Acute Inpatient Dialysis Patient-to-Nurse Ratios

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Hey all, a little background about myself:

I have worked in dialysis for two years, first at FMC outpatient, then I moved to a not-for-profit independent outpatient unit at the largest hospital in my state (Connecticut), and in October 2017 I transitioned to the Acute Inpatient Dialysis in my hospital.

I love the differences from inpatient to outpatient. I often do beside treatments in the ED, SD, or ICU units and I have been exposed to so much and learned an unbelievable amount in my short time as an Acute HD RN. The knowledge has been priceless and I truly believe it has propelled me into becoming a better nurse.

HOWEVER, I don't know how the Acutes work for hospitals contracted to Davita or FMC, but for my unit, we run 1-on-1 bedside treatments for Step-Down and ICU level of care, but Floor level care we bring them to our unit, where we have 8 stations.

On a typical day, we are staffed two staff RNs and one charge RN. One of the two staff RNs goes to do bedside treatments, while the expectation is the other staff RN runs 4 patients at a time with a CCHT, while the charge RN runs two patients and when a second CCHT arrives at 10am (we clock in at 6am), the charge RN is expected to add a third patient to their assignment and run three patients with a CCHT while still maintaining charge.

I have not done in depth research on ratios, but I have done some, and from what I've seen, while four patients to an RN and a CCHT is not unheard of, it is not frequently practiced.

My personal opinion is the ratio I currently operate under is unsafe. While the CCHTs I work with are very skilled and very good at their position, four patients means four assessments, four med passes, four reports, four everything. Often my CCHT only puts on two or three of the four patients because my manager expects any patient that enters the room to be put on dialysis immediately, so often I am putting on a patient while the CCHT puts on another, and then I have to go back and assess the patient the CCHT put on AFTER they've already been on dialysis for 10-15 minutes.

I have brought this up to my manager multiple times, but since there is no law in Connecticut concerning this, it often falls on deaf ears. I have been told by my coworkers that previous RNs who have left the position had the same concerns/complaints about what they considered an unfair ratio, and they were retaliated against.

My manager seems to like me, however I am afraid if I continue to push this issue, I fear retaliation. I am skeptical and untrusting of Human Resources as well, as I believe their best interest will always be to protect the hospital and not an individual employee.

So if I can pick some brains on this, I'd appreciate it:

What is your nurse-to-patient ratio on your acute HD unit?

If so, what state do you practice in?

What can I do about my predicament? Has anyone been in this situation where you felt your patient ratio was unsafe? What did you do? How was it handled?

Any insight would be appreciated. I am very passionate about Nursing and the unit I work on. I've gotten to know our frequent readmits quite well, and I often see and dialyze patients I know from the different local outpatient units I work on. Leaving the position is my ultimate LAST resort, and I do not want it to come to that. However, I worked very hard and went through hell and back to achieve my nursing license, and I plan to protect it with my life and while not risk it unsafely practicing under and organization's protocol.

Thank you for any insight you can offer>

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Can someone tell me what it's like to be a dialysis RN? What are the positives and negatives of this profession? I am considering a change.

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I work acutes and 4 patients with myself and a CCHT is the norm. You need a good system with your tech. As in, I write all the orders and assessments (we use EPIC, as well as our own proprietary billing system), my tech does put ons, take offs, and turn overs while I call reports and close the charts out. She does the flowsheets on her 2 patients and I do flowsheets for my two. If I have a severely acute patient, she will take over my flowsheets and help me catch up (like if I'm running blood and have to chart exclusively on that patient). Its very very doable. I work for FMC. Also, we don't have a charge (we only have 4 stations and a travel machine that goes to ICU/Step Down for bedside txs), so if I'm the only RN I also have to call for report on the patients I'm bringing down, call clinics to get treatment sheets on new admits, or provide information to the clinics on d/c'ed patients, coordinate the schedule for the day, and deal with the docs. I'm usually doing this while my tech sets up 4-5 machines, water tests and coordinates disinfection.

Its really not difficulty as long as you've got a great relationship with your techs. The techs I work with all worked clinics in the past and all have over 5 years of experience. They are used to working fast. For example we can put on 4 patients within 10-15 minutes, take those patients off after 4 hours, and turn over within an hour.

I really truly don't believe you are putting your license in jeopardy.

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Sorry, I don't think having 4 Acute patients with a tech is safe, even an exceptional tech. And doing all the charge nurse stuff on top of it? I travel. Most acute rooms have a 2 patients per nurse ratio. If it's a larger unit, you may have a tech who helps as it's needed, charting, putting on and taking off, etc, as certified. I would not accept an assignment with a higher ratio. It's not competence, experience, or stamina. It's called patient safety.

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Sorry, I don't think having 4 Acute patients with a tech is safe, even an exceptional tech. And doing all the charge nurse stuff on top of it? I travel. Most acute rooms have a 2 patients per nurse ratio. If it's a larger unit, you may have a tech who helps as it's needed, charting, putting on and taking off, etc, as certified. I would not accept an assignment with a higher ratio. It's not competence, experience, or stamina. It's called patient safety.

We will have to agree to disagree. I don't feel my assignment is unsafe, and if for some reason it is (as in a confused patient pulling at lines or needles) I have the autonomy to call the doctor to voice my concerns and recommend cancelling the treatment, or have the nephrologist order meds to help get through the treatment. My manager also always has my back. I guess it all depends on comfort level.

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Specializes in Dialysis.

2:1 in unit, 1:1 if at bedside. No techs. 600 bed big city hospital in Tennessee. Management tried 3:1 but too many staff quit. 4:1 sounds unsafe to me.

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Specializes in Peds Critical Care, Dialysis, General.

We are 2:1 in our dialysis unit. We have no techs. If we have an unknown Hep B status, that patient has his/her own nurse. Hep B, does of course, complicate staffing. We also do portables 1:1 in our ICUs. We often have more than one patient in a particular ICU, so we load up as much as possible and go from room to room. Our larger sister units in the largest city in the state have techs. Their ratio is 4:1 and there are at least 4 techs at any given time. The techs get all the fistula/grafts on (and these techs are awesome). The RN must put on any PermCaths.

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I used to do 3:1 in acutes and one hospital, with q 15 min charting on each pt, sometimes data transferred and sometimes it didn't, would often have to do all entries by hand. Sometimes had a tech (had to share with other nurses with their own 3 pts) sometimes didn't. Pts were all in different rooms, requiring constant running back and forth, and only being able to have one pt at a time in my line of sight.

If I had to get a bag of saline, I'd have to leave all of my pts unattended to go all the way to the other end of the unit to the Pyxus. Did all nurse and tech duties, arranged transportation to unit, labs, orders, doc calls, blood, add-on pts, etc.

If a pt needed extra attention, and my q 15 min charting got behind, mgr would call me out on it- she said "Charting is your number one priority."

No thank you.

Worked about 70 hours a week. Worked 20 plus hours straight without a break numerous times. We all did.

Very high turn-over there. I left after a year.

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Specializes in Dialysis.

I am a new nurse, leas than one year of experience. I currently work in one of the well-known dialysis outpatient clinics. The RN:patient ratio is usually 1:16 for the first shift and maybe 1:10-12 for the shift. Sometimes I have an LPN working with me. I do my best to provide the best care but I feel that this ratio is unsafe. I’m thinking about leaving the company and dialysis for this reason.

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