ER Ratios and Delegation

[apocatastasis]

Hey y'all,

I've been working ER for about 10 months now, and am curious about how other facilities staff their ERs. I've already searched what various posters have as ratios for their facilities, but what kind of responsiblities go along with those ratios?

I ask this because our ratio is 4:1, but essentially when the patient is brought back, we have a blank slate and are responsible for everything. IV, labs and istats, meds, urine, urine preg, etc. We don't have medics, and our techs can't start IVs or do anything even mildly invasive aside from foleys and I+O caths. Sometimes we have a float nurse on a good day, but that's not the norm. We have gone 5:1 when staffing really sucked, but I shudder at the thought of taking 6 patients and being responsible for all the tasks and getting them taken care of in a timely manner. Maybe it's just a matter of actually having to care for 6 and getting used to the flow?

One of my coworkers on orientation came to our hospital from a trauma center in Arizona where the ratio was 6:1, but she said she actually found that ratio easier to handle than the 4:1 at our non-trauma hospital because of delegation to support staff.

So, basically, how do y'all with the higher ratios do it?

[apocatastasis]

Actually, I lie when I say we don't have medics. Some of our techs are EMT-B and EMT-P but they are forbidden to do anything outside the scope of UAP, so essentially their skills are useless to us. We have been written up for asking a paramedic tech to start an IV for us.

[Altra, BSN, RN]

How do we do it? By busting butt.

I don't mean to sound flip. But I've worked in an ER where the support staff situation was as you describe ... and in ERs with paramedics who could start lines, administer fluids, O2 and neb tx ... but in those ERs we were always chronically short of medics, so we were often on our own anyway.

Yes, you often get more than one patient at a time who needs everything done 5 minutes ago. It is the nature of the ER beast.

[crb613, BSN, RN]

The only invasive thing our techs can do is draw blood, but not allowed to check bs. The rest is up to us. After midnight its nothing for us to be 7-8:1....with one tech if we are lucky! I agree with Altra....you bust your butt...run wide open, and just get it done. Last night at one point I had 8 pts....one was a trauma.

[FancypantsRN]

Our ER is pretty much the same. Once midshift leaves (sometimes by midnight, sometimes we have a 1p-1a), 3 RN's and 1 EMT who puts in the orders only are on our own. Sometimes you have more than 6 pt's and have to do everything for them. You just hope they are staggered at least 20 min apart. You just kick into prioritizing gear of who really needs what first and who can wait. It can be tough (especially if you get an emergent thrown in the mix).

[apocatastasis]

That's really sad. I can do and have had to do 5-6 patients on occasion, but you basically provide really crappy care. Sometimes with 4 it's a breeze... and other times even 4 seems too many, especially when you're holding 2 or 3 that need to go to ICU. I'm an ICU nurse, so I guess I'm still kind of control-freaky about being in control patient care. Bust your ass or not, I don't think it's safe to have 6 or more. Nature of the beast I guess.

[VICEDRN, BSN, RN]

I came from an ER that was 6 or7 patients to one nurse at a minimum. It isn't safe. In terms of delegation, there was a phleb for 20 some odd beds and one tech per 10 beds. Realistically, the tech did EKGs and nothing but EKGs to meet the 10 minute window (if they did anything at all) and the phleb couldn't start ivs so you were better off doing your own labs when you lined the patient.

The reason I will forever and ever favor primary nursing in the ER now is because delegation entirely depends on there being a responsible reasonable person available to delegate to. If the person is lazy, there is nothing RNs can feasibly do about it. They disappear? Guess what? Work load still the same. Would rather reduce the ratio and do my own work.

The new job is 5:1 and we have to do everything for each patient. It can suck when they are all ICU holds or whatever but sometimes they are all urgent care patients and that's how it be. Unfortunately, there are few places that manage the complexities well and the trend seems to be to throughput patients that are surgical traumas or ICU quicker and quicker and leave behind all of the urgent care complaints which is not WHY i became an er RN.

Welcome to the ER!

[ktsummar, LPN, LVN]

Wow, that amazes me. I work in a 47 bed ER as a nurse extern. Ours ratios are dependant on which POD/acuity level of the patients. Fast track are general illness and injury and are 5:1, All other patients are 3:1. We always have a large amount of support staff including techs, externs and EMT IV.