Input please on acuity and total care

[Mudwoman]

Our hospital normally does team nursing, but our floor is doing a trial on total care. We have 30 beds on our floor (neuro/med-surg). Day shift is a ratio of 5:1 and we have 3 CNA's on the floor taking 10 patients each. M-F we have a charge nurse and a support charge nurse. Then we have 5 RN's and 1 LPN. The support charge has to open charts and do the assessments for the LPN, and asst the charge nurse. On nights, the ratio is 6:1 and there are 2 CNA's and one charge nurse. On weekends, we just have a charge nurse (no support chg) and on days, we take one the LPN's patients and open those charts. In the long run, I don't think having the LPN is going to work, but it will take a while to convince management and it is not the most pressing issue. We have to do our own admits, but not discharges.

We started this with the idea of dividing the patients by acuity, but report was a nightmare and you might have one group of patients one day and different patients the next. Also, you have patients whose rooms were not together. So, we went back to assignments of rooms in blocks of 5 and the issue of acuity is back. We think we need a combination of both, but we don't have a good model to use to determine acuity. We were using a scale of 1-3 and it was all objective. I would really like to have a 1-10 scale and a check sheet of some kind. I invision that some nurses might have 3-4 patients, while another might have 6 due to the acuity level. We do not have computerized charting. We do have computers on wheels to administer meds via scanning.

If any of you are doing the total care model and have a way that you determine acuity that is working and you would be willing to share, I would be so appreciative.

Charlee RN

[racing-mom4, BSN, RN]

Our med surg floor has 24 beds( we are not always full). We used to staff 3 RNs and 3 CNAs during the day and MS mgr would help out as much as she could. We have no LPNs. The CNAs left at 11, and we had one night CNA 11-7.

Then just recently we went to 4 Rns and 2 CNAs and then the one CNA at night.

But that took the RN patient load from 8 max to 6max. They say it is working better. The CNA's now divide the hall in half vs each having their own nurse to work along side of.

As far as acuity, we do try and somewhat accomodate, say Mod 1 has a high acuity, they make give the one bed that is closest to Mod 2 to the Mod 2 nurse. Or if an admit is coming and Mod 1 is the next nurse in line to get that admit, but she has a high acuity, and Mod 3 may be full, but the load is not that sick, then Mod 3 may in fact get that new pt, even if it is down the hall.

[kstec, LPN]

I do remember years ago when I worked as a CNA the hospital used RN's, LPN's and CNA's in triads. It worked wonderful then, but now that the scopes of practice have changed so much for LPN's, it does seem that having them is almost a burden to the RN's. I'm a LPN, and just in that short amount of time, the scope has gotten smaller and smaller, especially in the hospital environment. From a LPN's point of view working LTC, I definitely think acuity has a lot to do with nurse/patient ratio. Where I work the residents are divided up by acuity. The more acute the less residents that nurse has. I know there isn't much of a comparison with hospitals, but I understand where you are coming from. I don't know what state you live in, but if it's like Illinois where I live, having or being a LPN in the hospital environment is actually not beneficial. I know some states actually consider LPN's nurses and will allow them to work almost independently of the RN and that would be more beneficial and cost effective. In Illinois LPN's work only LTC, or at clinics.

[suanna]

For one, I'm not a big fan of "primary care" or "total care" nursing. It would be one thing if the instatution staffed with only RNs but the job of an LPN and RN have differences. Whenever I've been on a floor that has gone off the "team" approach what is lost is the teamwork that gets the job done. As an RN I get tied up doing tasks that could be delegated to an LPN or NA, but when the LPN's patient goes to pot and I have to spend 2-3 hours calling docs and doing crisis intervention, it just gives the LPN a nice long lunch break. Rarely do they offer to trade patients for one of my primarys, and even if they did, in the middle of a crisis I don't have time to give report. Total care- no thanks!

[Mudwoman]

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