Open Heart 1:1

We try to keep our hearts 1:1 until they are extubated (we extubate in the unit). Once they are extubated, we usually can pair them up...unless they become unstable...

New concept for me, this 1:1 business.

Interesting about sitting at the nurses station, though. I saw a lot of CCU nurses playing online games and reading paperbacks when I was externing.

Hmmmm.

We recover our patients from anesthesia. The docs wheel the patient directly to us from the OR...no stopping at PACU. Whether a fresh post-op heart is assigned 1:1 on our unit depends on a couple of things.

1. The skill level of the RN taking the case.

2. The complexity of the case.

3. The stability of the patient.

Heart surgery, especially a planned, uncomplicated CABG is pretty routine (and kinda fun!). About 3/4-1/2 of the time our fresh post-ops are 1:1. But many times an RN will be given a simple, uncomplicated fresh post-op when he/she has another patient who's ready to transfer out or otherwise very stable. All of our hearts come back still under the effects of anesthesia and intubated. The uncomplicated cases may need just a bit of fluid resusitation and 5-6 hours to wake up before extubated. Almost never does one RN have two intubated patients at once (for me twice in 4 years, and not even for the entire shift).

If the surgeons had a difficult time in the OR for whatever reason (trouble getting off pump, bleeding, long surgery, emergent surgery), or the patient is unstable for what ever reason (they come back with labile hemodynamics on a bunch of drips, an IABP, VAD, ECMO), they are always 1:1.

We have float nurses on our unit who do not have a patient assignment. Their job is to help out on the unit where they're needed. So a float nurse will always help with fresh post-ops. So you could say that every fresh post-op we get on our unit is actually 2:1 for the first couple of hours with one RN assigned to the patient and one float. Sometimes a patient requires 3 RNs.

A newer nurse will always be 1:1 with their first several fresh post-ops to give them the opportunity to concentrate and learn learn learn!

It's a very rare case when an extubated patient is 1:1 for longer than the end of the shift during which the patient was extubated (unless extubation happened just moments before shift change).

The unique set-up of our CTICU allows all nurses to be bedside 24/7, even when the assignment is 1 RN to 2 patients. The only RN who sits at the nurses station is the charge nurse unless someone's on their break and that's where they choose to spend their breaktime.

Sorry this is so long, but like I said, it depends.

I haven't seen 1:1 patient assignments in YEARS! The only 1:1 CABG assignment I have ever had was a guy who came back with a VAD. My last shift is a good example of OUR ratios: I had an emergency CABG who was 4 hours old (intubated, bleeding, getting transfused, on neo and epi, C.I. 1.9) and then had to admit (MICU was full) a MI who crashed in the cath lab (intubated, IABP, hypotensive, natrecor, reopro, heparin, amiodarone, acute pulmonary edema, Spanish speaking only, 20 close family members in the waiting room...) I miss the good old days when we didn't even pair 2 Swans!

We try to "special" (1:1) our open heart patients for 8 hours. They are certainly always 1:1 for at least 4 hours. Unless you have some time with the patient as he is waking up how do you know if the patient will be stable? Our opens come to us straight from the OR table and stay with us overnight (usuall).

We're 1:1until extubated or unstable. Usually 4-8 hrs

I haven't seen 1:1 patient assignments in YEARS! The only 1:1 CABG assignment I have ever had was a guy who came back with a VAD. My last shift is a good example of OUR ratios: I had an emergency CABG who was 4 hours old (intubated, bleeding, getting transfused, on neo and epi, C.I. 1.9) and then had to admit (MICU was full) a MI who crashed in the cath lab (intubated, IABP, hypotensive, natrecor, reopro, heparin, amiodarone, acute pulmonary edema, Spanish speaking only, 20 close family members in the waiting room...) I miss the good old days when we didn't even pair 2 Swans!

That is totally crazy (and unsafe) IMHO...Thank goodness it wouldn't happen where I work!! There wasn't an easier pair that could have been made??

You must be superwoman (or man)...

At the DeBakey Heart center in Houston fresh cabs are never 1:1 unless the pt has a Balloon or VAD. We couldnt possibly staff the unit being 41 beds and admitting 12-20 pump cases a day. We have no private rooms except for isolation pt's and the unit is split into pods. Six rooms with six pt's in each room and the rest are isolation. Always at least 3 RN's to 6 pt's unless they have IABP or VAD or actively blding. WE do well with the set up though we work our tail off. Now that I am used to semiprivate rooms I love it. Other nurses are always watching your back and everyone can hear alarms and glance at the monitor. We also have Critical Care Anesthesiology Intensivist Teams and PA's and NP's in the unit 24/7 so that also helps out. Now that I am used to the pt load with the help we have I really dont think a fresh cab deems 1:1 in my facility. Like someone previously stated. I have worked at other facilities and seen so called Sr. RN's take cabs 1:1 and they are online after the cab flys for the first few hours. I think our set up allows us to take these pt with 2:1 ratios. If the RN had to sit at a nurses station to chart and what not I would say 1:1 is necessary. We have computers at each of the 41 beds and I sit in between both pt's and chart. The only time I leave my pt is for lunch.

Nitecap, your unit sounds a lot like mine. We have 25 beds with 3 private rooms for isolation and the rest are 4 bed suites that consist of 2 rooms side by side with a glass wall and a gigantic sliding glass door that can be left open or shut depending on the activity in each room. The nurse is continually in the room throughout the entire shift with a computer for charting at each bedside. Nurses in either room of the suite can see each patient and monitor from anywhere in each room and hear alarms from any of the four monitors. The rooms are huge.

We do a high volume of cardiac and vascular surgeries as well. Fresh cabg's/aneurysms/transplants are primarily 1:1. There will always be two nurses minimum in a 4 bed suite. Sometimes there are 3 nurses and sometimes, although rare, there will be 4 nurses in the suite, one for each patient.

Everything we need is in the room. If something is not in the room we call the unit's version of central supply and they bring us what we need or we call our "float RN," or our CNA to come and help. Each suite also has it's own Pixis. The only time we leave the room is for breaks and to get meds from the refrigerator.

We don't really have staffing problems. The hospital has been staffing ICU under CA Title 22 since the '70's, they've learned how to do it. A usual shift will have 19-22 RN's on (sometimes less depending on acuities and census) and sometimes the only time you see another RN on that shift is at the beginning during patient assignments, on break, leaving at the end, or as they walk by your room (lots of glass walls in this unit).

Our med/surg/trauma ICU is set up the same way. The only difference is that they have a few more beds.

I like it.

That is totally crazy (and unsafe) IMHO...Thank goodness it wouldn't happen where I work!! There wasn't an easier pair that could have been made??

You must be superwoman (or man)...

Actually, I feel like "stupidwoman" for putting up with this! In reading the next post, I'm thinking that maybe it's just a Houston thing...(I'm in Houston, too) I would definitely be more comfortable taking care of 2 in an open bay type unit instead of our glass door fronted private rooms. Can't see the patients very well, but at least the families have privacy and comfortable chairs! UGH!

I think that you all should read your state regs related to this type of unit. In my state there are ratios that must be considered for post open heart patients. However post open heart meant at one time post use of bypass which is now becoming passe in some instances.

As another responder stated these patients come directly out from the OR so of course it depends on each pt acuity and how your unit is set up.

Most patients are extubated as soon as possible. Our Open heart unit has 2 different setups. One large area with 8 bays like a recovery room so that the nurse can visulize easier for pts that barely stay in the room 24 hr befoe transfer. Another with single rooms for those more compromised or with needed dialysis, transplants, etc.

It is quite interesting to read the diffferent ways that our units are set up. I work in a mixed Cardiac Surgery unit and Medical Cardiac Unit...We have 16 beds...set up in a square, with four beds on each row...OUr units has all glass walls with sliding doors inbetween the rooms...however, I have never seen the door or curtians opened...In fact, most of us think it is annoying because your stent patient down two rooms can hear you trying to extubate, etc...OUr patients stay in our unit for two day...they come up right after surgery, we extubate, but they do stay for two days...we are going to start moving our stable day one patients out faster though...I have heard that our unit is farily well staffed...