Any PICU RNs from CHOP or Boston Children's here?

Esme12, ASN, BSN, RN · Nov 6, 2013

Welcome Back to AN! Long time no see!

I do not but there are many who do...they'll be around

NeoPediRN · Nov 7, 2013

Hi Sloan, I don't work at CHB but transported to there often and can tell you a few things...CHB has three ICUs...a medical ICU on 11 south with 12 beds, plus an ?11 bed IMCU on the same floor, a 30 bed med/surg ICU on 7 south that does ECMO/CVVH/transplants (except heart), and an approx 30 bed cardiac ICU that is absolutely state of the art and cares for some of the sickest kids in the country. It is also ECMO capable. ECMO is 2 RNs to 1 patient, sickest of the sick are 2 nurses to 1 patient, sick is 1:1 or 1:2. The CICU is divided into pods and admissions are done as a team. I'm not sure about the MSICU, and the MICU does not have true pods. As far as I have ever seen the charge nurse does not have an assignment, and the transport teams also work in the ICUs either as helping hands or a light assignment that can be absorbed. Medflight/Children's transport team do a lot of outside hospital transfers to the critical care areas. All of the ICUs are very well run and my friends who work in them are very happy and feel like safety is taken seriously. Hope this helped!

Pediatric Critical Care Columnist · Nov 10, 2013

NeoPediRN, now I have some questions. Does each of the ICUs at CHB have a dedicated transport team? Does each of the ICUs have a charge nurse? Do the ICUs utilize techs or nursing assistants? I'm gathering intel for a pitched battle I foresee in the future here and I know our attendings are all gaga over CHB, so this could be valuable information.

meanmaryjean, DNP, RN · Nov 10, 2013

Following this thread- always interested in intel...

LadyFree28, BSN, LPN, RN · Nov 10, 2013

Following this thread- always interested in intel...

Ooh...me too.

LadyFree28, BSN, LPN, RN · Nov 10, 2013

CHOP's PICU is a 50-bed unit; they have ECMO, CVVH therapy; transplants, post OP and critically ill pts; get traumas, respiratory, everything EXCEPT cardiac; there is a separate CICU.

MeganNYRN · Nov 10, 2013

Chop PICU does not really use techs only for stocking not pt care. There are three receptionists most if the time since the unit is in three sections . There are also three charge nurses without assignments. Plus a resource nurse or two with no patients just to help put plus management nurses that will pitch in on days and a paramedic that is more of an tech that can actually help. It's a great place to work gerenrally 1:2, 1:1 with sick kids, 2:1 cvvh or ecmo and 1-3/4 with very stable kids. Just a general idea not policy or anything, they are very flexible as pt needs change.

umcRN, BSN, RN · Nov 11, 2013

NeoPediRN, now I have some questions. Does each of the ICUs at CHB have a dedicated transport team? Does each of the ICUs have a charge nurse? Do the ICUs utilize techs or nursing assistants? I'm gathering intel for a pitched battle I foresee in the future here and I know our attendings are all gaga over CHB, so this could be valuable information.

I'm not at boston or chop but am at another large childrens hospital so if you're looking for comparable stats I can give mine. My hospital has a PICU/CICU/NICU. There is a peds transport team and a nicu transport team. For cardiac nicu will get the babies, peds will get the older kiddos. Size of units: NICU - 56 beds, PICU - 40ish beds (can't remember exact), CICU - 26 beds. NICU/PICU always have 2 charge nurses WITHOUT assignments, CICU typically has one charge RN and a "resource" RN if staffing allows, both without assignments. All units have patient care techs and patient service techs. "PCT"s can assist RNs with cares such as trach care, baths, bed changes, turns, dressing changes and can also string lines (fluids, non narcotic meds, tpn), they can also feed kiddos who have no aspiration risks and entertain kids that need it. "PSAs" help with stocking carts and supplies, picking up blood, meds, assist with transporting kiddos etc but can not do any patient care.

Staffing in all units is typically 2:1 or 1:1, NICU occasionally gets 3:1. Our staffing abilities fluctuate with with acuity/census of course but picu/cicu never have 3:1 and are usually 1:1 if able.

We did have a situation a few months back during a very high acuity/census time when a charge rn in the cicu was forced to take a patient. Well a patient on the opposite side of the unit coded and she couldn't be there. The attending was LIVID because our charge RN's typically co-run the codes with the docs keeping order and pretty much anticipating what the docs are going to do and making sure everything is ready so when the charge nurse was unable to be at the code the attending made a huge stink about it. That hasn't happened since.

Pediatric Critical Care Columnist · Nov 11, 2013

Thanks so much for that, umcRN... that's exactly the kind of information I'm looking for. We've been in the process of separating our PICU from our PCICU for about 3 years and it's not going well. In the beginning we were all in the same space, with just the physicians divided along party lines. It was confusing and there were times when one of the non-cardiac kids was in trouble and the only doc handy... "Sorry, I'm cardiac." Then we had dedicated respiratory therapists too, with similar goings-on. Then just about 2 years ago, the PICU moved across the hall into a space that wasn't large enough for our non-cardiac population and only had 2 iso rooms, which meant that when we had more than 2 kids with snot, we had to "borrow" space on the PCICU for them. At first there was a charge nurse and a resource nurse for each side, as well as 2 transport nurses that helped out where they were needed. Many times when I was in charge of PICU, half of "my" patients would be on the other unit - usually the sickest of them too. That arrangement continued for almost a year, then the administration decided that PICU didn't need a separate charge nurse, that both units could be managed quite well with just one person mainly situated on the PCICU side but running back and forth. Then in the spring we switched out the locations so that PICU was on the larger side with all the iso beds and PCICU would no longer be adulterated by those not-so-sick-dirty-med-surg-kids. There is no charge nurse attending PICU rounds any more because they're too busy with the PCICU rounds. The administration decided right at the beginning that the PICU only needed a unit clerk and nursing assistant for 8 hours a day on weekdays, so when they both go home there's no one to answer the phone, admit visitors, collect supplies or run specimens. We've up till now not divided up the nursing staff, so on any given day we never know which unit we're working on, although the more senior nurses are usually on the PCICU side because the kids on that side of the hall are more deserving of the best care the hospital has to offer. Not to say our junior staff isn't capable, but they do lack experience, have heavy assignments and are basically adrift with little or no support. The other day I originally had a PICU patient that I discharged home, then I admitted a post-op cardiac patient. The next day, I handed that patient off and admitted a DKA. There are plans to move the PCICU into another building but no one will say what they're going to do with the nurses. We don't use techs and our NAs are not permitted to help with patient care in any way, other than to amuse bored toddlers. We don't even decrease the level of care of patients who end up 2:1... or 3:1, as is starting to happen on the PICU side. So we're still doing hourly vitals, fluids, neurovitals, meds, treatments, feeds, super-redundant charting, q4h head-to-toe assessments and all the rest of it for 2 patients and covering as many as 4 for breaks. It's all getting to be a bit dangerous. So knowing what other top-of-the-heap units are doing will help when the time comes to argue for better staffing.

umcRN, BSN, RN · Nov 11, 2013

@jan, goodness that sounds like a mess!

Our peds transport nurses don't typically hang out in the unit, I don't know what they do when not on transport. NICU transport stays in the unit and helps out if needed or will take a patient to MRI/Fluro etc

As far as docs go each unit has their own dedicated attendings however there are a few cardiac attendings who will occasionally cover picu shifts. picu/cicu has an attending on the unit 24/7...for the cicu this was recently implemented in the last year or so because of dangerously high acuity for a few months. I believe they hired 3 new attendings during this time to get us to this point. We have peds ICU fellows and nicu fellows. The peds ones rotate between picu and cicu for a few months at a time, nicu ones stay in the nicu except for 2 months (in three years) that they do in the cicu to learn about cardiac babies. The only doc issues we have is that the picu team goes to all acute care codes so if a cardiac kiddo codes on the floor the picu team goes but like I said our docs are all pretty on the ball with the cardiac differences and you can bet if a cardiac kid is coding on the floor our charge nurse already knows about it and is sending our docs over. As far as nursing goes we all work in one specific unit unless we are floated which is rare, and in my hospital icu only floats to icu, acute care only to acute care. We also have an icu "float pool" to help fill the holes, these nurses are trained in all three units. All our units have unit secretaries, sometimes two, staffed 24/7, all the units are "locked" units meaning that visitors have to be buzzed in and our secretaries are usually pretty good about enforcing our 2 visitors at the bedside rule. All our icu rooms are private (including nicu) so that eliminates the isolation problem. We also do not decrease the level of care on a 2:1 assignment (or 3:1 in the nicu) so we still do hourly vitals, I&O, q4 hr assessments etc but our techs can also prime and hang feeds among the other things i mentioned which helps too. For breaks/lunch everyone is assigned a back up and it is written on the morning assignment sheet. Usually we only have to cover one other person but occasionally we end up in a 3-way but since we know ahead of time we can usually get a plan in place well before lunch. Respiratory therapists will only cover one unit for their shift (and we typically have anywhere from 2-4 RTs in each unit depending on census) but they are all trained in all the ICU's and will rotate between them. The role of the resource nurse in the cicu is continually being developed but they serve as a point person specifically for our newer nurses, to make sure they're on track, caught up, don't have questions about anything etc. we have found that this resource nurse is helping to get newer people working with the sicker kids sooner but not feel like they are completely on their own with them.

Hope you guys are able to make some changes, that does sound like it's getting unsafe!

NeoPediRN · Nov 16, 2013

Sorry for the delay in responding, I fried my laptop and had to buy a new one! Each ICU does not have a dedicated transport team. CHB has their own transport team that does air/ground transports from outside hospitals, and they also use MedFlight which is our area critical care specialist team that also does ground/flight. CHB's own transport team will float to various ICUs to support staffing until they get called, and I believe the NICU does some of their own transports.

Each ICU has a charge nurse and utilizes patient care associates (the name keeps changing, they might be clinical associates now but basically a fancy term for a tech). The techs assist with bed baths, some stocking, blood sugars, emptying catheters, vital signs, appropriate delegated tasks from nursing.

CHB definitely staffs well. Every hospital has their challenges but I'd say the overall opinion at this hospital is that safety is paramount.