California RN to tele PT ratios

BedsideNurse · Oct 21, 2018

Sorry not to be helpful, but just thought I'd comment.

When I worked in California whatever the ratio was for the floor, that was the number of patients we had, regardless of whether or not the patient was downgraded or their status was lower acuity.

So in ICU 2 was 2, even if one patient was downgraded and you were waiting for a step down bed, for example. They could not triple you up. Seems to me that if what your manager is saying is correct, hospitals could manipulate the ratio law with such regularity they could essentially nullify it. They could mix a small M/S unit with a tele unit and tack on a patient to every nurse on the floor, or add another pt to every ICU nurse as soon as a pressor was turned off or as soon as they were extubated, etc... The possibilities for exploitation are endless.

I live in a state that circumvents the ICU ratio law on a regular basis, using bogus acuity tools and triples, and occasionally quadruples up, ICU nurses with patients that "aren't that sick" or ICU but "fine" on a regular basis. It's so wrong. (And, unbelievably, I don't think the MA ratio law is going to pass due to misinformation and nurses taking the sword for admin--as usual--when faced with the opportunity to improve the number one factor in what kind of care our patients receive, that greatly impacts the quality of life for nurses on the job as well). We'll see what happens but it doesn't look good.

Anyway, 4 should mean 4, PERIOD! Hopefully someone who works in CA can chime in with something helpful for you. Good luck! Keep us posted if you can.

kaylee. · Oct 22, 2018

This is exactly what the hospital I work at in CA does. I work on the "tele" floor with a 4-1 ratio, but we house all the "step-down" patients, which in CA should be 3-1. They do this with a bogus acuity system, as pp mentioned. So we don't have a step-down floor, just tele, and since the acuity is vague, they are 4-1 ratio when they should be 3-1.

As for the med-surg/tele issue, they have tried to do what the op mentions, which is put 1 or 2 tele with non-tele and staff at 1-5. My union has spoken to this and it is definitely not ok. With a tele patient, 1-4 is the max.

The problem with my unit and the 3-1 vs 4-1 unofortunately is not ever addressed. Even though all the nurses I work with feel this way. I seriously am thinking of leaving bedside because of this, because I doubt it's better at any other places.

allnurses Guide · Nov 1, 2018

The definitions for each unit must be used.

By definition a "Telemetry" patient must be stable.

Patients moderately unstable or potentially severely unstable must be staffed at three or fewer patients per nurse at all times because they fit the definition of "Step Down".

Clearly a patient requiring such "Technical Support as an arterial line, mechanical ventilation, titrated IV vasoactive drips or insulin are unstable requiring 1:3 or better RN staffing.

Commencing January 1, 2008, the licensed nurse-to-patient ratio in a step-down unit shall be 1:3 or fewer at all times.
A "step down unit" is defined as a unit which is organized, operated, and maintained to provide for the monitoring and care of patients with moderate or potentially severe physiologic instability requiring technical support but not necessarily artificial life support.
Step-down patients are those patients who require less care than intensive care, but more than that which is available from medical/surgical care.
"Artificial life support" is defined as a system that uses medical technology to aid, support, or replace a vital function of the body that has been seriously damaged.
"Technical support" is defined as specialized equipment and/or personnel providing for invasive monitoring, telemetry, or mechanical ventilation, for the immediate amelioration or remediation of severe pathology.
View Document - California Code of Regulations

Commencing January 1, 2008, the licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times.
"Telemetry unit" is defined as a unit organized, operated, and maintained to provide care for and continuous cardiac monitoring of patients in a stable condition, having or suspected of having a cardiac condition or a disease requiring the electronic monitoring, recording, retrieval, and display of cardiac electrical signals.
View Document - California Code of Regulations

1RNlife · Jan 21, 2019

I live in PA and reading these posts I wonder why admin and supervisors in our hospital think its OKAY for us to be assigned to 6 telemetry patients (which can happen if all 6 in our zone are on tele which does happen) and patients on insulin drips in a 6 patient assignment. Generally admins are in their own bubble and don't see or understand what is going on, but supervisors should know better but let it go on.

Career Columnist / Author · Jan 24, 2019

On one of our MedSurg units we also have tele patients in one block of rooms. If a nurse has just 1 tele pt, she can only have 3 MedSurg pts. This meets the intention of the law, which is that a tele patient's nurse should only have 4 patients.

Same on Peds.

akulahawkRN, ADN, RN, EMT-P · Jan 24, 2019

On 10/20/2018 at 1:00 PM, kiraesparza said:
I work at a small critical access hospital in northern California. We have a basic Med/surg unit that has everything Peds, tele, comfort care, some oncology... We have been trying to figure out the RN to PT ratio for a tele pt or a peds pt, (standard ratio for MS unit is 1:5). All we can find is the ratio is 1:4 both tele or peds. The way we (RNs working of the unit) understand it is if you have 1 patient that is on Tele the you are maxed out at 4 patients. What our unit manager is telling us is that to be maxed at 4 all 4 of them have to be tele, so what she is telling us is that if the RN has 3 tele patients then they are maxed out at 5 not 4.
Is there anyone who here that can help clarify this, and do you have any written material to back it up so we can present it to our manager, so my staff is safe and compliant with the ratios. Thanks

The way that I understand the way ratios work is that basic staffing is going to depend upon how the unit is "organized." Because your basic M/S unit is set up to do Tele, Peds, and other specialty care, that changes the basic staffing to 4:1. It doesn't matter if you the unit has all M/S patients, because there's provision for Tele, Peds, or other patients to be there and they actually could be there, that's a 4:1 ratio for those beds designated for those services.

Furthermore, my understanding of an individual nurse's ratio depends upon the acuity of the "most acute" patient. In other words, if an RN's load consists entirely of M/S patients, then the ratio can be 5:1. However if even one of the patients is a higher acuity (is a Med/Tele, Peds, Oncology, etc as any of "specialty" patient is a higher acuity), then that nurse's ratio changes to that higher acuity level. So if that nurse that's got 4 M/S patients receives a Med/Tele for a total of 5 patients, then the nurse is now beyond the allowable ratio as this nurse's ratio is 4:1, not 5:1.

Under your unit's scheme, a nurse can take 5 patients, including an ICU-level patient, a Peds patient, Tele patient, Oncology patient, and a general M/S patient because the ICU patient's staffing ratio is 2:1, Med/Tele/Peds/Specialty care is 4:1, M/S is 5:1 because a single M/S patient is assigned to that nurse.

In short, if a M/S nurse (5:1) gets a Tele patient or a Peds patient, or any other specialty care patient where the ratio is higher than 5:1, that nurse "becomes" a Tele nurse or Peds nurse or "specialty care" nurse and the ratio for that nurse becomes 4:1. If that same M/S receives a patient that meets "step down" criteria, then that nurse becomes a "step down" nurse and their ratio becomes 3:1.

allnurses Guide · Jan 24, 2019

16 hours ago, akulahawkRN said:
The way that I understand the way ratios work is that basic staffing is going to depend upon how the unit is "organized." Because your basic M/S unit is set up to do Tele, Peds, and other specialty care, that changes the basic staffing to 4:1. It doesn't matter if you the unit has all M/S patients, because there's provision for Tele, Peds, or other patients to be there and they actually could be there, that's a 4:1 ratio for those beds designated for those services.
Furthermore, my understanding of an individual nurse's ratio depends upon the acuity of the "most acute" patient. In other words, if an RN's load consists entirely of M/S patients, then the ratio can be 5:1. However if even one of the patients is a higher acuity (is a Med/Tele, Peds, Oncology, etc as any of "specialty" patient is a higher acuity), then that nurse's ratio changes to that higher acuity level. So if that nurse that's got 4 M/S patients receives a Med/Tele for a total of 5 patients, then the nurse is now beyond the allowable ratio as this nurse's ratio is 4:1, not 5:1.
Under your unit's scheme, a nurse can take 5 patients, including an ICU-level patient, a Peds patient, Tele patient, Oncology patient, and a general M/S patient because the ICU patient's staffing ratio is 2:1, Med/Tele/Peds/Specialty care is 4:1, M/S is 5:1 because a single M/S patient is assigned to that nurse.
In short, if a M/S nurse (5:1) gets a Tele patient or a Peds patient, or any other specialty care patient where the ratio is higher than 5:1, that nurse "becomes" a Tele nurse or Peds nurse or "specialty care" nurse and the ratio for that nurse becomes 4:1. If that same M/S receives a patient that meets "step down" criteria, then that nurse becomes a "step down" nurse and their ratio becomes 3:1.

I think you are correct.

Before the ratios our hospital had telemetry and step-down patients on the same unit. After they created a step-down unit where so called "stable" patients requiring mechanical ventilation, pulmonary artery catheter or arterial line, non titrated Dopamine and other vasoactive drips are staffed at three or fewer patients per RN. "Stable" patients with continuous cardiac monitoring are classified as Telemetry patients and staffed at four or fewer patients per RN.

Acuity can decrease the number of assigned patients for other reasons than severity of illness. A patient with decreased ability for self care or with a high potential for a fall or self harm often needs more tome than a four patient assignment allows so the assigned nurse may need only two or three patients, OR a sitter or other additional nursing staff would be appropriate.

Link to the ratio regulations:

https://govt.westlaw.com/calregs/Document/I8612C410941F11E29091E6B951DDF6CE?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)

jbluehorseh · Feb 1, 2019

The ratio would be 4 to one . It does not matter what the mix is as long as you have one tele patient. the Department of health in your county in a good place to file a complaint , if you have a union file a complaint with them too. this is a patient safety issue and puts you license at risk.

I have a topic the forum entitle "Are hospitals putting nurse’s license at risk" and it has a poll questions if you could help me out with that.

Stella.didnt.doit, BSN, RN · Oct 2, 2019

she is or he, is a big liar pants on fire