Ratios changing in my department

[montecarlo64, ASN, BSN, LPN]

My hospital has a ratio of 4:1 for acute patients. In the acute zone, we get strokes, stemis, chest pains, syncopes, and other acutely ill patients. Even if a code comes in, there is no one to take over your other patients while attending to the code. This has been a struggle for me, since my previous hospital was 3:1 for acute and 4:1 for non-acute. Recently, the ratio for ESI 3,4,5 patients (and some ESI 2s) has increased to 5:1 for the norm. This area is non-acute; however, we see GI bleeds, PEs, some chest pains, sepsis, some syncopes, kidney stones, nausea/vomiting, acute abdomens, head bleeds (found out after the fact), and other extremely time-consuming patients. I really enjoy the work and staying busy; however, I am really beginning to feel that the patient load is becoming unsafe. I am an experienced nurse and I feel comfortable in most situations; however, lately I am thinking that this kind of patient load is unacceptable on an ongoing basis. All of the nurses are drowning all of the time. I am curious as to what state you work in and what are the typical ratios. If this is the new normal, I think I might be better to find another specialty. Thanks for all responses!

[amzyRN]

It sounds unsafe with your level of acuity. Where I work in CA, ratios are 4:1 regular ED patients (even esi2) in regular rooms, ICU patients 1:1 or 1:2. When I say ICU, I mean either they were a resuscitation on a vent and multiple drips. A STEMI would be considered an esi 1 at my facility and would never be in a regular room unless there are no other rooms. Our hospital is a STEMI receiving facility and those patients go to cath lab within 30 minutes of arrival. I would say the facility I work at now is safer than the last ER I worked in.

My last place we would be out of ratio sometimes and my facility was high acuity like yours sounds like. If you are getting head bleeds, a bad GI bleed and a STEMI in a 4 patient assignment that is really unsafe, then to have to help in a code on top of that is crazy. Be careful, if a patient dies (and they might) your hospital won't hesitate to throw you under the bus. I've seen this happen before.

This is why I left my last job. There was a travel nurse who worked there and had a patient code and die in one of her rooms and they fired her and tried to blame the death on her. Someone put a sick patient in her room and she never received report and by the time she came in to see the patient it was too late. Instead of addressing this issue of putting high acuity patients in the wrong room and not telling us we had a new patient and we got busy with something else, they fired this nurse. I know in the ER we must always check our rooms, but still, to put a person who is lethargic or other high-risk patient in a room and not tell the nurse or even put them on the monitor is very unsafe.

[Lev, MSN, RN, NP]

Some of those patients in the "non-acute" side sound like they should be ESI 2s. Maybe you have a triage problem. I have found that a 4:1 ratio is pretty typical in most ERs and 3:1 is a "sweet deal."

[Guest374845]

We used to be straight 4:1 except trauma and now we have a 3:1 area, 1 or 2 4:1, and 2 awful 5:1s. And we're supposed to shuffle patients around when a 5:1 is surprise sick (gets tubed or whatever) or conversely when a "sick" sounding patient ends up being low(er) acuity.

In retrospect I don't think we have any fewer FTE after the switch but we have to clean waaaay more rooms due to playing musical patients, or 3s sit in triage longer so they don't take up precious 3:1/ESI 2 real estate.

4:1 will always be the magic take-all-comers ER ratio for me.

[gemmi999]

My ER has basically 3 areas. 2 runs of 3:1 where super critical patient's are supposed to go; 4 or 5 runs of 4:1, but one of those is *always* a chair patient who doesn't need to be monitored (kids with abd. pain, cellulitis's, etc); and rapid treatment. Rapid treatment is *supposed* to be ESI 4s or higher and it's 8 to 1 ratio. However, in rapid treatment a full assessment doesn't need to be done, just a narrative focused assessment.

Where we run into problems is when patient's get either mis-triaged or when our beds are full and patient's are placed in Rapid Treatment who shouldn't be. But when that happens we can tell the Charge either they need to assign one of the floats to RTA to help or that we're closing down some of the chairs due to safety concerns. A lot of time our patient's that end up being sicker get moved to a bed in the main ER when possible. I've caught quite a few septic patient's who end up in rapid treatment because triage either misses some signs or the patient has a change in condition while in the ER.

For the most part I like my ER set up. By knowing your run, you know what kind of night you *might* have, but that can (and does) change. One nice thing is if a run gets a super sick patient, rather then moving the patient bed's get reassigned or the float nurse takes the sick patient until they're *more* stable.

[fRN765]

I'm extremely jealous of everyone here!

I work in a large academic medical center, well known throughout the country and we regularly have 8 patients. We don't have ratios. Patient load doesn't change whether you have an icu or stepdown hold. It's sad and very unsafe. There is a retention problem (as you can imagine), and so we are also regularly understaffed.

[AZQuik]

Ratios are ok but there needs to be some flexibility. Sometimes a migraine turns into a an acute stroke eligible for TPA(in a 6:1 zone, and other times a 2 turns into a 3, but someone freaked out and saw three 2's in a 5:1 zone and moved em all to a higher ratio. Turns out they are all reproducible chest pain tachycardic because they live in the desert and are dehydrated. BUT, since they are 50+ y/o men with a CC of chest pain, they are a 2 until the trop comes back.

So now you move them and have a 3:1 nurse getting them a sandwich, and pointing them to the bathroom, until the three hour repeat trop/ecg is due. Think their FB was updated during that time?