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

[nservice]

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.

You do realize that the LPN's are nurses? This might get ugly... Better duck!

[TikiRN]

Thanks all for your input.

It is interesting that when they say " it's the norm everywhere else" then they mention some hospitals somewhere are all doing this (always vague).

We do have monitor techs. Thank the Lord, we used to use the pagers. ( Nightmare!)

I forgot our techs do the stocking on nights too. And they have to strip the beds before housekeeping will even touch the room.

The MD's are difficult to get a hold of on nights. And as for discharging a pt. We have to fill out a bunch of paperwork, fax or call in any meds, and then get them out the door. They are monitoring our discharge time and want it down to 30 minutes from the time the MD writes the order. HA HA HA. Right. That is always fun when you have a set of sheaths to pull, one just got back from PACU, the other needs a pain pill, blah blah blah, you know how it goes.

Someone else mentioned about getting rid of older nurses. I noticed that they are the ones getting wriiten up more and two have been fired, or pushed out.

Another weird thing that they are doing that I know is totally wrong but I don't know how to fix it. Maybe I should start another thread....

Is that we have computer documentation, you give a pain med or have a PCA, the follow up documentation is 1 hour and 2 hours. IF we are even 1 minute late in getting into the room ( usually longer) and we are off on the assessment. We are called at home to come back in and "fix it" In other words, Lie and say you were in there. Same thing on restraints.

I am not saying that these are wrong rules, in fact I often think for PCA's and retraints it should be more often. But the truth is we are so busy that there is no way in hell we can get back in there in that time frame. Yes, sometimes I can, but usually not.

And no there is no one to cover for lunchs. Just the other RN's. We go two at a time. Which is actually an improvement. We used to not get lunchs very often. So that is better.

I actually heard my Team Leader say, "You are not 'entitled' to breaks, only lunch.

Anyway thanks for the input.

By the way this is a small midwest rural community 68,000. 300 bed hospital. And the CEO makes over 800,000 a year. No, I am no kidding, it came out in the newspaper, what he and the Dr's were making compared to a large city near us.

Anyway, thanks again

Tiki

[lindarn]

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.

I would demand to see the "research" that they are quoting you. The ones that state that "this is the national norm for staffing". If they cannot provide it, which they probably cannot, I would notify the BON, keep notes concerning the staffing, and problems that occur.

It would also be a good idea, when "things" happen, to make sure to write incident reports. And don't forget, make copies for your self. Include things like, misses/late medications, treatments, etc. Make it concrete, so there is no question that what is being asked is unsafe.

If you are ambitious enough, you might do some research your self, concerning staffing, in other parts of the country, and even the state where you live. Look up nursing journals that include sections about nursing litigation, and how staffing may have effected the outcome. Take the whole mess to the senior partner in the law firm who represents the hospital. Inform him/her that this is the mess that they will have to defend the hospital for, and you are saving the memos that you wrote to administration to cover you butt. I will bet that they were not consulted when the hospital decided to cut your staffing.

Lindarn, RN, BSN, CCRN

Spokane, Washington

[oramar]

Thanks all for your input.

It is interesting that when they say " it's the norm everywhere else" then they mention some hospitals somewhere are all doing this (always vague).

We do have monitor techs. Thank the Lord, we used to use the pagers. ( Nightmare!)

I forgot our techs do the stocking on nights too. And they have to strip the beds before housekeeping will even touch the room.

The MD's are difficult to get a hold of on nights. And as for discharging a pt. We have to fill out a bunch of paperwork, fax or call in any meds, and then get them out the door. They are monitoring our discharge time and want it down to 30 minutes from the time the MD writes the order. HA HA HA. Right. That is always fun when you have a set of sheaths to pull, one just got back from PACU, the other needs a pain pill, blah blah blah, you know how it goes.

Someone else mentioned about getting rid of older nurses. I noticed that they are the ones getting wriiten up more and two have been fired, or pushed out.

Another weird thing that they are doing that I know is totally wrong but I don't know how to fix it. Maybe I should start another thread....

Is that we have computer documentation, you give a pain med or have a PCA, the follow up documentation is 1 hour and 2 hours. IF we are even 1 minute late in getting into the room ( usually longer) and we are off on the assessment. We are called at home to come back in and "fix it" In other words, Lie and say you were in there. Same thing on restraints.

I am not saying that these are wrong rules, in fact I often think for PCA's and retraints it should be more often. But the truth is we are so busy that there is no way in hell we can get back in there in that time frame. Yes, sometimes I can, but usually not.

And no there is no one to cover for lunchs. Just the other RN's. We go two at a time. Which is actually an improvement. We used to not get lunchs very often. So that is better.

I actually heard my Team Leader say, "You are not 'entitled' to breaks, only lunch.

Anyway thanks for the input.

By the way this is a small midwest rural community 68,000. 300 bed hospital. And the CEO makes over 800,000 a year. No, I am no kidding, it came out in the newspaper, what he and the Dr's were making compared to a large city near us.

Anyway, thanks again

Tiki

This is EXACTLY what goes on when cost cutting program is in effect. Some people are advising you to demand this or do that. Just be advised you may lose you job if you do. Believe me I know. I personally never cared because I am the type that must say what I must say. Shortly after saying it in several cases I have found myself unemployed. I am an older nurse that does not need to work so it is OK.

[flightnurse2b, LPN]

i came from a large hospital in south florida and the staffing ratios there were horrendous for nurses...

ER: 4-5 to 1 days or nights

MSICU: 2 to 1 days, 3-4 to 1 nights

PP: 7 to 1 days, 8-9 to 1 nights

CVICU: 2 to 1 days, 2 to 1 nights

L&D: 2 to 1 days or nights

PCU/Tele: 7 to 1 days, 8-9 to 1 nights

MS: 9 to 1 days, 10 to 1 nights

CVSD: 5 to 1 days, 6 to 1 nights

it was horrible, i remember they called two simultaneous codes one night.. and we had to pick which one to go to first because there wasnt enough of us to go to both and all the charge nurses on the floors had patients...

[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.

You do realize that the LPN's are nurses? This might get ugly... Better duck!

Of course i realize lpn's are nurses, used to be one. Our lpn's are utilized differently than i've seen in other hospitals. They do not do assessments or chart assessments that is all. The lpn's do the med pass, dressings and whatever else that the Rn needs help with. We are a team and each group works well together. If someone needs an iv for example i will or the lpn will do it depending on who has the time. Yes they do am care, but so do i. These are acutely ill patients here and most are total patients so we each work together as well as separately. Some lpn's might take offense to this but most like this setup in our hospital. There are alot of hospitals that do not hire lpn's anymore in our area and most are resigned to work in a nursing home setting.

[Deseosa]

I would demand to see the "research" that they are quoting you. The ones that state that "this is the national norm for staffing". If they cannot provide it, which they probably cannot, I would notify the BON, keep notes concerning the staffing, and problems that occur.

It would also be a good idea, when "things" happen, to make sure to write incident reports. And don't forget, make copies for your self. Include things like, misses/late medications, treatments, etc. Make it concrete, so there is no question that what is being asked is unsafe.

If you are ambitious enough, you might do some research your self, concerning staffing, in other parts of the country, and even the state where you live. Look up nursing journals that include sections about nursing litigation, and how staffing may have effected the outcome. Take the whole mess to the senior partner in the law firm who represents the hospital. Inform him/her that this is the mess that they will have to defend the hospital for, and you are saving the memos that you wrote to administration to cover you butt. I will bet that they were not consulted when the hospital decided to cut your staffing.

Lindarn, RN, BSN, CCRN

Spokane, Washington

I'll just add that you need to decide how important this issue vs. your job is to you before you become too vocal, ie. if you are willing to be fired. Legally, they can't fire you for "whistle-blowing", but if they want you gone, they will find a way. I worked at a major hospital that was switching to computerized MARs. If the pharmacy entered something wrong, they wanted us to rewrite the order on a physicians' order sheet and send it to the pharmacy. I said I wasn't a doctor, and I wasn't rewriting orders that were written correctly the first time just for the convieniece of the pharmacy. At first they ignored me, but I got other nurses behind me and we took it to the head of the committee and explained why it was unsafe and that we wouldn't do it. I told some of those nurses I would consult the BON or JCAHO to see what they thought about nurses being forced to rewrite physician orders. Magically, they changed their mind, and changed the policy to what I suggested to them in the first place. Two weeks later, I was searched by security, drug tested, and told there were "performance issues" (I worked there 10 years without one single complaint or write up). Everything came back negative, but from then on it was a constant battle with them, so I quit.