Nurse/Patient ratios

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I'm a nurse in a level III NICU that cares for both level II and level III babies. Over the past year, nurse/patient ratios have gotten absolutely absurd!! Our typical used to be 1:1 for jets/oscillators/very unstable, 1:2 for stable vents, and 1:3 for IVs and feeders. Only under the most extreme of circumstances would a nurse ever find herself with a 1:4 assignment. Now, 1:4 seems to be handed out very casually. Any kid not on a vent could be in an assignment of 4, including new admits from the previous shift. :eek:

This seems very risky to me. It is very frustrating for the nurses. After all, those little guys aren't still in the NICU b/c they are stable, able to wolf down a bottle in a minute flat, and no longer having A/B's, now are they? Yet, when there are 3 others in an assignment, how do you keep a close enough eye on all of them (and not pull all your hair out by the end of the shift.) UGH!! The lengths to which some hospitals will go to save a couple of bucks... :(

It can't be like this everywhere! (In fact, I believe it's cause for reporting a unit in CA, now that they have mandatory ratios). What are the ratios in the other units out there? (And where are they...'cause if this keeps up, I'll be packing my bags!)

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Unfortunately I gotta say it's the same in our unit. I don't exactly know what're level III or II babies (maybe you could explain to me) as I'm from Europe but here in switzerland it used to be 1:1 for very unstable like oscillators/jets... now it even seems to be 1:2 or 1:3 even when one baby is ventilated. At least you gotta give it a go to see how you're getting on, when it doesn't work out due to the unstability of a baby the other's 're helping. For me it's not only frustrating - it's always a challenge as I hope the baby doesn't extubate itself - sometimes I just hope it survives my shift!

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Level II are "feeder/growers" - may have IV's, oxygen by hood or NC, perhaps a chronic with a trach or a stable vent, PO/IV meds, etc. The assignment challenges in this group are the kids that have A/B's every time you turn around, and those super-irritable chronics that take up a lot of time. That doesnt even get into the extra-needy parents or the risk for NEC that needs to be closely monitored - you can't just feed 'em and forget 'em. 1:3 is usually appropriate with these kids, but 1:4 can be almost impossible.

Level III are the critical kids - unstable vents, micropreemies (22-26 weekers), jets, HFOV, ECMO, surgery, and the like.

I know what you mean about hoping the babies survive until the end of the shift. After all, if anything happens with one baby (an extubation or a bad IV infiltration, etc.) while the nurse is tied up with one of the others, who gets the blame? The nurse (of course!) or the twit who stuck the nurse with an impossible assignment? (never!) :rolleyes:

Often times, there is nowhere to look for help b/c everyone else is just as busy.

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When I was working in Melbourne there was a nurse in charge making ward rounds, drugs, organising stuff..and she was helping. wherever there was help needed she was there and I was so impressed by this. Our nursing manager would'nt even bother to ask :(

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Specializes in NICU, PICU, PACU.

We just had our ratios put on paper...

1:1 Unstable osc., nitric, any baby on multiple drips and fluid changes, etc.

1:2 Stable vent with one NICU or stepdown kid, 2 stable vents

1:3 3 NICU non ventilated kids, 3 stepdown kids, one stable vent with 2 non-ventilated kids

1:4 stepdown kids, gainer growers, or 2 NPO NICU with 2 gainer growers.

If we are really busy we will stray outside of this.

Our motto is...never give an assignment you yourself wouldn't take!

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Specializes in NICU, Infection Control.

The problem w/ those "feeder/growers" is that parents need much more interactive support--breastfeeding, d/c teaching, etc. that is never taken into account. The baby is dismissed by management as "just an easy Level II baby". They can still get sick!!! Hello, boss! Sepsis, NEC, feeding problems requiring a lot of patience and perseverance, A's, B's and D's. If you miss early signs on a big problem because you have so much to do, you're screwed.

I think you need to start making some noise--let MD's know why stuff isn't getting done or followed through on, fill out Assignment Despite Objection forms whenever it's appropriate.

I know what it's like to work in such an environment--makes you want to seek other employment opportunities, at the very least.

I also know what it's like to work in an environment where you are supported in such a way that truly the best care is given.

Make noise! Babies lives are at stake, and so is yours!

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Specializes in Adult ICU/PICU/NICU.

I work part time adult MICU and often float to NICU/PICU when I need a little extra cash or when staffing is really short and have gotten comfortable in both places over the years (not that I would want a 24 weeker or anything like that). On time I went to the NICU they asked me if I would like 4 feeder growers or 2 premie/rds kids on vents. I choose the feeder growers, and I felt like a revolving door! By the end of the shift I was so nervous the I had missed something and ended up calling in the middle of the night to make sure I had not screwed up and then had nightmares that I had forgotten to feed one of the kids the entire shift. The next time I went I took two sicker babies on vents and I had a much easier time. I not only felt disorganized with 4 kids, but truly, unsafe and the regular unit nurses are all upset about it as well.

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Hazel ITA! I'd rather have the sickest kid on the unit with another than 4 feeder growers. GAWD! If half of them are poor feeders it's a real PITA!

We aren't supposed to have more than one other pt. with any kind of vent, but it happens.

Hey, anyone from CA here? I heard all vents there are 1:1!

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Specializes in NICU.

I understand about feeder growers. If you don't have anything else to do, it's possible to do four. Not that you can do much teaching, if the parents come in, because you have to run off to do the next one. The genius that makes nurses run like that has never tried to work it themselves.

When we have a vent baby, we try to do 1:1, ours are usually brand new and very unstable. It's also something we haven't done for very long, so we are learning still.

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Specializes in NICU, PICU, PACU.

All vents one to one...wow...I would be bored silly! Once they are stable we don't really do anything with them...they get hands on q4-8 and suction only as needed. They are pretty much left alone. We don't even weigh them everyday unless there is a big need.

I hate having 4 feeders. We changed our feeding schedules so that we have two now 2-5-8-11 or 3-6-9-12. It may seem like you are doing something cont but at least you have a bit more time to spend with them. Isn't that horrible when you hope one or two of them have a feeding tube and are only nipple qof LOL

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In our level III unit we usually have 2 vents or 1 unstable vent and a grower/ feeder. Or you might have 3 or 4 g/f's. It is very rare to have a 1:1 these days. Even our NO patients aren't unless they are extremely busy. We aren't an ECMO center though. A surgery patient will be 1:1 until he is stable back in the unit.

We also have 2 feeding schedules and the larger babies may be on q4 hour schedules so that always helps.

Our charge nurse takes an assignment as does our transport nurse. That can make tight assignments even worse!!

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Specializes in NICU.

HazelLPN - don't worry, I've been working full-time in a Level III NICU for 5 years and I STILL have those nightmeres that I forgot to feed a baby for a whole shift! Sometimes I even dream that I've misplaced one, and usually I find it in my locker. Don't know what that's about!

And NicuGal - I agree with you! If I only had one stable vent all night, I'd be bored stiff! We also try to leave them alone for the most part, and at most they're hands-on q4h, but usually are q6h.

Our ratios are a lot like most mentioned:

1:1 for new admits and post-ops (both for at least for 4 hours), sick babies on HFOV, NO, drips, etc.

1:2 for stable vents or CPAPS, or maybe pairing a slightly sicker vent, newer admit, or post-op with a grower/feeder.

1:3 for mixes of stable CPAPS, grower/feeders, IVs, etc.

1:4 for all grower/feeders, none with IVs to cause trouble

1:5-6 if we have a very busy shift and can't get help, but always easy feeder/growers and we have help from the NICU respiratory therapists who are trained to do PO/NG feeds, baths, etc. The nurse must fully assess each baby she's assigned at least once per shift, and she gives all the meds. Our RTs are very very good, they always have us check out the tiniest little change or problem and we've never had one "miss" anything.

Our charge nurse has no assignment but might pick up a couple of grower/feeders if we have more than 2 admissions during a busy shift. Our admit/transport nurse has an easier assignment (usually 2-3 grower/feeders) and gives those babies up if she gets a new baby - the pickups are pre-assigned to nurses whose assignments can handle another easy baby.

Some nurses like to have just the one sick baby, others prefer to be busy with 4 easy kids. I like variety. It takes quite awhile to be able to handle 4+ kids at once - lots of organization! Newer nurses always want to breeze past this part of the orientation but then find it harder than having a 1:1 kid in the end.

It helps that we don't put every single q3 or q4h kid on the same exact schedule. (i.e. our q3h kids can be on either a 1-4-7-10, 2-5-8-11, or 3-6-9-12 schedule; same deal with q4h kids.) This is a lifesaver because you usually don't have all your babies due at the same time, and we actually try to make assignments knowing the kids' schedules so no one is overwhelmed with 4 feeds due at once!

:)

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