staffing

[icunurse1955]

I am the Director of a combined ICU/ Telemetry Unit at a small rural hospital. We have six ICU beds and ten telemetry beds. We are having trouble staffing our unit appropriately due to both our size and the varying accuity of the patients that we get.

We have been admitting a growing number of psych patients (drug overdoses, attempted suicides, alcohol withdrawal, etc.) We also have the cardiacs, pulmonary, uncontrolled diabetics, vents, fresh post surgicals, etc. Just a little bit of everything.

Most of my staff feel that we have unsafe staffing for this unit. Night shift does not have nursing assistants, unit secretaries or monitor techs, and staffing ratio is usually 1 ICU and 2-3 telemetry patients per nurse. Because of our low census we usually only have two nurses on the night shift. They also may get 3-4 admissions through the night.

My question is this: What type of patients do you consider to need 1:1 care? Do you always have a monitor tech or some one to watch patients on camera beds?

We recently had a patient go into V-Fib and both of the nurses were in rooms with other patients and did not know that the patient was in trouble until a maintenance man came along and told one of the nurses that "something is wrong with the patient in the next room."

Thank you in advance for your suggestions.

[ljeanmarielouise]

Wow, this is a huge issue from a legal standpoint. Your hospital's policy and procedure manual should have staffing guidelines as well as using patient acuity to guide your staffing. As a legal nurse consultant who works on medical malpractice cases, I can say you are very vulnerable if no one is available to monitor the cardiac rhythms in your ICU and telemetry units. Why have monitoring if no one is watching.

As a former ICU nurse in a small rural hospital I understand your staffing challenges. However compromising patient safety is never acceptable. Perhaps you could speak with administration about closing some beds until your staffing issues improve.

Good luck and I hope you get your staffing issues solved soon.

[Becster]

Sounds very unsafe. I work in a 21 bed CCU. When we have tele patients that are waiting for transfer (sometimes this can take days) to the floor we sill staff 1:2 with rare exception. 2 or 3 tele patients can be really demanding of your time especially considering that CCU transfers to tele are considered the heavier tele patients. A couple of tele patients can really eat up the time the nurse needs to spend with the critical care patient. Our nursing staff has really stood together and refused to allow management to assign us more than 2 total patients when there is a CCU patient in the mix.

Our 1:1 policy is a little gray. Some patients that tend to be 1:1's include unstable balloon pumps, pts' requiring high FiO2 with high PEEPs, innercool pts being rewarmed, recent codes, pts with unstable arrhythmias, intra-arterial TPA with frequent neuro checks, intubated pts coming from the OR who require recovery, and pts requiring frequent gtt titrations. We don't have camera beds. All of our rooms have hard wired monitors so the primary RN is responsible for watching them. We do have monitors at the desk but our unit secretaries are not monitor trained. All of our monitors have alarm parameters and vfib would set off a loud crisis alarm.

Hope this helps.

[mpccrn, BSN, RN]

The same thing happened on our tele floor. Our manager used the incident to get administration to approve a monitor tech position on all 3 shifts. Tele nurse patient ratios are currently 5:1 which we are trying to get changed to 4:1 due to the increased acuity of patients. In the ICU, it's 2:1 usually, but circumstances (pt. status) dictate whether that can be negotiated. Rarely do we have a 1:1 in our rural hospital. If it's ordered by a physician, it means an aide sits with the patient taking care of their safety needs and they can be observed constantly, however, the nurse will give most of the medical care required.

[lmferrrentino]

Hello, first of all thank you for posting the staffing and the type of patient's you serve. There are several issues that I find need to be addressed with your current situation. First, yes you should always have a certified monitor tech watching the monitor's. It's patient safety. Second, a true 1:1 ratio should consist of patient's that are on CRRT, multiple pessors that are unstable, fresh post-op patient's that are severly compromised or declining. You need at least one nursing assistant that is able to assist the nurse's on nights if you are keeping your ratio's 2:3-4. You were lucky enough to have a maintence man aware enough to know that something was wrong with the patient ( or even speak enough english to notify the staff). Another item to consider is this what is more inthe budget one CNA and one monitor tech or the medical law suit and public opinion. Remember if something goes wrong or something is done that one person does not agree with they will inform 5-10 people they know or that maybe coming to your facility. You also need to have staff meetings with your staff and gather some of their ideas as to how they feel you could better staff the unit (within the budget) and then research the common ratio's and recommendation's of the ACCN and telemetry data. There is a way to keep patient safety the primary goal while keeping your experienced nurses happy and life long retention! You should also consider speaking to your facility administration and start a rewards system for above and beyond practices. This gives the staff an encouragement and a sense of "Wow someone does know how hard I work, try, and I care about my patient's". I hope this helps.

Another thing you can do is take a shift in the ICU on a night shift when things seems to be going crazy and actually see what it is like to work under those conditions. If you already have experience as a bedside nurse then you need to remember what it was like when you were in their shoes. The ultimate objective needs to be patient safety! Remember we are all in this together, if we remember that simple fact! Have a great day.