Would you take this assignment??

[SICU Queen]

I arrived to work last week (7p shift) and my assignment was:

Patient #1: 48 y/o male, s/p CABGx4, 6 hours out, still intubated, all the usual lines and tubes, CT output was averaging about 150/hour, needed FFP and PRBCs, on epi, dopamine, vasopressin, ntg, insulin, mag, and maintenance fluids, b/p super labile, was atrially paced with frequent episodes of non-capture and pvc's (despite the surgeon's meddling with the pacer).

Patient #2: 42 y/o male, s/p crani secondary to sah, about 3 hours out of surgery, ventric, aline, foley, and when I walked down to his room, screaming his lungs out and trying to climb out of the bed.

These patients were FIVE rooms apart, and not in a corner or curved hallway where it would be possible to see both, but five rooms apart down a straight hallway.

I NEVER complain about my assignment when I go to work. When I questioned this one, the day charge nurse who made the assignment got SUPER ticked off and we had a major tiff that ultimately ended up in me refusing the assignment.

SO, instead of the crani I got a brain dead patient, three doors down, waiting for our state's organ procurement agency to show up and do their thing. THAT patient came with her own nurse from the agency; all I had to do for that one was put in orders and get meds from Pyxis. I was SUPER busy with the CABG; one of my first hours he had 240 out from his ct! Once the FFP and PRBC's got in he was a little better, but I was never able to wean any of the drips that shift.

What would you have done? Am I wrong for thinking my original assignment was unsafe? What's your ratio for CABGs and how long, if at all, do they stay 1:1??

[traumalover, RN]

open hearts are never a one to one in our unit....unless they are on crrt. Have never had problem with double assignment anymore than wih a severe septic shock pt who kept coding all day long or unstable tbi with chest and abd injuries.

Sometimes when we have confused pts who are agitated PCT or CNA sit one to one to prevent them from self inflicted harm

[meandragonbrett]

open hearts are never a one to one in our unit....unless they are on crrt.

Do your post-op hearts and lungs to to PACU then? Because there is no way a fresh heart or lung can't be 1:1. Chest tube output q15m, Vitals q15m, Assessment q30 min (including swan numbers), your meds, labs, weaning from vent, etc......all of our patients are like this until 4 hours post-op. Then assessments go to q1h x2 then Q2h. If your post-ops go to PACU first, then I can easily see them not being 1:1.

[traumalover, RN]

POST OPS ARE DIRECT ADMITS. tEAMMATES AND CHARGE NURSES PITCH IN AND WATCH PT NEXT DOOR. THE ONLY TIME I'VE SEEN A POST OP HEART 1:1 IS WHEN SOMEONE IS NEW TO THEM. WE DO TWO-FOUR POST OP HEARTS A DAY AND WE DO TRY TO RESERVE A BED NEXT TO A STABLE PATIENT IT DOESN'T ALWAYS HAPPEN. BALLOON PUMPS ARE NOT ONE TO ONE EITHER. ONLY CRRT. TRAUMAS ARE NOT ONE TO ONE. I'VE NEVER EVEN THOUGHT ABOUT IT BECAUSE THIS IS HOW I WAS TRAINED. ST LUKES ACROSS THE WAY HAS THE SAME DEAL. AS DOES SEVERAL OTHER HOSPITALS IN THIS AREA

[clarkheart]

I've had cabg's 1:1 for 2-3 days postop because of their instability. We have a rating system that we strictly adhere to. I had a patient awhile back that was a CABG with an IABP, vent, multiple drips and quite unstable. I would not feel comfortable taking another patient with that kind of load, there is too much monitoring involved. It makes me wonder if they are pairing another patient with that kind of load whether or not the second patient deserves to be in ICU to begin with. Perhaps it has to do with the state you are in. In CA we can never have more than two patients per nurse and where I work we are very conscious of not overloading nurses with what many of us would consider unsafe assignments.

[traumalover, RN]

In our unit we are normally are 1:2 but people have been triple assigned. WE don't have a step down unit, so some pts we have are very easy-straightforward resp failure-vent, turn, feed. we have continous Swans and do not paper chart, just upload the data. Our new septic shock protocol involves a full set of lines placed along with fluid boluses until cvp is this, this gtt for this. Unstable CABGs are bad but a lot of our septic pts are just as bad. The majority of our CABGs, extubate the same day, dangle, have lines and ct dc'd the next day and sent to tele. The unstable pts are more work indeed, but I have great coworkers who watch my other pt while I settle the heart in and I have not felt unsafe or stressed. I asked several people on the Unit if they felt unsafe and the general concensus is we like the way we do it. We have ARNP from St Loius whose cvicu nurses settled in a heart then four hours later settled in a nother. Now that freaks me out!!!!

[HazelLPN, LPN]

Most of our fresh hearts are 1:1 for the first 8 hours, and if there is a lot of titration and fluid pushing.....occasionally 2:1 until they stabilize. It sounds like your CABG would have been at least a 1:1 on our unit.

The crain would have been assigned a "constant attendant" status. We have one or two nursing assistants or nurse techs per shift who can be assigned to these patients to make sure they don't crawl out of bed or harm themselves. If none are available, then float nurses, unit clerks or even security guards have been used. If its an aide category II or tech, they are student nurses and can also take care of the patients custodial needs, do some dressing changes and even write a "date collection" which the RN can use as part of the assessment.

Possibly.....a nurse would have had your assignment with a NT or NAII to help them....and probably the charge nurse would have covered the aide or tech on the other patient if needed.

It sounds like you had your hands full with the heart......and you stood your ground. Maybe next time the charge nurse will think twice before giving such an unsafe assignment.

[ptadvocate81]

Granted, I work in a smaller facility, but we TRY to keep our hearts 1:1 until they are extubated, after that, it is up to the charge nurse to decide their accuity and whether they warrant one nurse only. There is NO WAY I would have taken your original assignment. It was super dangerous and not practical at all. Kudos to you for sticking to your guns.