We've all heard "staff according to acuity" long but want opinions

[I<3H2O, BSN, RN]

Hi all! I work on a 35 bed Med Surg unit that encompasses Swing Bed as well. We have Orthos, general surgery (abdominal surgeries mostly), and general illness(pneumonia, exac COPD, etc) for 17 and up adults. Right now our matrix puts us(all RNS and LPNs) having 5-8 pts each with Charge Nurse taking 1-2 patients(usually none). We have 2 CNAs if census is 15-28 and 2 CNAs if our census is 29-35. Our census runs about 25.

Our director is looking to adjust the matrix and has made one step in doing that by starting a Charge Nurse position that will NOT take patients and works from 7-3 in addition to the Matrix we already have. The director is now looking to adjust the matrix to allow us to staff according to acuity and not just numbers. To me, this means that we will need someone who can evaluate the patients on a SHIFT basis to staff for the next shift. We need some type of TOOL that will allow us to staff by acuity.

The reason I came here is to see if I can find any information from you all about how you staff by acuity. Do you have a matrix that is just "by the numbers" and then you are allowed to adjust for acuity?

I've come up with obvious "acuity" things that need to be taken into account but I can't come up with a useful TOOL to staff by acuity.

• Fall risk >10
  
• Confused/Combative/Threat to self and others (ie. combative, feeder, climbing out of bed, bed alarm, restraints)
  
• Comfort Care pts.
  
• bed ridden/incontinent (by this I mean those who must be turned by staff every two hours and those who we all have had on our units that urinate so much you are amazed that they have any normal electrolye balance :chuckle )
  
• telemetry

So, what things am I missing? If you have one or more of these patients, how many patients do you feel is "safe"? If you had a Swing bed pt(only needs assist into and out of bed, meds, possibly 3 PRN meds a shift, and a dressing change), a fresh total knee with a Zimmer drain, a bedridden turnq2 with pneumonia who won't keep their O2 on, a 5day s/p bowel resection with colostomy, a r/o MI on tele with normal enzymes, and a car accident victim with a broken leg...would you say that's too much? VS exac COPD who is completely stable but cannot go home b/c she needs a NH and is waiting to find one that will accept her, Alzheimer's pt who is admitted for altered mental status (to obviously appease the caretaker b/c he is the same as he ALWAYS is when he comes to your unit), a young man with cellulitis who needs dressing changes and pain meds but his SO and P/T are doing the dressing changes PRN, pneumonia in middle aged man who basically is there for abx and O2, female with cellulitis who needs pain meds and IV abx and does everything else herself and a tele pt who has bilat PE and a DVT of the LE.

So there can be really EASY 8:1 days and really HARD 4:1 days. How can we solve the "staff by acuity" thought process and actually do it?

[Chaya, ASN, RN]

I would also include as high-acuity (ie labor intensive) the pt on aspiration precautions, especially if they require Ngt or PEG feedings-meaning 1:1 if also taking any PO's, or crushing all meds and giving via tube, flushes, checking residuals, monitiring that HO is always raised, and extra mouth care plus potentially suctioning if needed.

Also, pts on any drips that need constant monitoring; insulin, cardiac, etc.

We have 4-5 pts each on our MS/ Tele unit. We don't have a formal "tool" that I know of but you might have 3 fairly acute patient and be limited to 4 or have 1-2 acutes out of a pt load of 5.

[Daytonite, BSN, RN]

as i recall the questions on our acuity questionnaires had to do with time spent in actual patient activities for existing patients only that affected the next 24-hour period. when we argued about the unforeseen things that might come up (some of the things you've mentioned), i.e. falls, confusion, combativeness, being placed in restraints, being placed on telemetry or patients going bad and being transferred to other units we were told that these could not be considered because they were emergent, short-term incidents. because we were able to input information into the program and the acuities adjusted for each oncoming shift, unforeseen incidents could not be planned for--only actual ongoing problems. we had to depend on communicating with the supervisors who could get us extra help when it was needed for short term situations and as a supervisor this was part of my job. i can't remember if admissions or discharges after the initial acuity assessment of the 24-hour period were or weren't included or not. i do not think they were. as i recall we were told that the nursing time required for admissions and discharges in a 24-hout period evened out; that this had been taken into consideration in the programming of each basic unit's staffing to begin with.

development of patient acuity tools is all the buzz again these days because it is seen as a weapon against fixed nurse/patient staffing ratios which is the hot topic now with california passing it's law, illinois passing a law and other laws looming on the horizon. however, we were staffing by acuity back in the 80's.

1. the individual staff nurses should be the ones inputting the acuity information on their patients because they know what is going on with them. they are the ones interacting with these patients.
   
2. the charge nurse should be the extra pair of hands that can pitch in and help the staff nurses when there is a crisis or unexpected incident beyond what the acuity tool assesses. in other words, the charge nurse becomes your failsafe mechanism. that person should be there for your admissions, discharges, transfers, patient falls, confused patients taking up inordinate time, unexpected combativeness, restrained patients, or patients going bad.

[zooparade]

We a 28 bed m/s floor in a very rural area. Census is usually 12-18. Day shift takes up to 6pts and nights up to 7. However, staffing is based on acuity of pts. For example, this week was "nursing home week" and I came in to see 4 pts in geri chairs lined up at the nurses station. That day, I started with only 3 pts. All confused, bed alerts, you get the picture. Many days I start out with six. The charge nurse does not take pts. unless really needed. Charge nurse evaluates acuity at 0500, 1700, 2100 for the next shift and staffs accordingly. Hope this helps

[UM Review RN, ASN, RN]

.

So, what things am I missing?

Admissions? Fresh postops?

[psalm, RN]

Don't forget the Isolation pts. One night I had 4 Isolation patients, and 3 had PRN meds. I was in and out of gowns all night...and handwashing with soap and water instead of the antiseptic foam.

[dnnc52]

I am new to some of this matrix staffing. It seems there is no count to acuity, and they just have a ratio of warm bodies. In other words they consider the RN, NA, secreatry and Sitters equal. Many times we need to determine which staff member we want nurse vs secretary . Does anyone know of any study that deals with amt time a nurse provides service to a patient on a 12 hr shift as in, the time of 2 assessments, the administration of meds, and yes the time spent on the computer,which may seem like we are not doing anything to others however it must be done. dressing changes, and also a pet peve of mind discharge and admits, it seems they love to see pending dischages so that they and redo the body count to decrease staffing. However we as working nurses know that a complicated discharge can really but us behind. I think that with these studies then we should be able to come close to a fair matrix or staffing grid. Not exact but at least some acceptable standard. We get hit-up in our unit meets about "Not appearing busy" for the sake of our pts and families Today I 2 back-back discharges and the a complicated admit, who ended up on in the ICU, which i could tell that this pt was going to crash. When in a rush my adm nurse asked me to' get your dischrges done then attend to the admit. That goes against all my nursing beliefs as I feel that the most stable pts should be our discharges and the most needs are our sick admits. I have a hard time dealing with emphasis on DC vs admits.

[MedSurgeMess]

we do acuity staffing where I work. I'll check figures, etc, the next time I'm in there

[jrbl77, RN]

I know this an:banghead: old post, but wanted to add my 2 cents. Recently I had 6 pts on a med/ surg- swing bed floor. I had 5 isolation pts- how much time do you think I spent changing gowns etc. The rational was to give one nurse all the isol pt and the other the surgical pts. needless to say, I think I got the bad end of that deal.

[dnnc52]

Good Point: How long did it take extra to gown up?, then assessment, giving meds, then get admissions, get discharges. If they could place real time study on these issues they would know that we don't have the time we need to give the care our pts deserve. also not to mention our new Stealth Teaching or as what they call survival skills as in a new diabetic teaching where we may have a new diabetic in our hospital

[amr9077]

Our hospital is just starting to look at an acuity grid to help with volume-to-staffing while taking into consideration how sick the pts are. How do you "rate" or "number" the pts so we don't give one nurse 4/5 really ill pts?

[I<3H2O, BSN, RN]

Thanks for bumping this message up. I had forgotten all about it. In the last 2 years we have gotten a new matrix. We have 5-6 patients each now. Just recently, we had a patient that required 6+ ppl in isolation gowns and gloves to reposition, clean, etc. Our unit did really well with staffing that extra nurse so that we each had just 4 patients and therefore had the time to go help the nurse who had the patient. We still have not came up with any type of information on how to staff for acuity. Our charge nurse assigns pts. by printing out the census sheet and marking it off in sections of 5. You may get 5 walky-talky pts that are all there for r/o MI or you may get 5 confused, bed alarm, 35 meds each (that have to be crushed and given over 15-20 minutes). There is NO thought given to who the patients are in the group of 5. :sigh: It's tough sometimes.