Willing to Share about Progressive care staffing?

[suetje]

HI1 ANY help would be great to get input on your progressive care staffing. I am an old SICU RN, now the educator in a new "progressive care" unit (PCU). We have everything from tele patients to vents, weaing from vents, lots of trachs, wounds, drips and people needing close to 1:1 observation (pulses, neuro checks q 1 hour, frequent chemsticks, hourly urine outputs, low BP's...Etc. It is 50% medical and 50% surgical.

We were 'modeled' on supposedly other academic center PCUs...but that was 3 years ago. AACN's definition is somewhat vague, and reported staffing around the country is 3:1 and4:1. 3:1 in our unit, is nearly impossible (20bed unit separated in half by monitors showing only 1/2 of the total population. So, if you work on the North end, you can't see monitors on the South end and vice versa. So you cannot really have a north end patient paired with a south end patient because the monitors cannot be visualized (or heard!) when you are on the other end. Plus, we rarely have tele patients ("walkie talkies and EASY!) and al:)most all patients are in contact precautions, pandemic precautions etc. So it is not simple to just run in and suction someone. Also almost none of the patients can indicate what they want, how they feel etc. Sometimes we get a 'walkie talkie' post op and that is wonderful!

How are you all figuring acuity? what kind of patients do you have primarily? How many of you have 50% of your patients on vents/ weaning/ long term vents?

ANY comments and help I can get on this would be awesome! With Joint Commission requirements as they are, you can imagine how tough it is to have excellent patient indicators with this kind of staffing and this type of acuity. We had many of this kind of patients in SICU before we opened this unit. And we staffed 2:1 there. THANKS!

[Zookeeper3]

Whew, you said it all, the life of a PCU nurse!!!! I started in a PCU. We generally had all long term vents with multisystem issues. If we were lucky, a missplaced cardizem drip was admitted and we jumped for joy. We were smaller, only had 12 beds, took 4 patients a piece, had a dedicated resperatory therapist and an aid for each shift. We were never ever shorted and took 6 ever.

We did all drips except epi, levophed past 15 and the sick pure heart failures never came until fairly stabalized on dobutamine or primacor dosages. Of course sedation drips didn't exist either! We were not allowed to pressure controll, reverse the I:E or have a higher fio2 than 65%.

Our monitors were, and the ones I use now HP monitors. So they were programmed that any red star, or three star alarm popped up into every room so you could see everything deemed by the monitor that was life threatening. All vent alarms were on the door frames so you could hear an alarm anywhere even in the med room.

Every patient by your point is on isolation it seems, so that just becomes a quick but aggrivating chore.

So other than changing out your monitors, I have two other suggestions.

Assignments! consider a team meeting where it's decided by the group but here is what could work: Keep 4 vent patients always together... the heaviest load physically... you have 8 vents, fine two nurses... now they get the aid. The aid does all the turning with the nurse, all the accuchecks, changing the suction cannisters, emptying foley's that type of thing. (we had specially trained aids that could suction, do basic dressings hang peg feeds peripheral lab draws, don't know about your state rules)

The remaining nurses and their patients.... yep, no help from the aid, but these two three or four nurses had a buddy system with each other. The call buzzer and drip beeping, lab drawing group. These guys get the non trached but busier monitoring and documentation group. They all are on the same page and team up together.

So you can flex when you have more high acuity vents, the non vented group may take 5 patients and the others will have three. And this reverses as well. Because our vents were generally there for months, by day 2 or 3 we were able to change rooms to keep all the vents grouped together, in a closer and safer manner. What takes 30 minutes to move a paitent helped assignments tremendously with proximity and your airway concerns.

Good luck and well wishes. Also ask the staff for ideas and suggestions, not a ***** session... I'd bet they have some good ones in there.

[suetje]

Thank you so much! I can't imagine 4 vented patients together! Especially with everyone having PEG tubes, needing to crush all meds, mix them up, syringe them in, gown up (everyone has MRSA, VRE or c-diff, many are stooling often. ) I agree, tripe up people and the aide (tech, we call them) is dedicated to the heaviest. We are TRYING to have the Charge without an assignment so they can run around and act like another nurse/ Tech. We also try to have 'huddles mid shift to make sure everyone is holding up OK.

Our techs can do TONS of things, but still, it does not mean the RN is not in there checking and looking at the pt.! And with all the Joint Commission rules, especially about pulling out meds (often 15 or more at 9 and 9) in the med room, labelling them, brining them to the pt room, checking 2 identifiers, rechecking the meds on the computer in the room, then administering them, the going back to the computer and charting them...that in itself is a 30 minute task if not more. Of course, you go in and try to do whatever else you can because otherwise it is gown and glove up again. Thanks again!

[BedsideNurse]

Those patients sound like a lot of ICU patients. Just because someone isn't crashing doesn't mean the level of care isn't ICU. Seems to me Progressive Care Units like that are nuts. I think 3-1 would be the max. With all that going off you'd be better off working in ICU! At least you wouldn't end up with 4 patients. Anyhow, I've worked in both ICU and Progressive Care/stepdown and my vote is 3-1 for those kinds of patients. Otherwise it'd be seat-of-your pants-hope-nobody-dies-nursing. That's always a bummer.

[Gods_nurse]

I work in an ICU that also has a PCU that it not near as difficult as yours!!! It sounds like your should be 2:1!!! we use report sheets at the end of our shifts 2hrs prior to the end of our shift we have to have them updated. On them is tx, adls, labs, routine care, you give them a min,mod, or max and it adds it up, then when the team leader prints out her report sheet for assignments of the next shift it puts that on there for her to make assignments.

[CNL2B]

I have to say that what zookeeper is talking about sounds insane. There is no PCU up here in the midwest that takes a 4 patient vented (trached) assignment, although I know the LTACHs do. My experience with PCUs has been strictly 3:1 staffing, and the requirements were no pressors except the ones that the stepdown could take (renal dose dopamine and IV inotropes, no neo/epi/levophed) and as far as vents the patient had to be trached and not requiring a high level of ventilatory support (no PEEP>5, no high FiO2s, no PC ventilation, etc.) Other drips were ok. I think the LTACHs don't take any kind of drip at all on their "floors" (4:1), but I think their ICUs do. The PCU beds I am familiar with are primarily used as long term vent beds. To me, ick - ick - more ick. I would never want to work there. Most of the ICU nurses I know feel the same way.

I would think a fair assignment in this type of area would be one or two vents with one or two other patients to make three total, and enough nursing staff around (licensed or not) to provide assistance with basic cares. If the patients are stable I think it could work. It would be a heavy cares, high acuity area but I think when most nurses think PCU they know what that is and what they are getting into.

[ChristopherB, BSN, RN]

The progressive unit worked on did not have intubated patients or 24 hour a day BiPap/CPAP. Our staffing was typically 4:1 during day shift or 5:1 at night shift. At times when there was a shortage fo staff 6:1 was not uncommon.