Article in AACN Advanced Critical Care describes how L.A. County Hospitals, operated by the Department of Health Services, developed unit-specific guidelines to standardize 1:1 and 1:2 patient assignments in its critical care units
News — The L.A. County Department of Health Services (DHS) hospitals, including Harbor UCLA, Los Angeles General Medical Center, Olive View Medical Center and Rancho Los Amigos Medical Center, worked collaboratively to develop unit-specific guidelines for appropriate staffing when very critically ill patients require 1:1 nursing care.
The initiative began at Harbor-UCLA Medical Center, a 350-bed Level 1 trauma center operated by DHS. Patients in its five critical care units are extremely critically ill and require multiple resource-intensive approaches to care throughout their hospital stay, with rapidly changing acuity that can affect the nurse-to-patient ratio at any time.
“” describes the collaboration between direct care nurses and hospital leaders, as well as among healthcare professions, patient units and hospitals. It goes step-by-step through the process used to create the staffing policy, demonstrating the work required to shepherd the guidelines through development, approval and full implementation throughout the four hospitals in the DHS system. The article is published in .
Although the hospitals in the Los Angeles DHS system require minimum staffing ratios of one nurse to two patients, with additional requirements of staff by patient acuity, sometimes patients need 1:1 staffing for extended periods of time. Without a clear policy or objective criteria for these instances, nurses could be assigned to provide care for two very critically ill patients simultaneously.
Examples of care provided for these patients include actively titrating multiple medications and/or vasoactive infusions, drawing frequent blood samples, replacing electrolytes, and performing continuous renal replacement therapy (CRRT) and frequent assessment.
The guidelines standardized the 1:1 and 1:2 patient assignments across DHS hospitals and decreased subjective assessments. Furthermore, the transparency of equitable assignments increased staff morale and satisfaction.
The policy includes clear instructions for when, why and how 1:1 care should be provided. It also empowers the charge nurse to manually trigger the 1:1 criteria with a shift note, if the acuity scheduling system does not automatically reflect the need for a higher staffing ratio.
“The staffing process and budget were initially set with the assumption of one nurse to two patients, but a small subset of patients requires a more time-intensive level of care,” said Nancy Blake, PhD, RN, CCRN, NEA-BC, FACHE, FAONL, FAAN, chief nursing officer at Los Angeles General Medical Center. “This initiative provided an opportunity for front-line staff to effect meaningful change toward appropriate staffing, with the added potential for decreased staff burnout, improved staff morale and improved nurse retention.”
The article includes the various patient conditions that trigger the need for 1:1 nurse-to-patient staffing, including CRRT, postoperative open heart surgery, extracorporeal membrane oxygenation (ECMO), proning and critical burns.
AACN Advanced Critical Care is a quarterly, peer-reviewed publication with in-depth articles intended for experienced critical care and acute care clinicians at the bedside, advanced practice nurses, and clinical and academic educators. Each issue also includes a topic-based symposium, feature articles and columns of interest to critical care and progressive care clinicians.
Access the issue by visiting the AACN Advanced Critical Care website at /.
About AACN Advanced Critical Care: AACN Advanced Critical Care is a quarterly, peer-reviewed publication with in-depth articles intended for experienced critical care and acute care clinicians at the bedside, advanced practice nurses and clinical and academic educators. An official publication of the American Association of Critical-Care Nurses (AACN), the journal has a circulation of 1,500 and can be accessed at .
About the American Association of Critical-Care Nurses: For more than 50 years, the American Association of Critical-Care Nurses (AACN) has been dedicated to acute and critical care nursing excellence. The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. AACN is the world’s largest specialty nursing organization, with about 130,000 members and nearly 200 chapters in the United States.
American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656; 949-362-2000; www.aacn.org; facebook.com/aacnface; x.com/aacnme
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