How do your units/hospitals judge acuity and staffing loads?

[mappers]

So I was in charge for the first time yesterday and had the "pleasure" of going to bed huddle - the blood-bath, er I mean meeting we have 5 times a day to discuss staffing for the next shift. So of course several floors are down and they're discussing who gets the extra nurses/aides and they're talking about how floor X is at 5 - 1 now and really needs the extra nurse from floor y who will be 7 - 1 if they give up the nurse (I'm flor Y). Because floor X is a monitored floor......Ummm....Floor Y is a monitored floor too(???) I kept my mouth shut because I always figure it makes sense to someone, but asked about it later....Floor X has drips, she told me. (We don't, but we did have 2 chemo's that day.) So Floor X is considered a higher level of care.

(Did what I wrote make any sense at all to you guys??)

Acuity seems to fluctuate sooo much, how do your hospitals handle staffing and acuity? Just before floor X "can" have drips, doesn't mean they do today. But they'll still get more nurses than us. Sometimes we have a bunch of walky talkies who need little care besides monitoring and meds. Sometimes we have a bunch of incontinant total cares who need to be cleaned up every hour. Because we are oncology, we often have patients who get pain meds q1h, plus blood, platelets, chemo etc and your day is packed. (One day I had to go to BB 5 times on three different patients and still didn't get all my blood products in.) So shouldn't staffing be handled based on what you have that day?? But how do you pull this off?

When I did clinicals, the hospital attempted a system where patients where scored on acuity level. They had some formula (I think) where they could determine staffing based on the type of floor and the acuity level. I don't think it really worked because, let's face it, most people are going to "bump up" their acuity level to get more staff.

What do your facilities do? What works for you?

[Zookeeper3]

I have never worked a floor and god love you. We have ten ICU beds, by the end of the shift it's easy to see if the current assignment works or doesn't with admissions, changes in status and what not.

We do not use any formal system, other than employee input with the charge and common sense.

I shared this because my hospital eliminated a formal acuity tracking system... and I can't imagine how the floors do it? I hope others will chime in for you.

[Zookeeper3]

Oh wanted to mention that although we have 800 beds or so, the nursing supervisor rounds each shift and really knows whats going on for those that are in need, vrs, the dram queen nurses.

we have supplemental staffing, or a float pool, one for ICU, on for the floors, based on what the supervisor has actually seen in acuity... there be it the nurse. It stops the drama, the BS and the meeting.

I've been in staffing meetings, the squeaky wheel.... that cries wolf too many times... pays in staffing numbers when you need it most. just be upfront and honest and question others in that polite, "treat me as I'm stupid tone and explain it to me why you need the nurse". Should work, just fine.

So when you need the staff and speak up... they will listen, yes it's a game... but learn to play it well.

[RNforLongTime]

Um, they don't. We have 6 beds in our ICU and only ever 2 nurses. No matter what the acuity is. And we're lucky if we have a nurse aide to help out. I work night shift so I have to be respiratory and housekeeping on night shift so if we have to move a pt out to get another pt in, we have to clean the room ourselves. We've had EVERY pt in the unit on a vent and only 2 rn's and they pulled our aide! Didn't even get a pee break that night.

[bill4745, RN]

If we get to stop and eat for 30 minutes, we are over-staffed. If some of us are having anxiety attacks, we are properly staffed.

[RNforLongTime]

Oh and there's no unit secretary/ward clerk to answer the phones and take off orders. We have to also do that job as well.

[Chico David, BSN, RN]

Sure makes me glad to be in California, where we have a floor under our staffing levels - 5:1 med surg, 3:1 stepdown, 2:1 ICU, etc. That said, the law says that is a base level and the hospitals are supposed to staff up from there as needed and of course they mostly don't. Acuity systems are all a sham - hospitals manipulate them as needed to produce the result their budget says they need and match the number of nurses they have available. Acuities get magically adjusted in any system I've ever seen. I used to use a desk in the corner of the room where the bed meeting was held and I clearly remember many times hearing things like: "We have too many highs on your floor, we don't have that many nurses, have to make some of them mediums". Since the staffing law came in, there's at least a floor they can't go below, and pretty decent compliance with meal and break relief in most places.

[sasha1224]

One hospital I worked at used an acuity tool that had us fill out a questionnaire each shift. It would then assign the patient as a 1:1, 1:2, etc. This was translated as if the nurse had a 1:2, they could only have one other patient. One LTACH I worked at used an LTACH acuity that assigned levels 1-4 based on needs. The assigned nurse could not have a total of cares over 10. When looking at the LTACH acuity tool, 10 is about the maximum number of hours for direct nursing care based on the definitions. So if 4 patients came out level 3, the nurse could only take 3(3x3=9) but not all 4(3x4+12). The current facility I work at also uses the LTACH acuity tool, but doesn't have a way to assign the acuities. This one doesn't use that magic 10. This formula, for example, assigns a level 4 which equals 5 hours of nursing care. Census 6 with all being level 4. That is 6 patients x5 hours direct care =30 nursing hours. We divide this by 12(1 shift) and the number of nurses that should be staffed on one shift is 2.5 nurses. However, the administration will staff 2 nurses for a census of 6 level 4s with no aide on nite shift. According to the acuity definitions, this would not necessarily be posssible. A level 4 designates that 4-5 hours of direct nursing care is needed. In a 12 hour shift, 3 level 4s would neec 12-15 hours of direct nursing care. Obviously, 15 hours could not be provided in a 12 hours shift. Especially if there is no aide.

[Idontknowbetter]

We have this really stupid and inaccurate computer system that is supposed to generalize and estimate (like a psychic) how much staffing a floor will need. each nurse fills out an online form (with about 30 indicators for each patient, you click on the one that applies to that patient)every shift and new admission. This is supposed to determine "how hard'' your workload is and how many nurses/aides the floor needs. #1, it's always inaccurate. #2, if your accuity is TOO high, staffing/the supervisor will call you and say "Oh, you probably misjudged or something, your acuity isn't REALLY that high, can you please go back and redo it" (aka, we don't want to pay for an extra nurse/aide if we don't legally have to). It blows. If they aren't going to consider the acuity at all, then why even do it.

Sometimes I get attitude for not doing my acuity (it's supposed to be done and turned in within 1 hour of your shift) on time when I've been running around like a dog. Puhleeze.

[diane227, LPN, RN]

Acuity systems are not a static thing. The acuity of your unit can change from moment to moment. We have no set system but this is what I do. Total #of pts, # of isolation, # with bed alarms(high fall risk pts), restraints, sitters, total care pts, fresh post ops, patients with lots of medications and complicated care, and very obese pts and then I take into account if we are the only floor that can take admits and transfers. I make my staffing need decisions based on those factors and I write any staffing deviation from the fixed matrix down for my manager to justify that staffing decision.

[JeepgirlRN]

Acuity isnt taken into consideration, only how many patients are on the floor. Its a scary day if they leave us with say a 4:1 or 5:1 because we are either going to get slammed with admissions or theyre gonna pull a nurse to another floor halfway through the shift, causing us to have to redivide. This never fails. The outgoing shift makes up the oncoming shifts assignments to try to take in to account the acuity of the load and the appropriate patients for a LPN etc. By the end of shift we usually have atleast 6 or 7 patients. We do usually have a division clerk. We call for 2 techs but do not have enough hired so we only have 1 tech for 28 patients, so we are also having to do alot of complete care on our patients - Baths, walking, cleaning, vitals etc. I would say we have about 70% total care patients on our unit at any given time.

[Chisca, RN]

Management staffs by what they think they can get away with. I find it rather humorous that a nursing supervisor can make a walking round, basically a snapshot in time, and determine that any given floor does or does not have enough staff. Argue in a rational way why your unit needs more staff based on acuity and the response is "do the best you can, everyone is short". Safety seems to have left any staffing equation and as long as nothing bad happens it is assumed the unit had adequate staffing. And if something bad happens the individual nurse is blamed rather than the system.

Being a patient in a hospital is fraught with danger. In motorcycling there is a acronym ATGATT which describes all the gear all the time. Helmet, gloves, proper clothing all the time no matter how inconvienent. For a patient in a hospital the single most important safety device is a nurse.