level 2 picu units- 4-8 bed units

Hey Laura.

Our unit has 15 actual beds, but at various times we've had as many as 19 patients. We're primarily a cardiovascular surgical and transplant PICU with the odd trauma or other type of patient thrown in; our ratio is usually 1:1. We have two float pools, an NICU-PICU pool and a CV surgery stepdown-PICU pool. The stepdown unit is called the ICE Unit, or Intermediate Care Environment, where the ratio is 2:1. The NICU-PICU pool used to have eight people in it, but it has shrunk to only three. The nurses in this pool will work in whichever unit has the biggest need... usually determined not to be us... a rant for another time. Sometimes the nurse will take a PICU patient, others they will take a neonate following CV surgery who will be ready for transfer back to NICU so that we're able to actually transfer the child out. The other pool has about a dozen members, who will work in whichever unit has the greatest need... see above. Oftentimes our assignment sheet will have a note on it: "All 4C/ICE-PICU pool nurses have been scheduled to work on 4C ONLY for the next two weeks!!! Do not change!!!" The rest of us nurses in the PICU are considered to be an extension of the the Child Health float pool, as we've all been sent out to the floors or to NICU, sometimes two and three of us at the same time, even when we have people in on overtime!!!! They do not, however, float anyone to us, because our patients ARE TOO SICK. Better that one of us has two of the TOO SICK kids than for one of them to come down and take on a less-sick kid.

If you decide to go the modified closed unit route, you would be well-advised to put the rules for floating down in writing and have the hospital administration sign them. You want to clearly define the terms under which PICU staff float out of PICU, what kinds of assignments the PICU nurse will take, that the PICU nurse will need to be freed up quickly if conditions in PICU change and s/he needs to return to the unit, what types of assignments nurses from outside the PICU will be expected to take on, what kind of orientatio they are to be provided, and any other niggly details you can think of. Trust me, if you don't have it all in writing and agreed to specifically, they'll sneak things by you until you are staffing the whole place and nobody ever helps you out.

We don't typically use on-call. Our administration doesn't believe in paying someone to sit home by the phone. They'd rather have those of us who show up work twice as hard, or to pay someone overtime. The only exceptions are our extra-corporeal life support team and our transport team. If we don't have a primer or a transport nurse in house, we'll have one on call.

We have a large casual list, and some casuals can be counted on to come in in a pinch but others will only come in on weekends or statutory holidays, and still others will sign up for a shift then call at the last minute and cancel. Where I used to work, if you accepted an extra shift you were expected to work it, unless you were dead.

I hope you're able to come up with a plan that meets your needs but gives you control as well. Good luck!