Acuity-Based Staffing?

locolorenzo22, BSN, RN · Aug 3, 2008

Yeah, my hospital said that we were going to acuity based staffing....but this creates unsafe practices when it winds up that a nurse has to go home 1/2 way through the shift due to the "grid"...and techs are overworked, underpaid, and there's not enough of em...the hospital puts more nurses on at times(good) but takes techs away(bad)....and the other night as I was leaving there was 1 tech for 26 patients....can't be done...when I get to nights, I most certainly would have gotten my own vitals, just because hey, I've got to get their meds and assess them anyway, so while i'm in there, I'll take care of that....

glasgow3 · Aug 3, 2008

How many hospitals use acuity-based staffing for their "general" floors such as medical-surgical, etc? I know that most states have mandated maximum patient to nurse ratios for ICU, CCU, etc, but how many have staffing ratios for other areas? And how many hospitals adhere to those ratios?
This has become an issue where I work because of a recent State visit in which they expressed more than a little concern (a warning attitude perhaps?) that staffing on the general acute care floors was bases strictly on gross ratios rather than patient acuity levels was unacceptable. .
The Acuity model may call for a staffing of 3 - 5 nurses but the staffing grid we are stuck with calls for much larger ratios regardless of patient acuity levels.
In my opinion there is nothing intrinsically wrong with either system (minimum nurse-patient ratios or staffing by acuity) however the devil is in the details.
Staffing grids are almost always based on budgeted care hours. If you budget enough care hours per patient AND you actually
staff using those adequate care hours in most cases you should be safe. The problem is many many facilities simply do not budget a reasonable number of care hours in the first place and/or they permit floors to be understaffed per their own grid .
Similarly, acuity based systems would be fine if the selected system accurately reflected nursing care needs and you once again staffed to reflect what the acuity system called for immediately and without exception; Again, many hospitals fail to do either or both-------yours, for example.
Mandated minimum nurse-patient ratios represents the safest alternative in my view; You may not have optimal staffing but you DO know at all times whether the minimum standard is being met. Carefully set mandated ratios can keep less than optimal staffing events to a minimum. Like the other systems, however, the hospitals must actually meet those staffing ratios at all times; to be meaningful, there must be consequences when they do not.
As mentioned above, your hospital's mistake which caught the State's attention was that they didn't even staff by their own acuity system. Unfortunately this can be remedied by using a less labor intensive acuity system which in turn will essentially agree with the inadequate budgeted hours (ie the grid)
This is why hospitals fight mandated minimum ratios so strenuously----the opportunities to manipulate variables is greatly reduced. Less flexability as they are fond of saying.

Pediatric Critical Care Columnist · Aug 3, 2008

I only wish we had acuity-based staffing. We're a level 4 PICU with a very active ECLS program and a transport team. We have 15 physical bed spaces but often have 18 or 19 patients. Our staffing is strictly done by numbers, even though we have an acuity scale and it's updated every day. Our acuity would dictate 1:1 for 99% of our patients 99% of the time. Last night we had 10 nurses and 12 patients: one on CRRT who also has an open sternum, one with two Berlin hearts (VADs), a "significant organism" and sepsis, one with ICPs of 40 and on c-spine precautions, one on ECLS alert, one on HFOV for pertussis and RSV, and one teenager with CP who had multiple drains and a trach. Of the 12 kids we had there were 4 on significant organism isolation. No tech. But I could have predicted the staffing for that shift... the Friday night before a long weekend (Monday is a civic holiday here) we're always desperately short. Monday on days they'll probably be down to 10 kids and have 22 staff.

allnurses Guide · Aug 3, 2008

I only wish we had acuity-based staffing. We're a level 4 PICU with a very active ECLS program and a transport team. We have 15 physical bed spaces but often have 18 or 19 patients. Our staffing is strictly done by numbers, even though we have an acuity scale and it's updated every day. Our acuity would dictate 1:1 for 99% of our patients 99% of the time. Last night we had 10 nurses and 12 patients: one on CRRT who also has an open sternum, one with two Berlin hearts (VADs), a "significant organism" and sepsis, one with ICPs of 40 and on c-spine precautions, one on ECLS alert, one on HFOV for pertussis and RSV, and one teenager with CP who had multiple drains and a trach. Of the 12 kids we had there were 4 on significant organism isolation. No tech. But I could have predicted the staffing for that shift... the Friday night before a long weekend (Monday is a civic holiday here) we're always desperately short. Monday on days they'll probably be down to 10 kids and have 22 staff.

Wow . . . . almost speechless . . .. you are amazing. :clphnds:

steph

RazorbackRN, BSN, RN · Aug 3, 2008

I only wish we had acuity-based staffing. We're a level 4 PICU with a very active ECLS program and a transport team. We have 15 physical bed spaces but often have 18 or 19 patients. Our staffing is strictly done by numbers, even though we have an acuity scale and it's updated every day. Our acuity would dictate 1:1 for 99% of our patients 99% of the time. Last night we had 10 nurses and 12 patients: one on CRRT who also has an open sternum, one with two Berlin hearts (VADs), a "significant organism" and sepsis, one with ICPs of 40 and on c-spine precautions, one on ECLS alert, one on HFOV for pertussis and RSV, and one teenager with CP who had multiple drains and a trach. Of the 12 kids we had there were 4 on significant organism isolation. No tech. But I could have predicted the staffing for that shift... the Friday night before a long weekend (Monday is a civic holiday here) we're always desperately short. Monday on days they'll probably be down to 10 kids and have 22 staff.

This sounds much like our pt population, but I can't imagine only having 10 nurses for this load. Typically our Berlins are 1:2, unless they are just really long-termers and "stable".

We have used acuity based staffing for a few years now and I think it's great (providing you enter your acuities correctly). However, some places don't allow the staff RN's to enter the acuities and the charge or sup does it. That creates a problem, because really only the staff know how busy the pt is. Since we enter our pt's acuities and realize our staffing depends on it, we make sure to enter them accurately.

In the ICU's we are usually always 1:1 (unless they are a Berlin, ECMO, fresh post-op, or just crazy unstable, then they are 1:2). On our floors, the loads are usually 3-4:1 and the stepdowns are typically 2-3:1. We are an RN only facility (no LPN's), and usually have 1 tech per 4 pt's.

This is peds though, so it may be different for adults.

I will also add that regardless of our acuities, if it still seems that staffing isn't sufficient, then the acuity based model will be overridden and our sups will provide extra staff.

GrumpyRN63, ADN, RN · Aug 3, 2008

Our lg teaching hospital uses pt/nurse ratio for staffing, acuity means nothing. Deviate from the the staffing grid and you'll get h--- for it.

Charge nurse takes full pt load, it's all BS

RNsRWe, ASN, RN · Aug 3, 2008

Acuity would have to be accounted for in some way on each patient. I did clinicals in a hospital that worked this way, assigning an acuity number for each patient, and those numbers were reviewed each shift to aide in staffing. Sure doesn't work where I am now!

Supposedly acuity is worked into the staffing grid, but if it is, I sure can't see it. It just seems to be a numbers game: how many patients can you stick with how few nurses. The staffing office will check to see how many post ops we've got, how many isolation patients, like that, but NEVER EVER do they take into account the insanely heavy patient who is not a post op and not an isolation, just the equivalent of two or three other patients.

And when there happens to be enough staff, you'll hear how the grid is working, and how well they accounted for our acuity (ha!). And when there's NOT enough staff, you'll hear that "according to the grid, you are well within your ratio" when you are faced with 27 patients for 3 nurses. Oh, and when there's two nurses for 24 patients, including 7 post ops and four isolations? Sorry, we know you should have one more (ONE?) nurse, but that's all we've got....

Acuity staffing. A joke in my facility. And oh yes, day and evening charges do not take patients, but nights takes up to a full load as needed. 'Cause all the patients just sleep at night, right?

Pediatric Critical Care Columnist · Aug 3, 2008

This sounds much like our pt population, but I can't imagine only having 10 nurses for this load. Typically our Berlins are 1:2, unless they are just really long-termers and "stable".
We have used acuity based staffing for a few years now and I think it's great (providing you enter your acuities correctly). However, some places don't allow the staff RN's to enter the acuities and the charge or sup does it. That creates a problem, because really only the staff know how busy the pt is. Since we enter our pt's acuities and realize our staffing depends on it, we make sure to enter them accurately.
In the ICU's we are usually always 1:1 (unless they are a Berlin, ECMO, fresh post-op, or just crazy unstable, then they are 1:2). On our floors, the loads are usually 3-4:1 and the stepdowns are typically 2-3:1. We are an RN only facility (no LPN's), and usually have 1 tech per 4 pt's.
This is peds though, so it may be different for adults.
I will also add that regardless of our acuities, if it still seems that staffing isn't sufficient, then the acuity based model will be overridden and our sups will provide extra staff.

Can I come work with you?

I think I'm going to print your post for my next meeting with management. (I'm the chair of our team-building committee, at lesast for now...) Our patient care manager keeps telling us that we're the "best-staffed PICU in Canada" and that all the others are routinely doubling all their patients. Of course, out of the 15 or so PICUs in Canada there are only two others that care for patients with the same acuity as ours. And I know it's not true in the unit where I used to work, because there intubated patients aren't even cross covered for breaks. It's good news to me that your hospital is 1:1 AND that you have techs. I'm pushing really hard for them, especially if we're going to always be doubled (as I was last night with an insane workload) because right now we're doing total care... q1h vitals, minimum of q2h narrative charting, all meds, all personal care, all treatments, all turns... and cross covering for breaks. Here's a question for you though... when you have CRRT, are those kids 1:1 or 1:2? Lately we've been running them 1:1. If the kid's big, you're constantly mixing bags and changing bags, but you still have to fit in total care for your patient too. Thanks so much!!

gilf7243 · Aug 3, 2008

I work 7p-7a shift in Ohio on an ICU step-down floor and our hospital just layed off all the LPN's and a few RN's plus many from other ancillary departments. They also just decided to change our Matrix. Our Nurse staff ratio has never been based on acuity but rather by numbers. However, now if we are no longer full with every bed filled on our unit we will have to either lose the tech or techs depending on the number or lose one or more nurses depending on our numbers. The techs are usually responsible for 10-15 patients. We will be responsible for 3-4 patients a piece depending on wheter we lose a nurse or not. Here lately we have had 4 a piece. Sometimes we get patients who should stay a few more days in ICU but are forced to leave b/c of an incoming trauma. These patients don't deserve less care but we can't give them as much attention as they can in ICU. We have one secretary for the entire critical care block. It is rare to actually have the privilige of utilizing her unless you get an admission. We don't have any other extra help on our floor. We read our own tele strips every 2 hours. Here lately, nurses have been called off losing hours or sent home early losing hours because our census is down. This is happening more and more. Half of our staff have other jobs to make up for the lack of hours. I am also thinking of looking for something else as well. Nursing jobs aren't in much demand in my area. There are too many nursing schools in this area. Plus, our hospital keeps pumping into us that we need to have a high patient care satisfactory level. Its all about customer service. The demands just keep getting more and more and more. Just wanted to know if this is true in other states as well. :banghead:

grammyr · Aug 3, 2008

So, when Joint Commission comes through, what do you tell them when they ask if you are acuity based or numbers based?