Step-Down woes need info please

[TikiRN]

Hi all new to the forum and need some input

I work on a very busy CVTU unit 48 beds. 98% full most of the time. When I started working there 10 years ago the ratio was 3:1

Now the "new" managment is pushing for 5:1

Tonight was very short staffed and 2 RN's had 6 pt's each. The rest had 5.

They tell us that we are below that national norm for a step down unit. That we need to start taking more pt's cause that is what every one else is doing.

Here is how it is set up.

We have no anciallry support on days or nights.

Our techs are responsible for passing trays, picking up trays, transporting pt's (no transport in this facility) Ambulate all the pt's.

No phlebotomy. RN's do all lab draws.

We finally got an EKG tech from 8:00 to 2300. The techs used to do that too.

We take every gtt except for Nipride, Levophed, and Diprovan.

We pull arterial sheaths on the floor. Which takes 2 RN's about 30 minutes. We do cardioversions on the floor.

There are a lot of admissions on this unit. Day shift RN's may go through 7 pt's a shift.

We get CABG's 18 to 24 hours post op. With chest tubes still in. Some even have temp pacers. About half are on gtts. Dopamine or Amiodarone/Cardizem.

Then there are the post op Thoro's and vascular pt's. That come straight from PACU.

Now I could see it is we had more techs, or ancillary support. Or if they stopped doing so many procedures on the floor and kept those in the Cath lab.

Not only are they pushing for the higher ratio but now they are big on "Corrective Action." That means do more, go faster, but don't make any mistakes or you are written up for it. We have a HUGE turn over in nurses. We can't even hardly get the new ones off orientation before they transfer out.

Is this really the national norm? How does this really stack up to other step-down units out there.

Thanks in advance for your input

Tiki

[Deseosa]

I work at Duke University Hospital in Durham, North Carolina.

Our CT step-down takes up to three on days (four if the staffing is really bad), up to four on nights (five for bad staffing). Our telemetry step-down, that also does all the drips you mentioned, takes 5 on days and nights regardless of status. Tele step-down at night only has one tech which means you rotate your vitals and i/o's every other. However, our surgical step down floors are 3:1 if you have 1 or more stepdown status patients and 4:1 if all your patients are intermediate care status.

I will say though, that we have much more ancillary support 24/7 than it sounds like you do. Since we are a teaching hospital, we have 24/7 MD support a text page away, CPOE, and MDs are required to do many of the things the nurses had to do at the community hospital at which I used to work.

I'm surprised your floor management is pushing for higher ratios while, ours are begging for FTEs for lower ratios. If you ever feel like it's becoming an unsafe situation either leave or contact your state nursing board for help. It's not worth your license. When they can't staff their floor and have to resort to travelers and agency nurses, they will realize there is a problem.

[EmmaG, RN]

Don't work step-down, but I know BS when I see it (referring to your working conditions, not you). I certainly hope you have Liability Insurance.

[jmgrn65, RN]

our step down unit that I still work on prn is just like you described. our ratio is 3-4 to 1 on days, and 4-5 on nights and we have aides. we don't do blood draws lab does that, trays are passed by nutrition services. Good Luck

[glasgow3]

Stating one thing or another is the national norm or benchmark has been the mantra of consultants and hospital administrations since the 1990s. But even if something is the norm (which I don't even believe is the case here for a stepdown unit) that doesn't mean something is workable or safe.

Administrations are quick to mandate working conditions that have not been studied carefully before implementation in order to save a buck. They don't know and for the most part don't care. Their actions which result in unsafe conditions rarely, if ever result in severe personal consequences when things go wrong. In most cases they can always blame the nurse for not following policy-----policies that they had no hope of meeting in their entirety because they had to "cut corners" just to keep up let alone give quality care.

And look what actually happened in this hospital: "They" now say 5 patients is the national norm but apparently 6 patients can be acceptable as well. It's what I call staffing without true standards and exemplifies why I believe minimum staffing ratios should be mandated by law: Hospital administrations have long demonstrated that they can not be trusted to provide adequate staff otherwise.

I'd be willing to bet that no additional help will be provided here for lunch and other breaks------so for limited periods of time watching 12 patients will become acceptable. Will there ever be a limit? Not for some administrations.

[oramar]

I work at Duke University Hospital in Durham, North Carolina.

If you ever feel like it's becoming an unsafe situation either leave or contact your state nursing board for help. It's not worth your license. When they can't staff their floor and have to resort to travelers and agency nurses, they will realize there is a problem.

I totally like the first part of your post. The advice about calling the BON flumoxed me. I have never heard through any verifiable source of any BON doing anything about understaffing. However, they have punished plenty of nurses that have made mistakes while under horrendous pressure from understaffing. THE BON is not my friend as far as I am concerned. Also, I have been at quite a few hospitals where staff left in droves after staffing was cut. Alas managment could give a @#$% less. My only PERSONAL experience is that things get worse on the units then worse again. I personally have yet to see a single person in higher levels of managment respond to complaints about understaffing or loss of staff due to understanding with improvements in condition.(I have read a few articles but that is so unusal it is printable news) Sadly, I have seen managment people who were delighted with the improvement in the bottom line that occured when nurses with many years experience were replaced with newbies making $10 less. That is just my personal experience. Perhaps there are loads of nurses out there that are treated like GOLD. I hope so.

[NurseCard, ADN]

I just wanting to say that pushing for higher ratios "because that's what everyone else is doing" is a complete and total BS statement.

[RNperdiem, RN]

I work days in a large teaching hospital and have done lots of floating to step-down units. Medical and Surgical stepdown units have 1:3 staffing, a stock clerk and a secretary. These are busy places with lots of patient turnover.

Cardiothoracic and cardic stepdown is more like 1:4, but there is a secretary, nursing assistants, and often a transport nurse available by pager to take monitored patients to procedures. An IV team can be paged to do IV starts also.

There are places out there that do take care of the nurses so nurses can take care of the patients.

[oramar]

I work days in a large teaching hospital and have done lots of floating to step-down units. Medical and Surgical stepdown units have 1:3 staffing, a stock clerk and a secretary. These are busy places with lots of patient turnover.

Cardiothoracic and cardic stepdown is more like 1:4, but there is a secretary, nursing assistants, and often a transport nurse available by pager to take monitored patients to procedures. An IV team can be paged to do IV starts also.

There are places out there that do take care of the nurses so nurses can take care of the patients.

A stocking clerk and a secretary. Impressive!

[chocokitten]

I work in a 20 bed tele/step down unit at the Veterans Affairs Medical Center. Our staffing ratio is about 3-4:1, maybe 5:1 if we are VERY short staffed. Plus we have at least one aide on the floor on days (usually more), and half the time we have an aide on midnights too. We do not have any EKG techs but the number of drips we have on the floor and the acuity of patients is limited. The RN's here are VERY good about making sure that any patient that SHOULD be in ICU goes to ICU. I can't imagine having 6 patients with no ancillary staff! That is NOT the norm. No wonder RN's are fleeing! I would run too, that's scary! VIVA LA REVOLUTION you guys need to stand up for your rights and the rights of your patients. Someone is going to get hurt or killed and it won't be management that gets the blame.

we also do not do lab draws from 0600-1800 m-f and 0600-1330 sat/sun, dietary aides pass and pick up (most) trays and we have volunteer transporters m-f

[Suninmyheart]

I am a new grad in cardiac stepdown. We have a unit secretary, telemetry tech, cna's who do all the I&O's and vitals, a resource nurse who does the BS's and assists prn, an IV team to call on if needed, plus transport and stocking services. Our ratio is 1:4. I am only 3 days into my orientation but so far, even with all this support, I see that it is intensely busy.

[rn-jane]

I work on a stepdown unit with a ratio of 1 nurse for seven patients. We have a 21 bed unit . The difference is i have one aide and lpn for seven patients and a charge at the desk. The aides are responsible for doing am care, blood sugars ect. The nutrional aides pass the trays the patients order, the lpn's pass meds and help with am care and are iv certified(they are awesome). The charge nurse calls the doctors for orders when needed and round with the docs. We do have nitro gtts, levophed ect, phlebotomy draws the blood except our central and picc lines. The resp tech we have two assigned to the unit with icu and one is for ekgs when needed. Our staff works so well together. we don't do vents, they go to one of the icu's. I'm able to assess my patients and give teaching with the staff i have, yes it still can be crazy but our unit does work. When i am pulled to the icu we have three patients with vents and usually no aide or ancillary help and do everything on our own.