Ratios? Do you have them in ER, or are they just for the floors?

[Lurksalot, BSN, RN]

Curious if your ER has any sort of ratio for nurses to patients. In my ED, for example, we self-assign patients most of the time. At shift change, we will be assigned patients from the offgoing nurse, but then we pick up new patients as we are able to. When a critical patient needs to come back immediately (medics, Level 1 and 2's) the charge nurse might ask or assign if no one jumps in, but that is pretty rare since we usually have a group of us go right in and one of us will just take the patient. So according to the acuity of our patients, we make our own assignments, and we all keep in mind the goals of keeping flow moving in the ED.

I see that the floor nursing units have ratios. Does anyone have them in their ER? And how does that work? If our med/surg & tele floors are 6:1, CCU is 3:1, ICU is 2:1, does that only apply to patients actually in that unit, I guess?

Meanwhile, I have a septic ICU patient, a CHFer on a NTG gtt, a stable pneumonia, a I-missed-my-period-want-apregnancy-test, and a suture removal. And I am about to help with the next chest pain medic coming in (which could end up mine).

I'm not complaining, I love my job.:heartbeat:heartbeat I like having a variety of acuity level patients, and I love self assigning. I could be at the bedside for 12 hrs with a very sick ICU patient crashing and it's my only patient, or I could have 4-8 patients rotating throughout the day. But after trying to send a floor patient up and being refused because the nurses would be over census gave me pause to consider how such a system could work in the ED.

I have heard of ED's having blocks of rooms and assigning a nurse to the block. Like one block of 4 is ICU patients, one block may be cardiac, one may be fast track, etc.

Would love to hear how other ERs work. Do you get assigned patients, or do you self-assign, and how does your unit work?

[tattooednurse]

My ED doesn't have any set ratios just how many patients can three nurses take.

[neneRN, BSN, RN]

We assign our nurses to a room or block of rooms and the charge nurses places them as they come in. I think our ER is too big and spread out to self assign. We have several different areas...bear with me, its a complicated set up!

Our ER is divided into 4 sections that each have their own staff and management:

Fastrac (which is a separate building and is staffed by an RN and 2 LPNs)

Intermediate care (OB/Gyn, Ortho, Psych, abd pain, minor MVCs, minor c/o that are too sick for Fastrac) is separated into blocks of 6 rooms staffed by an RN and an LPN for each block.

Pedi ED is separate from adults, I don't know how they staff, I never go over there!

Critical care:

We have three rooms for our sickest patients that have 2 beds each. One RN is assigned to each of these rooms, so its a 2:1 ratio, although 90% of the time, each of these rooms also has 2 hall patients, so really 4:1; these are our MIs, vents, strokes, sepsis, DKAs, etc...all of our ICU type patients. During our busiest hours, 1p-1a, we have an RN that assists in these 3 rooms.

Then we have three blocks of rooms for patients still considered critical care, but not unstable (routine chest pains, NH pts, COPDers, CHFers, AMS, etc.) These are staffed: (5 beds and 4 halls to an RN, LPN, and tech), (8 beds and 2 halls to 2 RNs and an LPN), and (8 beds and 3 halls to 2 RNs, an LPN, and a tech).

We also have a Chest Pain Screening Area staffed by one RN; as patients come in through triage (they get their EKG out there), as long as they're not an acute or unstable pt, they go through the CPSA, where the RN starts a line, draws labs, does bedside Chem 7 and Troponin, gives ASA, completes a risk factor assessment, and then sends them over to the critical care side.

Triage is staffed by 3 RNs and 1-2 techs. They have their own staff, we don't rotate through triage.

Our Trauma nurses are two of the RNs from the blocks of rooms; they are pulled from their assignment when we get a Trauma Alert.

The assignments are rotated daily, but within your own area; you're rotated through different sections of critical care if you're critical care staff, rotated through intermediate assignments if you're intermediate staff, etc. We're hired for each specific area.

There is a charge RN for each of the four areas, and charge does not take an assignment. On the critical care side, the charge sits at a desk to watch monitors, place pts, take admit orders, answer EMS calls, etc., so she is stationary where she can't really be out on the floor. The other charges are more mobile.

There are also always 2 clinical supervisors on shift; one is over triage, peds, and intermediate and the other is over Fastrac and Critical Care. They are usually on the floor to help with the sickest patients, handle staff and pt complaints, etc.

[traumaRUs, MSN, APRN]

The ENA advises a ratio of 1:4. However, am unsure how this is possible unless one quits answering radio calls and closes and locks the door - lol.

I think ratios are a nice idea but not really doable in the ER. And...certainly not in this day and age of so many uninsured or underinsured.

[Blee O'Myacin, BSN, RN]

On a "perfect day" we have a 4:1, but if someone gets a critical hit, we all pitch in, even if it means giving meds or otherwise caring for the other patients in that nurses' assignment until he or she can catch up.

[ed_rn1234]

We dont have ratios. I work in a small ED, where we assign rooms/bays, but we don't really stick to that, everyone pitches in on each others patients. There may be a patient in one of my rooms that I might never even see, depending on whats going on. But it works.

[Lunah, MSN, RN]

We do zone nursing -- one nurse in triage, one in rooms 1-5 (fast-track type stuff, but the isolation and OB rooms are room 4 and room 5, and room 1 is our psych room), one nurse in 6-10 (6 is our trauma room), and one nurse in 11-15 (15 is our peds room). We also have a charge nurse. If we're short, the charge nurse takes an assignment. We only have 15 beds, so the most each nurse gets in his/her zone is 5 patients.

Our ER is VERY teamwork-oriented, probably because we're a freestanding ER -- not so many resources. We all help each other out. Great environment for a new grad like me!

[TraumaNurseRN]

We have 4 teams, each team staffs 4 RNs for 12 patients, and then w have a command center nurse, trauma nurse ad then 2 nurses back in the Peds ER (7 beds). The team leader takes the nonmonitored rooms such as the psych room the ENT room and then 2 non-monitored. The assignments shift depending on the time of day and staffing. For the most part though we have a 1:3 ratio and are expected to help throughout the team. We normally have a tech as well that helps.

[futurecnm]

In our ED, 2 RN's are assigned 6 rooms so each RN has 3 pt when we are full. If one leaves, that RN takes the next to be put in that section of rooms. I work eves so we are typically always full. If we are short staffed, we may have to take 4 pt but I have not seen that happen often. We have 2 RN's in triage, 2 in our urgent care area, 1 charge, and 2 RN's who are for incoming trauma's. We have 3 trauma rooms. If they are empty, those nurses help out the rest. We are assigned our block of rooms when we arrive and take report from the leaving RN in that block. We all help out everywhere when possible but we do have assignments and stick to those rooms. So, in short, our ratio is 3:1.

[Roy Fokker, BSN, RN]

Our Track area typically has 2 nurses (3 on good days when no-one has called out). Track has 16 beds (13 room plus 3 hall).

On the acute side we staff typically 1 nurse to 4 beds (room or hall). On days when staffing is good, we even have nurses just for the hall beds or a float/flex nurse (go around help others).

The charge nurse or triage nurse handles assignments (triage nurse does the walk-ins. Charge nurse handles our medics/EMS patients).

When we get slammed, everyone helps out. I love that about this place - there is usually no whining "But I have 4 patients already!" type attitude. Everyone is expected to "man up" and step up to the plate and give it all you got :)

Sometimes we nurses will switch patients around (e.g. Have an altered mental status pt. in room 11 start going south with pressure issues, I'll switch 'em to the bigger trauma room 7 up front in case we need pressors/intubate etc.)

We see over 6000 pts./month so it can get a little nuts ...

cheers,

[Larry77, RN]

We assign sections of 3 rooms but do pick up a hall bed as needed. I don't understand the recommendation by ENA for 4:1 staffing...do they give clarity on the triage acuity of these 4 patients?

I work agency as well and have never seen a dept that the nurses start with 4 patients routinely...on busy days yes but not always.

[PeachyERNurse, BSN, RN]

We assign sections of 3 rooms but do pick up a hall bed as needed. I don't understand the recommendation by ENA for 4:1 staffing...do they give clarity on the triage acuity of these 4 patients?

I work agency as well and have never seen a dept that the nurses start with 4 patients routinely...on busy days yes but not always.

In my ED the most we get is 4 per nurse. But most of the time there's no tech or secretary so we're doing EVERYTHING. It's really easy to get behind and I don't know what I'd do if I had to handle more than 4.