Patient assignments by room # not acuity

Nurse ABC · Oct 21, 2012

We are assigned a group of rooms regardless of acuity. We get different rooms each week depending on the number of patients so we don't always have the same block of rooms. It is nice having all your patients close together. No one likes to work the back hall as well because those are the isolation rooms and they are very far from the nursing station so it's a lot of running all day but at least we aren't always stuck there. There are days it's not fair as far as acuity but everyone just sucks it up and does it and asks for help if they're drowning.

sapphire18 · Oct 21, 2012

Doesn't sound like a particularly good idea to me. The unit can't be THAT big, can it? We should be clustering care anyways as much as possible for the pt's benefit, which cuts down on running around.

Before I worked ICU, we were assigned pts based on acuity, and then if say 2 patients were similar in acuity, they would assign the one closest to the other pts in that assignment. This unit was shaped like a "T" with 3 hallways...sometimes all your patients were in one hallway, usually you had at least 2, sometimes you had pts in all 3.

Assigning patients based on location can create some very unfair assignments.

SaoirseRN · Oct 21, 2012

We use a global-type assignment on days, but we can adjust things if one nurse has a particularly high acuity team by swapping patients with a neighboring nurse. On nights it is by acuity since our staffing levels differ between nights and days (days we have five RN-LPN pairs and work in teams, nights we have 5 RNs and 3 LPNs). However we try to keep the night assignments as close to each other as possible, though it doesn't always work out.

Anna Flaxis, BSN, RN · Oct 21, 2012

When I worked in a 36 bed inpatient unit, our assignments were by room #. While it is nice to have all of your patients in the same area, I often felt that acuity should have had a part in it. You could easily have 2 fresh from the cath lab with sheaths in, 1 on a dilt drip, 1 pre-op OHS on nitro and heparin gtts, and a COPDer in for a tune up. I remember one time we had a new nurse with a patient on a dobutamine gtt, so to be nice, the charge gave her only 4 patients instead of 5.

At the same time, I can understand the difficulty of assigning by acuity, given the physical layout as well as the unpredictability of admissions and their acuities (typically they go wherever there's an open bed). You could discharge the patient right next door to the bariatric quad on contact and droplet isolation, and end up putting a person on nitro and heparin gtts in there. You can't just go shuffling the patients around each shift to distribute the acuities evenly. Imagine the infection control implications there!

So, to answer your question, yes it can work but there are pitfalls. You could easily end up with a very heavy assignment because it just so happened that those high acuity patients were clustered geographically, while a nurse across the unit has a gravy assignment, but to come help you out, s/he might have to go too far away from her/his assignment, depending on the size and layout of your unit.

I'm not sure what the solution is. Appropriate staffing levels is one big piece, and I often read on AN about units with patients similar to what I've described above where nurses routinely have 7-8, which just seems like a sentinel event waiting to happen. So clearly staffing levels are part of the picture, but I think hospital design needs to take this into consideration as well. I often wished we had pods, like in the ICU. You could have pods of four beds each, and two pods right across from each other. You'd have two nurses in each pair of pods, and one CNA. You could see ALL of your patients from one place in the center of your pod. The nurse in the pod across from yours would be your break buddy, and you'd coordinate the CNA's workload together. Efforts could be made during the patient placement process to put only one higher acuity patient in each pod, thereby distributing them evenly throughout the unit. I know it wouldn't be possible all the time, but with the ability to visualize all four patients at once, and with your RN "buddy", it could be a lot easier to get help. Also, I think an extra nurse should be standard for each unit. This extra nurse would not take a patient assignment, but rather, would float around the unit and help out as needed. This nurse would know where all the heaviest/sickest patients are and check in with those nurses that have them. This nurse would be available to restart IVs, do admission assessments and med recs, and whatever other help is needed.

ashleyisawesome, BSN, RN · Oct 21, 2012

our unit normally assigns this way. the only exception is if one of the pts is receiving chemo and i am not chemo cert. yet, another nurse will take that pt and i will take one his/her pt. every once in a while if one of us has a strictly spanish speaking pt, and there is a spanish speaking nurse working, she will take that patient, but she isnt obligated to.

i work on a surgical floor, so many of our patients are on heparin/insulin drips, epidurals, and PCAs. if someone's assignment is heavy with these types of things, the charge will usually give them less patients (4 or 5, as opposed to 6), if possible.

martymoose, BSN, RN · Oct 21, 2012

we assign by pods and it sucks- sometimes you will walk to all your rooms being empty and getting all the admits. Or have a very high acuity with 3 postcath labs - dont plan on getting out on time when that happens :-(.

Or worse yet you get 3 confused pts that should have sitters and we dont have any , so you end up staying in the room as therir sitter , and your other pts suffer, cause you cant leave the room. Kinda sucks when you are hoping your other pts dont bleed out or something cause you cant check on them because of the confused person who refuses to stay in bed

Anna Flaxis, BSN, RN · Oct 21, 2012

Or worse yet you get 3 confused pts that should have sitters and we dont have any , so you end up staying in the room as therir sitter , and your other pts suffer, cause you cant leave the room. Kinda sucks when you are hoping your other pts dont bleed out or something cause you cant check on them because of the confused person who refuses to stay in bed

Off topic, but this is why I won't work as a floor nurse unless I am forced by circumstance to do so (i.e. need $$$ or I'll be homeless, etc.). I'd much rather work with 1-2 critical patients than 4-5 who aren't considered critical but could be in a heartbeat and I can't adequately monitor them because my hospital chooses to staff like cr@p.[/rant]

PediLove2147, BSN, RN · Oct 21, 2012

Thanks for the replies. It seems like those who do it don't really like it

We're a 32 bed unit but usually have a max of 25, post op floor. The other problem I see arising if someone discharges 4/5 and someone else doesn't have any until late in the day. That puts the charge nurse in a tough spot since you can't give one nurse 4 admissions? Hmm. Guess we'll see. A few of the nurses really think this will work, I'll give them the benefit of the doubt. I definitely see a few pros so I look forward to those. Sometimes it works out (our current way) that you have a few in neighboring rooms, those days are nice.

KelRN215, BSN, RN · Oct 21, 2012

This would have been a disaster on my hospital unit. Our floor was shaped like an L- 7 double rooms in one hallway, and then 12 singles in the corner to down the other hallway. At the far end of the hallway, your assignment would be cake... every patient would be an elective admission for long term video EEG monitoring. All on q8hr VS. If they weren't seizing, you could reasonably do absolutely nothing from midnight on. Closest to the nurse's station you'd have the dying patient, the patient who's acutely decompensating and is going to need to be rushed to the OR in the middle of the night, the stroke patient on a heparin drip and q 2hr neuros/vitals and the total care patient with no parents.

allnurses Guide · Oct 22, 2012

We are assigned by both with less emphasis given to room number than acuity. Most days most nurses have their four patients all in the same hall.

Good Morning, Gil · Oct 22, 2012

There should be a balance as to how they assign patients, not just always adjoining rooms. They're going from 1 extreme to another. Just because running around all night didn't work before shouldn't mean that everyone always gets adjoining rooms no matter what now. If there are multiple acute and/or difficult assignments in 1 area, then the assignment should be rooms 1-3, and then 6-7 (if rooms 4 and 5 were difficult, as well, and 6-7 were more low key) if one is given 5 patients, for instance. There shouldn't be a hard and fast rule: well, you're always going to get all rooms in a row no matter what since that is also recipe for "not very satisfied nurses."

That way of doing assignments, though, is not out of the ordinary, though not the best way of doing assignments. Acuity should always be taken into account.