RN Staffing Ratios

h/t EDNurseasauras

EDNurseasaurus had a post about MA and staffing ratios, and a very typical shift in any ER in the country.

I may have covered this on this blog before, but it bears repeating:

CA calling.

1) I started in the pre-ratio days.
On but one memorable night in Busiest ER On The Planet (no, really!), I was the third nurse in triage.
My assignment:
Everyone coming in on ambulances too weak/fragile/fall-prone to put in a chair.
Everyone seen, treated, admitted, but not needing a monitored bed, so pulled out so we could hot-stack new patients in their old rooms, and the pre-admitees moved to the hallways.
All the traumas downgraded from trauma monitoring, and in the back hallway.
The fresh chest pains who needed to be moved to the EKG tech booth, then back to the triaged-but-no-bed-open pit.
Move the admits to the floor after calling report, when beds become available: no tech. 18 floors.
Get food/water/urinals/bedpans/blankets/pain meds/barf basins for any and all of the above.
Discharge anyone seen, treated, and released in my flock.
Total body count tonight, just for me: 79.
Seventy. Nine.
I shit you not.

As I received report from day shift, thinking he was kidding me, and then finding out he was serious, I did some napkin math: at 5 minutes apiece for vitals, that's 12 an hour. 6 + hours to get from A to Z, and start with A again.
"Yeah, that sounds about right." he confirms.
He only tells me the highlights on the 10 sickest ones. The other 69 are either unknown, stable, or GOK: God Only Knows.
I look at his vital signs updates. In our 1-2 hour standard-of-care ER, they are listed every q6+ hours.
Spot-on.
In the pre-EMR world, I spend over an hour just finding the charts, locating the bodies that match the charts, and writing down a list of the names on everyone's favorite ER scratch paper, a brown paper hand towel. (*Bookmark this note.)

I locate a portable vital sign machine, and except for full-arrest traumas, it takes the entire staff, including Trauma and ER Chief Attendings, about 3 minutes to realize I have the right of way at all times, owing to my demeanor, size, and attitude, and they'd better GTFO of my path, or be run over like the extra in the chariot race in Ben Hur.

Vital signs - urinal - blanket - pain med - vital signs - jello - straw - blanket - vital signs - bedpan - water - report - transport - vital signs - accucheck - snack - vital signs.
Lather, rinse, repeat, 200X.

Come 7AM, I have six patients left. No one died, everyone got to the floor/a room/discharged/whatever.

Last year, going through my papers, I found the *paper towel, with all 79 names. It went home in my cargo pocket, and I was hoping JCAHO would stop and ask me about the place.

As if. They took one look at the place after 5PM, pronounced "Privacy issues must be challenging for you." and were never seen in the ER again.
2) A few years later, CA (i.e. nurses in CA) put nursing ratios on the ballot. It sailed passed voter acclaim, over the fear-mongering b.s. of penny-pinching corporate sh*tweasels.
For ER:
Normal: 4:1
Critical 2:1
Super-critical trainwreck 1:1
If I have one ICU player, I can have 2 normals as well, for 3 total
And obviously, if TSHTF, and there's a train wreck, plane crash, 7.0 earthquake, you're gonna get what you get, and suck it up.

It's still too much sometimes, but is one helluva lot better than nothing.

And any place busy, you're getting patients shoved up your butt as fast as you D/C the last one, with about 60 seconds to strip and flip the gurney, shpritz it with cootie-cide, and slap a fresh sheet on it.
I've taken up my ICU player, only to return to two fresh untouched normies or another ICU player before I even get back with the empty bed.

That's everywhere, all the time.

Ratios? Hell yeah!
Next stop: mandatory ancillary staff: EMTs/CNAs, etc.
If I and another nurse split a tech, that tech, for 1/4 to 1/3 of my hourly rate, doubles my output and productivity and, can do all the stupid but important stuff you don't need a license to do: vitals, blankets, water, code brown-yellow/ transport to x-ray/CT/U/S, the M/S floor, doing EKGs, D/C'ing IVs on patients for D/C, running samples to the lab, etc.

Paying me $40/hr to spend twenty minutes looking for a fricking tube system transport container to tube my samples to the lab is cost-ineffective b.s., and keeps me from doing patient care. And I spend three hours out of twelve a night doing that. So I point out regularly to manglement that they're paying me $120/shift to play hide-and-seek with $40 worth of plastic, while lawsuits are waiting because I couldn't care for $50K patients. (Whereupon, they look at me as if I've grown another head.)

We could have enough techs to speed throughput for a thirty-something bed ER, for the price of one additional nurse, and there'd only be 1200 ambulance company EMTs who'd leap at a chance for 12 hour shifts instead of 24, benefits, and a chance for tuition reimbursement to become RNs/PAs/MDs, so of course fully staffing techs is not a staffing priority, because they could fix it in about 5 seconds, forever, and have a 100-person float pool to ensure we'd never be short techs, even with 10 psychs needing sitters.

But they'd have to pay money for that, while simultaneously cutting wait times, admit times, and sending patient satisfaction scores to the moon, so, not a priority for the clipboard commandos and the Good Idea Fairies who haven't been at a bedside since the Johnson Administration. (I'm not sure whether it was Lyndon's or Andrew's.)

I feel ya, sister.
MA should vote "Yes". So should the other 48 states.

Somewhere Else

It's happily rarer than people imagine, even in knife-and-gun-club trauma centers, but Death visits the ER.

Nobody's death comes easy, even the gang-banger who brought a knife to a gun fight, as his mother sobs agonal soul-shaking cries to the heavens. It's not my job to pass judgment, nor torture the living with the final sins of the dead. They'll be able to do that themselves anyways, and for months, soon enough.

I hate death with a passion when early, or some unbidden surprise visitor, and only when the awardee has lived at least their threescore and ten can I see it as a transition, while for only those dying in terminal pain is it the truly welcome arrival of a long wished-for friend.

The sudden, random, unexpected variety is waste beyond explanation, and the recipient of my quiet rage. Like Captain Kirk, I don't believe in the Kobayashi Maru scenario, and the ones you couldn't pull back are the hardest to bear, and the ones you remember long after the others happily fade from memory.

In Gene Hackman's line in Uncommon Valor, some faces never leave your mind's eye, but you make friends with them. Not to do so would drive anyone mad.

This very morning I was happy to be working on a critical patient, because it kept me too busy to deal with the one right next door, dying with no help nor hindrance from me, despite the earnest efforts of 20 others, and I was glad to be able to let others focus on that problem while I got my guy - awake, alert, and very much alive - ready for the cath lab and then ICU. It could have just as easily been the other way around.

I understand and pity the doctors, because they always get to make the notification, generally face-to-face, and they try to keep it simple and as subtle as a scalpel slicing your throat: "Your xxxx is dead. We tried everything we could. I'm very sorry for your loss."
And then understandably try to get back to work on the living, because there are always more live patients to see.

Dealing with the new patients in the room, the next of kin, family, friends, coroner, mortuary, etc., and calling to tell those unknowing to come in, but safely, and without revealing news over the phone, falls back on the nurse responsible for the man or woman or child they'll eventually have to disrobe, clean up, make less fearsome, and remove pads and tape, while leaving tubes and IVs and such in place, in case the coroner takes the case. Covering the patient for modesty, removing blood and worse; and then, after all the sobs are finally spent, zipping them exactly as naked as the day they entered the world into their final sleeping bag for that trip to the Eternal Care Unit. Tag on the toe, tag on the zipper, hands crossed, and please God, in the couple of hours' grace before rigor mortis starts to stiffen limbs and make it impossible to put grandma or auntie or son Jack into the bag without difficulty, and no limbs extended to other points of the compass than due south.

I've bagged some dozens, of all ages. Some mine, some as a favor to an overwhelmed co-worker. Gently and respectfully, sometimes with help, sometimes alone.

Mindful of the fact that fluids accumulate, muscles relax, and fluids follow gravity. Bad enough to handle the dead without getting slimed by them after their departure. Worst of all, the traumas, some where they've cut them open to reach the heart and stimulate it by hand, often to find the offending missile has penetrated the bullseye, and rendered further efforts more than futile, and sometimes after the patient has been sawn virtually in half from each side, with only the spine maintaining the semblance of a whole person.

I don't know what others do, but I tell you freely and honestly, I talk to them as if they were still there as they're being prepped for that last gurney ride. Maybe they still are there, or nearby, in some way known but to God. I have no idea how soon the bus gets there afterwards, or how quick the departure occurs. They may even still be alive inside there, seeing and hearing, trapped inside the body for a minute or few as things fade away after everything fails. It's simple respect for them afterwards, and it helps me to deal with what I'm doing. Quietly, but sincerely, knowing this is as close as I'll ever be to the doorway they've just entered until it's my turn to be zipped into the bag. They get the same compassion they'd merit if they were still breathing, because they're not carcasses.
Not yet.

I'd happily never have done it, but if not me, who? At least I know it'll be done properly, and with what measure of dignity I can accord someone who probably woke that day with no idea it would be their last.

I have my own suspicions as to what happens to them afterwards, but no one truly knows, nor but seldom is in any great hurry to find out, the trip being always a one-way turnstile.

At this point in my life, I still agree with the man who, when asked where he wanted to be when died, answered quite sincerely, "Somewhere else."