Nurse to patient ratios and acuity in YOUR PICU

[NotReady4PrimeTime]

It appears that there will be some big changes coming for the staff in our PICU, and I suspect they're not going to be good ones. We're having a real problem with staffing and I think it will only get worse if what my gut tells me is going to happen. If my allnurses.com PICU peers could help me gather some information about how other units function, it would be of enormous help. How about it? Please answer the following:

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?)

2: How many beds do you have? What is your usual nurse to patient ratio?

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)?

4: How do you manage breaks in your unit?

5: How is continuing education provided in your unit?

6: Does your unit hire new grads? What kind of orientation program are they given?

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?

8: What is your turnover like?

I know I'm asking a lot of questions, but this information will be of great help to me when I meet with management and administration in a few weeks. And the more information I have, the better my position will be if forced to advocate for my coworkers. I'll thank you all in advance.

[NotReady4PrimeTime, RN]

Thanks PICNIC. I'm feeling a little more optimistic that we'll have a few people turn out for the meeting, since she agreed to pay them. Up to now, all our staff meetings have been on a volunteer basis... if you just happened to be disorganized enough to be on your lunch break when the meeting started in our staff break room, you "volunteered" to attend. Not that anything ever came out of those meetings except more frustration. I could take the minutes from the last ten meetings and without looking at them, tell you exactly what was discussed and what the plans were.

It IS a very challenging place to work. Since yesterday was a holiday, there was no manager on in the unit, only someone on call. She told the charge nurse to cancel all the overtime for the night shift (there were three people booked) because it was quiet. We had a transport nurse and a resource nurse but no admitting nurse. HELLO!! :dzed:It's Labour Day!!!! The transport team went out at 2100 to pick up a 30% 2nd and 3rd degree burn. At 2130 we received an 11 year old special needs kid who had fallen in the tub and was down more than 30 minutes before ROSC. In the first two hours after his admission, there were three physicians two RTs and four nurses working on him trying to get lines, continue with the resus and whatever. I held his contractured leg in abduction for more than 30 minutes while our fellow put in a central line using Doppler to find a vessel. When he finally died at 0300, his epi was at 1, his norepi at 0.5 with a systolic of 65, his stats hadn't been above 55% for hours and he was in DIC. The family withdrew. Meanwhile, we admitted another kid from one of the floors who had bowel surgery yesterday, now in shock at around 2300. He needed RSI, lines, fluid resus and pressors. I didn't even look at my patient, a fresh trach from suppertime, for four hours. For a while, one of our junior nurses was responsible for four kids! PCM's reaction? "Good job. That's team work."

[NotReady4PrimeTime, RN]

Okay, so. I had two meetings today, one with our director of critical care nursing and our managers and one with a good portion of the staff. Both went much better than I was expecting. The bomb the admin dropped was not the bomb I was thinking was coming. And when it was all laid out for me this morning, I was very relieved. We will be hiring 13 more full time nurses for our unit (if we can find 13!!) and increasing our baseline staffing dramatically. The master rotation is being revamped to reduce the number of short shifts and the collective agreement is going to be enforced. (We have a significant group of people who never work a weekend, stat holiday or night, even though we do rotating shifts and the CA says full time people work every other weekend.) My rotation isn't being touched because it's already contractually compliant and it's a very manageable one! There were some disgruntled people but I think when it is in place and they see how much better it is, they'll come around.

All that aside, I still found the information you provided to be very useful. When I put it all into a spreadsheet, I was able to distill the important information to our situation and will be bringing it forward at our next team-building meeting. Thank you so much.

[kessadawn, BSN, RN]

glad your meetings turned out well, jan. maybe things will finally turn around for you and your co-workers. good luck!

[NotReady4PrimeTime, RN]

Having better, more predictable staffing won't hurt. But there are still a lot of things that have to be fixed. And our lack of leadership isn't going to help with that. Our patient care manager sat there in the first meeting and admitted that she really didn't know the details of the new rotation or staffing plans, and that she had delegated that responsibility to someone else, and she said it in front of the DON. We'll see what the next couple of months brings.

[caseyspen]

hi,

i work in a 16 bed picu in a level i trauma center, large teaching hospital. we have a resident and fellow in house 24 hours a day and attending in house during the day and on call at night. our attendings all live close and can get to the hospital in minutes if the fellow cannot handle the situation on their own. our docs are wonderful but we are headed for a fellow shortage next year and that is going to be very difficult.

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 have a seperate transport team with rns and rts. we do everything listed above although, we see transplants now and then and ecmo once every couple of months or so.

2: how many beds do you have? 16 but will expand to 20 beds early next year.what is your usual nurse to patient ratio? we never have more than 2 patients, patients that are singled are fresh post op hearts,critical airways that are chemically paralyzed and sedated, and any really sick kiddo requiring interventions frequently or one that needs close monitoring. being on vent is not a reason for a patient to be singled unless they are on jet or the oscillator (although in a pinch i have had a kid on cvvh and the oscillator paired with a chronic stable trached pt but that only happens in a severe staffing crunch)

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)?

there are a couple of na's and/or nurse externs that work in our unit but they only work day shift and mostly help with traveling to scans, stocking and running to blood bank. on nights we do total pt care.

4: how do you manage breaks in your unit? we have combined our 30 min and 2 15 minute breaks, so we get an hour break . if the patient is really critical then the charge nurse (who does not carry an assignment unless we were really short staffed) watches your pt. otherwise we just get another nurse to cover for us for the hour. we try to have everything done, make sure nothing will beep off, and our kid is well sedated before we leave. the goal is for the person covering for you to not have to do anything for your pt while you are gone. and we see our charge nurse frequently because they don't have an assignment they float around the unit helping where they can. they also have to do iv starts on the floors, and go to every pediatric code or rapid response call.

5: how is continuing education provided in your unit? we have hospital wide competencies that must be completed yearly and we have a picu education committee that meets monthly to come up with quarterly competencies and other cont ed opportunities.

6: does your unit hire new grads? yes.what kind of orientation program are they given?12 week orientation rotating days and nights. staff with nursing experience is given 8 weeks.

7: how difficult is it to transfer patients out to other levels of care when they're ready? our main problem is bed space, most of the time we can get stable kids out as long as there are floor beds available. i do think we need a step down unit because some kids tend to hang out in our unit because of one issue that i think could easily be managed on the floor but the floor nurses don't feel comfortable taking them so they get stuck in our unit. do you ever discharge patients home from your picu? it happens rarely, most discharges from home are chronic home vent pts (our floors can't take home vents even if they are stable which i think is so silly considering these pts are managed by lpns in a home setting!) or a kid that probably didn't need to be there in the first place and once problem is solved it just makes more sense for them to go home. i've only seen that happen a handful of times in 4 years though.

8: what is your turnover like?

our turnover isn't too bad, it's usually related to life changes, births, marriages, relocations of spouses, furthering education (nps,crnas etc). once in awhile we will have a group leave at once it seems like but most are not leaving because of the unit itself. most people that come seem to like it if picu is their thing. we have had a few nurses leave that couldn't deal with sick kids or they came from nicu and didn't like all the different diagnoses and big kiddos so they went back to nicu.

hth!