What is a reasonable nurse: patient ratio in ICU?

[Kitiger, RN]

What is a reasonable nurse: patient ratio in ICU?

What is a reasonable nurse: COVID patient ratio in ICU?

What is a reasonable nurse: COVID patient ratio in step-down?

Hospital beds are not adequate if we don't have enough of the right nurses.

I am not one of those nurses. I haven't worked ICU since 1980. (I do private duty home care, which is also needed.)

[A Hit With The Ladies, BSN, RN]

I'd say two patients per nurse, unless they're on something like a Rotoprone bed where one patient per nurse is appropriate.

Now, if the patient's family members are very annoying and won't let you do your work or charting, then it should be one patient to no nurse!

[NurseBlaq]

Reasonable for ICU in general, I've always been told 1-2 max based on acuity. Maybe 3, but ONLY if 2 of the 3 are stable and possible transfers to lower acuity unit and it's a short night. As for covid, I'm interested too. I never took care of covid patients.

[Rose_Queen, BSN, MSN, RN]

I would say it depends on the nursing approach. What my facility did was divide nurses into levels. Level 1 has current or recent (last 3 years) critical care experience and can independently function as an ICU nurse. Level 2 nurses are those who have a remote history of critical care experience or work in PACU. The ICUs took a team approach. Level 2 nurses provided the bulk of nursing care to 2 patients with a level 1 nurse per every 4 patients for the ICU components.

[KR]

1 hour ago, NurseBlaq said:

Reasonable for ICU in general, I've always been told 1-2 max based on acuity. Maybe 3, but ONLY if 2 of the 3 are stable and possible transfers to lower acuity unit and it's a short night. As for covid, I'm interested too. I never took care of covid patients.

I have worked in at least 8 different ICU's maybe more, either as staff or agency (local) and travel & only 1 hospital was 1 nurse to 2 patients the norm. Everywhere else a lot of the time being tripled (having 3 patients) was the norm the vast majority of the time. If u had a patient with IABP or fresh open hearts it may be 2, very rarely 1 if the patient was very unstable and practically coding the whole shift. I live on the east coast for reference. The hospital that staffed 1:2 in the ICU was out in Neveda. I'm talking Level 2 Traumas (ski/snowboarding accidents, MVA, horse accidents, etc), head injuries and people with ventricular drains in. Thankfully if the patients were in a drug induced coma, those ones were 1:2. This has been my experience over 15 years. Hospitals from 26 beds to 1,000 beds.

[herring_RN, ASN, BSN]

I too have not cared for COVID patients. I have cared for newly diagnosed TB patients and, in the early eighties many AIDS patients when we didn't yet know enough so protected ourselves and each other with surgical mask, bonnet, shoe cover, gown, and gloves. AND we were short staffed (1 RN and 2 LVNs or 31 RN, 1 LVN, and 1 CNA.)

Over many years we in California learned a lot about staffing. When our acute care hospitals are following regulations our staffing is safe. Here is a link to the staffing regulations:

https://govt.westlaw.com/calregs/Document/I8612C410941F11E29091E6B951DDF6CE?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)

Some important paragraphs: "No hospital shall assign a licensed nurse to a nursing unit or clinical area unless that hospital determines that the licensed nurse has demonstrated current competence in providing care in that area, and has also received orientation to that hospital's clinical area sufficient to provide competent care to patients in that area. The policies and procedures of the hospital shall contain the hospital's criteria for making this determination"...

ICU: "The licensed nurse-to-patient ratio in a critical care unit shall be 1:2 or fewer at all times." This includes ICU!

Twenty years ago the American Association of Critical Care Nurses (AACN) developed Criteria for 1:1 Staffing Ratios which I think are still helpful. They are attached.

Step-down: "Commencing January 1, 2008, the licensed nurse-to-patient ratio in a step-down unit shall be 1:3 or fewer at all times. A “step down unit” is defined as a unit which is organized, operated, and maintained to provide for the monitoring and care of patients with moderate or potentially severe physiologic instability requiring technical support but not necessarily artificial life support. Step-down patients are those patients who require less care than intensive care, but more than that which is available from medical/surgical care. “Artificial life support” is defined as a system that uses medical technology to aid, support, or replace a vital function of the body that has been seriously damaged. “Technical support” is defined as specialized equipment and/or personnel providing for invasive monitoring, telemetry, or mechanical ventilation, for the immediate amelioration or remediation of severe pathology."

Currently a COVID-19 Unit for non critically ill patients is classified as a Specialty Unit: "Commencing January 1, 2008, the licensed nurse-to-patient ratio in a specialty care unit shall be 1:4 or fewer at all times. A specialty care unit is defined as a unit which is organized, operated, and maintained to provide care for a specific medical condition or a specific patient population. Services provided in these units are more specialized to meet the needs of patients with the specific condition or disease process than that which is required on medical/surgical units, and is not otherwise covered by subdivision (a)"

ACUITY: "In addition to the requirements of subsection (a), the hospital shall implement a patient classification system as defined in Section 70053.2 above for determining nursing care needs of individual patients that reflects the assessment, made by a registered nurse as specified at subsection 70215(a)(1), of patient requirements and provides for shift-by-shift staffing based on those requirements. The ratios specified in subsection (a) shall constitute the minimum number of registered nurses, licensed vocational nurses, and in the case of psychiatric units, psychiatric technicians, who shall be assigned to direct patient care. Additional staff in excess of these prescribed ratios, including non-licensed staff, shall be assigned in accordance with the hospital's documented patient classification system for determining nursing care requirements, considering factors that include the severity of the illness, the need for specialized equipment and technology, the complexity of clinical judgment needed to design, implement, and evaluate the patient care plan, the ability for self-care, and the licensure of the personnel required for care."

Regulations outlining the responsibilities of a registered nurse in California:

A registered nurse shall directly provide:

https://govt.westlaw.com/calregs/Document/IFD69DB90621311E2998CBB33624929B8?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)

Feel free to ask any questions and I'll try to answer.

AACN-Establishing Criteria for 1 to 1 Staffing Ratios.pdf

[NurseBlaq]

IMO staffing and assignments should always be based on acuity, not number of patients alone.

[CCU BSN RN]

Proned patients were always 1:1 before COVID.

Paralyzed patients on multiple pressors were always 1:1 before COVID

At the beginning of COVID, intubated COVID patients were 1:1

Once we had too many intubated COVID patients to staff at that level, it was basically 'anything goes'. I had up to 4 intubated, proned patients on multiple drips in the COVID ICU for several weeks in a row. They got abysmal care. Many died. We were told to be ready to take 6 COVID ICU patients. We were occasionally provided with untrained nurses from other care areas who were unable to give ICU meds, titrate drips, touch a ventilator, or really do anything terribly useful.

The question isn't 'what should the staffing level be?' it's 'how criminally unsafe is my hospital's COVID ICU compared to others?'

[Here.I.Stand, BSN, RN]

6 hours ago, CCU BSN RN said:

Proned patients were always 1:1 before COVID.

Paralyzed patients on multiple pressors were always 1:1 before COVID

At the beginning of COVID, intubated COVID patients were 1:1

Once we had too many intubated COVID patients to staff at that level, it was basically 'anything goes'. I had up to 4 intubated, proned patients on multiple drips in the COVID ICU for several weeks in a row. They got abysmal care. Many died. We were told to be ready to take 6 COVID ICU patients. We were occasionally provided with untrained nurses from other care areas who were unable to give ICU meds, titrate drips, touch a ventilator, or really do anything terribly useful.

The question isn't 'what should the staffing level be?' it's 'how criminally unsafe is my hospital's COVID ICU compared to others?'

What. The. ****. I’d be curious to see what happened to the HAPU, CAUTI, and VAP rates. I can’t imagine you have much (any??) time for basic nursing care

[herring_RN, ASN, BSN]

8 minutes ago, Here.I.Stand said:

What. The. ****. I’d be curious to see what happened to the HAPU, CAUTI, and VAP rates. I can’t imagine you have much (any??) time for basic nursing care

Frightening that you can't care for your patients. This is SO WRONG! Is there anything we can do? Write letters to your state board, health department, CMS, or newspaper?

[KR]

Yes, please let us know how we can back u! This is so very wrong!

[Kitiger, RN]

Thank you to all who have replied. The reasonable requirements are what we had 40 years ago. Back then, in ICU I could figure on 2 or 3 patients, and in ICS (Intensive Care Surgery) I could figure on 1 or 2 patients.

Of course, many of those patients would be classified as step-down now-a-days. But now, we know more, and we can do more.

Oh, the stories I could tell . . . ?