Nurse to patient ratios and acuity in YOUR PICU

NurseLay · Aug 16, 2008

Hey Jan, I can only answer a few, since I basically am only 2 weeks in, and I am not at a true children's hospital (unfortunately)

1. I don't know if there are any programs implemented, but about 50% of the kids are cardiac, there are some transplants, some neuro, and I've seen a few traumas since I've been there, I know they have an ECMO team, and they are capable of doing CVVHD, but I haven't seen it there thus far.

2. 14 beds, ratio 2:1

3. PCAs are employed, but there are not allowed to deal with patient care. However, some nurses allow the PCAs to feed the babies.

4. With our breaks, there is a "buddy" system. While your buddy is on break, you are responsible for their patients and yours, and vice versa.

5. I don't know about this one.

6. Yep! I am a new grad. I have six months of orientation. I have two preceptors who I rotate in between, and I also have new graduate classes that I attend.

7. Um, so far, I've seen only one discharge from PICU to home, but I have noticed that it seems that it is quite difficult to transfer the kids out the regular floor.

8. I don't know about this one, but lately, I've been hearing a lot of complaining.

Like I said, I've only been there for a short time, but hopefully I helped you with something. Good luck!

Pediatric Critical Care Columnist · Aug 16, 2008

So while your buddy is on break you're responsible for four children? In a fairly high-acuity PICU? Do you feel safe doing that? They must be deeply sedated for that to work. Do you have an unassigned nurse to help out?

What is you charting like? We are still using pen and paper for everything and have a five page flow sheet that needs to be filled in manually every hour. We also document our meds manually, are expected to write a narrative note at minimum of q2h and provide total patient care.

How do you manage turns, repositioning and diaper and linen changes on bigger kids and teens?

Is the layout of your unit private rooms or one big open space?

Thanks for your input!

NurseLay · Aug 16, 2008

Um, I've noticed so far, that most of the time the nurse who is going on break will make sure that both of her kids are stable and the buddy doesn't really have to do anything, but watch them, and check on them, and the charge nurse is always there and willing to help out. And yes, a lot of times, most of the kids are sedated and vented and stuff like that. There are central monitors at each nursing station and when they also alarm at those central monitors. So far, it seems as though the buddy system works out pretty well....

The acuity is fairly high, oh and there are also at least one attending, fellow, and resident on the unit at ALL times, and the docs there are really good......

I'm not really ever alone because I'm still on orientation, so I don't know how I would feel if I were responsible taking care of four kids, especially being straight off orientation.

Charting is also pen and paper, a critical care worksheet and assessment, but the docs put in their own orders and the unit secretary brings the print out to the patient's box when they come out, however, we do chart all meds on the computer.

A pca can help with the diaper changes and turns on bigger kids if there is no one else available, however, besides the bed side nurses and charge nurse, there are other picu nurses who have other roles within the unit who definitely help out.

There are 12 private rooms, and one room that holds two beds.

Pediatric Critical Care Columnist · Aug 16, 2008

Okay, more questions. You have 14 beds. How many nurses does your unit consider to be the baseline staffing number per shift? If all your patients are 2:1 do you have 7 nurses and a charge? Or are there other, unassigned nurses roaming around? How are your ECLS patients, fresh post-op cardiacs and CRRT patients managed? I couldn't imagine having a patient on ECLS and another one as well... and cover two more for breaks. What about isolated patients? And patients on neuromuscular blockers? You say that you ALWAYS have a physician on the unit. ALWAYS? Do you do daily CXRs? What time of day is your CXR parade scheduled for? I'm sorry to keep coming back with more questions, but I have to have some solid, concrete information to base my arguments on. Thanks again!

PICNICRN, BSN, RN · Aug 16, 2008

Ok Jan, I'm gonna give you 2 senarios(1 my old unit and 2 my new since I moved). Both are childrens hospital- one midweast, the other out west.

1. (1) The works!! ECMO,CVVH,transplant program(hearts/lungs/liver/kidney/small bowel/bone marrow)level 1 trauma, complex ENT(trachealplasty),neurosurg, and a transport team.

(2) Less complex-- occasional ECMO(perfusionist run the pump), occasional CVVH, NO transplant, Level 1 trauma, neurosurg, NO transport team(use outside service with flight nurses-adult flight nurses with PALS-don't get me started!)

2. (1) 32 total beds- usually 1:1 ratio, often 2:1, sometimes 1:2(like CVVH/ECMO (2) 24 total beds- usually 2:1, sometimes 1:1, very rarely 1:2.

3. (1) there were techs that basically helped stock the unit, help transport pts, pick up blood or meds- they were great! (2) Nobody but us RNs!

4. Both breaks on buddy system- but on both units, the "charge" nurse has no assignment, so they are always available if you have a really sick one.

5. This one is COMPLETELTY different! (1) HUGE (teaching and recearch hospital) with WONDERFUL continuing ed opporutinities- education committee with opportunities every month for CEUs, staff expected to lecture on at least 1 topic a year. (2) You are pretty much on your own except for mandatory things like PALS.

6. (1) YES... I was one of them:redbeathe I cannot say enough- Months of coursework and bedside orientation - I think it was at least 4 months before I touched a patient on my own(and you were never really on your own). (2) Do not hire new grads.

7. I do not think I ever d/c a pt from the PICU! I never even knew this was common practice until I left! There was NO "Intermediate or floor status" pts here- if you did not need ICU- you were GONE! The floors were all specialty floors(cardiac, renal,resp, ect) so the nurses were very educated and comfortable with pretty complex pts- for example, pts could be still on dopa/dobut drips up to 5 mcg/kg/min as long as they were "weanable" and the nurses were very comfortble with this(this is for cardiac and hem onc pts). For example, a simple VSD went to the cardiac floor after 12 hours in PICU. (2) It is common for cardiac pts especially to be d/c from PICU--- I think both the surgeons and floor nurses are just not comfortable with the pts on the floor. I see alot of Intermediate or floor holds on this unit, however, there are Intermediate nurses that usually care for these kids.

8. (1)Someone pretty much had to die for a day shift to open up!:chuckle I worked with nurses that had been on that unit for 35 years! (2) I got a day shift position in 1 interview.

Hope this helps... these are 2 very different units! Truthfully, I do not think anything will ever measure up to my first unit- so I always compare everything to it!

Feel free to PM me with any questions, and good luck with your cause!

AliRae · Aug 16, 2008

I know I'm asking a lot of questions, but this information will be of great help to me when I meet with management and administration in a few weeks. And the more information I have, the better my position will be if forced to advocate for my coworkers. I'll thank you all in advance.

As far as I can remember ...

1. I'm not sure if our cardiac program exists anymore. It was just a baby, anyway, when I left. We do CRRT but not ECMO. We do some transplants- mainly kidney, but I've seen a liver or two. Neurosurgery with all that entails. We're a level I trauma centre. We do transports, picking up from around 20 local hospitals as far away as an hour and a half, give or take. The charge nurse is also the transport nurse, which leads us into huge problems often, when you need to get out on a transport and there's no one who can take charge report.

2. 20 beds. Ratio is usually 1:1 for vented kids (unless they're stable trachs or a paralyzed kid paired with a nothing kid). 2:1 for CRRT with one nurse manning the pump. 1:1 with hourly PD kids, when at all possible. Otherwise 1:2 or 1:3 if at least one of those are floor overflow and your other 2 aren't too heavy.

3. we have PCTs who assist with hands-on care. They help bathing, turning, feeding etc. With less sick kiddos, they'll do baths independently. Huge help, but usually only one for 20 beds, so you often end up doing total care anyway. Housekeeping stocks our supply carts in the rooms, but not at night, so you end up running around a lot then.

4. What's a break? I used to routinely work a 12-hour shift with maybe 20 minutes for lunch. My record is 17.5 hours without peeing. If the charge nurse isn't out on transport (see where that gets tricky?!) she goes around and covers breaks. This just about covers lunch usually, since charge goes on rounds, too and that can go on forever. If you want any other break, you have to beg borrow and steal another nurse. I didn't realize how much I needed breaks until I got here and starting getting them. I'll never be able to work in a place again where I can't sit down in the middle of a shift!

5. continuing ed is usually inservices during work hours that no one could go to anyway. Not terribly helpful. But we did have a wonderful educator who was great at making sure we were all up to speed on new equipment and policies. Once she'd trained a couple of us, she would often recruit us to pass on the info, which worked when she was overtaxed. But courses for credits were rarely available.

6. Yes to new grads. I was one. 6 months orientation with a primary preceptor. 10 weeks of classroom (8 hours of class one day a week) during that time to put theory behind what you're doing on the floor. Our preceptors were amazing at picking appropriate assignments and getting a god pregression from stable to sick; I felt totally ready (as ready as you can be) once I started on my own.

7. We discharge home often. Kids stay who aren't really sick enough to be in the PICU, which gets my goat. We often used to have peds overflow kids when the floor was full. Generally though, not a huge problem to get them to the floor. Oru children's hospital was a seperate building off a main grown-up hospital, and we all suck pretty close together and tried not to shaft each other too badly. =)

8. I left in the middle of a mass exodus. Management wasn't great, and there was a lot of dissatisfaction. No breaks, no feeling that we meant anything, poor MD/RN relations. In the less than 2 years I was there, I was more than halfway up the seniority ladder!

I'm out of here ... off to play with monkeys! I'm never coming back to north america...

NurseLay · Aug 16, 2008

My understanding of the baseline nursing staff is 8 nurses and a charge, but sometimes there are 7 nurses and charge. Depending on the acuity level, there are times when pts are 1:1 like with ECMO patients, fresh Post-Op Cardiac patients, and I'm not sure about patients on CVVHD (I haven't seen any yet). Isolated patients are in private rooms, I don't understand what you mean by what about them? Patients on neuromuscular blockers are there, and they are closely monitored. We are a magnet facility and so nurses who are higher up on the clinical ladder are there performing other roles like office things and inservices, but they come and help and they are great resources and help to us...And yes it is a requirement of the unit to ALWAYS have one attending, fellow, and resident on the unit at ALL times. They are ALWAYS ALWAYS ALWAYS on the unit. As far as CXRs, they do bedside CXRs every morning.

Pediatric Critical Care Columnist · Aug 16, 2008

picnicrn, thanks for the comprehensive answers (two for the price of one as well!). ditto to my good friend alirae. (monkeys bite, watch your fingers!) i'm seeing a recurring "charge nurse is always there to help" in the responses i'm getting, and wonder how it it that those units have charge nurses that are free to help... in our unit i'm lucky if i even see the charge nurse for rounds. many shifts i don't lay eyes on a charge nurse for the whole 12 hours, never mind get help from one.

the new grad orientations sound very good, unlike ours. on paper ours sounds really good, 16 weeks with 2 of those in classroom, but the truth of it is that the end result isn't stellar. the people chosen to precept are often junior nurses who are still learning a lot themselves, or should be, and the assignments are made by management who decides which patients the orientee and preceptor have based on unit needs first and foremost. many times the assignment isn't appropriate for the orientee (experienced or not) and they sit and watch for 12 hours.

nurselay, i'm wondering how it's possible to observe and intervene for isolation patients in rooms with doors closed if you're also responsible for 3 other patients. in the time it would take to see something happening, finish what you're doing, garb up and get into the room, the kid could be dead. in our hospital it's policy that patients on neuromuscular blockers be "constantly observed by a specially-trained nurse" and we viloate the policy all the time.

now i'm wondering about nights. as nurselay says, at her hosptial there are always people higher on the clinical ladder roaming around who help and that's wonderful. but they aren't there at night. but then you have three physicians there on the unit around the clock, so maybe taht's the saving grace. i can't imagine that. during the day, our docs might be in the unit on rounds, but they also go off for meetings, grand rounds, academic halfday on wednesdays, to their offices in another wing, or wherever. we usually have to page them if anything's going on. at night we might have a fellow and a resident or just a resident, but the attending is gone home as soon as things "settle" down, unless we've got a really sick kid on the unit. not too many nights where the attending is still on the unit at midnight. the resident and/or fellow go to the call room and sleep for part of the night most nights and we call them with major concerns. there are a lot of things that we do and then get an order to cover it later.

our cxr parade is an early morning ritual, starting around 0545 to 0600. so between then and our change of shift at 0700, we x-ray all the kids in the unit. then they're all awake and agitated, needing sedation so that we can get through report. it's a gong show. many nurses leave their linen changes and baths until just before x-ray, so there's never any help for the person next door.

oh, and we have to have all our meds double checked and cosigned. we dont' have a unit dose arrangement and the pyxis is in the center of our unit. we have 15 physical beds, but 2 rooms have been turned into double rooms, sometimes we squeeze two kids into a third room, and we opened up a storage closet and made it into a room too. so we could in theory have 19 patients. our staffing baseline is for 15 patients plus charge, resource and transport. most of the time we're actually staffed for 13 patients and charge, on call transport and a resource nurse with an assignment. the unit layout is a central nurse's station (glassed in on two sides with a wall on the other two) /pyxis /respiratory area six single rooms along the long side (facing the nurse's station/pyxis/resp area), two double rooms along one short side, five open beds opposite the single rooms (behind the nurse's station where the wall is) and three open beds along the other short side. we have a central monitor, but we don't have someone sitting there watching it. the charge nurse, as i said, is usually who-knows-where and the unit secretary ansers phones and sometimes thins charts. they usually bring the printouts to the bedside for the nurse to file. the nurse transcribes all orders, scans the med orders to the pharmacy on the central (single) scanner then lets the secretary know if we need a special diet, specialized tests ordered or other logistical arrangements made. lab work is the responsiblility of the nurse, from order to receiving the results. (transplant workups are a nightmare.)

i'm probably getting close to my 5000 character count so i'll end with that. more to come. thanks for the support, everyone.

NurseLay · Aug 16, 2008

All of our rooms are completely see through, and there are curtains to provide privacy and if need be, you can access the room via the neighboring patient's room. As far as rounds and meetings, there is a central conference room and rounds are held in that room as well as the doc's meetings. They never leave the unit.

kessadawn, BSN, RN · Aug 17, 2008

okay, here goes. hope this helps!

1. we have a cardiothoracic surgery program, with many of them sicker than snot post-op. we don't do transplants or ecmo, we do use crrt, traumas, complex ent, neurosurg, hem-oc. lots of weird genetic anomolies, some of the sickest kids i've ever had.

2. we have 23 beds, all are private rooms, the unit is shaped in a large "u", with 4 nurse's stations in corners. all tubed patients are 1:1, regardless. we have a very low self-extubation occurance rate. sicker non-intubated pts may also be 1:1 if busy, usually hem-oc pts. most non-intubated post-op hearts are 1:1, many are so busy they are 2:1 for the first 24-48hrs. crrt patients are 2:1, i've only ever seen one that was not. stable, non-intubated pts are 1:2.

3. my children's hospital does not employ cnas, but we have mas on the general care floors, and the occasional techs in the picu. the techs assist the rns with pt care, feed and rock babies, stock, go-fer, act as scribe during a code, may watch a stable non-intubated pt for the rn to take a lunch if needed.

4. we have specific staffing protocols based on the amount of 1:1 and 2:1 pts on the unit that provide us with either 1 or 2 "rp" nurses. "resource persons" are not assigned to a certain pt, they do relieve lunch breaks, assist with admissions, respond to general floor codes, pt care on the big kids, road trips to ct and the like, and basically run around like a crazy person for 12 hours. very busy position, usually needs to be an experienced nurse. as for our paired-up pts, if they are in proximity to another pair, those nurses may sometimes relive each other for breaks. our charge nurses also help.

5. most continuing education is available for us online to do when we have time, always with a deadline. we have to nurse educators for the unit, i believe they are both considered parttime, but both seem to put in a lot of hours. one of these two makes herself available for nights, the other primarily days. hospital-wide education is online.

6. we hire new grads...we have many. they are provided an extensive orientation, usually about 4 months with a nurse preceptor, also provided several classes. i should point out that every new hire into picu gets the same extensive orientation, but nurses with prior icu experience may move through faster.

7. most kids transfer to the floor without a problem. cardiac babies go back to nicu for feeding/growing and d/c from there. we do d/c home right from picu occasionally. usually they are trached chronic ventilator patients as our general care floors are not trained to have vents. sometimes a long-term cardiac kid is d/c'd from picu to home.

8. i'm not sure how to answer this. we kind of go in spurts. we have recently hired in many new grads, but we have also greatly increased our bedspace in the last few years. we do frequently have a larger number of new nurses on compared to experienced, which is a little unsettling. hence the need for experienced rp nurses.

hope this helps, i'm a little longwinded tonight! :rolleyes:

kessadawn, BSN, RN · Aug 17, 2008

I forgot to add, our transport team is a completely SEPARATE department, staffed with RNs, Respiratory therapists and paramedics. We also have docs at night, always one attending and one resident, and recently started having a nightshift nurse practicioner 3-4 days of the week as well.

I could not imagine not seeing my charge nurse all shift. Unless she/he is coding a kid all night, they usually pop in my room to check on me once/twice a shift. The docs, NP, RPs, charge RN and respiratory all carry portable phones, so they're easy to get if you need them.

Okay, think I'm done now!:)