ICU staffing guidelines

heartICU · Nov 17, 2004

I agree with you - one nurse with an aide in a unit alone is NOT safe! If your patient codes, you can't run that code alone! even with a doc there, who will be documenting while you push meds and while someone else does CPR or hangs fluids? I don't know of any laws or studies or anything, but to me that just seems common sense. I would rather have two RNs than one RN and an aide.

CarpeDiem2004 · Nov 17, 2004

In my ICU, we have 2 RN's for 1-4 patients. We never have just one RN in the unit.

pickledpepperRN · Nov 17, 2004

Since 1976 in California the regulations require two licensed nurses present in the unit when one or more patients in the unit. One may an LVN.

I think this is fine for two patients unless one needs 1:1 care.

The LVN can record and so one. There needs to be a button at each bedside to get help in the event of a code.

11:11 · Nov 28, 2004

My first job was in a rural 5 bed ICU. It was almost always staffed with one RN unless the ration of over 1:2 then we added a floor RN to help, then another ICU RN if the pts were true ICU acuity

However there was always an RN supervisor in house, and the floor was just outside the door.

We had panic buttons at each bedside we could hit, and ppl would come running in a hurry.

It worked for us-

stevierae · Nov 29, 2004

since 1976 in california the regulations require two licensed nurses present in the unit when one or more patients in the unit. one may an lvn.
i think this is fine for two patients unless one needs 1:1 care.
the lvn can record and so one. there needs to be a button at each bedside to get help in the event of a code.

actually--ab 394 requires that the minimum rn ratio to patient in icu be 1:2. in the event of higher acuity, even more rns may be needed. governor gray davis signed this bill in 1996, or 97, i believe, and in january 2004 the provisions became mandatory statewide.

however, administration gets away with attempting to use lvns as part of the nurse to patient ratio--minimum staffing-- by cleverly citing the title 22 clause that calls for licensed nurses. using their rationale, since lvns are licensed nurses, they can be counted independently to satisfy "minimum staffing." in fact, they can not.

this is why ab 394 became a necessary augmentation to title 22--to clarify the fact, in writing, that lvns cannot assess patients, and therefore must work under an rn's license--therefore, cannot be counted in the "safe staffing" ratio. they cannot be assigned their own patients--so, in ca, if there are 6 patients in an icu, but only 2 rns, that hospital is breaking the law--even if they have 4 or more lvns. they have changed the rn to patient ratio to 1:3--not allowed. it's also very insulting to rns--administration seems to think we will blindly accept their word (and their cost cutting efforts) without doing our own homework and advocating for our patients.

in any situation in which there is a disagreement about the terms of title 22 vs. ab 394, ab 394 prevails. of course, the provisions of the ca nurse practice act and rn scope of practice prevail over both.

the ca nurse practice act is very clear in stating that rns' scope of practice is unlimited as long as they do not cross over into practicing medicine--however, the scope of practice for lvns is extremely limited, and they simply cannot assess.

we are lucky to have the only safe staffing law mandating rn to patient ratios in the nation. i am glad to be a practicing ca nurse, and proud that we along with cna made it happen. the slogan "every patient deserves a registered nurse" continues to be heard and be repeated all over northern ca.

you can read some history about ab 394 (and the complete text of the bill) as well as some great questions and answers about real or hypothetical staffing and ratio situations on the cna website at http://www.califnurse.org the law applies to all ca hospitals--not just those staffed by cna rns. it may prove helpful to rns in other states who are attempting to lobby for their own safe staffing law.

here are some sample scenarios off the site:

rn staffing ratios - it's the law

questions and answers about california's rn-to-patient staffing ratios, as required by the california nurses association sponsored safe staffing law, ab 394.

q. when do the ratios go into effect?

a. all hospitals must be staffing with the new ratios by january 1, 2004. hospitals that are not staffing by the ratios on that day are breaking the law.

q. are these rn ratios?

a. based on patient acuity and scope of practice laws, in accordance with a patient classification system, no rn can be assigned responsibility for more patients than the specific ratio at any time, under any circumstances.

q. what if more rns are needed because of sicker patients?

a. once the minimum ratios are in place, additional staffing must be assigned based on a hospital's patient classification system.

q. can hospitals use lvns in the ratio count?

a. under law, lvns are authorized to practice only under the direction of an rn or licensed physician.

q. what duties can lvns perform under ab 394?

a. data collection and other nursing care tasks may be assigned to the lvn, but validation of that data and incorporation into a plan of care remains the responsibility of the rn. jcaho defines "data" as uninterpreted observation of facts. only an rn can assess a patient.

q. what if hospitals lay off ancillary staff?

a. the ratios are premised on dhs surveys of existing hospital staffing patterns, including the percentage of lvns and other nursing staff. it is cna's position that any hospitals that cut non-rn nursing staff must hire additional rns to assure safe patient care.

q. can rn assignments be averaged?

a. the ratios are the maximum number of patients assigned to any one rn at all times during a shift.

q. are charge nurses out of the ratio count?

a. if the charge nurse has no direct patient care assignment, she/he may not be counted in the ratios. charge nurses, whose competencies have been validated, may provide break relief so other rns in the unit will not have additional patients exceeding the ratios.

q: according to our hospital management, state hospitals are exempted from implementing the new rn to patient ratios this january 1, 2004. is that true?

a: all general acute hospitals licensed under health and safety code section 1250 (a) are subject to the staffing ratios. the staffing ratios in ccr title 22 section 70217 do not, however, replace the nurse-to-patient ratios that already exist for hospitals operated by the state department of mental health. psychiatric facilities that are licensed under the general acute care facilities of hsc 1250 (a) and that are not operated by the state department of mental health are subject the staffing ratios.

q: how are we supposed to cover for classes or in-service sessions under the ratio law"

a: staffing ratios are in effect "at all times." that means that classes or in-service programming that require rns who have patient care assignments to attend, must provide for rn coverage just as is required for meals and breaks.

q: because the law does not specifically say "rehab" but specifies "specialty care," the administrator says that the law does not cover rehab. i have read the full text that is posted on your website and it does not specify rehab although in your fact sheet, it says specialty care includes rehab. how can this be changed to explicitly state "rehab" or is there another provision of law?

a: the law does cover "rehab" if the specialty care unit description of patient care services applies. the distinction that is made in the "specialty care" unit is that there is more care than is given in the medical-surgical unit. for example, some hospitals have trauma care patients who have had severe injuries but who are in need of rehabilitative services and are transferred to "rehab" for that care. these can be medically stable patients such as those found in the lowest acuity level medical-surgical who need the additional care that would be rendered in a rehab unit and who need increased assessment or observation. the rehab patient may also be a high acuity medical-surgical patient in need of rehab.

the rehab unit was the subject of much debate during the hearings and industry opponents of the law continue to seek revisions that would erode staffing in rehab units. dhs did not separate rehab units out from the specialty care units because they are literally a unit that provides a distinct type of care and that are not referred to as medical-surgical units. if the level of acuity and care of patient in your rehab reflects that of the specialty unit, the specialty unit acuities apply. if the patient population reflects that of the medical surgical unit and the rehab services do not require assessment and care that exceeds that of the medical-surgical unit, then the "specialty unit" designation ratios would not apply.

q: i work at a large urban non-profit medical center licensed as an acute care facility by the dhs. the manager of the "outpatient" recovery room told our staff that the ratios don't apply to outpatient surgery. is this true? (our unit is not a free-standing surgi-center). our staff rotates through pre-op holding, same day surgery recovery, and the "a.m. admit" unit. we pre-admit patients for "outpatient" and "inpatient" surgical procedures. we recover "second stage" pediatric and adult patients who transfer to us from the "main recovery" room, such as lap- chole, tonsillectomy, hernia repair; generally they have been recovered for one hour, sometimes less, following general anesthesia. these patients have been medicated for pain and are often drowsy and spend one or more hours until they are ready for discharge home with instructions. sometimes we admit patients to the surgical ward if they are not able to be discharged or have complications. we also recover "local/sedation" patients, regional block for hand or foot surgery, eye surgery, etc.

our unit is staffed with lvns also, and the manager uses "dream team" nursing, with one rn who covers two lvns who may have three patients each. we are on the same "float grid" as the "main recovery" and share the same clinical educator, executive vp, etc. the "main recovery" nurses are told they can give report to the lvn because the patients are transferred to a lower level of care. is it true, that the ratios don't apply to outpatient recovery?

a: many "outpatient" surgical units share the post anesthesia care service with the main operating room. the ratios apply to the "post anesthesia recovery unit of the anesthesia service." patients are monitored in the post anesthesia care unit until discharged or until transferred to a lower level of care (such as a skilled nursing facility) or admitted to an inpatient unit. the ratios apply to these post anesthesia care units regardless of the patient's final destination, based on the fact that the unit cares for surgical service patients in the immediate post-operative recovery period.

outpatient surgical services that perform outpatient surgery must have "sufficient nursing and other personnel to provide the scope of services provided" and "appropriately equipped and staffed operating room and post anesthesia recovery area." a determination cannot be made without knowing how the anesthesia service is structured and whether or not the "outpatient service" performs "outpatient surgery" and has a separate post-anesthesia recovery area" distinct from the "main recovery" that is not under the "anesthesia service."

rn and lvn scope of practice applies in every setting. rns cannot transfer responsibility for care management of a patient in the post-operative and post-recovery room period to an lvn. the responsibility of care management can only be handed from an rn to another rn. the lvn cannot accept shift report or a report on a patient being transferred to any level of care unless the rn accepting care responsibility is also getting the report. the lvn can listen to the report jointly with the rn who is assuming responsibility for care management but the lvn does not have the authority or expertise to assume that responsibility alone.

q: i am an rn working at a major hospital on a med-surg floor. a typical assignment is one in which the rn has 5 patients of her/his own and team leads three of the lvn's patients. i see this as 8 patients instead of the maximum of 6 patients. our manager insists that this is not so since i have an lvn for those 3 patients.

a: effective january 1, 2004 a registered nurse cannot be assigned more than six patients on the medical-surgical unit. patients cannot be directly assigned to lvns because lvns are dependent practitioners who can only perform nursing activities delegated by the direct care rn. regardless of the model of care, an rn cannot be assigned more than six patients on the medical-surgical unit and the rn cannot delegate nursing care activities to the lvn for more than six of those patients assigned to the rn. it is acceptable to delegate nursing activities to three of the six patients assigned to the rn as long as the lvn has documented clinical competencies and the activities are within the lvn's scope of practice.

q: i am an lvn. how many patients is an lvn expected to have, ten or twelve?

a: on a medical-surgical unit the baseline licensed nurse-to-patient ratio is 1:6. patients are assigned to the rn who delegates nursing activities to the lvn. the direct care rn cannot delegate nursing activities to the lvn for more than 6 patients.

q: if the patient assignment includes an rn and an lvn for 12 patients and the rn is required to assess the lvn's patients is that within the 1:6 ratio?

a: every patient is assigned to an rn. in the scenario you describe the rn would be assigned care management of 12 patients. an rn cannot be assigned more than 6 patients on a medical-surgical unit. additional licensed staff must be assigned based on the patient classification system but no more than 6 patients can be assigned to one rn, regardless of acuity.

q: if an rn is ultimately responsible for the patient's assigned to an lvn, how can she or he be required to take a full team of his/her own? in the dhs' statement of reasons, it says something to the effect of "team nursing" will not be prohibited by this law. can you clarify the implications of team nursing?

a: the staffing regulations must be interpreted within the context of existing regulations as well as within the context of the scope of practice for each licensed professional. lvns cannot be directly assigned to patients. lvns are assigned to rns who delegate nursing activities within the lvn's scope of practice and for which the lvn has demonstrated competencies. the rn who delegates nursing care to the lvn has responsibility for effective clinical supervision of the care delivered by the lvn. the lvn is responsible for correctly and competently carrying out the delegated functions, for documenting those activities and for reporting back to the rn.

team nursing is a model of care that involves the coordination of care activities under the direction of the rn with the assistance of other healthcare providers. regardless of whether the care model is "team nursing," or "primary" nursing the rn cannot be assigned more than the number of patients identified for the unit population. lvns cannot lead a patient care "team" but they are certainly members of the team that is led by the rn. regardless of whether the model of care is "team nursing" or "primary care" or any other model of care, the rn has ultimate responsibility for care outcomes and for the decisions about care that can be appropriately delegated or assigned to other caregivers.

q: if our facility does cut nursing assistant staff, requiring total patient care, what can i do about this?

a: the dhs final statement of reasons notes that "a hospital cannot reduce overall staffing by assigning licensed nurses to duties customarily and appropriately performed by unlicensed staff." in order to clarify that responsibility, dhs stated that staffing for care not requiring a licensed nurse is not included within the ratios and shall be determined pursuant to the patient classification system. if you have a collective bargaining agreement, the process of taking a position against these unjust reductions would be different from a hospital where the rns and other healthcare workers do not have a collective bargaining agreement. cna opposes and has challenged the displacement of any other caregivers which increases the rn's workload and jeopardizes care.

q: our unit is mixed with pediatrics, telemetry, and general medical/surgical patients. if i had 3 telemetry patients and 2 pediatric patients, how would that work? i do read a lot about the pcs still being in effect, but it does not seem to matter. what can i do to ensure that our pcs system is in accordance with the law?

a: the unit you are describing is referred to in the regulations as units that may "include mixed patient populations of diverse diagnoses and diverse age groups who require care appropriate to a medical/surgical unit." although the ratio minimum is 1rn to 6 patients, the dhs has stated that the pcs will continue to coexist with the minimum ratios to require an increase in nurse staffing in response to increased acuity and/or needs of the specific population, e.g. pediatric patients. mixed units with pediatric and adult patients are found in hospitals that do not have eight or more licensed pediatric beds. hospitals that have eight or more licensed pediatric beds must have a pediatric unit [ccr 22 70543©]. both pediatric and telemetry patient have acuity needs that would require richer staffing than the 1:6. the dhs noted in the final statement of reasons, "because of their immaturity and their dependency, hospitalized children and youth require significantly more nursing attention than adult patients. the need is greatest where dependency is greatest: for infants and pre-school children." [emphasis added].

the pcs should not contradict rn judgment about safe staffing. it should reflect the direct care rn's judgment. if is does not, something is wrong with the pcs. every rn must advocate for safe patient care and for staffing levels that allow for delivery of such care. ccr title 22 70217 ©(h) requires every facility to have a "process by which all interested staff may provide input about the patient classification system." in addition, your hospital must review the pcs tool for "reliability of the patient classification system for validating staffing requirements" [ccr 22 70217 © (e)] at least annually. organizing your colleagues to advocate for safe staffing standards through cna will not only help your patients, it will enhance your own work life.

q: i work at a level 1 trauma center with an all rn staff. the unit i work in is currently considered a "med/surg trauma" unit. reasonable staffing is 1:4. the new law with a 1:6 ratio for a med/surg unit is a detriment to our all rn staff and is unsafe. i believe changing our unit status to a step-down unit depends on the patient classification system form. what are the details of the pcs and who is responsible for completing and submitting this document? are there any safeguards to protect pcs data from being manipulated by the biased budget goals of administration?

a: the new ratio regulations states that " identifying a unit by a name or term other than that used in this subsection does not affect the requirement to staff at the ratios identified for the level of type of care described in this subsection." that means that a unit that "provides for the monitoring and care of patients with moderate or potentially severe physiologic instability requiring technical support" and who require "less care than intensive care, but more than that which is available from medical/surgical care" are "step-down" patient and the ratios for step-down (1:4) apply. a med/surg trauma unit in a level 1 trauma center is not a medical-surgical unit in which minimum staffing of 1 rn to 6 patients would apply. it should be made very clear that any hospital that reduces staffing in response to implementation of the nurse-to-patient ratios is not only violating the law, it is placing the health and safety of patients at extreme risk. the current staffing in your unit has been determined based on patient acuity as reflected in your patient classification system (pcs). the pcs requirements have not changed and your patient population has not changed. the dhs admonition says, a unit must be staffed based on the level of care required by the patient population.

BadBird, BSN, RN · Dec 6, 2004

We staff with a 2:1 ratio unless someone is on a balloon pump or prisma, they are stiff 1:1, seems like we are lucky because most hopitals are not staffing 2 or 3:1

onconurseRT · Jul 23, 2006

I was wondering if anyone can point me in the direction of an "acuity" system that is used in hospitals for just regular medical nursing. See, my hospital assigns pts to nurses based on their room number and could care less how much actual care they require. I worked in a hospital back in CA and there was such thing as "acuity", now, I don't even think that the word is written anywhere in the hospital where I work here in VA. Anyone know of a place I can view basic acuity Low-Medium-High??

Thanks

GoodAsGoldRN · Mar 9, 2007

actually--ab 394 requires that the minimum rn ratio to patient in icu be 1:2. in the event of higher acuity, even more rns may be needed. governor gray davis signed this bill in 1996, or 97, i believe, and in january 2004 the provisions became mandatory statewide.
however, administration gets away with attempting to use lvns as part of the nurse to patient ratio--minimum staffing-- by cleverly citing the title 22 clause that calls for licensed nurses. using their rationale, since lvns are licensed nurses, they can be counted independently to satisfy "minimum staffing." in fact, they can not.
this is why ab 394 became a necessary augmentation to title 22--to clarify the fact, in writing, that lvns cannot assess patients, and therefore must work under an rn's license--therefore, cannot be counted in the "safe staffing" ratio. they cannot be assigned their own patients--so, in ca, if there are 6 patients in an icu, but only 2 rns, that hospital is breaking the law--even if they have 4 or more lvns. they have changed the rn to patient ratio to 1:3--not allowed. it's also very insulting to rns--administration seems to think we will blindly accept their word (and their cost cutting efforts) without doing our own homework and advocating for our patients.
in any situation in which there is a disagreement about the terms of title 22 vs. ab 394, ab 394 prevails. of course, the provisions of the ca nurse practice act and rn scope of practice prevail over both.
the ca nurse practice act is very clear in stating that rns' scope of practice is unlimited as long as they do not cross over into practicing medicine--however, the scope of practice for lvns is extremely limited, and they simply cannot assess.
we are lucky to have the only safe staffing law mandating rn to patient ratios in the nation. i am glad to be a practicing ca nurse, and proud that we along with cna made it happen. the slogan "every patient deserves a registered nurse" continues to be heard and be repeated all over northern ca.
you can read some history about ab 394 (and the complete text of the bill) as well as some great questions and answers about real or hypothetical staffing and ratio situations on the cna website at www.califnurse.org the law applies to all ca hospitals--not just those staffed by cna rns. it may prove helpful to rns in other states who are attempting to lobby for their own safe staffing law.
the pcs should not contradict rn judgment about safe staffing. it should reflect the direct care rn's judgment. if is does not, something is wrong with the pcs. every rn must advocate for safe patient care and for staffing levels that allow for delivery of such care.

administration (read: nursing supervisor) constantly tries to get around this rule. i was working on a med/surg floor on the night shift at a larger hospital in the bay area with myself and one other rn with 13 patients between us. well...this was "okay" because we had an lvn assigned to five patients, i had three patients while "in charge" and the other rn had five patients.

i took this all the way to the cno...did anything happen? i dunno - but no one has tried to pull that one on this nurse again.

firehawkrn · Mar 19, 2007

we use an "acuity" system in the hospital where I work. I use the term loosely, because in all honesty, the "acuity" is only considered when convienent for management, or when state or JCAHO is in the building. Then we have staff coming out of our ears!! Med-surg is usually 1 nurse for every 10 pts, sometimes more. The nurse is either RN or LPN. In CCU/ICU where I work, it's usually 1:2 nearly all RNs, unless patients are overflows.

LaRose · Jul 15, 2007

Have you checked the AACN (Critical Care) website? I believe that they require 1 nurse: 2 patients. You should be able to find some guidance there.

BBFRN, BSN, PhD · Jul 15, 2007

My hospital would never, ever leave 1 nurse on the ICU- even if there is only 1 patient. Heck, they won't even leave 1 nurse on a TCU with 1 patient. And I'm not in CA.