First off, sorry for the length and the spelling/grammar errors...its been a long night.
I work nights on a busy 33-bed telemetry floor at an inner-city nonprofit hospital. I am a new grad and have been on this floor for 1 year and 4 months and I just finished training for charge. Our administrators have been making a big push to consider our floor a CICU step-down unit (but so far without the national certification). When I began working on this floor I had 4-5 patients during nights. There has since been a high turnover of staff, many RN's are moving to CCU/ICU and I find myself some nights being the most senior person on the floor. We are in a budget crunch and now are staffed 1:6 at nights with 2 CNAs and 2 monitor techs. We are accepting more complex pts, more confused/total cares and pts with gtts we've never worked with. Ok I apologize regarding the following text if it makes little-to-no sense...I would just like your opinion on the acuity of my pts this shift. how many do you take and whats your acuity? Do you think I am crazy for thinking this is too much?
Tonight I started with 5 pts and then got an ICU transfer for a total of 6.
Pt1- chf exasc, leg ulcer, chest pain (frequently on the call light for pain meds, random tasks...one of "the needy types" as horrible as that sounds.
Pt2-my icu transfer, anemic h/h (7and 21), here with SOB/CP and CHF exas) on an insulin gtt (our protocol states chemsticks q 1 hr) and just finished her 1st of 3units RBCs when arrived on the floor. MD did not order lasix between units Paged MD, did not hear back. Pt initially, stable until 15 minutes into 2nd unit of blood, then her temp spiked, o2 sats down to 80s on 6Lo2, lungs increasingly coorifice. I stopped blood called MD, and demanded lasix, benadryl and that she be transfered back to unit
Pt3- chf exasc on a dobutamine gtt going at 7.5mcg/kg/ (our unit protocol states we can't take dobu >5 mcgs but CCU/ICU full and pt "stable" so MD allowed pt on my unit)
Pt4- heparin gtt and morphine PCA, s/p fem-pop and then an emergency thrombectomy...most likely going to lose her leg...dealing with low BP/urine output and tachycardia as well as pain thru HS... poss shock? should have been sent to CCU/ICU but only 1 bed left in each reserved for codes
Pt 5 32 y/o with CP, frequent requests for dilaudid, trops (-), ct abd, lungs and angio (-)
Pt 6 another young pt with CP, turns out was gastroparesis...my only pt that was low acuity except for the frequent requests for $ from her husband spending the night
What types of gtts and what pts do you see? We used to take a limited # of gtts (amio,cardizem, dobutamine, dopamine, insulin, heparin and protonix) and now we are getting alcohol gtts, lasix gtts, isuprel, higher rates of dobutamine) and pts who require q 30 min vitals, bed alarms, turns q 2 hrs, and more and more confused people. To top this all off our staff is almost entirely new grads at nights who need a lot of assistance. Is this what its like on your floors or am I crazy for feeling overwhelmed? Thanks for the input.
You are not wrong to feel overwhelmed with an assignment like that. Where I work, when we have a patient on an insulin gtt we can have a max of 4 patients. Currently, our policy states that we are to stay at a 5:1 ratio at all times, "unless a staffing shortage" requires us to take 6 patients, which is every other day. My tele floor also accepts amio, dopamine, heparin, and cardizem gtts along with PCAs. If we feel that a patient assignment is too heavy to be a 5 or 6:1, then we have the option of requesting that the patients be placed in a "care-pod" 4:1 assignment, if not on our shift, then on the next. Perhaps this is something that could be addressed at your hospital.
You are not crazy at all, that is a ridiculous assignment and very unsafe. Having just 1 or 2 of those patients would have been very difficult to manage. Was there a manager around that could of helped? Did your coworkers have as difficult of an assignment?
oh my goodness, stories like these just freak me out..I went straight into hospice after doing ltc ..I just reinstated my license after ten years and KNEW right away the hospital would not be for me...this post confirms that the staffing ratios scare me..it's way too unsafe. BTW I work with MEDICAID members now, I have a desk job..the pay is less but I breathe easy. Please take care..
You are not crazy, this kind of pt load is unsafe for any nurse and for any patient. I am a PCU nurse and these are the kind of patients we have,but the benchmark staffing across the nation is 4:1.for PCU.It is for reasons like this that there is a shortage of nurses. My suggestion to you is if you and your fellow nurses can not convince administration to correct this problem, I'd pick up my stethescope and go elsewhere.
That sounds like my tele floor.. It is usually no problem because we all work really, really well together at night. One night I started with a combo amiodarone/cardizem drip, another cardizem drip on TPN with an NG tube and just about every other line you can stick in, a total care trach pt who was tachy 150's and an unexplainable fever.... and a demanding walky/talky w/ acute CP. We had many admissions that night...but my fellow workers were kind enough to take six patients instead of giving me another. I expect to get 6 patients when I work, but ive had as few as three all night. Keep in mind that i've been an RN only since June. As long as I DONT PANIC and think everything through, I have been fine. (And asked for advice from my fellow nurses!)
It has been my experience that they will give you whatever you will take... If the charge nurse accepts that a transfer is coming out of the unit on sn insulin gtt or a dobutamine gtt running higher than the unit standard and a nurse accepts the assignment, then these ICU patients will continue to be downgraded to tele. IMO it is unsafe for these patients and it is definitely contributing to the burnout of very good, caring nurses. Let you charge nurse and/or manager know what is happening and that is a patient safety situation. If you feel strongly about this and they aren't taking action, go up the chain of command. Ultimately, we as nurses are responsible for being patient advocates and sometimes that means refusing to let patients be transferred out of ICU prematurely because they "need a bed for an ER pt".
I was looking back at my previous posts and came across this one! Its amazing I totally forgot about the night I wrote about. Probably blacked it out!
Phew, got out of that position a year ago! I now work days in ICVR (like short stay for cath lab) and I still float to that unit at times. Things seem much better on that unit these days. They changed their staffing/acuity system and most of their night shift staff are experienced now. As strangely horrible as this sounds, I think one thing that has helped the unit is the poor census in CCU. Our 18 bed CCU has been averaging 4-6 patients a day, thus CCU has the ability to take their higher acuity patients. A lot of their staff has been given mandatory time off and people are taking a lot of PTO. Sucks for the CCU staff, but nice for the rest of us and our patients!
Wow, it was def not you.. That sounds like a nightmare!! So glad you got out of there. I have been thinking of relocating but all the horror stories I read here about staffing ratios around the country make me very leary of leaving my "cushy" med surg job. ARG!
OH MY!!!!! And I thought MY unit was bad! We are staffed 1:4 at nights with 1-2 CNAs, a resource RN, and we have a tele techs on a different floor that monitor all our pts and call if anything changes. Our highest acuity level is 4. We have also been accepting many confused/total cares, more complex pts, and our staff turnover is moderately high too. We take amio,cardizem, dobutamine, dopamine, (used to take insulin, but ICU does that now), protonix, argatroban.
I'm surprised that it's a 1:6 ratio where you are at. Even the acute care med-surg floor at our hospital caps it at 1:5, and the pts on that floor are super easy.
First off, sorry for the length and the spelling/grammar errors...its been a long night.
I work nights on a busy 33-bed telemetry floor at an inner-city nonprofit hospital. I am a new grad and have been on this floor for 1 year and 4 months and I just finished training for charge. Our administrators have been making a big push to consider our floor a CICU step-down unit (but so far without the national certification). When I began working on this floor I had 4-5 patients during nights. There has since been a high turnover of staff, many RN's are moving to CCU/ICU and I find myself some nights being the most senior person on the floor. We are in a budget crunch and now are staffed 1:6 at nights with 2 CNAs and 2 monitor techs. We are accepting more complex pts, more confused/total cares and pts with gtts we've never worked with. Ok I apologize regarding the following text if it makes little-to-no sense...I would just like your opinion on the acuity of my pts this shift. how many do you take and whats your acuity? Do you think I am crazy for thinking this is too much?
Tonight I started with 5 pts and then got an ICU transfer for a total of 6.
Pt1- chf exasc, leg ulcer, chest pain (frequently on the call light for pain meds, random tasks...one of "the needy types" as horrible as that sounds.
Pt2-my icu transfer, anemic h/h (7and 21), here with SOB/CP and CHF exas) on an insulin gtt (our protocol states chemsticks q 1 hr) and just finished her 1st of 3units RBCs when arrived on the floor. MD did not order lasix between units Paged MD, did not hear back. Pt initially, stable until 15 minutes into 2nd unit of blood, then her temp spiked, o2 sats down to 80s on 6Lo2, lungs increasingly coorifice. I stopped blood called MD, and demanded lasix, benadryl and that she be transfered back to unit
Pt3- chf exasc on a dobutamine gtt going at 7.5mcg/kg/ (our unit protocol states we can't take dobu >5 mcgs but CCU/ICU full and pt "stable" so MD allowed pt on my unit)
Pt4- heparin gtt and morphine PCA, s/p fem-pop and then an emergency thrombectomy...most likely going to lose her leg...dealing with low BP/urine output and tachycardia as well as pain thru HS... poss shock? should have been sent to CCU/ICU but only 1 bed left in each reserved for codes
Pt 5 32 y/o with CP, frequent requests for dilaudid, trops (-), ct abd, lungs and angio (-)
Pt 6 another young pt with CP, turns out was gastroparesis...my only pt that was low acuity except for the frequent requests for $ from her husband spending the night
What types of gtts and what pts do you see? We used to take a limited # of gtts (amio,cardizem, dobutamine, dopamine, insulin, heparin and protonix) and now we are getting alcohol gtts, lasix gtts, isuprel, higher rates of dobutamine) and pts who require q 30 min vitals, bed alarms, turns q 2 hrs, and more and more confused people. To top this all off our staff is almost entirely new grads at nights who need a lot of assistance. Is this what its like on your floors or am I crazy for feeling overwhelmed? Thanks for the input.
So glad you got out of there. I have been thinking of relocating but all the horror stories I read here about staffing ratios around the country make me very leary of leaving my "cushy" med surg job. ARG!
kates2185
1 Post
You are not wrong to feel overwhelmed with an assignment like that. Where I work, when we have a patient on an insulin gtt we can have a max of 4 patients. Currently, our policy states that we are to stay at a 5:1 ratio at all times, "unless a staffing shortage" requires us to take 6 patients, which is every other day. My tele floor also accepts amio, dopamine, heparin, and cardizem gtts along with PCAs. If we feel that a patient assignment is too heavy to be a 5 or 6:1, then we have the option of requesting that the patients be placed in a "care-pod" 4:1 assignment, if not on our shift, then on the next. Perhaps this is something that could be addressed at your hospital.