Safe staffing in clinics/office setting?

klone, MSN, RN · Oct 22, 2015

I'm not aware of any recommendations, but if there are any, I imagine you could find them at the AAACN website.

BDOGGRN · Oct 22, 2015

Thanks Klone, I will continue to check such resources, but so many of the "policies" in effect are often difficult to decipher, and still leave a lot of information subject to the interpretation of the reader. I appreciate the reply!

JimmyDurham9 · Oct 28, 2015

Primary care models are in a state of change currently. Unfortunately, the norm tends to be the idea "least number of staff that maintains the bare minimum of quality care."

If a clinic sees approximately 50 patients a day on average, it's not unreasonable to expect that there should be one provider, one clinical care person, a receptionist, and possibly a cross trained individual who can help with labs, vitals and receptionist duties.

I'm an advocate for at least one RN operating as a clinic manager/nursing supervisor present if not whenever the doors are open, then at least 50-70% of the time in addition to either a medical assistant/lab tech and/or LPN. I'd add MAs and/or LPNs according to patient volume.

A RN costs more, but they are well worth it and what they bring in terms of training and education reduces costs, increases clinic efficiency, decreases patient wait time, increases daily volume, and increases patient care quality and safety.

The current models where an urgent care employees only LPNs or MAs is clunky and outdated given that urgent/primary care patients are sicker than they used to be since many have several co morbidities and/or don't use urgent care facilities appropriately(i.e. Going to an urgent care for MI or stroke symptoms instead of the ER).

The reality is that urgent care clinics are gonna get high acuity patients who's symptoms require fast recognition and appropriate intervention. MAs lack the assessment skills and scope of practice to legally and safely provide this care. LPNs could arguably be more or less adequate if they have protocols in place and those protocols are enforced.

I've worked in an urgent care with LPNs and MAs and patients with symptoms that indicated potential life threatening issues went unreported or properly addressed until the provider happened to make it around to them. We're talking O2 sats of 80%, chest pain with SOB and N/V, and people with head injuries and altered LOCs. One patient presented with a laceration actively bleeding and the receptionist had him sit out in the waiting room in clear view of the LPNs and MAs who would step to call patients for their turn. No one stopped and went "Wait a minute that guy has a saturated towel wrapped around his arm.

LTCNS, LPN · Nov 5, 2015

Primary care models are in a state of change currently. Unfortunately, the norm tends to be the idea "least number of staff that maintains the bare minimum of quality care."
If a clinic sees approximately 50 patients a day on average, it's not unreasonable to expect that there should be one provider, one clinical care person, a receptionist, and possibly a cross trained individual who can help with labs, vitals and receptionist duties.
I'm an advocate for at least one RN operating as a clinic manager/nursing supervisor present if not whenever the doors are open, then at least 50-70% of the time in addition to either a medical assistant/lab tech and/or LPN. I'd add MAs and/or LPNs according to patient volume.
A RN costs more, but they are well worth it and what they bring in terms of training and education reduces costs, increases clinic efficiency, decreases patient wait time, increases daily volume, and increases patient care quality and safety.
The current models where an urgent care employees only LPNs or MAs is clunky and outdated given that urgent/primary care patients are sicker than they used to be since many have several co morbidities and/or don't use urgent care facilities appropriately(i.e. Going to an urgent care for MI or stroke symptoms instead of the ER).
The reality is that urgent care clinics are gonna get high acuity patients who's symptoms require fast recognition and appropriate intervention. MAs lack the assessment skills and scope of practice to legally and safely provide this care. LPNs could arguably be more or less adequate if they have protocols in place and those protocols are enforced.
I've worked in an urgent care with LPNs and MAs and patients with symptoms that indicated potential life threatening issues went unreported or properly addressed until the provider happened to make it around to them. We're talking O2 sats of 80%, chest pain with SOB and N/V, and people with head injuries and altered LOCs. One patient presented with a laceration actively bleeding and the receptionist had him sit out in the waiting room in clear view of the LPNs and MAs who would step to call patients for their turn. No one stopped and went "Wait a minute that guy has a saturated towel wrapped around his arm.

IMHO, I believe this comes with experience in the case of LPNs working in urgent care clinics. As a LPN with close to 20 years experience, if someone came into the clinic I was working in with the above bolded symptoms you described, I would not be ho-hum and step around them to take the next patient on the schedule. The patients in all scenarios would receive prompt attention from myself and the provider, given care with the resources available to us before being routed to a hospital, and the less acute would have to wait. In the case of this particular clinic, there was no access to x-ray machines or stat labs. The only thing they do have is one EKG machine in one clinic. I no longer work in that clinic due to reasons too numerous to count.

I cannot wrap my head around why anyone with any sort of medical background would ignore a patient in distress, or a patient who is bleeding profusely. This is what gives the good LPNs a bad rap, and why there is a belief that experienced LPNs do not have the ability to critically think.

*This is not a LPN vs. RN argument. It is simply a personal opinion based on my own experience*

JimmyDurham9 · Dec 26, 2015

Thank you for your comment! I LOVE that you would not commit the patient oversights I have seen in my experience!

I agree that experience plays a large part in it as I have seen RNs commit similar and sometimes worse errors and not blink twice; only reacting when someone else intervened, and only then to be offended.

In hindsight, I realize that my comment may have been a bit adversarial from a RN/LPN perspective, which I didn't intend. LPNs have their place and value in health care; I just believe given the worsening health of average patients in clinic settings, it's becoming imperative for urgent care and primary care clinics to stop excluding RNs. Patients will benefit from it or suffer because of resistance.

xoemmylouox, ASN, RN · Dec 30, 2015

I have never heard of any staffing ratios. I seriously doubt there ever would be due to the unpredictability of patient volumes.

As an nurse in a clinic setting I am part of the medical emergency response team and have seen a lot. Patients who were WAY too sick to be here, but came here instead of an ER. It's scary, but people feel that they cannot afford hospital care or that their PCP is a God and is the only one who knows how to treat anything.

That mindset has killed more than one patient during my time here. We have had young mothers miscarry babies in our bathrooms, patients die in the pharmacy picking up OTC pain relievers for crushing chest pain, a family wanted to deliver their baby here VS the hospital that was literally across the street and refused to leave so we had to call for an ambulance, etc. Some days it is sheer madness. Luckily they seem to come in groups so things will be calm for a few weeks, and then we will have several in a week.

For me the paper work that follows an episode is painful. Its pages long and then has to be entered into a database for risk management to review. We have to notify PCP's, document in charts, etc.

BDOGGRN · Jan 3, 2016

Fully agree. A lot could be done to educate patients so they get the appropriate level of care in the appropriate setting. But who will ever be able to do that when staffing and supervision has been cut so drastically in primary care settings? In the locations I currently serve, I am typically the only nurse, so I am the emergency response team, and I have found myself in a few situations in which there was NOBODY that I could even direct to call 911, let alone bring an AED or oxygen. I don't care if it's a clerical staffer or clinical staffer or anyone else, I just need someone else to be aware, available, or within earshot when such a situation presents, and often there is no one.