I handled it fine...but was I safe?
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  2. 22 Comments

  3. by   mitchsmom
    Good question... we are over the recommended ratios alot too. I haven't really had it much because I'm new and they are taking it easy on me so far but I know it won't last. But it seems like everyone has staffing problems, so...
  4. by   UKRNinUSA
    No you can't force management to hire more nurses but if you did go ahead and unionize you could get the ratios enforced as part of the union contract and perhaps more RN's would consider working there. Apparently the nurse ratio law in California has made a significant impact on recruitment and retention. I'm not a legal expert but I understand that if your unit is operating at a level below the generally accepted standard of care, you need to report it to your manager and/or risk management to avoid a malpractice claim against you.
    I think that the worst thing you can do in this situation is nothing -good luck in standing up for yourself, your colleagues and your patients.
  5. by   UKRNinUSA
    sorry duplicate post
    Last edit by UKRNinUSA on Nov 4, '06
  6. by   UKRNinUSA
    sorry triplicate post
    Last edit by UKRNinUSA on Nov 4, '06
  7. by   MamaMadge
    CoopergrrlRN, that sounds like a heavy load for someone with only 5 months experience! The legal ratio in CA is 4 mother baby couples per RN. We are also over sometimes when we relieve each other for breaks but our hospital tries really hard to keep the ratios safe. Have you approached your shift lead when you have an assignment like that? I don't think you have to "refuse" the assignment but it helps if you tell someone you aren't comfortable with the acuity of the patients you have. Nothing has happened yet.....but why wait until something does happen? Then everyone is sorry and you end up in a law suit! Just remember how hard you worked for that license!! I only have a year and a half experience and I still wouldn't take the assignment you had!
  8. by   MIA-RN1
    Quote from MamaMadge
    CoopergrrlRN, that sounds like a heavy load for someone with only 5 months experience! The legal ratio in CA is 4 mother baby couples per RN. We are also over sometimes when we relieve each other for breaks but our hospital tries really hard to keep the ratios safe. Have you approached your shift lead when you have an assignment like that? I don't think you have to "refuse" the assignment but it helps if you tell someone you aren't comfortable with the acuity of the patients you have. Nothing has happened yet.....but why wait until something does happen? Then everyone is sorry and you end up in a law suit! Just remember how hard you worked for that license!! I only have a year and a half experience and I still wouldn't take the assignment you had!
    The thing is that we all had crappy assignments. There were four ap's on the floor all together, and some others w. stuff going on as well. That assignement I mentioned, I left out that one of the babies was not doing well either, kept haveing temp drops.
    I was reading another thread...I can't believe that there are other hospitals where the ap's and mag pts etc don't even go to the postpartum floor. I mean I believe it, but I can't believe its that way where I am! We are probably the second or third smallest maternity unit out of the 4 local hospitals and we only have 6 beds in our special care unit; no NICU. But the moderate risk ap's and the pp's with issues still come to us. A few weeks ago, we admitted someone with an increased bp TWO WEEKS after delivery for mag (yea I got her) And the other night, a C-sect came to ED 2 weeks after discharge with what they called a late-onset hemorrhage and retained clots. Her crit was 23, for some reason they felt she needed to be on our floor, and also receive a transfusion....yep, I got her too. (We normally don't transfuse higher than 20 but I guess the ED docs felt different) Don't get me wrong, the nurses I work with are awesome and they help me whenever I need it. I guess I should say that I am glad to get so much experience out of the realm of routine PP care. We also get any ap's who are more than 16-18 weeks, no matter what their issue. Like the ap w/ kidney stones, she went for surgery (can't remember the name of it, I think ureteroscopy? and another surgical procedure, came back to our floor, found out the surgery was NOT successful and was going for stent placement and again to our floor. Seriously, she did not need maternity care. Q4h doptone FHT's can be done on any floor and the fetus wasn't viable anyway so the question of monitoring fetal heart tones is up in the air. But that's how our hospital does it.
    hmm..maybe I should move to CA?
  9. by   MamaMadge
    hmm..maybe I should move to CA?[/quote]


    CoopergrrlRN....come on over!!! We could use you! The weather is great, it's a little expensive to live here but a very good overall quality of life!

    We also get all of the AP's that have any type of problem at all! No matter what the issue, if they are pregnant at all we get them....oh well, good to brush up on those med-surg skills right?
  10. by   MIA-RN1
    lol yup. Tonight for some unknown reason I had a TAH w/ BSO....
  11. by   flytern
    You're stuck between a rock and a hard place!
    There are patient ratio standards that are set from ACOG and AWHONN.
    However, try to get a hospital to abide by them is another thing.

    Management (and I think particularly in OB) just assumes that we will suck it up, go without breaks/lunch to give our patients good care. How many times do you ever get out on time? You give all to the patients and there's nothing left for yourself.

    I work in a hospital w/a union. I've not seen much difference. We're still understaffed, overworked, burned out. We could refuse an assignment, house supervisor would be called (the usual chain of command).....
    but what had are they going to pull the extra nurses out off? It's not like you can take a med/surg nurse and instantly teach her labor or even post partum.

    I'm not sure what the answer is, or even if there is one.
  12. by   MIA-RN1
    last night we had to use both our call people, and another nurse who said she'd work and we STILL had heavy caseloads. I had five couplets myself; the AP's and TAH were thankfully not mine last night. But still...two of my mothers were c-sects, one baby was coombs +, and they were all but one breastfeeding.
    No break, no dinner, and no sitting down til after my shift ended.
    We had a pt who was postpartum who was dx'd w/ pulmonary embolism and put on heparin drip. Stayed on our floor too.
    I heard that the NM showed up unannounced on the night shift the other night and said that she didn't give a $^!+ about our concerns about staffing because we were well staffed. (We have said that our ancillary staff is just not enough because so many of them are in school that we can't get enough techs and secs on the floor to help. We are often taking our own orders off, and doing our own vitals. Just the other night, I taught two techs, who had been there way longer than I, how to do the QC on the bg machine! DUH. And I taught one of those two techs how to do a fingerstick bg. She had never done one!) NM asked where our overnight tech was. When she was told she was out on disability, and that labor floor only had one, she announced that the labor floor tech should cover both sides. That would be like 40 patients. Vitals alone would take hours. She feels we are staffed adequately. I'd like to see her come work in our shoes for a while.
    I am really worried about my license. I am providing good care, although we all got in trouble for not taking enough time to sit and hold our patients hands etc. (and we must not say its because we aren't staffed adequately because NM said that's an excuse), we had to go to a mandatory class about compassion believe it or not.
    Anyway, what if something happens because I am too busy and pulled in too many directions? Two of my patients had breathing issues develop on my shift last night. Thankfully they were both okay but what if I had missed something? What if I am running around so fast I miss something important? I know its probably like that everywhere but one of the reasons I went into OB is because I like the time to spend teaching moms about their babies and caring for the baby and themselves. And because the ratios should be enforced since we are dealing with newborns. I guess I was naiive in thinking that just because something should be one way, that it really would be that way.
    My coworkers are great, no complaints at all. But its hard on all of us, morale is down, and we've lost some already.
    Is it like this everywhere????
  13. by   rassccal
    o.k guys here's our recent problem, I live in a very small community we have about 180 deliveries a year. We have at all times 1 rn nurse and one tech but obvisouly if we get slammed we can call an lpn every once in a while. Also, our nurses due labor and delivery post-partum care and nursery, 1 nurse for a 12 hour shift filling all those positions. We have 2 LD rooms and 3 postpartum rooms.
    Now, heres what's going on, within the last couple of years we have hired in new ob/gyn and family doc with a gynecology background so our census is slowly climbing. but upper management is still refusing to give us a second nurse all hours of the day. There looking at numbers and most patients come in as observations and stay that way till deliviered and they also dont consider those that must stay the night due to uti's and so forth. So i need to know where can i find some concrete evidence to bring before upper mangament about paitent ratio dealing with our unique situation.
    This has been a team effort and several of the nurses have called surroundings hospitals to gain info. But the info they give us doesnt' nessccarily apply to us do to the fact that we must perform the job of 3 nurses (labor and delivery nurse, post partum nurse and nursery nurse), Yesterday, a meeting was called that the new policy is that this one nurse now must be able to handle 2 pitocin patients plus whatever else. Needless to say we are on the verge of a walkout so where if anywhere can i go to get more info to help us out or i'm afraid of an ob shutdown. Oh by the way we are the only nurses in the whole entire hospital who know ob, theres food for thought and our prn list is useless due to you can never get them to come in, and there is no on call list
  14. by   SmilingBluEyes
    Ihave said for years, OB is more like the ED than med-surg or other units. We have to see everyonel, directly and promptly, who is 20 weeks or over for any complaint that may even be slightly related to the pregnant condition. Anyone who has been in the ED know it's feast or famine, from one minute to the next and it's really hard to staff for "what ifs" in our situation. Shifting patient assignments is the only we can handle it on busy shifts.

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