One to one assignments

We usually do 1:1 assignments when the patients require vigorous interventions/tasks that keep the nurse in the room for way longer than would be deemed "safe" if you were watching another patient as well. There is no protocol really, we just know.

For example, today I had 2 patients. Acute respiratory distress on Lasix gtt, and sepsis/acute renal failure status-post stroke on Levo. The Levo patient WAS stable enough to assign to a nurse along with another one, but her BP was tanking towards the end of the shift, lytes were way out of whack, so as I was leaving she went 1:1.

Last week I had a lady converting from SQ Remodulin to IV, mostly stable, but she required very vigorous monitoring so she was 1:1.

Protocols are just that, your own clinical judgment should really dictate the assignments. We are asked for our input about our patients near the end of the shift as the charge nurse makes up assignments, no one ever seems to crab about having a heavy load. We do a good job with our current system, if you want to call it a system.

Nursing judgment is supposed to decide this in critical care. I know many places set protocols where say: a fresh open heart, or IAPB patient , or CRRT patient is always 1:1. But also,nursing judgment is supposed to mean something. If Patient is on 9 drips, and still tanking--hello? Sometimes i wonder what management expects of us. At the same time, some nurses who would be livid that their patient was not made a 1:1 would never step up & pick up the other patient for another nurse in the same situation....

Sometimes whether or not a patient is a 1:1 depends upon whether or not you have the staff to provide the 1:1 nursing. If there isn't enough staff available then it just doesn't happen. If you have a good group working you're lucky and others will pitch in and keep an eye on your more stable patient for you. If you are working with a less-than-wonderful bunch then you are on your own. You just swing into high gear, set your priorities, and remind yourself that it will all be over in twelve hours.

And sometimes whether a patient is a 1:1 depends more upon the individual nurse's skills than the needs of the patient.

Don't jump on me here---just stating what I've seen. With the trend towards hiring new grads into the ICU it's not unusual to be working a shift where a good number of the nurses working that night have limited skills and undeveloped critical thinking capabilities. So they need a lot of help, which we try to give them, and if they have an even slightly unstable patient or bedside procedures are being done they tend to drown. If that patient is not made a 1:1 then it becomes dangerous. It's just a fact of life that nurses with limited skills often have a tough time handling complicated patients. Not a judgment call here, just a fact.

Don't misinterpret this---the hiring of new grads into critical care is the way things are done now. It's not expected that they be able to hit the ground running and it's expected that it will take time for them to learn and develop. Most of them are trying really hard to be successful in ICU.

It just makes things really hard, sometimes, for those who are left to pick up the slack. We don't get staffed according to nurses' abilities---we get staffed according to patient accuity. All done by plugging in numbers on the computer and woe be it to the charge nurse who uses "nursing judgment" when staffing and goes over the staffing matrix number dictated by the computation.

Agree with above for our hospital it depends on the patient, your judgment and if staffing allows. We are a level 1 in big inner city and therefore get very sick pts. Not unusual for our 24-bed unit to have 3-6 CRRT going at once- well we certainly never have 16 nurses on board to make them all 1:1. Most smaller and community hospitals that I've heard of having the ability to do more one on one usu do so with CRRT, IABP, VADs, fresh open hearts. We are used to having a pt on 6 gtt, vent, crrt and another stable pt. [not that its the best, safest scenario] but we're used to it and have good teamwork. if staffing allows (census or acuity low enough) we will try to make our coding, sicker crrts, s/p arrests, etc. 1:1. we were recently able to make an incredibly sick H1N1 pt 1:1 (as recommended by infection control)

The only problem with , "If staffing allows we can make the really sick patients 1:1" is that, then all of a sudden, you have to take a really sick critical admit because you are the only nurse with "one" patient, and now you have two "really sick" patients, and would have been better off with "the really sick patient" and another stable patient. Sometimes those who make the assignments don't think ahead, or don't think and change things around after **** hits the fan. Honestly, if a charge nurse will pick up the slack or even know enough to change assignments around when the **** hits the fan, it wouldn't be such an issue. But it is an issue.