INTRA AROTIC BALLOON PUMP RATIO/RN/PT

[mror44]

RECENTLY WE WERE ASKED TO PAIR TWO BALLOON PUMP PTS TOGETHER AS AN ASSIGNMENT FOR 1 RN

WE REFUSED BECAUSE WE STATED IT WAS UNSAFE. THE SUPERVISOR REPORTED THIS TO THE DEPUTY DIRECTOR WHICH HAS STATED THAT IF WE REFUSE

WE CAN BE CHARGED WITH INSURBORDINATION. WE HAVE COMPLAINED TO OUR UNION BUT TO NO AVAIL

SINCE THEY SAY WE CANNOT REFUSE AN ASSIGNMENT EVEN IF WE FEEL IT UNSAFE. SO I WOULD LIKE TO GATHER DOCUMENTATION FROM OTHER INSTITUTIONS AS TO WHAT IS THE RATIO FOR THESE PATIENTS.

I APPRECIATE ANY RESPONSE TO THIS ISSUE.

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[hoolahan, ASN, RN]

A patient with IABP should be 1:1 no matter what their acuity. Anything could happen. We may become blase about some equipment when we use it all the time but remeber this thing is IN THE AORTA! One patient bends at the groin the wrong way while you're with your other patient and they could die!! It is like leaving a surgical instrument unattended while in the middle of surgery. Have you ever had a balloon rupture on you? We had a bad batch of balloons several years ago and we had 3 ruptures in 1 week! So K Reinhold, while agree that we should ensure safe staffing for ALL patients, IABP patients should not be left alone. perhaps stable balloons can be paired if it is in an open unit and the other stable patient is right next to you in the case of a staffing crisis, or another patient in the unit codes and needs to be 1:1 more, but only until the staffing can be corrected. Just MHO.

[RNed]

I think in most CCU/ICU settings, IABP patients are 1:1 , unless proven over time to be stable.

However, I note that adminstration has inferred a possible charge of insubordination. This bothers me. When adminstration attempts to imply or infer threats it represents the difficulties occurring in staffing and the means inwhich they (adminstration) is attempting to solve problems. Of coorifice, they can charge any employee with insubordination. The question is, are they willing to follow thru for this case!

If they got their way the first time,I suspect adminstration will continue to manipulate the staff by these means. I recommend the nurses get together and education themselves in labor practice and nursing regulations in their particular state.

Threats or implied threats work when we are uninformed about our rights,laws and responsibilities. We put our patients, ourselves and our hospital at risk.

We serve our adminstrators well to correct their mis--interpetations. We keep ourselves out of trouble and therefore by default the hospital out of trouble.

It is best to call there bluff (tactfully), when you have all the facts. Insubordination is vague in scope and practice. You stated this assignment was unsafe in your staff, bedside view. It was her obligation to prove to you or the state labor and nursing board this in fact was a safe nursing assignment and that your refusal to accept was do to other reasons.

First, she needed to prove your assessment was false and hers was true. Hard to do if you are management and not a bedside nurse. Second, she needed to identify a reason outside of patient safety why you would refuse this assignment. Again, unless you have documented disciple actions in your personal file a difficult task.

The nursing board most likely would ask, what alternatives were discussed regarding the assignment?

what were the resources available if either patient became unstable during shift?

what is the experience level of the nurses on staff that night and the nurse in question? of the nursing supervisor?

what was staffing? etc.?

what is hospital policy?

Most hospitals would not charge a nurse with insubordination without one darn good case. Also remember insubordination is labor and not neccessarily a nursing board issue. No threat of losing your license, unless you took the assignment. They, the hospital, risk the loss of face with the remaining staff and possible countersuit by the accused nurse.

I pose this because,once someone accepts the assignment a precedent has been set and it makes it difficult for the next nurse.

I may be wrong here, so feel free to correct me.

Just a thought !

[jenadox]

In the hospital where I work, IABPs are always 1:1. Contrary to a previous post, IABPs are NOT just another piece of equipment! A patient who extubates themselves can be bagged until another ETT can be placed. But a patient whose balloon ruptures their aorta as they are thrashing in bed is most likely not going to make to surgery for repair. I don't think that any patient on a pump should be considered stable. These patients are on the pump for a reason and they can go from seemimgly "stable" to extremely unstable in a matter of seconds. I had it happen to me last week!

I agree with RNed. The administration would have a hard time proving that you were being insubordinate. I would definitely check into either having a policy written or revising what is already in place. Besides, would administration take the fall if something happened to the IABP patient while you were with patient #2? Surely they wouldn't go after your license, would they? Of course they would!

[ June 17, 2001: Message edited by: jena25 ]

[keysecret]

I work in a very large institution where we do transplants and VAD's, so most of our pt's are very sick. Most of our baloon pumps are a 1:1 ratio d/t the acuity of the pt, (some of our pt's are even 2:1). There are very few exceptions to this rule, i.e. if we have a tele overflow pt who's vitals are q4hrs, and a very stable baloon pt who is weaning off of the baloon those may pair, it also depends on the skill level of the RN. Please remember that if you accept an assignment you are responsible, and will be held liable in a court of law. Dont let management intimidate or threaten you in to doing something that you are not comfortable with. I have always carried mal practice insurance, and I think that every one should as well. Im proud of you! we are about saving lives.

[nightshift82]

Our policy is written 1:1 as it should be!

[joeyzstj, LPN]

In my facility it is a policy that the IABP be one on one while the pump is on 1:1, which really makes no sense to me becasue the charting on 1:2 or 1:3 is exactly the same and the procedure is exactly the same. I would be happy to send you the policy if you need it.

[TLCinCICU]

Our assignments are all based on acuity. The only patients we have that are 1:1 by policy are CRRT (CVVH) patients. IABP patients are paired with the more stable ones - like the standard "turn/water/feed" vents. It doesn't mean that it's an easy assignment. It's why good teamwork with the other nurses beside you is essential.

On a side note, why is it that chronic back pain and periodic confusion seem to be indications FOR inserting an IABP (along with hemodynamic instability)?

:chuckle

[ghillbert, MSN, NP]

I would query the poster who spoke about a balloon rupturing an aorta - that would be extraordinarily rare. The balloons are made of material which would rupture before damaging the vessel.

Staffing depends on the unit and the patient - at my hospital there are balloon techs/engineers who do all the assessment, timing and troubleshooting of the IABP console. So the nurse basically disregards

the IAB apart from doing patient assessments (ABI/pulses/groin). They absolutely double balloon patients. Heck, they double VAD patients.

[estherojin]

I would query the poster who spoke about a balloon rupturing an aorta - that would be extraordinarily rare. The balloons are made of material which would rupture before damaging the vessel.

Staffing depends on the unit and the patient - at my hospital there are balloon techs/engineers who do all the assessment, timing and troubleshooting of the IABP console. So the nurse basically disregards

the IAB apart from doing patient assessments (ABI/pulses/groin). They absolutely double balloon patients. Heck, they double VAD patients.

Sorry, but I disagree with you. I worked in the cath lab for 5 years and have heard quite a few incidences of dissections, not all fatal, but dissection regardless. Even if the material of the balloon is pliable (which I don't know if you've felt, but is actually pretty tough), not all patients have perfect ideal aortas, many are calcified, many are plaque-ridden, many are aneurysmal. When the balloon pumps are inserted in the lab under fluoro, we generally do an aortogram, but in dire circumstances, if the patient is in shock, we put it in without losing time even before revascularizing the occluded vessel. Even small movements by the patient can cause significant migration of the balloon especially in short patients, it can make the difference of pre renal and post renal balloon placement.

Regardless, I think it's a no brainer that IABP pts ought to be singled, even if the patient's being weaned. Docs don't put in IABPs willy nilly, they're wicked invasive, expensive, and incredibly helpful. I have a big problem with attitudes that assume things will be fine because there have been no problems in the past. Perhaps there were no problems because of the vigilent nurses! At the hospital I work, the nurses are one to one with VADs and IABPs, we don't have techs to manage IABP timing. It sounds like a great idea, but I think knowing how to manage IABPs is a critical care nursing skill.

[ghillbert, MSN, NP]

You're certainly entitled to your opinion.

I am a device engineer and critical care nurse, and having managed hundreds of VADs and IABPs over the years, I can count the number of dissections on one hand.

Balloon materials have changed significantly over the years, and are certainly not "rough" these days. You're absolutely right though, most of these patients have crappy/torturous/calcified aortas and vigilance is required.

I don't think the risks of an IABP are any more onerous than those of a ventilator, which are doubled every day.

[CrazyPremed, MSN, RN, NP]

In my ICU the IABP are 1:1. I've had stable patients on them who are preparing for weaning. Sometimes it almost seems boring if I have had the patient for two days and I am just watching vitals signs. But - although I may not be doing much - I am constantly watching. If anything goes wrong with the pump, I don't have the leeway to take 1-2 minutes to get to the bedside because I am working up another patient. I would never put myself in that situation.

Think about it this way, if you were sick enough to need a balloon pump, would you feel safe if your nurse had an additional patient? If they are sick enough to get the pump, they are sick enough to have one nurse.

There are enough ICU's hiring that have 1:1 ratios with IABP. Find one.

CrazyPremed

[nrsmelissa1]

I work at a busy heart hospital where we frequently see IABPs. At times we may have 3 IABP pts on the unit. Only the unstable IABP pts (multiple gtts and lines) aren't doubled. I am yet to see a problem from this practice. I think each pt needs to be evaluated on an individual basis for staffing purposes.