Nurse to patient ratios and acuity in YOUR PICU

[NurseLay]

Okay so I worked a night shift, there is one attending and resident there at nights, I think if there is a fellow at nights, then there is no attending, and I was told that the attending only stays at night if there are really sick kids in the unit, and our attending stayed last night. Nonetheless, there is still a physician there. It was a lot calmer than day shift, they did get very busy with one patient, who was a post-op kid, but everyone was there to help and of course the charge nurse was right there. On night shift, it doesn't seem as if there are as many resources as on the day shift, however, the charge nurse last night was one of the resource nurses who comes during the day. Anyway, just wanted to give you the night side of it.

[NotReady4PrimeTime, RN]

You're all going to think this is a trick question. It's not.

Do you ever take patients off the unit for social purposes? By this I mean taking them outside to watch the traffic, or to the playroom, or just for a walk around the hospital. And I mean ICU patients, not those waiting for beds on the floor. Real ICU patients who are intubated and ventilated, on multiple infusions such as pressors like norepinephrine, with drains or open abdomens. If you do this, what are your protocols?

[PICNICRN, BSN, RN]

Gosh... can't say that I have. I did go out an get a bath tub of snow for a kiddo to play with once.

Have you gone on social outings???

[NotReady4PrimeTime, RN]

Well I usually find an excuse why we can't go. Like there aren't enough RTs to go off the unit for non-urgent reasons, or something. But we have one intensivist who writes in the orders, "Take Jane to the playroom for 30 minutes today. RT and RN to attend. May go physicianless." On Saturday they took one of our chronically critical kids outside... this kid is a hypoplast>transplant x 2 months but inotrope dependent/CRF on CVVH/myopathy of critical illness (no trach, parents refuse)/FTT never out of hospital or off the vent with cortical blindness. When the CVVH filter clotted off and they had to discontinue treatment to prime a new one, Doc Holiday says, "No time like the present... off you go!" Last summer he had us taking a liver tranpslant patient who was actively dying and comatose out for walks because it made the parents feel better. We're not staffed for crap like that!!!!!!!!

[kessadawn, BSN, RN]

oh. my. gosh. jan, that is the most ridiculus thing i have ever heard. only once have i known about us taking one of our kiddos out of the unit, and he was cardiac patient that we could do nothing else for. he was maybe 8 months old, had a trach, and parents had made the decision to let nature take it's course. he had never been outside before, and staff was able to get him out to out little playground/park area with av briefly for some beautiful family fotos. glad i wasn't one of them, i had coded that kid more times than i could count, wasn't about to do it in the park!

if one of our docs tried to write an order like that, he'd be bombarded by nursing. that's just crazy, and an accident just waiting to happen!

[NotReady4PrimeTime, RN]

That's exactly how we feel about it, and because he's the medical director of our unit and he usually makes these kinds of orders in front of the parents (you know the 'parents' I mean, too), we're kinda stuck. (In our unit we don't practice family-centered care, it's family directed care!) He knows exactly how far away from the building we can go without needing EMS for an emergency, and will even suggest that we sit under the ambulance bay canopy so the kids can "watch" the traffic! A few years ago he left orders that a five month old with such extreme PHN that we were running a Flolan infusion (along with the usual norepi and epi) who was being nursed on an overbed warmer be taken for a walk. The nurse assigned to that patient that day refused and told him if it was so important to him that this kid go off the unit for a social reason, he should do it. The kid didn't go.

[kessadawn, BSN, RN]

(you know the 'parents' i mean, too)

let me guess, the kind of parents who don't get just how sick the kid is? hmmm, with playtime orders from the director, i wonder why. phn needing gtts but hey, gotta get that playroom time in. someone is gonna die, and i would not blame any nurse who refuses to follow that order.

have you been able to use any of the info from us yet? hope it all helps!

[NotReady4PrimeTime, RN]

Oh, I think they know how sick their kids are, but they don't realize that we can't save 'em all, and there are some we shouldn't try. We seem to get a lot of parents who have a huge sense of entitlement, and a conviction that they should get everything they want. No matter how it affects their child. So it's fine to have a child intubated for every single one of its first 363 days (and counting) on earth if Mom and Dad don't want a trach (mostly Mom) and it's fine to ignore a child's pleas to be allowed to die because Mom and Dad aren't ready (until on Day 199, there isn't anything more we can do to stop death) and it's fine to continually do CPR on a child whose previous arrests have left her in a vegetative state and put her on ECLS when CPR isn't enough... twice. And it's okay to put the livelihood of a nurse and an RT at risk every day so that kids like these can go for a "walk" to the courtyard to see the Christmas tree or to watch the buses.

[kessadawn, BSN, RN]

jan, so sorry you have to work under those conditions! thank god we have a few attendings who will put a stop to that type of stuff. but every once and a while we still have it happen. it's so hard to try to be emotionally supportive to the parents when what you really want to do is grab them by the shoulders and yell "enough is enough!" are your attendings on the same page as the nursing staff at all, or do the parents just kind of take over?

[NotReady4PrimeTime, RN]

They don't even agree with each other! Our director is a blow-sunshine-up-your-butt kind of person who sees hope in every situation. He even mentioned dialysis to the family of a kid whose brain I was sucking into a canister from his nose and ears who was already on code doses of epi and vasopressin. A couple of them are realistic but don't like to tackle the difficult conversations so they wait until Dr. Happy is on. One of them is really good at taking the bull by the horns, but he's a 'junior' intensivist. And one totally sees the moral distress in the nurses and is very supportive of our feelings, but rarely does anything to alleviate them. None of them would ever refuse to do something that a parent wanted done unless it was abundantly clear the child would die from it. One of our kids had all the symptoms of HLH and was actively dying. A bone marrow biopsy would have confirmed the diagnosis, but the parents refused to allow it. So we kept the kid alive for almost two more months. The kid in my first example should have gone for a flow study but the family was afraid the kid would die en route, so it didn't happen until long after we saw a K+ of 8.9 and treated it. There are so many more... Some days I feel like I work with Dr Mengele.

[AliRae]

You're all going to think this is a trick question. It's not.

Do you ever take patients off the unit for social purposes? By this I mean taking them outside to watch the traffic, or to the playroom, or just for a walk around the hospital. And I mean ICU patients, not those waiting for beds on the floor. Real ICU patients who are intubated and ventilated, on multiple infusions such as pressors like norepinephrine, with drains or open abdomens. If you do this, what are your protocols?

When I started reading the question, I thought "sure we do!" and then I kept reading and realized that you were talking about the actually sick ones. Absolutely not. No one in my former PICU thinks that the really sick ones need to go outside. I had a Duchenne's kid who progressed to being trached and vented who got really sick and septic and was in the hospital forever. Once he was better and up in his chair and getting ready to go home, I used to take him out on the balcony for fresh air occasionaly on the weekends. But not, for crying out loud, while he was sick!

I just found out that the little PD baby I mentioned earlier went home after 14 months on the unit. I don't think he left his room the entire time.

[PICNICRN, BSN, RN]

Oh Jan.... you guys are brave!!! Never have I been asked to "take the hypoplast on flolan out for a walk"!! Sounds like a huge liability for the hospital??