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What is a reasonable nurse: patient ratio in ICU?

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Specializes in Private Duty Pediatrics. Has 42 years experience.

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

Specializes in Psych. Has 5 years experience.

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!

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

Specializes in OR, education. Has 16 years experience.

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

Specializes in ICU, Agency, Travel, Pediatric Home Care, LTAC, Su.

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

Specializes in Critical care, tele, Medical-Surgical. Has 49 years experience.

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

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

CCU BSN RN

Specializes in CICU, Telemetry. Has 7 years experience.

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

Specializes in SICU, trauma, neuro. Has 16 years experience.

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

Specializes in Critical care, tele, Medical-Surgical. Has 49 years experience.

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

Specializes in ICU, Agency, Travel, Pediatric Home Care, LTAC, Su.

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

Kitiger, RN

Specializes in Private Duty Pediatrics. Has 42 years experience.

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 . . . 😮

subee, MSN, CRNA

Specializes in CRNA, Finally retired. Has 49 years experience.

On 7/1/2020 at 8:32 PM, A Hit With The Ladies said:

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!

Don't have to worry about families visiting on a Covid unit:) Few staff want to actually be on that unit but that is one of the plusses.

Hi! I work on a COVID floor and rotate to a COVID step-down. We use a system with the primary nurse being the only person to enter a room (no EVS, no PCTs, no ancillary staff) with a team member from another furloughed area of the hospital serving as a PPE monitor/runner. We are required for all care of the patient and cleaning of the room. I really think I've been able to provide the best care with a 1 nurse:1 monitor:3 patients ratio on the floor or 1:0.5:2 on step down. I have worked at 1:0:5 on the floor and 1:0.25:4 on step down. Those ratios were very unsafe and just bare minimum care. Frequently I'm in patient rooms for over an hour with all of the bundle care with COVID patients. I can't speak to ICU ratios with COVID patients from experience. Now that we are getting more patients with COVID as their secondary dx, their sx are just really too complex to have inappropriate staffing.

IRN2011, ASN, BSN

Specializes in CCU, CRRT. Has 6 years experience.

Currently at my hospital we have a typical 1:2 with the occasional 1:3 ratios for ICU's. If a patient is a fresh hypothermia, is rotoproned, CRRT, or IABP/impella than they are 1:1 unless we are severely short, but they would go out of their way to tripple all the other assignments first before giving a second patient to that assignment.

Covid-19 units on the other hand are kind of the wild west (at least at my hospital). In florida, things are starting to up-tick a bit again... they converted three units to covid-19 stepdown/ICU's.. they are the only units that mix stepdown and ICU acuity.. mostly because what we find is when a covid patient is crashing, we don't have time to move them to a new unit. Stepdown nurses still treat the stepdown patients and the ICU nurses treat the ICU patients, the only difficult part is that unlike traditional ICU rooms in where there's only 1 patient in each room, they are doubled.. you can have two step-down patients in the same room.. one ICU and one step-down, or even two ICU patients in the same room (I feel for the patients.. I'd hate to be the step-down patient on high-flow or bi-pap and sitting next to a fully intubated and proned patient in the same room). in COVID-land, our nurses used to be 1:2 max for ICU and 1:4 for stepdown... however as we continue to get more patients and open up more rooms... we are now 1:3 for ICU and 1:6 for stepdown covid.

Kitiger, RN

Specializes in Private Duty Pediatrics. Has 42 years experience.

When a hospital expands their COVID rooms, or opens up another COVID unit, do they then expect the existing nurses to cover that unit, too?

4 minutes ago, Kitiger said:

When a hospital expands their COVID rooms, or opens up another COVID unit, do they then expect the existing nurses to cover that unit, too?

At ours, when your unit transitioned to COVID, you transitioned, too. We had a number of staff who bumped their retirements up a few months when this happened and a few who medically were cleared to transfer to other floors or be furloughed, but for the most part, all of my coworkers just transitioned to COVID RNs.

NurseSpeedy, ADN, LPN, RN

Has 19 years experience.

On 7/1/2020 at 8:34 PM, 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.

My uncle was a COVID19 patient. Floor, not ICU, for one week. First and only COVID19 patient in the hospital at the time. The night before he went to the hospital he felt like he wanted to die-the next day he entered the hospital-got a positive test that he was still waiting for with from the week prior I. An outpatient testing center-and was admitted with COVID19, pneumonia, and a few other unpleasant add ons. He spiked a 105 F. Fever that evening-was given meds to lower and the controversial hydrochloroquine regimen. He was release a week later. Took several more weeks to be tested negative and is still monitoring the aftermath of COVID19 long term. With this disease-who knows what ratio is safe? They can tank quick-floor to ICU-or can have it in the community and never even know it-complications should be considered.

the ICU was typically 1:2 ratio, when understaffed 1:3- step down 1:3/4. The floor-not going to lie-a total crap shoot1:6/7/8/10-whatever you got what you got-glad I’m no longer there’d to experience it-get agency requests multiple times daily. I have a different nursing job #1....#2 are you nuts??? How about paying the nursing staff there what they are worth first? Then you don’t need to bribe and agency nurse with incentives-I’m high risk anyway so I would have to decline anyway but still-staff nurses do not get paid enough for the crap they are dealt and then the agency nurse is paid more along with the agency fee-does not make sense.