Saturday, December 3, 2011

Levels of care

The hospital is packed with very sick people this week. The ICU is so full it's overflowing, and their overflow comes to my stepdown unit. So we had to put some stepdown patients upstairs on the telemetry floor, and telemetry patients out in general med/surg. This situation doesn't mean the patients get any less care; we're just providing that care in a different section of the hospital.

I tried describing this to a friend who's not a nurse, and she asked what the heck I was talking about. So this is probably a good excuse to explain what these different levels of care mean in my hospital.

Med/Surg (medical/surgical, aka "the floor") is the bread and butter of hospital nursing. They care for all the adult patients who are sick enough to be in the hospital, but are quite stable and don't have critical needs. Patients get a vital signs measurement and a complete, head-to-toe nursing assessment every 8 hours. A floor nurse in my hospital can have up to 6 patients at a time.

Telemetry is like floor nursing but for patients who need special attention to their heart and lung function. Patients are hooked up to continuous ECG monitors that read cardiac activity, and sensors that read blood oxygenation level. Any sudden changes in the readings will sound an audible alarm. The patient/nurse ratio here may be as high as to 5:1.

Critical Care Stepdown is where I work. We get patients who are still stable but too sick for the floor, either because their condition is borderline and requires very close watching, or because they have multiple complicated care needs. We are also the first stop for patients leaving the ICU after their condition has stabilized. Assessments are every 4 hours, instead of 8. Each of us may have up to three patients at a time.

The Intensive Care Unit is dedicated to care of the most critically ill and unstable patients. These are the people who, without care, are in imminent danger of morbidity and mortality. Many are intubated and on mechanical ventilation, or have other invasive devices for life support and monitoring. A specialist physician, called an intensivist, is on duty there at all times. Vital signs and assessments are recorded at least every 2 hours (but sometimes as often as every 10 minutes). Each nurse has no more than two patients to care for, and sometimes must spend her entire shift with just one.

Though the different levels don't all have the same equipment or experience, most everyone is cross-trained to handle one level higher if necessary. That lets us deal with situations like last night, when the ICU was already full, when two more patients showed up in the the ED with life-threatening accidental injuries. Those patients needed ICU beds proper, so to make room, the unit sent their two least acute cases over to me.

Even when physically moved to rooms in stepdown, both my patients remained at the ICU level of care. Relatively low-acuity by that standard still means they were still quite sick. One was intubated and on mechanical ventilation, which we were carefully weaning in order to retrain his own respiratory function. The other was a lady on drips of multiple medications to prop up her blood pressure and heart rhythm, requiring lots of adjustment to keep her vital signs within defined limits.

To make room on my unit for them, two stepdown patients got sent up to the telemetry floor. Nurses up there have all the monitoring equpiment required for these patients, and know what to watch for. A few telemetry patients got sent over to med/surg, on monitors borrowed from elsewhere in the building. And if med/surg were full, any new inpatients from the ED would have had to spend the night in the ER exam room on a stretcher. (Fortunately, we haven't had to do that to anybody this week.)

What still surprises me is that the workloads pretty much even out. A med/surg nurse with 2 assessments per shift times 6 patients, and an ICU nurse has 6 assessments per shift times 2 patients. The ICU nurse has more complicated tasks, but never has to answer a call light. Either way it's a busy twelve hours.


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  2. ICU nurse never has to answer a call light? Please!

  3. Well of course I'm overgeneralizing, because it's a blog post and not a whole textbook.

    ICU patients are a lot more likely to be sedated or otherwise unconscious. In my hospital, most of the time, by the time you're healthy enough to find and press the call button you have been transferred out of ICU onto my stepdown unit. But, like most everything else, there are lots of exceptions.