Staffing ratio for this patient

SmilingBluEyes · Oct 7, 2005

1:1 if at all possible.

small community hospital, less than 100 del/mo

LDRP set up

fergus51 · Oct 7, 2005

Should be 1:1, especially in a smaller hospital which may have less resources than a level 3.

babynurse2001 · Oct 8, 2005

1:1 and transport her to level 3 facility

USA987, MSN, RN, NP · Oct 8, 2005

There probably should have been 2 of you working on her when she came in until you could get everything going. Then she should be 1:1.

NurseforPreggers · Oct 8, 2005

What is the criteria for transferring this patient out to a Level III facility? I work in a Level II facility and we have similar patients all the time. Actually I don't think I've seen a single patient transferred out of our facility until after delivery, and then I've only seen babies transferred, not mommas. I'm just curious what the criteria is.

babyktchr, BSN, RN · Oct 8, 2005

Working in a level I facility, this patient would've definitely been transferred to a tertiary facility...no question. We transfer anything that is preterm with possible delivery. Our teritiary facility is 2 hours away and sometimes it takes a while to mobilize the NICU team for a newborn transport. Bagging a baby for over 3 hours gets a bit hairy, so we like the mom/baby package to go for safe care. We also transfer sick ones like the one you have described.

I know you wanted to hold out on details, but I am interested in knowing what lab results for this patient were.... especially her Mg levels after all of that Mg,and what the strip was like. Really interested to see what her DIC screen was.

Do tell..................................?

malibu03 · Oct 8, 2005

In a perfect world, I'd say 1:1. Yikes, still contracting through the mag at 3gm/hr? At this point, I would certainly be thinking of transferring her, but wondering if more stabilization is needed for the 100 mile ride to the level III.

We recently had a 30 weeker, 3/50/-2, bulging bag, contracting q 2-3 min on 3gm/hr Mag and we transferred her to a level III fairly quickly.

You have to tell us what happened!!

30 weeker, twin gestation, contracting q 2-3, dil. 1+,75,-2, BP's 145/85, +3 DTR's, On Mag.... 6gm load, 3gm/hr. When she was still contracting q 2-3... additional 2gm load and ^ to 3.5 gm per hour. Q 15min vitals. Q 2 hr mag levels. PIH labs. Q hour I/O and DTR's. Level II hospital w/ approx 100 del/month. Our closest level III is 100 miles away.
Just throwing this out there. I don 't want to tell the whole story until I get some feedback...

fourbirds4me · Oct 8, 2005

I know you wanted to hold out on details, but I am interested in knowing what lab results for this patient were.... especially her Mg levels after all of that Mg,and what the strip was like. Really interested to see what her DIC screen was.
Do tell..................................?

Well... this is just another event in the long line of short staffing issues at my hospital. Sometimes I feel like I only post when everything just gets TOO overwhelming. Of course... I too, feel like this pt should have been at least 1:1 and should probably have been transferred. We even have a policy that says pt with obstetrical complications should be 1:1. However, she happened to be one of my 3-4 pts that night (including a labor... going natural... progressing quickly...complete...coaching her to breath through ctx for over an hour while the doctor, anesthesia and 2/4 nurses on the floor were in a c/s.) At one point I realized that I hadn't been in to see her in >2hours. Our manager refused to get us more help... saying there was no one else that could come in. Finally the DR on call intervened and called administration to get us some help.

This had tragedy written all over it... THANK GOD... we dodged the bullet once again. When I last heard...This pt. is still undelivered... she was transferred the next day to level III. Her mag levels got up to 8.5 ... at which point she stopped contracting and starting complaining of shortness of breath and severe headache and nausea.

I LOVE the people I work with... like my hospital... LOVE my pts.... HATE that our management doesn't have a clue... HATE that pts don't get the care they deserve and that everytime something like this happens my license and livelyhood are on the line.

The funny thing is... this wasn't the most critical pt that night. Another nurse transferred a 33 weeker with "asthma" to our PP unit. She had just had a pulmonologist consult and was electrolyte replacement... MAG and K Phos... OOOOPS. Nurse just wasn't thinking. Very much concerned about clearing space for waiting labors. Turns out this pt was in congestive heart failure. Had multiple undiagnosed heart problems that only manifested with the overload of pregnancy.

DAMN why can't ... "but the unit was sooo busy" be a defense in court!!

Thanks for listening...

Paula

babyktchr, BSN, RN · Oct 8, 2005

Honey....what you NEED to do is fill out an incident report, or whatever your institution uses for risk management. A patient with that high of an acuity should have been a 1:1, or at least the very LEAST paired with one other patient, and nothing comes to mind that would be appropriate not knowing the situation of your unit. If you have a documented policy for 1:1 care for the complicated OB patient and it was not followed, risk management should know. Iffin I am not mistaken, AWHONN also has a standard of 1:1 for this type of patient, but I just got up and really can't find my resources at this juncture.

Shame on your manager for not assessing a situation that could've really gone to a bad place, and kudos to the doc for sticking up for you. Why was your manager not on the floor helping????The only way things will change is if you document these occasions..that way you risk management department can be aprised of what is going on. And, if anything had gone wrong, you would've had something on record to say that. It is hard in a specialty unit to get help when there is "no one". You can't float just anyone in to help out. Seems though, that they found someone to help out when a doc screamed loud enough.

Administrations are infamous for not "getting it" when it comes to patient safety and the nurses mental health. Unfortunately we do dodge the bullet and get away with it. It seems it takes a bad outcome for any change to evolve.

It may not go over well with you manager, but if it were me, I would write an incident report and send it to the risk manager directly. It only serves as a reference to cover your A** and to document breeches in policy. Ultimately if enough is generated, risk management can get involved to get more help to reduce a potential problem.

I am sorry that you had this happen. It is a shame. It happens though, unfortunately. I am sure everyone that reads your post has had a similar event and still gets goose bumps thinking about it.

Do something good for you....I personally indulge in ice cream therapy. :lol2:

mugwump · Oct 8, 2005

OK I feel like I'm going to burst your bubble. But I am in a levl three facility but we usd to be a level 2.5 and I would have her and 2 other patients. First of all We do not do mg levels q 2 really ever. Did the patient have DTR's was she breathing more than 14 times a minute (then she's fine) Q 15 minutes vitals for 1 hour then q hour for 4 hours then every 4 hours (granted we can do them more if needed ) Did the doctor try terb or indocin?

SmilingBluEyes · Oct 9, 2005

We don't do magnesium levels, as they do not prove very useful, either. We judge and titrate mag needs by patient response, and fetal/maternal wellbeing. I agree w/mugwump on that account. But where I am, no way would we be 1:3 w/this sort of patient. 1:1 during the critical time we are trying to stablize and then perhaps 1:2 or 3 after she and the fetus' are stable.