Do you have a system for making fair pt assignments?

steelydanfan · Jun 17, 2010

Since most hospitals only have an acuity system in place because JCAHO requires it, and no charge nurse in my recent experience looks upon it other than a chore to be completed; I would have to say no. i have a hard time getting a pt. transferred to telemetry, not because he needed telemetry, but beause the 4:1 ratio at least meant he would get closer observation. My most recent charge nurse on both day and night base assignments on who they don't like, and who is of certain ethnic syatus. that is why some of us work like dogs, and some of us play with the internet and text all day long.

CNL2B · Jun 17, 2010

This is a hard question. Previous poster is right -- most hospital's acuity classifications suck. I work in a SICU and the patient classification scale goes from 1-4, with 4 being the sickest. Most of our patients are 3's and 4's. We often will transfer out 3's to stepdown and if they are doing well enough to be 2's, to the regular ward. Well, guess what? I floated out to the ward the other day -- and all their patients were 3's and 4's, too!!!! Sounds like somebody doesn't know how to use the classification system out there ...

Regardless, those numbers aren't really considered when making a patient assignment. I feel like I have it a little easier when I split stuff up in the SICU as I can only hand out two patients max per nurse. I usually try to pair up a complicated ventilator patient with someone else a little less acute. (Obviously 1:1s are singled.) Nurses in my unit make a big hairy deal about proximity as well, even though we're only 13 beds. Nobody seems to want to walk from one side of the unit to the other to do patient care, so I usually try to factor that in. I also look at who had what patient the day before and try to provide continuity if I can. Those are pretty basic staffing guidelines for any unit though, and things I try to communicate on to whoever I am orienting into the charge role.

If anyone that works for the Mayo Health System (Rochester, MN) and knows what their classification/acuity system is called, would they post on here? I worked there years ago, and it was EXCELLENT. It allowed you to enter nearly 20 different patient acuity designators in 8 or so different categories, and once you did this for all the patients on the ward, it spit out a piece of paper with the number of nurses/aides your unit needs to staff it adequately. It was WONDERFUL - it was the one system I have actually ever worked with that took patient acuity into account and not just patient census when you were trying to figure out how many nurses you would need. You still did need to pass the different patients around evenly between the nurses you were given though. I wish I could remember the name. I'd like to look it up and see if it still exists.

steelydanfan · Jun 17, 2010

i am sure Mayo's system is excellent; as so was our hospitals. The problem came in when the pt.s acuity got higher; and the need for more nurses became clear; our PTB's simply CHANGED the criteria!

oguesswhat · Jun 17, 2010

Basically we try to do it on proximity rather than anything else. Then most of the time you get most of your pts back the next day (if you work twice in a row) unless you got new admits (common) that are all over the floor (common) so you might not get all of them back...just the ones from your original section. Sometimes someone will suggest to break a certain area up...but generally it doesn't work that way at all. The only good thing is that sometimes...and only sometimes when you are extremely busy...the charge nurse may hold off on giving you a new admit for a couple of hours...until your set has calmed down some (such as you have blood you have to give right then and a couple other pts issues besides ha)

jmtndl · Jun 17, 2010

I have a simple system that everyone thinks is really stupid, but it works for me. I have a diagram of the unit...the halls with room numbers in blank spaces. No names. I highlight total cares in yellow. I outline heavy assists in pink. I write tele box numbers,P for procedures, TF for tube feedings, DM for diabetics. On the form itself are definitions of Total care (speaks for itself) and Heavy Assists...i.e. pt cannot moblilize without staff presence, confused,poor safety sense,restraints. It takes me about 15 minutes to complete it, working with the nurses and the techs.When it is done, I can see the whole unit on one page and have a relative idea of the acuity. I can see the locations and not put too many totals is one assignment. I can tell if I am splitting the halls comfortable when I have to do that. It just helps me see what I am including in an assignment.

Bill E. Rubin · Jun 17, 2010

We have a hospital program that does pt classification (WinPFS) that's used for staffing but not looked at by anyone in the unit.... good thing too, since the classifications are FTMP pretty useless.

For pt assignments, the resource nurse really does try to assign the pt load fairly, though precedence is given to the level of care required for a patient on the "independent" to "total care" continuum. For example: independent, light assist, assist, heavy assist, total (sometimes light total through heavy total). The problem with this is that it doesn't take into account such other factors as relative stability of the patient, level of incontinence (for example, the once per shift bowel movement vs. the C.diff diarrhea incontinent care). And then there's the level of coping and call bell abuse and the jack-in-the-box bed alarm nightmare patients, or pts requiring wound care/dressing changes etc.

All that being said, the resource nurse does try to take those things into consideration but there isn't a classification system for them per se. All said, they do a pretty good job most of the time, though admissions are taken based on one's order in the hit list and a reasonably balanced assignment can go amok with a train-wreck admission (I am remembering a night shift where, having an already heavy assignment and a new admission with a GI bleed who needed a bowel prep and a blood transfusion and had heavy coping issues bordering on hostility.

Tait, MSN, RN · Jun 17, 2010

I work nights going into days.

I get report from everyone paying special attention to discharges, level 4's (heavy total cares), fall risks, PCA/Epidurals, procedures and any psych/family issues that might slow someone down.

Then I get out my list of numbers, assign patients back to nurses returning for the day, then divvy out the 4's/PCA's and then balance discharges.

We do the best we can!

Tait

Oh yeah and isolations too!

drew123 · Jun 17, 2010

I work on a Pulmonary PCU currently as an Assistant Nurse Manager.

We went from having a 5:1 ratio with nursing assistants, to a 3:1 ratio without assistance. I made an excel spreadsheet with eacho room number on it and various categories across the top (line draw, o2, complete patient, on CWA protocol, etc..). Each patient is then given a number and the patients are evened out between the nurses on that shift.

Some times this causes a problem where the staff wants ALL of their patients back, but due to the acuity levels we are asking them to work with us on this.

It really seems to work, and when someone says that "its not fair", or "how come they only have..." we can point to the acuity system and use is as back-up.

The acuity system must be made for each specific unit as we are still tweaking it from time to time.

Sonjailana · Jun 17, 2010

We have nurses fill out a sheet giving a brief bio/report on each pt. Then each pt is classified into team, nice team, or primary pt based on the nurses' perception of acuity. The charge nurses use the nurses info plus the computer acuity system for staffing for the next shift. Generally it works pretty well.

emoening · Jun 17, 2010

We have been dealing with this issue on my unit forever. We have a staff meeting next week to talk about this so I would love to bring some suggestions with me. On our unit, we do NOT staff by acuity whatsoever. We staff by location. Our unit (med-surg / ortho) is 2 long hallways with groups of 4 rooms we call "pods". Our ratio is 6:1 so the rationale is to keep the nurse in 1-2 pods so he/she doesn't have to walk all over the place. However, our unit is rarely full, so half the time your 6 pts. may be spread out amongst 3-4 pods anyway, so you end up walking the entire hallway. To me, this system is insane. You may be kept in 1 pod, but every single one of those pts. in the pod is a total care, or a new post-op hip, etc. Additionally, our hospital is so small we don't have a peds unit so guess where they bring the peds pts? To us. This is also not factored into our assignment, it still goes by room location. I have had assignments where I have had 2 postop hips, a 6 month old with pneumonia, a postop spinal fusion, a confused woman setting off the bed alarm every 5 min, and a complete total care..but it was "fair" because they were all in the same 2 pods. I've also had assignments where all 6 of my pts. were self-care and stable, but another nurse is sinking, because "it goes by pods." And the real clencher is the night shift nurses make up our (day shift) assignments at the end of their shift. Not the charge nurse. No, our charge nurse is just whoever is working on the floor that day who happens to have the most experience, she still takes a full pt. load just like everyone else, the only difference is she carries the "charge phone."

Okay I realize I got off on a little rant there, but I could use some serious suggestions to bring to this meeting next week because something has got to change. We NEED to start assigning by acuity, I can't understand why our clinical lead / nurse manager doesn't understand this. I would much rather walk a little more than do what we're doing now!!

findingmywayRN · Jun 17, 2010

I have a simple system that everyone thinks is really stupid, but it works for me. I have a diagram of the unit...the halls with room numbers in blank spaces. No names. I highlight total cares in yellow. I outline heavy assists in pink. I write tele box numbers,P for procedures, TF for tube feedings, DM for diabetics. On the form itself are definitions of Total care (speaks for itself) and Heavy Assists...i.e. pt cannot moblilize without staff presence, confused,poor safety sense,restraints. It takes me about 15 minutes to complete it, working with the nurses and the techs.When it is done, I can see the whole unit on one page and have a relative idea of the acuity. I can see the locations and not put too many totals is one assignment. I can tell if I am splitting the halls comfortable when I have to do that. It just helps me see what I am including in an assignment.

Although possibly time consuming, this is really a great way to not only make fair assignments, but back up assignments as fair when questioned. Also this gives the charge nurse a good overview of the floor acuity - something not always known by everyone.