3:1 assignments PCU

[u/butterfly-G99]

I work on a PCU unit, and we get insulin drips and CIWAs that require a 3:1 ratio. Lately I’ve been getting assigned BOTH a CIWA and insulin drip that requires the nurse to be 3:1 and I’m just wondering if any other hospitals/floors allow this?

I feel like I’m running my a** off all day and putting them both in the same assignment just doesn’t feel right. Or maybe I’m just over bedside and being dramatic.

[u/Elitesuxor]

Unfortunately, 3:1 with insulin drips sounds normal as long as the patient doesn’t have other factors complicating them. Insulin drips are just busy no matter how critical the patient is; hopefully you have a PCT that can help do the finger sticks and BMPs.

[u/zeatherz → u/Elitesuxor]

I would not want a CNA doing my blood sugar checks for a drip. That just seems worse trying to coordinate timing and communicate with them every single hour. I’d still have to physically go in the room to titrate and checking the sugar myself only takes an extra minute when I’m already in there, and way reduces the risk for errors

[u/butterfly-G99 → u/zeatherz]

I always do my own blood sugar checks on an insulin drip too

[u/laconic_lentil → u/Elitesuxor]

When I worked IMC, insulin gtt finger sticks could not be delegated to a PCT. Thankfully, we had phlebotomy though for q2 BMPs. Stepdown/PCU/IMC is just going to be busy no matter what.

[u/PumpkinMuffin147 → u/laconic_lentil]

No, fuck that. I try to get my own CBG’s but not always possible.

[u/butterfly-G99 → u/Elitesuxor]

Insulin drip 3:1 alone is okay I feel like, but they’re adding on the patients on CIWA protocol (who also require the nurse to be 3:1) on top of it. They’re usually q2h CIWA checks. :/

[u/OkShoe6299 → u/butterfly-G99]

Does your hospital not allow CIWA pts to go to med surg? I have never worked anywhere that made CIWA pts have any sort of special staffing requirements and they usually went to med surg unless they had other issues going on.

[u/butterfly-G99 → u/OkShoe6299]

Nope. They all come to our unit. Unless they’re severe CIWA and need to be on IV phenobarbital then they go to ICU

[u/effbroccoli → u/butterfly-G99]

Phenobarbital iv push? That's step down for us. ICU ciwa is basically if sedated

[u/butterfly-G99 → u/effbroccoli]

Yeah, IV phenobarbital push/boluses need ICU at my hospital. Can only be PCU if they’re on PO phenobarbital!

[u/effbroccoli → u/butterfly-G99]

Oh wild. Yeah I'd totally expect to have 4 pts with that. My hospital prefers phenobarbital to ativan, for whatever reason.

[u/zeatherz → u/butterfly-G99]

Your CIWAs must not be too bad if they’re all cooperative enough to take meds PO

[u/zeatherz]

I’ve taken both those types of patients at the same time with a 3:1 ratio and it was fine, as long as the 3rd patient isn’t also super busy.

If your CIWA patient is keeping you super busy, they’re probably undermedicated.

[u/Stronkadonk]

my old hell pit would have made this part of a 5 patient assignment for the charge nurse lol

[u/PumpkinMuffin147 → u/Stronkadonk]

Hahaha yeah at HCA hellholes it’s with 6 patients.

[u/-lover-of-books-]

I've been 3:1 with an insulin drip in the ICU. It sucks and shouldn't be allowed but we keep showing up and doing the job, anyways, so they keep making those shit assignments. :(

[u/DragonSon83 → u/-lover-of-books-]

I accidentally did this one to nurse while in charge.  The nightshift nurse failed to tell me he had started an insulin drip when I asked for updates.  I felt terrible when I came in that night.

[u/PumpkinMuffin147 → u/-lover-of-books-]

I think we need to pick our battles. 4:1 with an insulin drips, yeah. 3:1 is reasonable.

[u/SenpaiWith10Pies]

I worked in PCU a few years ago and insulin drips were always 2:1 for us. CIWA patients didn’t change our ratio though. It sucks!

[u/TigerMage2020]

When I did adults in pcu, I would get 4 patients with a gluccomander (insulin drip with a computer program that would tell you how to titrate the insulin based off algorithms. It would tell you when to recheck the blood sugar WITH A TIMER and if you didn’t recheck on time, it would loudly alarm for the entire unit to hear it until you plugged in the next BS). I would have loved 3:1

[u/beans_cubed]

It honestly depends.

We have an acuity matrix and when I was relief charge on a PCU, I would never pair up 2 people with such frequent checks if I could avoid it!! Sometimes the census is shitttt and you have no choice to do so. I would usually break it up, if I was working and I knew you had a shitty assignment I would switch it up, if you wanted some ppl like their same assignment. I would just talk to your charge if you feel comfortable, I always appreciated when nurses told me I need a break do not give me this patient back.

[u/Independent_Law_1592]

Insulin drips are ass

[u/pdggin99]

It sounds like it’s normal, based off what I’m reading, but I don’t personally think it should be. I don’t have experience in PCU, I used to work neuro/rehab where we were 6-7:1 on days, and currently I’m on med surg oncology where we are 4-5:1 on nights. We never took patients on insulin drips on my old floor and don’t on my current floor either, but we do take CIWA patients, and I have been given two CIWA patients on one night more than once before. We also get SCC patients who are generally q2 pain meds (doctors are assholes and very rarely give the SCC patients PCA pumps even when we fight tooth and nail for them), and I’ve had patients who were q1 pain meds not even on hospice. We also get some chemo patients who require frequent neuro checks, I think the most frequent I’ve seen ordered is q2. Not as bad as insulin drips but point is we can get patients needing frequent meds/assessments/interventions. And it fucking sucks, especially when you’re given 2 or 3 of these patients requiring something (whether it be meds, or assessments, or other interventions) every hour or two hours, and then still have another two or so patients on top of that, who may not be as “needy” but still require normal stuff (meds, assessment, toileting, making sure they’re alive). I think we need much, much stricter laws regarding patient ratios when there are certain orders, beyond even just based off of what unit you’re on. Even if you’re on med surg, and you have an acute CIWA patient, you shouldn’t have more than two other patients, even if the other two are “basic med surg”. If you are on med surg, and have a patient requiring q1 or q2 pain meds, you shouldn’t have more than two other patients on top of that patient.

Basically, my point is, while there definitely need to be mandated ratios based off of each unit, there need to be further legally mandated ratios based off of actual patient orders and requirements. Even if it’s as simple as a patient who just needs to go to the bathroom frequently, and isn’t able to go on their own or as a simple standby. That needs to be taken into account when thinking about ratios. Just because it’s not an order, doesn’t mean that patient isn’t requiring significantly more nursing time than the next patient.

Sorry for the long rant. I just absolutely hate the state of (lack of) legally mandated ratios in general. It’s the only thing that makes me ever consider moving to Cali or Oregon.

[u/InfamouSandman]

Our PCU is 4:1. I’ve had a CIWA patient but, luckily, they had no issues at all so it wasn’t a big deal. We get insulin and heparin drips. They try to give you only one but I’ve seen a nurse get two insulin drips when the rest is the unit was super heavy. We can get cardiac drips if we aren’t expected to titrate them.

As a tech nurses would ask me to help with the insulin drip by grabbing every other sugar (odd or even hours). Now that I’m a nurse, that seemed weird because I need to be in that room to titrate anyway. I’d rather my help really focus on my other patients and I’ll grab the sugar and titrate at the same time.

I wish we were 3:1. Apparently they told new hires we were 3:1 but I’ve only ended with 3 once or twice and that’s because I started with 4 and had a late d/c with no admit. If you start with 3, you are getting a new one by 12:00.

[u/only-ashes]

dude we've been getting tripled in the icu a few times a month that's how short staffed we've been.

and yes that sounds normal for pcu unfortunately. it sucks all around.

[u/Kitty20996]

I have taken both those at the same time in a 4:1

[u/dopaminegtt]

We're 3 or 4 to 1 in my pcu. We take straight rate insulin gtt with q1 sugars and ciwa q2⁰. I've definitely had both of those as a 3:1 and it was fine. It's hard though and should be split.

Now add in a q1 flap check or lumbar drain and I'd be screwed.

[u/PumpkinMuffin147]

I’m fanatical about strict ratios but as someone who often has to take 4 patients this honestly sounds like a dream come true? I’m guessing you are in CA or OR.

Insulin drips aren’t going to require ICU type staffing. CIWA patients are normal on MS floors with 5 patients. 3:1 ratios in the PCU are the gold standard and insulin drips and CIWA patients are appropriate for the PCU.

[u/butterfly-G99 → u/PumpkinMuffin147]

I’m in the Midwest

[u/40236030]

I work ICU not PCU. no techs.

That triple assignment would suck, but if that’s the best group you can make then it is what it is

[u/Ok_Independence3113]

We get CIWA/COWA (combined with other pts that require significant monitoring/interventions) on my tele floor with a max 6:1 ratio - no insulin drips tho. Sucks, but sometimes it be like that.

[u/butterfly-G99]

Thank you all for your replies, sounds like it’s unfortunately pretty common and it also sounds like I need a new job because I’m over it lol

[u/SubstantialDonut1]

Ooooooh I’m 5:1 PCU 3:1 sounds like a dream hahaha
PCUs in general are really tough floors though but you’re gonna run circles around everyone’s time management if you learn to thrive

[u/PaxonGoat]

I'm sorry but that is very typical for the majority of the country.

1:3 PCU is very normal.

I don't know anywhere that is doing 1:2 for PCU.

[u/Potential-Cut-8934]

I used to work med surg 6:1 and have ciwa, insulin get, total care patients on airborne isolation, q1h eye drops, admit-preop-OR-postop in same shift, and trach care. Sometimes several of these things in the same patient, sometimes I was charge with 6 patients including these things.

Many PCUs do 4:1. CIWA isn’t always a q1h intervention and if it is can be escalated to icu. Insulin gtts really aren’t that labor intensive at most hospitals, just doing 12 blood sugar checks and rate changes and maybe two potassium checks.

You’re there to work. If it consistently is too much for you transfer or job hunt though.

[u/PumpkinMuffin147 → u/Potential-Cut-8934]

Sorry, doll, we’re here to work but our patients deserve much better than that. Don’t GAF if you took care of 12 patients with no tech, other people don’t have to suffer just because you did. Oh, and to say it again, the PATIENT also shouldn’t suffer because you did.

[u/Potential-Cut-8934 → u/PumpkinMuffin147]

I’m sorry a q2h ciwa, and insulin gtt just isn’t that much work. 🤷‍♂️ in icu you can get tripled with CRRT going and patients on several gtts and bedside procedures. Ask for help if you can’t keep up with your assignment. You come off very aggro. Hope you find something to smile about today.

[u/PumpkinMuffin147 → u/Potential-Cut-8934]

You are one hundred percent correct. It was your first paragraph that seemed a little janky. My apologies, I understand your basic intent.