Not Many Vented Patients - How Acute if Your ICU?

[BiscuitStripes, BSN, RN]

I'm pretty new to the ICU, I came from the ED at a different hospital.  I was wondering how acute your ICU is and if mine isn't very acute compared to others? 

My hospital is 320 beds, Level III Trauma Center, in the suburbs of a major metropolitan area. The ICU is 20 beds, non-specific/specialized, just the one ICU in the hospital. Our typical patients include CHF, COPD, ETOH Withdrawal/OD, Pneumonia, STEMI, Post Arrest, Hypothermia After Cardiac Arrest, Post-Cath Lab with sheaths, Stroke, Subarachnoid Hemorrhages, EVDs, Deep Brain Stimulator Placement, DKA, COVID. We do CRRT but it's fairly rare, probably <10 a year. We also do balloon pumps and impellas but I've been told we get maybe 3-4 a year. 

On any given day, we average about 1/3 of our patients being intubated.  If 1/2 of our patients are intubated, that's a lot of vents for us.  Usually I have two non-vented patients, sometimes I have 1 vented and 1 non-vented.  I've yet to have two vented patients, that's pretty uncommon and if it were to happen, they usually reserve two vented patients for very senior nurses. Most patients are alert and oriented and can get out of bed for PT and to use the commode. 

Of course I'm learning a lot because I'm new, but I feel like we're not a very acute unit? On average, I had more vented patients in the ED than I do in the ICU. How does this compare to other ICUs? I feel like when I talk to friends who work in or did internships in ICUs, most patients were very acute, vented, multiple drips, etc., a lot of our patients are saline locked or just have maintenance fluids. 

[LovingLife123]

Sounds like most of the acute pts go into the city for the higher level of care.  I work in the city at a level one trauma center.  Our acuity goes in waves.  Sometimes it seems like everyone is vented and other we may only have a few.  We are constantly admitting patients from our outlier hospitals because we have all the specialized services that an outlier does not.

[JBMmom, MSN, NP]

I'm also in a smaller community hospital, about 200 beds. Our unit is 12 beds and we have a 9 bed stepdown. When I left this morning we had 6 vents. Our acuity sounds like your unit except STEMIs get shipped, we don't have much in the way of cardiac other than transvenous pacers, no EVDs or balloon pumps, no swans, we don't even use CVP monitoring. I'd say we probably average 6 vents so if we're fully staffed you're likely to get one vent. We have had rare instances with 10 or 11 vents, not all 12 at once in the three years I've been there. The average assignment is probably one vented patient and one non vented. 

Even with vented patients, acuity varies. We had no pressors running in the unit when I left this morning. Two patients on precedex for detox. One that probably won't survive COVID, one that probably won't survive alcohol induced liver failure. Two have metastatic cancer, one is intubated the other in an intubation watch. We went through a run, just before COVID where were were averaging 75% detox patients. Since COVID our overall acuity has definitely gone up. 

I figure I can still learn something from almost anyone as a patient. There are always consult notes and imaging studies to look at and labs and tests to study.

[acmt27, BSN, RN]

I float around the ICUs at my hospital, but mostly stick to our SICU and MICU. We are a level I trauma center in a large urban area. We also have a CCU and PCU, 10 beds for each unit. We are a very trauma heavy hospital so even when I'm in the MICU I tend to have surgical patients. We go through waves of high and low acuities. Sometimes we're completely full and every nurse has 2 intubated patients, sometimes we have more downgraded patients (waiting for a bed on the floor) than actual ICU patients. 

We usually have at least 2 patients on CRRT at any given time. We get post cath swans frequently. Occasionally we get craniotomies with ICP monitoring and EVD drains. We don't do open hearts or ECMO, although I heard our hospital is trying to initiate an ECMO program. Lots of STEMIs, overdoses, and post arrest hypothermia.

Our CCU is dedicated to COVID ICU and PCU patients. Most of them are vented. Lots of them who are vented end up getting paralyzed with nimbex.

[JustAnotherNursemaybe, BSN, MSN]

You perfectly described my ICU. Like, I'm going to look up how many total beds we have because you perfectly described my unit. 

It's been a good learning experience (I've been here a year). I just got trained to CRRT and had a swan the other night. The second swan I've even seen in the last year. Someday I think im going to move to a bigger hospital downtown, but for now there's still a lot to learn 

[JustAnotherNursemaybe, BSN, MSN]

Oh look, 320 beds too... hmm 

Well, if the name Merry means anything to you, come to night shift. Everyone's been leaving to day shift or pacu, which means we get way more fun assignments because there's no other option. I had 2 stable vents and an admit last week because going on divert apperently doesn't mean we don't actually get more patients. 

[LJ_RN]

Work in a level 2 trauma facility with a 40 bed ICU unit. Our unit has a high acuity of traumas, heart Cath recovery, COVID, and Neuro surgical. Honestly a huge mix of it all. Evds, artic suns, impella, balloons, (crrt is in the works). Assignments are pretty heavy right now due to low staffing. Typical night will be 1 vented COVID proned and on a paralytic sedation and pressors, heparin and insulin drips. The next may be vented with an EVD with q1 hour Neuro checks and a mannitol orders and a CT scheduled. The other is a confused vented trauma who you have to monitor outputs and replenish them all the while giving several units of PRBC.  They have bilateral chest tubes And are trying to fight you out of the bed at the same time with a pelvic binder on and external fixator. This was a real assignment for me and I worked my tail off just to keep everyone safe and alive. Totally unsafe ratios for the high acuity. But my understanding is that this is happening everywhere and we are just doing the absolute best that we can. 

 

 

[JBMmom, MSN, NP]

On 6/3/2021 at 1:04 AM, LJ_RN said:

This was a real assignment for me and I worked my tail off just to keep everyone safe and alive.

That sounds like a nightmare, and keeping all three alive for the whole shift deserves a TON of credit. Nice work!

[yesrun, MSN, RN]

I'm in a Level 1 academic center in a 12 bed CVICU. Our acuity definitely comes in waves, but it's much higher than that of the surrounding community hospitals that I've worked at. The sickest patients in this service area always get transferred to us, with the exception of a few cardiac cases if we are full that get sent to a level III with a big cardiac program. That number of vented patients isn't exactly unusual though, and it's definitely not unusual for those types of assignments to go to experienced nurses (1. for acuity and 2. because everyone loves double vented assignments). But, the patient doesn't need to be vented to be very sick. Some of my sickest CHF patients on multiple drips and acute cariogenic shock are not intubated - intubation is a big deal, and not all sick patients have an issue with airway protection. If you are looking for higher acuity, try to get into one of those level 1 facilities in your metro area after you get a little bit of experience! Also figure out what type of patients you like working with the most, since most large level 1 centers have specialty ICUs. I love cardiology, so the CVICU is my home. Depending on job openings, you'll have surgical, trauma, cardiac (sometimes separate cardiac medical and cardiac surgical), neuro (ew), and medical. Some metros have further specialized like dedicated burn ICUs too. 

 

Edit: To give you an idea of acuity with devices, CRRT is a weekly event for us, often more than 1 at a time, IABP/Impellas also often weekly (balloons more than impellas), and there are metro level 1s that are much larger and busier than us (we are only about 400 beds).