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

[I<3H2O]

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?

[amr9077]

I don't see why this is so difficult. Instead of assigning a nurse rooms 1-5 (just because they're right in a row) why can't the individual pts be looked at and distributed evenly? You can have a great team of five pts if they're independent and there for simple treatments; then you look at your fellow nurse with five pts where maybe two are getting blood transfusions, one is climbing out of bed, and the other two are total care. That just isn't fair. We all have those nurses who will sit in the station no matter what even if a fellow nurse is crashing.

I love being a nurse and I love taking care of people but some days assignments make it extremely difficult. We can't be in five rooms at once. They all deserve better. I would love a job where I could spend as much time as I'd like with a pt without feeling guilty that I'm taking too long. In this profession we are working with the Human Element. Pts aren't robots. They have feelings and needs. When 80 year old Mrs. Smith is on diuretics and has to void every hour but moves slowly because of her arthritis and osteoporosis...who are we to hurry her along? Is this just the way it is on a Med-Surg unit? It's the only unit I've ever worked on so I don't know how it is to work in any other environment.

[jrbl77, RN]

As a former charge nurse and someone who made out the assingments- I have done it both ways. I have given alot of thought to the assingment, tried to make the level of care equal, and just went down the line. It seems sometimes like it is " six of one, half dozen of another" I am no longer a charge nurse, work at a different hopsital. We have 2 halls and often each nurse gets a hall. Usually I would rather have all my patients grouped together rather than have 1 patinet at each end of the hall- and yes that has happened. Staffing according to acuity has been around as long as I can remember and I don't know if there is a "perfect method".