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.

[Zaphod, BSN, RN]

Yes, that sounds unsafe. an ICU RN cant have 1 ICU and few other patients. Maybe just give tele pt to one RN and ICU to other. A secretary to put orders and watch monitors would be a good idea. An ICU patient is either an unstable patient, or on titrating drips, or on a ventilator, or fresh Sx who lost good ammount of blood(cant think of anything else at the moment)

[HiHoCherry-O]

Wow! I sure hope you let your nurses know they are awsome!! Frequently!!

The ICU I work at nursing to patient ratio is 1:2 UNLESS, the patient has a balloon pump, on CVVH, fresh post op (usually for the first few hours until "stablized") etc, then they are 1:1. It is difficult to say which one would need ICU level care outside of being able to look at doctors orders (did the doctor request ICU level care?) labs and overall picture of the patient.

The unit I work on ALWAYS (24/7) has a monitor tech. Usually this is the same person who is the unit secretary and has video monitors right next to her telemetry monitors. If a monitor tech calls in and we are unable to obtain one from the float pool or per diem, then we assign a nurse and request another nurse from staffing to cover or we reassess the acuity of our patients. The monitors we have in our patient rooms also allow us to pull up other telemetry monitor screens from other rooms to view alarms and patient current rhythm, vs etc (Phillips monitor).

Your nurses are overloaded and the patients are unsafe as a result. It is easier said than done to request more staffing. However, it is cheaper to pay an additional couple of staff members versus a law suite or lose a nurse because his/her license was suspended.

[CNL2B]

I see this as unsafe for a variety of reasons.

1. You can't run a unit with ICU level patients with only two nurses regardless of how many beds are there (even if there are only 4 beds.) This is just not enough backup -- appears that you have found this out the hard way. If a patient gets into trouble and two nurses get tied up, there is no one to watch the other patients (in your case, this could be 15 other ICU level + tele patients.)

2. It's very hard to put ICU patients and tele patients together in an assignment. If you have 1 ICU patient and 3 others, it's likely that your ICU patient is not getting watched as well as they should based on the other 3 patient needs. Even though they are lower acuity, that doesn't mean they aren't time consuming. Depending on what part of the country you are in, on some wards, 3 higher-acuity tele patients is a full assignment. You may be asking your nurses to take more than one assignment -- closer to an assignment and a half. My suggestion to you would be to pair your ICU patients (so one nurse would have a two patient assignment, or whatever depending on how many ICU level patients you have) and then divvy up the tele patients.

I would recommend that you staff no less than 3 nurses no matter what your census is for patient safety. Likely you need more like 4,5, or even more depending on how full your beds are and patient acuity (more if more patients/higher acuity).

[meandragonbrett]

1--You need more than two staff members there. As you have found out, things happen when the two on-duty staff members are tied up with other things. At a minimum you need two RNs if there are 2 ICU status patients plus a secretary/monitor tech/nursing assistant staff member.

2--I work agency in a 16 bed ICU that houses ICU and step-down patients as well as tele/MS (when there are no beds). We generally combine patients as if they were ICU patients. Never more than 3 patients (when staffing is bad) and we combine as such: ICU + 1 Step Down, ICU + 1 Tele, etc. We still maintain the 2 patients to 1 nurse staffing ratio regardless of acuity. We also only chart on step-downs Q4h, Tele q8h, and MS qshift. Not sure if you're requiring your nurses to document according to ICU standards on non-ICU patients.

3--Two RNs cannot keep control of the unit and also be responsible for admissions, order entry, monitors, bathing, etc.