Benchmarking Level III NICU nurse/pt ratios....please help

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Specializes in Neonatal ICU (Cardiothoracic).

Hello friends....

I recently volunteered at a showdown staff meeting [don't you love those?] to benchmark our staffing ratios and acuity tool with those use by other hospitals. We have recently experienced the loss of about 30% of our staff due to unexpected illness, opening a PICU, and just plain old job dissatisfaction. Our nurse/pt ratio has never been great, but now it's just unsafe. Our charge/resource nurse had 4 unstable vents, including an admission, in addition to having charge and transport duties. The rest of the staff is being hit with 2-3 vents + 1-2 feeders or intermediates, and maybe 1st or 2nd admit. Anyone who floats in to help can only take feeders/growers, which leaves us with 13 unstable vents to manage with 5 nurses on average. At this meeting, they told us they hired 5 people, who will be starting in a month or so, but our staff is currently in meltdown. I suggested that if we can't justify hiring more FTE's due to unpredictable census, why don't we change our outdated and ineffective pt acuity assessment tool to prove the need for hiring more FTE's/PRN's. We currently divide intensives by 2, [vents, dop/dobut] Intermediates by 3 [iv's vapotherm, etc] Continuing care by 4 [og/po feed/grow] and that gives us the # of rn's needed. however, a nurse won't get just 2 intensives. You may get 2 intensives and a intermediate.....#of meds, o2 instability, a's & B's are never considered.

Sorry for the long intro.........

Please tell me your unit size, teaching vs community, normal [real world] nurse/pt ratio, and what type of tool you use to determine a workable acuity level.

Thanks so much!!!

:confused:

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We are a large level 3 with anywhere from 50 to as many as 85 babies at a time. I think we're supposed to have around 60. We do everything except ECMO and cardiac surgeries. It is a teaching facility and we do struggle with keeping staff too.

Our ratios are babies on room air are on three baby assignments. Babies on O2of any kind are on two baby assignments (NC, VT, Vents of any kind). Unstable babies, those on dop or dob in excess of 5 mcg/kg/min or immediate post op babies are 1:1. The admits go to whoever has the lightest assignment at the time and they usually get help from the charge nurse and/or our 2 helpers if we have any that shift (we are always supposed to have a charge nurse and 2 other nurses to go to deliveries, transports, help out, etc). When we aren't over census, we generally stay pretty well in those guidelines on days. At night we do have more push assignments where a baby that was a 1:1 on days will be on a 2 baby assignment. We do get 3 babies that should be on 2 baby assignments or 4 babies that should be on 3 baby assignments, but we never have the kind of staffing you've described. It's no wonder you are losing staff, cause I would never work under those conditions. We have crazy busy shifts on occasion, but nothing on a regular basis like that. Can I ask if your hospital is at least shut to transports or tranfers babies who are stable enough to other facilities?

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Specializes in Maternal - Child Health.

My heart goes out to you because you and your colleagues (those who are left -:) are trying with all your might to give good care in a bad situation. I'm not sure what caused the staff exodus you have have experienced, but without an adequate number of qualified nurses, your staffing ratios will not improve, regardless of what the policy says.

Unless administration limits high risk deliveries and closes to transport for the time being, things will not change. As for the new hires, it will be at least 4-6months before you reap the benefits of their presence, if they stick around. Some of them probably won't.

Sorry to be so grim, but I've been there, seen that, done that, and know that is how things will go.

I worked in SC in the 1990's, in a combined well-baby and Level II nursery. At that time, DHEC had mandatory staffing ratios for newborn nurseries. Do those still exist? If so, then that may be your trump card to get your census reduced until staffing falls into line.

Good luck!

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Any way your unit could take on some travelers until your new hires get trained? Like another poster said, that could be 4-6 months down the road if the working conditions of the rest of the staff don't scare them away first. You could start out with 13-week contracts and then extend at the end if census is still high/staffing is still low.

A well-treated PRN pool of nurses is also a true blessing in unexpected situations of high census and low staffing. But, PRNs who are not well-treated will find greener pastures -- just like the staff nurses. Many facilities tend to neglect their PRN pools (or treat them like second class nurses) and then wonder why they do not have a large pool of people to call when the diapers hit the fan.

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Specializes in Neonatal ICU (Cardiothoracic).

We are still open for transports, b/c we are the only LIII in our "perinatal region" The other 2 regions have level III's, but they are full to the gills too. We shipped out 3 feeder/growers to a level 2 the other day, but that still leaves us with sick vents that floats can't care for. It's not as horrible as I probably make it sound. The staff that left mainly went to our new PICU, b/c that's what most of them originally wanted to do. Our neos discussed shipping out moms to other hospitals before they deliver, but the ob's will not like not getting paid. We seem to have a good plan, even though there's no immediate fix. Travelers were eliminated permanently from our hospital when we went to an in-house shift auction system. But we really need a new acuity tool.....any other input regarding your n/p ratios?

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We wouldn't make our target staffing levels without travellers. I think your facility needs to reevaluate what really matters (money or baby's safety?). More than 2 vents on an assignment is unsafe and even when your new staff is trained, you won't want a high number of new people looking after a lot of sick babies with floats taking the rest. The OBs may not like it, but I would ask how their patients like having their baby's nurse responsible for too many patients. You may not have worked anywhere else yet and that gives you a different level of tolerance for crazy assignments than some others, but that type of staffing for any period of time is not ok.

I have worked at hospitals that used complex patient care hour calculations. You would put in how often your baby ate, how long it took (all NG feeds or nippling well or nippling poorly), how many procedures you had, how often you suctioned, how many times you had to draw labs, what type of respiratory support your baby required, how much support and teaching the parents needed, etc. All of these combined to tell you how many nurses you needed on each shift and what type of assignments the baby's should be on. If you're interested in the program let me know and I'll call my friend who still works there to get the name (I can't remember it now).

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Our ratios are babies on room air are on three baby assignments. Babies on O2of any kind are on two baby assignments (NC, VT, Vents of any kind). Unstable babies, those on dop or dob in excess of 5 mcg/kg/min or immediate post op babies are 1:1. The admits go to whoever has the lightest assignment at the time and they usually get help from the charge nurse and/or our 2 helpers if we have any that shift (we are always supposed to have a charge nurse and 2 other nurses to go to deliveries, transports, help out, etc).

Woweee!!!! Nice lookin' ratios!Where are you again? ;)

We've had two stable vent assignments every now and again. Usually a vent and some other stable kid, nother worse than on NC. Can have a couple of CPAPa and a feeder/grower or three feeder growers of two NCs and a feeder/grower. Never three on any respiratory support.

1:1 are very rare. Usually a "not expected to make it" kid or a PDA ligation.

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howdy! hailing from the land of oz (also known as utah) we consider a level 4 baby 1:1- oscilator, or unstable vent, dopamine, dobutamine, blood, pda, blah blah- although we have on a rare instance had to do a level 4 with a feeder grower- level 3's are vented but stable, iv fluids, some fds, etc. generally 2:1. we try really really hard to never have more than 2 kids when 1 or both are on vents. I can't imagine trying to manage 4. wow. level 2 are feeder growers, we never get to level 1- so why is it there? dunno- :-) level 2 babies are 3:1, but occasionally go 4:1- we do have CNA's who can help, (diaper changes and feeding) and our RT's are great to help too. we use agency quite a bit, though no travelers. seems like your in-house staffing isn't quite up to snuff- maybe agency can come fill in gaps till you get staffed? seems like emergency staffing would be indicated, no matter what policy is.

good luck!!

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Woweee!!!! Nice lookin' ratios!Where are you again? ;)

We've had two stable vent assignments every now and again. Usually a vent and some other stable kid, nother worse than on NC. Can have a couple of CPAPa and a feeder/grower or three feeder growers of two NCs and a feeder/grower. Never three on any respiratory support.

1:1 are very rare. Usually a "not expected to make it" kid or a PDA ligation.

California. We routinely have 2 stable vents, it's the really unstable ones who are 1:1 (those on high amounts of pressors, immediate post op, kids with suspected pneomos needing chest tube insertion, etc). Having an oscillator and a jet is fine according to our ratios, because it's treated the same as 2 babies on NC. Like I say, we occasionally have push assignments (much more when we are way over census), but fortunately our management does what it takes to get us more staff most of the time. Where do you work?

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DHEC does still have the staffing ratios for nurseries. When I worked in Columbia, our nurses would call all the time if our ratios weren't right and we were fined and if we couldn't staff DHEC would require us to close some of our beds until we had the proper staff. I will have to look through my old stuff to see if I can find the paper that lists what kind of assignments were acceptable. We had access to this information that's why the nurses knew when we weren't in compliance.

Hope you guys can get things straightened out in Spartanburg!

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Specializes in NICU.

Steve,

Can you pm me and let me know what hospital you work for in South Carolina?? I am moving to the state in June or July, and hoping to get on with the Level III in Charleston....Any info you have about the area hospitals would be greatly appreciated. I will have 1 year of experience in a Level III by June. :)

P.S. Our unit is a Level III NICU. We accept transports from central Alabama. We are a 40 bed unit and do everything except ECMO or cardiac stuff. (We ship those straight to Birmingham!)

We are using travelers. We have heavy assignments. Sometimes 2 vents and you're still assigned as first admit. Sometimes you'll have 4 grower-feeders...Maybe you'll have one HFOV and an isolette on feeds.... They are generally good about Nitric though...usually just 1:1 ratio in that instance.

Let's see.....after our neos make their morning rounds...they leave for the day...we have a phone number in which to call them and we usually have a back-up neo to call if the other one is unreachable. Sometimes, they make it in time for a birth of a micropremie..... Let's see.....our unit is scary to me at times because as a new grad, I feel like we are functioning like nurse practicioners sometimes.... Our experienced nurses intubate, they administer fentanyl for the eye surgeries....We draw blood gases and make vent changes based on them.... We look at x-rays and determine if we need to advance the ETT....

My orientation consisted of 3 weeks in Rooms 3 and 4 (our grower feeders) and then 7-8 weeks in Rooms 1 and 2 (the ventilators, cpaps, iNo, admits, etc) We have a charge nurse and sometimes a transport nurse at night when I work.

I mean, I don't know what's normal compared to what I know from where I work....I just listen to the travelers and they paint a very different picture of what we are.

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Did you ever find the paper with the "appropriate" staffing guidelines?

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