Where Have All the Nurses Gone?
One of the most important issues for any critical care unit is the staffing. After all, the term intensive care means that the care has to be more thorough and rigorous. Each nurse has to spend more time providing for the needs of the critically ill patient. However, there are varying levels of acuity (severity of illness) depending on whether or not the vital signs are stable.
Ideally, no critical care nurse should ever have more than three patients assigned, and the charge nurse should not have any. Sometimes patients cannot survive without one-to-one care twenty-four hours per day. Unfortunately, in most hospitals the reality is that administrators are stretching the nurse dangerously thin with assignments of three to four patients per nurse. This reduces the amount of time and attention that the critically ill patients receive, resulting in catastrophic consequences. The night shifts, weekends, and holidays are the most dangerous times, because it is hardest to find enough nurses for those periods.
In order to assess whether there are enough nurses to take care of your loved one, you will need to know a little about patient acuity, or level of sickness. This way you will be able to ask your assigned nurse, "How many other patients do you have and what are their acuity levels?" This refers to how sick a patient is and how much is going on in the way of tubes and drains. The highest level of acuity is 5. This denotes a patient who has any two or more of the following:
- a need for continuously regulating the drip rate of intravenous medication to control blood pressure and/or heart rate
- unstable vital signs
- postoperative for open-heart surgery
If any of these conditions apply to your loved one, you have a right to expect a critical care nurse assigned exclusively twenty-four hours a day. 1f your nurse has even one other patient, this is a dangerous staffing condition, and you should contact your state health department to lodge a complaint. If you don't have Internet access, there is usually a toll-free complaint number that you can get by dialing directory assistance (also toll-free) at 800-555-1212.
To qualify for an acuity level of 4, the patient would have two or more of the following:
- central lines for intravenous fluids and monitoring
- multiple blood transfusions
- open wounds with drains
- endotracheal or tracheostomy tube attached to a respirator
- arterial line for blood pressure monitoring
- Swan-Ganz for infusions and monitoring the heart pumping function
In such a situation, your nurse should only have one other patient to take care of. On the other hand, the charge nurse or supervisor might tell you that your nurse has to take care of two or three others. In that case, you should ask why. In some instances, you will get a reasonable explanation that the acuity of the other patients is low enough to give your family member the attention he or she needs. Most of the time in today's reality, the supervisor will tell you that there are not enough nurses available. At this point, you need to say, "That is unacceptable, and I am going to hold the hospital, the supervisor, and the nurse accountable if anything happens as a result of this dangerous staffing level". Most likely, this will not change anything in that moment, but you will alert the administration to the fact that you are watching how they respond to the situation. As long as management personnel know that you understand the duty that they owe to you and your loved one, they will spend a little more time and energy focusing on patient safety and satisfaction (customer service). When you find yourself in the middle of a critical care staffing shortage, you need to follow up on it every day by stopping at the CEO's office and asking to see him or her. If the receptionist tells you that the CEO is unavailable or not in, you should leave a handwritten or typed note (prepared in advance) in an envelope with the person's name on it. The note, which should be on letterhead that includes your name, address, and telephone number, should read as follows:
My [husband, wife, parent, sibling, child, etc.] is a patient in your ICU [specify location with bed number]. Her/his name is -------------------. I stopped by your office on an urgent matter. The nurse staffing in your intensive care unit is at a dangerously low level. My [husband, wife, parent, sibling, child, etc.] is not getting the necessary amount of nursing care because the nurse has to take care of ------- other patients. This is a dangerous situation, and I am worried that there will not be a sufficient response if an emergency should arise. This is unacceptable. As the leader of this institution, you have the authority to make the changes necessary to bring the nursing care up to acceptable standards, and you have command responsibility for the injury or death that will occur if you fail to do so.
I am so concerned about this situation that I am thinking of contacting the department of health and the local news media. Therefore, I urge you to contact me to tell me what you are going to do to immediately increase the staffing to safer levels.
If you do not receive an answer by the next day, call the health department and the local newspaper editor. Most likely though, you will receive a response from a lower-level hospital executive who will call you to speak on behalf of his or her boss. You will have to judge for yourself whether you are satisfied with the response. In my view, any answer other than "We have increased the staffing levels so that each patient will get the care that he or she needs" requires further action as specified previously. You should also discuss this situation with your doctor and ask about the possibility of transferring to another hospital. Remember that hospital executives are not accustomed to having patients and family members being assertive with a full understanding of what is going on. In this situation knowledge is power.