Nurse to patient ratios and acuity in YOUR PICU

[NotReady4PrimeTime, RN]

Thanks so much for your very informative response kessadawn. That was exactly what I was looking for. Building my case...

[littleneoRN]

Hi! I actually work in the NICU but spent some time as a student in a PICU before I graduated. Hope some of this helps, even though I may know have as detailed of answers.

1. Big cardiac surgical program, providind half or more of the PICU patients at any given time. ECMO, CRRT. Transport. Complex ENT. Neurosurgery. No transplants. No trauma.

2. 20 beds. Private rooms arranged in a square with glass front walls for ease of viewing. Five beds are in an open bay area. Report room, stock supplies, HUC, charge, etc. are in the middle of this square. Most patients are 1:1. You might have a paired assignment if they should be ready for the floor or for step-down that day. Or otherwise very very stable. Occasional 2:1, and ECMO patients have a separate RN for the pump.

3. RNs are responsible for total care with the exception of RT.

4. You and your neighbor nurse try to cover for each other. There is also a CRN without assignment and charge without assignment. The CRN helps with breaks if there aren't other fires to put out. If you were 2:1 you wouldn't cover breaks for another 2:1 assignment. That's too many to keep track of.

5. Various continuing education classes and talks are offered hospital-wide and are often PICU pertinent. CEUs are offered fairly regularly. At least every 1-2 months, often with several CEUs in one opportunity. Clinical practice updates are also released that are pertinent to patient care. There are multiple bulletin boards that have various topics, updates, etc. for educational purposes.

6. New grads are hired at times. Orientation is supposed to be 6 months. I don't know much about the actual quality. I can tell you as a new grad to the NICU I had the typical 1+ weeks of general hospital orientation, 3 months with a preceptor doing patient care, and 6 days of neonatal specific classroom time.

7. Generally beds are available as needed for kids coming out of PICU. There is a stepdwon capable of taking stable cardiac kids and chronic trach vents who will be vented at home. In addition, if kids who are vented at home come in the hospital for some reason, they can go to the regular floors assuming airway/ventilation is not the reason for admission. It is typically more difficult to transfer our patients out of NICU than PICU.

8. Turnover is alright. Could be a bit better but is good I think relative to other places. People wait years for day shifts, but there are typically a few openings posted. There are many *very seasoned* nurses on this unit.

Additional thoughts. As mentioned, there is always a charge and a CRN without assignment. An intensivist is always available 24/7 either in the unit or nearby in the hospital, and if it's truly a crisis, he/she will be there within 1-2 minutes. We don't utilize residents, students, or fellows. Our daily cxrs are done 03-04. No IV team--RNs responsible for IV starts, art sticks, venous draws, etc. Most labs drawn by the bedside RN. HUCs are very helpful but consumed by transcribing doctor's orders into the computer. Charting done on the computer--slow as a snail. There is usually 1-2 float team RNs available to the whole house to assist with road trips.

Hope this helps!

[NotReady4PrimeTime, RN]

It certainly will, littleneoRN. I'm envious of the units I'm hearing about where the unit secretary/clerk transcribes the orders. In my previous unit, that happened all the time... but here it never does. They don't even do the filing. Most of them bring the stuff to be filed (lab reports, imaging reports, OR notes, consults) as well as additional progress notes, assessment sheets, flow sheets and such for the clipboard to the bedside and leave them in a pile for the nurse to deal with.

I just thought of something else... does your unit move patients around from one bed/room to another whimsically or for convenience? One of our managers (glorified charge nurses) makes it her mission to move at least half the patients into new spots around the unit every shift. Such a waste of human resources!

[AliRae]

I want to work at kessadawn's hospital!

To add: our unit has 14 of the beds arranged in a U around back-to-back central nurse's stations. The other 6 beds are in a back offshoot that's not terribly well-stocked and it's scary back there. When we did hearts, they would often go back there because it was next to the cath lab. it scared us all to death because, as we used to say "no one hears you scream." All private rooms with sliding glass doors and a central monitoring system.

We have a unit secretary. usually. Docs enter all orders on computer and we're not allowed to take verbal orders, which helped. It's a locked unit, so when there's no secretary, the RNs closest to the front desk spend their entire shift ringing people in and out of the unit. Which isn't cool, because hte really sick kids usually get placed in the front rooms there.

Our patients sometimes got moved around to make pairs possible. The best was opening and then closing the back unit (those extra 6 beds) in one day. I must say, though, I do a great deal more shuffling patients around here on the ship. Just the other week I got handed a list of pretty much all the patients with new bed numbers and just had to move everyone around because they wanted to close a ward for the weekend. Oh well. It's not so hard when the beds are 2 feet away from each other...

[kessadawn, BSN, RN]

What exactly does your unit secretary do, Jan? Ours are wonderful, a godsend. The enter all orders into the computer, take care of consults, put together the chart, there really isn't much to file since we're paperless. When there is a code in PICU, they are there, with a portable laptop, entering orders as fast as they are yelled out, calling xray, etc.

Sometimes we play musical patients too, in order to arrange our less critical kiddos near each other so they can be paired. If the only 2 stable, non-intubated patients are 12 rooms apart, and can't be rearranged, they won't be paired, and bed control doesn't like that! We don't have any type of step-down, so sometimes our pts can be "floor-worthy" but still hanging out for whatever reason.

[NotReady4PrimeTime, RN]

What exactly does your unit secretary do, Jan? Ours are wonderful, a godsend. The enter all orders into the computer, take care of consults, put together the chart, there really isn't much to file since we're paperless. When there is a code in PICU, they are there, with a portable laptop, entering orders as fast as they are yelled out, calling xray, etc.

They mostly answer phones, page physicians, book scans and other tests, put charts together for new admits (of which we usually have at least 3 per day), enter diet orders and distribute print-outs from the lab. As I think I said, they don't do anything with the vast majority of orders, the nurse is responsible for it all. We're still 100% paper charts (even our MARs) although we're moving to computerized in the fall sometime. (They want us to continue to chart on paper too for several months until we get all the bugs out!) When there's a code, a nurse does all the documentation, including catching the orders as they're called out. When I'm giving drugs in an emergency, I write them all down on a scrap of paper (or the sheets) with the dose and time then transcribe it all later. our CNAs may run for supplies, equipment and blood products if they're not busy doing something else, otherwise that's a nurse too.

Sometimes we play musical patients too, in order to arrange our less critical kiddos near each other so they can be paired. If the only 2 stable, non-intubated patients are 12 rooms apart, and can't be rearranged, they won't be paired, and bed control doesn't like that! We don't have any type of step-down, so sometimes our pts can be "floor-worthy" but still hanging out for whatever reason.

We have 8 intermediate care beds where each nurse will have 2 patients, which might have been enough when we had 15 beds in PICU, but now that we have 19, it's not. As more and more of our kids are colonized with significant organisms, they end up in PICU for their whole stay. We've got a number of chronics now, too, although we're not equipped (or staffed) in any sense to care for chronic patients. Our docs are stuck in the past where the kids in PICU were ALL critically ill so we can't ever relax our monitoring, our documentation or interventions. They'll still be on q1h vitals, q2h narratives, q4h gases, daily CXRs, have an art line until hours before they go home, for heaven's sake.

[PICNICRN, BSN, RN]

Yep, Jan!

I think you need unit secs like some of the rest of us! I feel like they are more informed than the charge nurse as to what is going on on the unit half the time! They put in all of the orders(very quickly), file the results, aswer the phones, direct "traffic",make phone calls for us(where is my blood? where are my stat lab results?ect ect). I swear I would NEVER want that job--- talk about stress!!! Our secretary is a GODSEND!

[NotReady4PrimeTime, RN]

I was so used to having a unit clerk who did all that in the unit where I used to work. I was stunned when I came here, to the hospital with the oh-so-wonderful reputation... so MUCH better than my old one... I went to the unit clerk and told her I needed a unit of PRBCs stat and she told me, "The blood bank number is *****." I just stared at her!

[AliRae]

We've got a number of chronics now, too, although we're not equipped (or staffed) in any sense to care for chronic patients.

Amen, sister. I just talked to my old extern, now turned fabulous new grad nurse. She informed me that a kid I primaried last summer (renal agenesis, PD) is still on the unit. He's fourteen months old. Holy cow.

[kessadawn, BSN, RN]

We've got a number of chronics now, too, although we're not equipped (or staffed) in any sense to care for chronic patients. Our docs are stuck in the past where the kids in PICU were ALL critically ill so we can't ever relax our monitoring, our documentation or interventions. They'll still be on q1h vitals, q2h narratives, q4h gases, daily CXRs, have an art line until hours before they go home, for heaven's sake.

Holy Cow! A few of our frequent fliers who only come to PICU d/t the need for a ventilator literally have an order in the chart that states "do not disturb from 2200-0600, may suction trach throughout night as needed." They may not even have IV access!

Glad your going paperless eventually...once all the bugs have worked out, it will be such a timesaver for nursing.

[AdvTechSondra]

1: what level of care does your unit provide? (do you have a cardiac surgery program? do you have an ecls/crrt program? do you have a transport team? transplants? neurosurgery? complex ent? trauma?) we do everything except ecmo and transplants

2: how many beds do you have? what is your usual nurse to patient ratio? we have 26 beds, typical is 1rn:2pts obviously if they are more acute then 1:1 or even 2rn's:1pt

3: does your unit employ ancillary staff such as cnas or patient care techs to assist with hands-on care or is the nurse responsible for total care of the patient(s)? we do not use cna's or techs, we have two secretary's during the day and 1 at night but no direct pt contact.

4: how do you manage breaks in your unit? here's an area we are truly lacking... we don't get breaks, we eat lunch/breakfast and dinner in the unit, another nurse watches our pt while we run downstairs to get food in the cafeteria.

5: how is continuing education provided in your unit? we have 2 unit educators who are responsible for orientation as well as disseminating information to our staff....monthly "policy updates" pals, skills and stuff like that but any serious ce is pretty much on your own.

6: does your unit hire new grads? what kind of orientation program are they given? we do hire new grads, however we try to keep it to 1-2/year. they are given a minimum of 12week orientation and then depending on how they're doing it's often extended.

7: how difficult is it to transfer patients out to other levels of care when they're ready? do you ever discharge patients home from your picu? our issue with transfering out is only limited by space available. today for example we ended up sending 4 patients directly home because for the past few days there haven't been beds available in the general care areas.

8: what is your turnover like? our average length of stay is 3.5 days for the patients, obviously we have a few that are weeks and many that are overnight.

hope this helps, the more data the better.

[NotReady4PrimeTime, RN]

Thanks, for your input. How's your staff turnover? Do you have a lot of people "taking advantage of other opportunities"? That's what our management says when we ask why we're losing staff left and right, they left to take advantage of other opportunities.