Tele overflow patients in the ICU

Celia M, ASN, RN · Aug 10, 2005

We are a small ICU in a rural hospital and aften have overflow patients. Title 22 states that if the patient is physically in ICU they are subject to ICU ratios, therefore the ratio should be 2 patients per nurse. On very rare occassions we have been out of compliance for an hour or so while we shuffle patients around or wait for staff to get in. Often the problem is patients on the med surg tele floor who have been on tele forever cos the doc has forgotten to dc it. On the one occassion we had several overflows we staffed 2:1 for ICU and 4:1 for tele.

TamaraRN · Aug 14, 2005

As I'm also in California, any pt in an ICU bed gets the ICU nurse patient ratio. I'm working on getting approval for licensing several beds to flex into an intermediate level of care when needed. That would be 3 or 4:1, q shift assessments, q 4hr vitals. Right now I'm facing huge resistance, but I'll keep trying. That worked very well on the unit I worked in Oregon.

Celia M, ASN, RN · Aug 15, 2005

We went through the whole application process a while back for flexing, with what we thought was a very strong case, but were denied. I hear that very few people get the OK to flex. Good luck and let me know how it goes. :)

mattsmom81 · Aug 15, 2005

This is hard because inevitably, when these patients move to tele (usually that shift)those 4 now empty beds will be filled with real ICU patients and the nurses will then be working short. Sometimes I think that's management's plan.

The best option, IMO, is to encourage the supervisor to pull in a tele nurse to manage their tele patients but I know this isn't always feasible. Usually we just do the best we can and try to keep a proper ICU nurse to ICU patient ratio.

Good luck in working out a good policy!

papawjohn · Aug 15, 2005

Hey Y'all

This has always been a problem in places I've worked. I 'member that in the Neuro ICU of a 'great metropolitan city', we would have ambulatory pts on all po meds because the step-down units had no beds---because the rehab units had no beds---because the SNF units had no beds. The entire system would become constipated!! I remember one night that I had a pt on continuous A-V dialysis, vent, ventriculostomy, was doing calculations of Cerebral Oxygen Uptake and all that kinda stuff---and my other pt kept sneaking off to hide in the bathroom and smoke!!

The biggest bummer is that the least-sick pts tend to be the most 'needy'--which is reasonable if you think about it. If my really really sick pt has a complex dressing change to do--I (the night nurse) can do it on my schedule. But if a 'less-sick' ("why weren't they transferred yesterday?") pt has the same dressing change I'm much more likely to do it on THEIR schedule so they can get some sleep. They're more likely to need bedpans and discover they need a sleeping pill or pain med and to use a call light. All part of their getting better--I'm glad for them, don't resent it. But it can screw up my sense of control over my time--which I like to control.

I tend to get grumpy and march back and forth to the pyxis and ice machine for my 'alert' pts mumbling under my breath things like: "The whole system needs an enema" and "there's really no such thing as hospital administration; everything happens by accident"!

Wish there was a good answer. I guess we can't do much more than blow off a little steam, though.

Papaw John

Zoomer · Aug 21, 2005

This is hard because inevitably, when these patients move to tele (usually that shift)those 4 now empty beds will be filled with real ICU patients and the nurses will then be working short. Sometimes I think that's management's plan.
Exactly!!! That's the part that makes this whole thing stink. I posted on the general discussions about a bad night and how angry I am at my nurse manager. We had the same situation where we moved out the tele patients and got some very sick ccu patients. The management seems to think that the census and patient acuity never change. If we pull in a tele nurse they do me no good when I've moved out all their patients.

mattsmom81 · Aug 21, 2005

This is hard because inevitably, when these patients move to tele (usually that shift)those 4 now empty beds will be filled with real ICU patients and the nurses will then be working short. Sometimes I think that's management's plan.
Exactly!!! That's the part that makes this whole thing stink. I posted on the general discussions about a bad night and how angry I am at my nurse manager. We had the same situation where we moved out the tele patients and got some very sick ccu patients. The management seems to think that the census and patient acuity never change. If we pull in a tele nurse they do me no good when I've moved out all their patients.
What I try to do as charge is anticipate this..and pressure the supe to float a tele nurse in to take care of and transfer these patients, staying with them on tele...and keep an ICU nurse on call for new admits. I was fortunate to work with nurses who shared oncall duties just for these situations...so we tried to outsmart the short staffing gremlins...LOL!!

Straydandelion · Aug 21, 2005

We had a stepdown unit that was very helpful for this. The unit would send patients to the stepdown and it would also take care of overflow.

amnesia · Aug 21, 2005

I actually made the decision to leave ICU because of all the overflow problems. I got tired of worrying that maybe I didnt suction someone enough or missed giving meds/drips because of the"higher maintenance" overflow pts. wanting this diet or that drink etc. There were many nights that I worried that I had inadvertantly harmed someone like my ventilated pts. because I was too busy taking care of my "attemted suicide, drug addicted pt". I went to PACU and love it! Still get to do my ICU stuff but most importantly ratios are the greatest(1:1 for ICU/BURN/TRAUMA and 1:2 ambulatory). The best of all worlds in my opinion.