Nurse: Patient ratios

Specialties MICU

Published

Hi,

I was wondering what kind of nurse: patient ratios you have in the ICU. Here in NM we try to stick to 2:1 (1:1 for the very ill), but I have also worked in TX where we routinely had 3:1 and in Baltimore where is was even worse! I would love to hear about the staffing in your state and units, especially with such shortages of ICU nurses. Thanks.

Specializes in Cardiac/Vascular & Healing Touch.

what is HWPPD? I don't know this abbrev. Healers with Post Partum Depression? Just kidding... I really dont' know what this is....

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Specializes in M/S/Tele, Home Health, Gen ICU.

Here in California we are are guided by title 22 and the new ratio law enacted this year. Our ratio is 2 patients for one nurse for ICU/CCU. This applies even if the patients are not ICU/CCU status but are "overflow". If a patient occupies an ICU bed that the ratio is 2:1. We may also not have more than 50% of the staff as LVNs. This has been the standard for at least 15 years and I have never seen it broken. We get good support from administration :)

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Specializes in Cardiac/Vascular & Healing Touch.

We could only have it so good here. My best friend travels to CA every other month to work but resides here in AL, she is on the plane home today after a 6 week assignment in Redding. She loves the rules in CA & the traveler pay. It's hard not seeing her kids & hubby though. She comes back to AL & works for/with me in CCU & gets frustrated because we don't have the rules. We get soooo dumped on. No union, people are scared to start one. I tried to several years back & boy do find out who is scared to talk to ya! Oh, well, I just want ya'll in CA to know that kudos to you who try to employ safety where the clients are concerned.

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We have a nursing union here in Miami and it makes all the difference. We tabled nursing/patient ratios at the last contract negotiations in October 2003--Florida's legislature is currently considering legislation similar to California's. This is the future for nursing. Hopefully it will go national. But, having the union definitely helps to maintain safe working conditions including keeping a safe level of nurse/patient ratios.

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I just finished a shift where I was in charge, had an extremely unstable LVAD, had to hold a new nurse's hand who never took care of a fresh open heart before, and had to deal with an agency LVN who would not respond to her patient's ventilator alarm because she "doesn't do vents." We have staffing guidelines (for example 5 nurses and 1 PCA for 10 patients) but that doesn't take ACUITY or nurse ability into consideration, nor does is factor in the unexpected admissions we seem to routinely get. We are a SICU/CVICU that also functions as MICU overflow (they're always full) and Cath Lab overflow (they can't stay a minute past 10 pm or they will melt!) I have refused admissions due to no staff on my shift only to have the patient wheeled up anyways, accompanied by the nursing supervisor and the patient's family, the supervisor saying loudly, "see, I knew thay had a bed!" I'm afraid for our patients and would never EVER let one of my family members be a patient in my unit.:crying2:

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I work in a small community hospital in the ICU. Our ratios are 2:1 and 3:1 most of the time. We do not have open hearts but our patient population is aortic aneurysms, ventilator patients, ETOH withdrawl, sepsis, acute MI's and any surgery that doesnt go as expected. We had a patient last week that had 11 drips and that wasnt even considered an 1:1. How are your organizations evaluating acuity? Do you have a grid of some type? I think our hospital just counts heads.:bluecry1:

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We are combined SICU/MICU/trauma - no union, no state laws. 1:1's on IABP, CRRT, and first 4 hours (or until extub) fresh hearts. Otherwise 2:1 unless except in the instances when we have a couple pt's with xfer orders to med/surg floors -- then a 3:1 is very do-able. The RNs have actually had a second pt "taken away" and taken by charge or a float when one of the patients proves to be too time-consuming. I think all the difference is the charges and the manager willing to stand up for acceptable staffing levels on the unit.

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... had to deal with an agency LVN who would not respond to her patient's ventilator alarm because she "doesn't do vents." ... Cath Lab overflow (they can't stay a minute past 10 pm or they will melt!) ...I have refused admissions due to no staff on my shift only to have the patient wheeled up anyways, accompanied by the nursing supervisor and the patient's family, the supervisor saying loudly, "see, I knew thay had a bed!" I'm afraid for our patients and would never EVER let one of my family members be a patient in my unit.:crying2:

The problem with the agency LVN isn't that she works for an agency. The problem is that her assignment doesn't match her skills. She shouldn't respond to a vent alarm if she doesn't know how to fix the problem. If she can't handle the patients in your unit, then she shouldn't be there. She is wrong for accepting the assignment, the hospital is wrong for accepting her from the agency, and I don't know what the board would say the charge RN's responsibility is for assigning a vented patient to her. Nothing good about that situation- hope it was a one time screw up.

So Cath Lab gets to go home at the end of their shift and dump their problems on you? Sounds like they fought harder or have more support than you do. The ICU has to be supported just as much. I feel the same way I do about ER nurses complaining that ICU gets to say no to more patients than they do.. Don't blame the other unit for doing it right. Applaud them- and follow their lead. Make your safe staffing as much a priority as theirs. Maybe a deal to accept their overflow only when you have staff to do so? An emergent case likely needs to go to the unit anyway. A planned case should be finished early enough in the day for cath lab to recover them. If their cases routinely run late, then cath lab needs to change something about their patient or nurse scheduling. If the problem is the docs are running late, than the doc needs to feel the pain- either he needs to pay for and find a nurse to stay/come in to recover the patient, or that last case needs to be cancelled (sorry, patient...)

A supervisor who embarrasses an RN into taking an unsafe assignment by challenging you to refuse the patient in front of them and their family should hand her license in at the door at the end of the shift. Absolutely unacceptable. Write it up. When I was a new nurse I would have accepted it or been cowed into it. Now I would say "Mary, I told you we have a bed but you know we do not have enough nurses to take care of that patient safely. You need to bring them back until you find us a nurse." Refuse report. If she leaves the patient, it's abandonment. I feel so badly for that one patient. But hopefully it will protect all the patients she'll never do that to again.

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Rachit,

You seem to have a lot of things going for you. Sounds like you have been there and done that...Good for you. Maybe you can help me out. I am a manager of ICU and CCU. I have no director because my VP fired her and now I have to interact with the VP directly. She is not a reasonable woman. There is no negotiation. Just her way or the highway. She has never worked critical care and her background is home health. I have worked as a staff nurse in ICU for 17 years before I took the management position. I fight for staffing al the time and get no where with her. She tells me that ICU is use to those types of patients and should be able to handle 3 patients each. She doesnt believe in acuity. She counts heads on a regular basis. She decided that we needed to change the way we do report. I argued my case and her response was..."Im the VP of Nursing and I have the final decision." We have had 15 managers and directors leave in the last 2 years she has been VP. We have had over 30 nurses leave due to her. We will probably have more. Why cant our CEO or COO see whats going on? What can I do to maintain my position yet fight for my staff?:imbar

The problem with the agency LVN isn't that she works for an agency. The problem is that her assignment doesn't match her skills. She shouldn't respond to a vent alarm if she doesn't know how to fix the problem. If she can't handle the patients in your unit, then she shouldn't be there. She is wrong for accepting the assignment, the hospital is wrong for accepting her from the agency, and I don't know what the board would say the charge RN's responsibility is for assigning a vented patient to her. Nothing good about that situation- hope it was a one time screw up.

So Cath Lab gets to go home at the end of their shift and dump their problems on you? Sounds like they fought harder or have more support than you do. The ICU has to be supported just as much. I feel the same way I do about ER nurses complaining that ICU gets to say no to more patients than they do.. Don't blame the other unit for doing it right. Applaud them- and follow their lead. Make your safe staffing as much a priority as theirs. Maybe a deal to accept their overflow only when you have staff to do so? An emergent case likely needs to go to the unit anyway. A planned case should be finished early enough in the day for cath lab to recover them. If their cases routinely run late, then cath lab needs to change something about their patient or nurse scheduling. If the problem is the docs are running late, than the doc needs to feel the pain- either he needs to pay for and find a nurse to stay/come in to recover the patient, or that last case needs to be cancelled (sorry, patient...)

A supervisor who embarrasses an RN into taking an unsafe assignment by challenging you to refuse the patient in front of them and their family should hand her license in at the door at the end of the shift. Absolutely unacceptable. Write it up. When I was a new nurse I would have accepted it or been cowed into it. Now I would say "Mary, I told you we have a bed but you know we do not have enough nurses to take care of that patient safely. You need to bring them back until you find us a nurse." Refuse report. If she leaves the patient, it's abandonment. I feel so badly for that one patient. But hopefully it will protect all the patients she'll never do that to again.

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Thanks for the praise. Never enough of that in nursing!!

I have not been around as many blocks as other people, but I have been around enough. I was a bedside nurse for 9 years, about 5 of it as a traveler (so a lot of time spent at hospitals that had serious staffing and morale issues since hospitals with adequate and happy staff don't need travelers...) and about 6 of it in critical care.

I just recently left bedside nursing. I was really sick of the games and fighting and the types of things you described- I was tired of awful schedules and having to fight for the staff, supplies, and even linens needed to take care of my patients. I hated the bed availability game- we KNEW we were going to get slammed and tried to get patients out but there were no floor beds.. Until a doctor wanted their patient in the unit. Then it was all frantic rushing and somehow the nurse's fault that the move wasn't organized. I got tired of being injured and tired all the time. I hated how pharmacy, transport, dietary, and maintenance got to dictate to nurses about nursing care. I wasn't completely burned out, but I was getting there fast.

Sounds like you're at the point I was at a couple months ago with your job. You have superiors that think they know your job better than you. You can't help your subordinates out because you are being denied the resources. Your reasonable requests to your boss to look at what is needed for safe care are being dismissed out of hand. Is she seeing you as a manager or is she treating you as what she considers lowly staff?

I think you have 2 choices.

1) You can suck it up and count the days until you are hated and hate yourself for being a part of a system that abuses nurses and puts patients at risk. Or-

2) You can go to your boss and say you will be going to her boss because you cannot in good conscience be part of care as your hospital currently provides it. Have numbers to back you up- typical ratios, other state's staffing laws and the increased risk with higher ratio studies that back them up. Maybe budget numbers that include the increased cost of recruiting and orienting people to replace those she has driven out, not just the cost of maintaining a 2:1 ratio. Then if she doesn't budge, go over her head. You have a chain of command; IMHO if things are that bad you are obligated to use it. Could you sleep at night knowing you could have prevented a bad outcome and didn't? Do you want to be on a witness stand saying "I was just following orders?"

Sadly, you are likely to be fired for this. The hospital might say it is better to lose you than her since she is the bad guy for them... Or she might be in the same position you are, just a couple rungs up the ladder- the board may have told her how it will be and she is toeing the company line.

You sound like a decent person to work for- but if the organization stinks from the top down, a manager in the middle can't fix it. I think you need to go to the top or get out.

Of course, this is all very easy for me to say. I was looking for a way out and only responsible for my own nursing care when I got a call offering me a job that treats me well, pays me fairly, and lets me work with nurses. I got really lucky.

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I work in an icu in michigan. Or nursing rations are 2:1, unless a fresh post of heart, which in 1:1 for 4 hours or unless unstable, cvvhdf if always 1:1, and any patients on echmo (although we don't run the echmo a perfusionists stay at the bedside and it is only for our open heart patients if they can't get them off bypass). Some extremely sick patients have required 2 nurses and our unit has done that. Sometimes we do take three patients but only the ones that are awaiting stepdown beds can be tripled off. There has been times when we have done write up (that is what any complaint in my hospital is called) for unsafe patient practice when staffing is so short (To help save our licenses). that usually works and they seem to find someone to send us.

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Wauw!! Our patient : nurse ratio is 1:2 in the daytime monday-friday - yes! that is 2 nurses per patient, and this is an MICU. The rest of the time it is 1:1, exept in the very critically ill where it is 1:2 24 hours all week.

Mind you though, that we are NOT all intensive care nurses - about 50% of the staff is IC nurses, the rest do not have the 2 year IC education - but a thourough training program (4-5 months). But here it is more a title than anything else (and a bigger pay check). There are no difference in the type of patients you have.

Vikingnurse

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