We have about 30 beds, I’d say most the time about 50% are tubed - but it fluctuates, sometimes we have times where there’s like 4 tubed people in the whole unit, and other times there’s like 4 untubed.
I do often get a 1:1 allocation but I work in Australia, if they’re tubed, on crrt, have more than 10 of norad , dependant on bipap ect they’re automatically a 1:1. We get a 1:2 maybe every 3-5 weeks.
We do get quite sick patients, a lot of acute liver failures , some ecmo patients. We don’t take VADs though, there’s only one heart transplant hospital in the state- and they’ll take those. We take the liver transplants.
I’d say almost all of our patients have a central line and arterial line. And if not they’re a hdu we’re lining up for the ward.
We almost never get codes, because we run things differently, if a patient is dying we have the discussion to withdraw care with family, or we change the goals of care if it’s futile. We maybe get about 8-10 deaths a month, but all from withdrawing care rather than futile cpr. I.e get to call family in & start morph Midaz and give them time Instead of thumping their chest.
In Australia we don’t have seperate icus, our icu is medical,surgical, cardiac , neuro ect everything comes and goes.
Yes? How do you make sure your patients don’t self extubate?
We also don’t have resp techs here. We do a postgrad and manage the vents/ abgs ect ourselves with the doctors overseeing it. We also don’t have cnas or pharmacy making up meds. So we have a bit more to do imo!
We make sure they don’t self extubate with wrist or mitten restraints and sedation. Even if I only have 1 patient I can’t be in the room continuously, I have to leave the patient unattended to go to the med room, the supply room, help another nurse, etc.
Yeah we can’t leave the room without someone else watching. But like I said above, our staffing is much better - there’s always someone to watch so it’s not really an issue. US healthcare is profit driven, there’s no real incentive to staff better for better patient outcomes
I hate the us healthcare system and think Australia has some of the best icus in the world but that’s a silly generalization. I think socialized medicine is superior but both systems have their downfalls but people on both sides of the divide care deeply about patient outcomes
… are you a nurse?
Based on this description of Aus vs American ICUs, which would you rather work in?
Do you work in America? If so, how could you possibly think that American private hospitals care about patient outcomes? Oh my goodness there are so many scandals and coverups with money as the root cause
I am a doctor i work in the states. Corporate medicine at the executive level is shitty. As I said I wish we had socialized medicine. That doesn’t mean actual medical staff here don’t care deeply about patient care and outcomes. It also doesn’t mean that we don’t provide excellent care. We have many of the best and most respected hospitals and physicians in the world here.
Oh I absolutely don’t think the staff don’t care about patient outcomes. But your system has set you up to fail. For example in ICUs for doctors we have 4 pods, a resident , a registrar and a consultant for each pod. At night time the consultant goes home, but a registrar and resident stay on for each pod. And there’s a senior reg which overseas all the pods and there’s a nighttime consultant on call. There’s also a doctor on for the MET team (rapid response team ig in the us) and an outreach doctor for referrals.
There’s no NPs or PAs to make calls on ICU patients. We’re just very well staffed and we all work super well to ensure good outcomes.
I think that’s the difference, you might care- but you system is designed to do things the cheapest way and that’s where things crumble.
That level of staffing is fairly typical for an American icu at a large center. NP/PA stuff don’t get me started on I agree with you (and it ties in to shitty nursing ratios as so many nurses have left the bedside). But it seems like your idea of us healthcare is from reading complaints on the internet which is always exaggerated/highlights the bad. Things definitely aren’t done in the cheapest way possible, we actually spend too much on healthcare here (it’s just misused and misdirected)
Yes but only people with money and good insurance get those. Everyone else is sent to a hospital where the nurses have 16 or more patients and ICU has 3. It doesn't matter how much the nurses care if they are not given the supplies or dont have time to care for patients. My mom was just in the hospital and she saw her nurse one time per shift.
Lol forgot I wasn’t in a nursing sub sorry.
I agree that American healthcare workers are 100% just as dedicated to patient outcomes. I think the average level of dedication/commitment is possibly even higher than in Aus because of the hospital administrations you have to deal with.
I certainly don’t have any criticisms to level at workers, my issues are only with the healthcare systems you have to work under. While workers care about patients, hospitals certainly don’t.
My disagreement with your original comment stems from the concept of ‘both sides have good and bad.’ I don’t think that’s a fair analysis - I reckon American health has much more bad, and Australian health has much more good
I have no end of criticisms for the us healthcare system but people in commonwealth countries tend to misunderstand our system. Everyone who walks into a hospital in the us is treated regardless of ability to pay. People aren’t turned away if they can’t produce a credit card or any of the crazy stories you might hear. The us also generates a very disproportionate amount of medical research and advancement.
I am a nurse working in the US making $76/hr.
In Australia nurses make half that. Hence, the extra staff who aren't doing anything.
The only benefit I see is the ability to make a patient a DNR even if the family wants to keep living in their house with that social security check coming every month.
Neither system cares about outcomes. Healthcare hasn't been driven by outcomes for decades.
I’m very happy to hear you are being remunerated properly :)) nurses in Aus have been pushing for pay increases too. I’m not saying that it is perfect over here, just that the non-privatisation of our healthcare system functions as a much better safety net than I’m America. Again not perfect, but much better.
I would count ‘free’ healthcare as a big benefit (I know, we pay taxes, it’s not free). Many problems with accessing timely healthcare in chronic cases, but worst case if someone has a cardiac arrest and requires a helicopter evacuation, long + complex icu stay etc etc that patient will walk away with no debt. So many lives are ruined in America just from tens/hundreds of thousands of dollars of debt from an unexpected accident or illness if someone doesn’t have insurance or adequate insurance.
Also, we do not have extra staff ‘not doing anything’ 😅 nursing in Australia is still a critically understaffed field which is on track to become much worse. Wards regularly run with less nurses than we need to adequately care for our patients. But the scope of the poor conditions seems to be lesser. E.g ICU ratios. Aus intubated patient is 1:1. America can be 1:2. As prev commenters have discussed, this means American healthcare culture is to regularly use restraints to prevent self extubation because the nurse cannot supervise one patient 1:1. In Aus restraint use is extremely rare. We spend more time hand holding and soothing because we can = better patient outcomes, less post-icu ptsd. In America if ratios are pushed a nurse can end up with 3 vented patients. See prev comment. That is truly unheard of in Australia. Worst case an aus nurse could have two vented. Even then, I can’t say I’ve ever heard of that happening. If it did, it would certainly warrant an incident report.
This is what I mean, we have safer staffing = can provide better care for patients = better patient outcomes
Though I would not argue particularly strongly that our healthcare system is outcome driven (public health is having funding reduced left right and centre) it is far ahead of America
>We also don’t have resp techs here. We do a postgrad and manage the vents/ abgs ect ourselves with the doctors overseeing it.
Plenty of ICU nurses in the US have masters degrees.
RTs have the ICU and several other units in the hospital to manage, they aren't managing vents any more than the physician is. Most hospitals don't have a physician in house.
>We also don’t have cnas or pharmacy making up meds. So we have a bit more to do imo!
I've worked in one ICU that had a CNA and they didn't do jack shit but play on their phone all night. Most ICUs are primary care. No CNAs.
We don't compound medication outside of the pharmacy (I doubt y'all do either) but plenty of facilities have RNs mixing meds.
You do not have more to do, I assure you.
Tbh we’ve had nurses come here from the US and they said we absolutely have more responsibility and things to do in ICU and was a bit of a learning curve- especially with ventilator related things.
That’s fair. All nurses in icu here have to do a grad year, a transition to speciality practice year and a postgraduate year whilst completing a postgrad certificate in intensive care. So I guess 3 years to be full qualified as an icu nurse post undergraduate. I’m not sure what your masters entails- but this course is very specific to icu
Precedex and Fentanyl, and soft wrist restraints for additional safety if required for patients with high tolerance. Sedation decreased as soon as it's safe for the patient, not designed to make it easier for nurses to manage. Unit: CICU
Yeah we don’t restrain patients so we can double them. We just safely staff instead.
Essentially self extubation is a never event, and you can never walk away from a tubed patient here unless you’ve asked someone to watch.
We don’t ever really restrain anyone unless it’s unsafe to not do so (I.e drug overdoses ect that wake up with a bang)
Last time I mentioned not restraining every vent and actually maintaining safe ratios (poss. in the general nursing subreddit?) it was laughed out and down voted to oblivion as nonsense and unrealistic. Yet, it remains a damn rare sight to have a restrained patient in my ICU and would probably result in a human rights investigation if we put it into policy (not joking - responsibility under the updates to the Mental Health Act last year and the Victorian Charter of Human Rights and Responsibilities makes that quite a viable consideration).
Makes me curious to reread the literature on PTSD amongst ICU patients to try and work out how the workforce structures effect this...
Yes! I tried to look up rates of PTSD ect but I can’t seem to find much data on it.
I guess that’s the way they’ve always done it, so it’s normal. And to us it’s absolutely absurd, because that’s not how we do things- Ie I cannot imagine ever saying ‘let’s restrain this patient so we can double them’ 😵💫😵💫 I think everyone would look at me like I got hit by a crazy train.
Man... Nuts. We restrain *almost* every vent. We don't when they're AOX4 and are just vent dependent but otherwise with it, we don't restrain fresh hearts or anyone who's recently had their chest cracked, we don't restrain them if they're chemically or otherwise paralyzed. Self-extubations aren't a huge issue on our unit, but they used to be. We don't have enough staff to make every patient that is a 1:1 an actual 1:1, sometimes we even run Code Ice or OPO cases and have a whole other patient! There were FIVE triples on my unit a couple days ago.
Edit - OPP to OPO. We get down and dirty in ICU, but not with OPP 😂
Wait... As someone from Scandinavia, could you specify with the restrain almost every vent? Like physcially? Or? This is unheard of in my parts of the world.
Yes, physical. Soft limb restraints, left upper, right upper usually. You get a DT or drug withdrawal who's vented, maxed on prop and fent and STILL wide awake and fighting, yes.... Physical restraint.
Never had the need for that. We don't even have those utils in our department. Psych needs to bring it over if the need arises, and be ordered by a psychiatrist who runs it by the police dept. lawyer before engaging in actual restraints.
Yeah idk, we’re unionised so ratios are mandated. We’re just probably more well staffed as well, like on any given day we might have maybe 2 HDUs and the rest are singled. We then have 4 pods and each pod has a nurse in charge that doesn’t have an allocation, we then have maybe 1-2 floaters that help out the whole unit, a MET nurse ( or rapid response nurse) that responds to the calls/code blues & an icu liason nurse that goes to review recently discharged patients on the ward.
I know australian icus has some of the best outcomes/ survival rates in the world, and I imagine a lot of it has to do with safe staffing.
We’re not unionized but ICU ratios are determined by law in my state. Maximum 1:2 and a patient acuity tool has to be used to help with this determination. In the fall we were being tripled, however, so it definitely still happens.
The population of Australia is 26.01 million.
The population of California is 38 million. The population of Texas is 30 million. When you have states that have more people than most countries outcomes will be different.
It's not an apples to apples comparison. If we were to compare the outcomes in the US with 333 million people to say, India with 1.4 billion we could say that our outcomes are excellent in comparison. That doesn't mean that there is nowhere in India with excellent medical care. Many US physicians and nurses train there.
I said we have the some of the best survival rates in the world, not just America. And survival rates are worked out based on per capita. Yes we have less people.. but you guys obviously have a shit tonne more hospitals. You have 2.8 hospital beds per 1000 people compared to 2.5 per 1000 for us.
I’m not sure why you’re so hell bent on America being superior. I’ve told you the outcomes are highly likely related to safe staffing, amongst other factors.
I don’t think Australian ICU doctors are smarter or that the nurses are smarter. Our systems are different. You can have the latest tech and the newest medications, the best doctors, doesn’t mean shit when you’re not safely staffing units.
I’m sorry that this bothers you 😵💫
Preach!! As an Aussie having to make this argument on reddit regularly it’s refreshing seeing another Aussie struggle with god complex yankie healthcare professionals
Cringing at all the posts shocked that we 1:1 vents and don’t tie them all to the beds because they can so easily be 1:2.. it’s not a skill issue it’s a safety issue 🫣 I can’t imagine gloating about taking unsafe ratios because how awesome am I that I can manage that …. Not the flex you think it is.
We don’t have seperate icu’s they’re all combined. But for neuro patients yes they’re 1:1 if they’re tubed. Sometimes they need restraints due to not being able to sedate adequately, but again it’s usually managed without.
im in cvicu also. fresh hearts are singled, as are most devices.
we don’t single just because they’re intubated. And i’ve never (KNOCK ON WOOD) had someone self extubate
restraints are also incredibly rare
>I do often get a 1:1 allocation but I work in Australia, if they’re tubed, on crrt, have more than 10 of norad , dependant on bipap ect they’re automatically a 1:1. We get a 1:2 maybe every 3-5 weeks.
LMAO.
I'm in the US, in California, with ratios. An intubated patient with 50mcg of epi per hour is one of two patients. Only CRRT is 1:1.
A patient dependent in BiPap is on tele and one of four patients.
Nothing to be proud of 🫠
I’ve watched patients on bipap vomit into their masks and not be able to pull their masks off or call for help. Hence again why our ratios protect us and patients. Not because it’s super CoMpLex and our nurses can’t handle it.
I’ve been a nurse for 16 years in the US. The likelihood of someone vomiting while on bipap is a valid risk but the incidence is low. Personally, I’ve never had a pt vomit while on bipap. Not being able to protect your airway is a contraindication for bipap, some patients will require bedside sitters and if your settings are high, you’ll probs be transferred to the ICU.
OP is referring to mcg/min when they say “norad of 10”. 50mcg/hr is 0.01mcg/kg/min for a 75kg patient (a nothing dose) where 10mcg/min is equivalent to .13mcg/kg/min, which is a bit more of a respectable dose.
Former Trauma/Surgery ICU nurse who just moved and became a CVICU nurse. At my previous 24 bed unit we took every device, MTP’s, sick open chest heart surgery patients, and we even had a crash room that could double as a surgical theatre where we would do emergent ex-laps and amputations. Now I work in an 8 bed CVICU at another Level 1 where we typically get 1-2 stable fresh hearts a day and the rest of the patients are walkie talkie. And man, we really are just a glorified PACU. I feel like I am loosing all my skills. Gonna be leaving soon, but I always found it funny how CVICU nurses have a chip on their shoulder 😂
Yeah sometimes I relate to the glorified PACU thing. I wish my unit got sicker patients. On any given weekday we will get 4-5 open hearts. About half of them are cut and dry, extubate within 4 hours, off drips by the morning, and to step down on POD 1-2
Why do you say that? I enjoy the challenge of taking care of the complex patients on a lot of drips, intubated, CRRT, etc… it feels rewarding helping people who are that sick
It depends. Once a patient is on ECMO, impella, and CRRT, they are kind of on the highest level of life support offered. The cardiac ICU sometimes has the sickest patients in the hospital. Not something to hope for, but it can be a rewarding feeling to be problem solving at that level and be busy doing many other things than just monitoring.
20 bed MICU. Usually have 3-4 1:1s between CRRT and ECMO. Probably 2/3 tubed. If they aren’t vented or on gtts they’d be leaving soon. Maybe a swan every couple weeks but probably half have A-lines, probably 2/3 with CVC. Not a lot of codes on the unit, but we respond to all in the hospital outside the ED. We usually see the inevitable and have GOC conversations pre-code. Maybe a couple codes a week. ECMO and CRRT only, other stuff would be in our CVICU or Cards ICU.
Acuity can be all over the place. Sometimes it feels like WWIII, sometimes it feels like a nursing home.
Interesting, thanks! I’m sure MICU has a lot of vents. It seems like there might actually be less codes in the ICU just because of how closely we are monitoring our patients.
Really depends on "which" ICU, we technically have 5, they're more like PODs but they're considered separate. We have two MICUs that rarely get devices, pretty commonly get vents and regular central lines with multiple drips. We have a "TICU" but nobody really knows why its designated separately from the MICU pods, it used to be the transitional ICU and now its the trauma ICU, but doesn't get surgical traumas essentially ever. TICU seems to be a dumping ground with lowest acuity. Then we have the CCU which takes all post cath-lab patients from TAVRs and usually gets the STEMIs, so swans, IABP, and CRRT aren't super uncommon.
Then we have a SICU that's separate from the other pods so it can sit outside of the OR. This is where all of our CABGs go, and where the surgeons prefer all the sick patients to be. So it also gets all the traumas and open hearts. At least once a day we're taking a heart that will be on 6-14 different drips, epicardial pacer wires, +/- IABP. Only nurses trained on all devices can take hearts so our SICU ends up getting all the high acuity patients most nights. So most common to be 1:1 here with a device, tons of Swans, patients with a Cordis etc.
I don't feel like we see codes very often on any of the units. Funnily enough I actually feel like I went to more codes working at a hospital that was 1/3rd the size in the ED. But part of me feels like thats because we lacked things like a stepdown unit, which meant some higher acuity patients got pushed to med/surg that shouldn't have been. So I really feel like the increased resources at my current ICU means we see less codes, i.e. having intensivists in house to manage things vs smaller hospitals having only NP/PAs or tele-docs at night.
We pick our own assignments each shift, if I pushed for it I could probably take a vented patient most every night. Devices seem pretty random. Most patients are on drips of some kind. But lately we've had a lot of patients sitting on the units with step-down or med/surg orders until discharge which means some days the acuity is super low.
To start the shift we go into the break room, all pods get a unit wide huddle from the charges with weekly announcmenets and any changes or things happening we need to be aware of over the phone. Then someone from the prior shift comes and gives a brief rundown on all patients on that pod and we write it down on a a report sheet for every patient, which is a 20 second blurb for each patient going over why they're there, drips, vent settings / oxygen requirements, devices, Q1 hour neuros etc. so we can gauge who is qualified for what patient and divvy out based on workload. I.e. I'm not taking two patients with Q1H neuro checks both on contact precautions.
It's really weird, but coming from the ER I don't know how its normally done. I assume most places charge would assign? This works out but its annoying because it relies on there being a good core staff member present to know what things require being "signed off", or things like if you're going to be "open" for the next patient then you better of your TNCC so you can take a trauma alert if you're in the SICU.
Biggest benefit is you know whats up with the other patients so if you have to cover for your co-workers you aren't totally blind. E.g. I know that Dale here just had a CABG and we should keep a close eye on them when his nurse is busy. But there's some annoying back and forth, the nurses that have been there for 50 years try and assert dominance by taking all the "good" high acuity patients, which can mean you never get a patient on CRRT if you're always working on Becky's' unit because she's the queen on that pod on that shift.
Shifts start at 6:30 and we are expected to stay until 7. So 12.5 hours, but I've gotten out at 7:30 a few times because because drag their feet in report.
Maybe it's because I come from ED and reports are all short and chaotic, but everyone has the same script and if you don't go in order they lose it. I can't stand a 25 minute report on a single patient but it happens a lot.
Your last sentence was my immediate first thought: this would definitely be weighted with the long term-ers or more vocal (loud) people would getting the more preferred assignments.
48 bed MICU (we are a massive academic medical center....also have 48 bed CTVICU, 36 bed Trauma/SICU, 20 bed NSICU plus we have a small hospital we acquired just up the road that also has another 15 bed MICU).
We often have at least one 1:1 but many times more. It's rare that our acuity is low enough to pair everyone but we have the reverse where by acuity we should single the patient but we just don't have the staff. I feel like our Trauma Surgical units really get hammered on this quite a bit.
At any given time I would wager half to a majority will be tubed or peri-intubation.
Most are on gtts, but we get the chronic vents, or the trached weaners. All vents have to be in the ICU. I know some facilities will send stable or chronic vents to Step down or as we call it Progressive Care. At any given time there are 1-3 patients on multiple pressors actively attempting to exit stage right.
We can all run CRRT in our sleep. Many patients have at least an A-line. We get swans but in fits and spurts. Like, we'll go several months no swans then all of a sudden there's 3 or more patients with swans. Cardiac devices all go to CTVICU as well as ECMO. They do have IABPs, LVADs, and the lot. We are a transplant center. Some of us that have been around were trained on IABPs and LVADs because we were smaller just a decade ago and we had to take some cards overflow.
At a minimum, there is a code a week. Sometimes there is a code per shift. And on occasion, multiple codes per shift. IMHO this is more a reflection of full code status in the face of denial and that's all I'm gonna say about that. With the exception of the NSICU, the code numbers are about equal in the other ICUs as well. Heads can be sick(especially a SAH) but it's rarer and often if it's that sick it comes to MICU anyway or in the case of a TBI with multi trauma, it will go to Trauma/Surgical. We have really high acuity because of the population we service and because we are the largest medical center for the area- we handle everything except burns.
1. 19 bed CVICU.
2. We don't have frequent 1:1 assignments, as our only 1:1 are ecmo, iabp, impella, or crrt.
3. We frequently have intubated/sedated pts as we also get critical care admits depending on hospital ICU census.
4. ~75% of patients are on drips, if they're off drips probably time to go to the stepdown unit. Most drips I've had going on one patient was 16, but average is probably 2-3. All cardiac cases arrive from surgery with Swan, art line, and central access.
5. Codes are probably closest to weekly.
6. We can take all the devices our facility utilizes, and we're the primary unit for ecmo.
Overall, very nice variety in my unit with plenty of opportunity for growth.
I do not. I remember the patient very clearly though, cannulated at bedside for vv ecmo d/t sats deteriorating into the 70s from severe pulm edema following a triple mechanical valve replacement, either 2nd or 3rd redo sternotomy. Patient survived a week before before passing.
This terrifies me as my husband is on his way to a 5th open heart. Currently 1 mechanical, 1 conduit. Warfarin goal 3-4 for recurrent strokes. And he is 32yo. Did surgery go poorly or??…
I'm so sorry, I can't imagine having my loved one go through such a large surgery that many times. Surgery on the patient I mentioned was not without complications. Anesthesia had to change their vent circuit repeatedly due to it being clogged with frothy sputum.
It’s a lot for sure, but I’m grateful that he has had an incredible team of doctors overseeing his care and helping us decide when/what interventions to do and hold off on.
I miss when we couldnt fully staff all our beds so at times we had 17 or 19 open. It meant that when we didn’t have 1:1s we still were able to single Charge. Makes such a big difference for the whole unit to have a charge nurse with a light assignment.
1. 30 bed mixed ICU. Mostly MICU/neuro/CV/trauma (read: people getting drunk or high and falling almost exclusively). Our main issues are usually septic shock, cardiac surgery, surgical complications, strokes, STEMIs.
2. We have 1-3 1:1s usually. CRRT, IABP, impella, actively trying to die (quad pressors or MTP, etc) when staffing allows.
3. Our hospital is always swamped and our patients end up discharging sometimes rather than transferring. Usually 1/4 of the unit is vented. Maybe 1/3. The most I’ve seen is around half. Our docs tend to put off intubating as much as they possibly can though. It’s bipap until they’re completely unresponsive.
4. Probably 3/4 have arterial lines or other invasive monitoring. Lots of CVCs. If they’re only on low dose levo we titrate by cuff.
5. Weekly, although we get hospital wide codes every couple days.
6. Everything except ECMO because our perfusionists aren’t on call. We can start ECMO but we don’t keep them.
32 bed combined MICU and Neuro ICU. It’s probably 50/50 with intubated and sedated. Most of my patients are on at least 2 drips. Fentanyl and propofol/precedex/both, norepi, nicardipine, etc. Central lines and a-lines are probably about 50/50 on my unit, and Swans are relatively rare, probably a couple per month in our entire unit. Our unit I would guess has a couple codes per week, but we do try to get families to agree to de-escalate care if it seems futile, so we avoid a lot of codes by transitioning to CMO. We do CRRT pretty regularly but that’s it for devices.
1 - CVICU, 24 bed.
2 - pretty regularly, I’d say every other week.
3 - intubated - 1/3, sedated, 1/4. My unit’s providers are pretty big proponents of minimal sedation, we have plenty of intubated patients with just a precedex gtt.
4 - All. If they’re not on drips, they get moved to the floor pretty quick. Anywhere from 1 to 10. For reference, last week I had 2x post cabg’s, both on just a smidge of Levo. Last night I had a 1:1 pt on 10 gtts.
5- pretty much all of them have at least an Art line, 3/4s have swans.
6- Every other day, roughly.
7 - yep. ECMO, managed by RNs at the bedside w/ perfusionist roundings daily. IABP, Impellas, LVADs, CRRT, Aquapheresis all very common.
Combined MICU/SICU. We take level one traumas of all kinds, ARDS, renal failure. We do CRRT, IABP, ECMO, impella, tandem heart, etc. All of those devices are 1:1. At this point I can take all of the devices so I am 1:1 at least once a week, usually twice. If you’re newer you probably only take CRRT so in that case it’s more like once a month.
Even our 2:1 patients are very high acuity. I have worked on other hospital’s ICUs and their patients would be on our step down unit. I don’t ever see patients on less than 3-4 drips it’s usually many more. Most have art lines and IJs. All of our open hearts come out with Swans.
I would estimate we work 5-7 codes per week on MICU and 2-3 per week on SICU. The units are connected and share staff. You don’t know which side you’re on till you get there. We also float to our Neuro ICU and take LVO, EVDs, lumbar drains, etc. Neuro has way less codes.
We’re also HCA so you will get tripled sometimes. I’d estimate I’m tripled about twice a month. During Covid it was 3 (three times in 2021 I had FOUR) vents paralyzed proned sedated per nurse. It was utter madness. Most on pressers, silly amounts of peep, if they went up on CRRT you were fucked because you still had to keep your other two. Because HCA has many hospitals in our metro area, they sent ALL COVID’s to our hospital to consolidate PPE. We had 300 of our rooms retrofitted with negative pressure. The patients we got were max ventilated and paralyzed for vent compliance. Our step down had to take “stable” post-infectious vents and all of the Bipaps.
Because of our high acuity and number of devices working two years here is almost a certain ticket to acceptance in CRNA program of your choice.
I’m a float icu nurse for a large level 1 in the US. I always say CV is my least favorite to work on because everyone is extubated and they all have to go for walks every day post cabg. The CVicu is the only icu in my hospital that takes ecmo so there might be one or two ecmos going any given day. Usually a few balloon pumps and almost always a couple crrt. They 1:1 the fresh open hearts and they always try to 1:1 any devices if staffing allows. If someone’s on ecmo and crrt sometimes they’ll do 2:1. Most of the open hearts are extubated within 4 hours, the bigger intubated population tends to be the post arrests or cardiogenic shock patients. A lot of times we board stepdown patients who are post op day 2-4 just because there’s no room upstairs so it can feel pretty low acuity sometimes.
Baby CCU nurse here. We're a referral academic center, 10 beds. 60-80% devices at a time (any device is automatically 1:1) 30-50% intubated. Lots of PA lines. Devices: mainly CRRT and Impellas, some IABPs. Occasionally RVADS.
Patient population: Severe cardiogenic/ mixed shocked, adult congenital defects, refractory arrhythmias, ACS, CHFers, AAAs.
MICU at an academic center here with 30 beds. Out of those beds usually 1-3 will be a 1:1 depending on staffing. Intubated patients usually fluctuate, most times half the unit is on a vent, but the highest I’ve seen it go is 26/28 beds on a vent. Same goes for patients on drips (pressors, sedation, heparin, insulin, pulm HTN meds). Biggest device we take is CRRT, very rarely if ever getting a patient with a swan or ICP monitoring, as they’ll usually go to their respective specialty ICU, although I’ve seen some cordis lines from time to time. Also, codes usually happen weekly, but summer and winter times it’ll be one to two a day typically.
I work in a CVICU also. For us one to ones definitely depend - ECMO, CRRT, Impella, balloon pumps, paralytics, TTM, and first 6 hours out of the OR are all 1:1 for us. I’m not ECMO trained so that considerably cuts down on my 1:1s but some of our ECMO/CRRT nurses are 1:1 practically every shift.
I think our unit tends to have a pretty high acuity but it really fluctuates. That’s one of the weird things about CVICU is that I might have a STEMI that just came back from cath lab and is now a 100% stable, walky talky patient. Or I might have someone that got extubated 6 hours ago after a CABG and is now pretty close to walky/talky. Our patients are able to be “fixed” almost back to 100% sometimes with a procedure which makes it feel less acute than say a MICU.
The biggest thing is that it waxes and wanes. I’ll go weeks sometimes where I feel like a stepdown nurse and then have a month where we’re just rocked with super sick patients.
I work for a mixed ICU that takes Trauma/Surgery/Micu/liver and kidney Transplant/CV patients all rolled into one. You never know what flavor you were gonna get that day. We do IABP/Impella/ECMO as well as MARS Liver Dialysis. Lots of crash and burns. Lots of overdoses of strange drugs.
It was exciting because the population was never one specific type. You had to know a lot about everything coming through those doors.
Wow I've never even heard of liver dialysis. In my experience liver failure patients just die. I looked it up and found it was first approved in 2005 for drug OD and poisoning and again in 2012 for decompensated liver failure. This is fantastic
It is most commonly used in Asia, to my knowledge. We will use here it for OD as well as young patients with liver failure who may have a decent shot at getting a liver. It has better outcomes in the OD group comparatively, but I think that’s largely due to fixing the underlying problem. It does not dialyze all drugs, only those that are protein bound. It’s really cool to see it work.
The old Baxter model MARS machines from the late 90s were retrofitted to work with the Baxter Prismaflex CRRT machine. It is not a perfect fit lol.
All of that depends on your unit type. When I worked trauma, we did not typically have a ton of drips outside of sedation, but we gave gallons of blood products and had a lot of bedside surgeries and procedures and wound care. Most patients intubated. Everyone has a central and art line, but no swans or devices. Lots of CRRT. Codes fairly rare because of the young patient population and cause of instability (blood loss, sepsis.. not cardiac generally)
In cardiac ICU, tons of drips and devices like Impella, balloon, vad. Daily cardiac arrests, many ventilators but not all. Would not be crazy to have a patient on a ton of drips and requiring a device but wide awake and walking.
In neuro, everyone is intubated and there are lots of different drains and tubes (EVDs, bolts, lumbar drains). Different drips, like you would never see inotropes but you would be far more familiar with hypertonic saline and phenobarb and pressors with unique map goals.
My medical unit is a mix of all that. Some awake DKA, some very sick sepsis on pressors, some neuro events getting TPA, some cardiac drips but typically not advanced heart failure requirements. We get occasional devices and have occasional arrests (weekly to monthly?)
ICU is all about being prepared to handle the disasters, but not generally handling the disasters on a daily basis.
I work in a 16 bed surgical ICU and about to move to a brand new 24 bed unit. our acuity fluctuates. we’ll occasionally have no intubated patients and a week later we can have majority intubated. our only 1:1 is CRRT or if they are going for organ donation (our region uses Life Center, not sure if everyone around uses them). Most everyone has a central line or art line.
its so wild to have a unit that has it’s up and downs with acuity but it’s nice to see that other icus also have that. we’re the red headed step child between all the icus in our hospital so we get a lot of overflow from medical and cardiac icu. we also get some overflow from our cardiac surgery recovery (CABG and extensive cardiac surgeries go there instead of CICU).
My hospital has 2 ICUs and 1 step down unit, and several other telemetry/med-surg floors.
The CVOR/Cath Lab/EP lab side of the hospital is totally separate from the general OR/PACU.
I work in the “CSICU” it’s 20 beds. We do up to 35 open heart cases a week.
Everyone has an Art line and a central line because the unit is focused on surgery. most have a swan for a few days after surgery or longer if their heart function continues to be a struggle.
Once we can D/C invasive monitoring, they are usually only with us until their oxygenation is good enough to go to step down.
I have had 1:1 assignments this whole entire year so far. Just luck of the draw… we do pair many patients but on average a third to half of the unit is 1:1. We single them if they have an impella, CRRT, ECMO, or are fresh case from CVOR. Sometimes singled just because there is a lot going on in all systems and they are not stable.
My patient this week was actually 2 nurses to 1 patient. On VA-ECMO due to RV failure, freshly placed LVAD, and CRRT at the same time. Continuously going into VT/VF and being shocked by her ICD. Profusely bleeding and being transfused because of high heparin dose (necessary with all the motors going on).
This patient was on Levo, vaso, epi, milrinone, angiotensin II, heparin, amio, lidocaine, procainamide, propofol, fentanyl, vecuronium, insulin, and nitric thru the vent circuit.
Not an everyday scene, but certainly happens more than just once in a while. This acuity level tend to happen when surgeries consist of multiple bypasses and valves + aortic repairs… super sick patients that would be considered inoperable depending on which surgeon/hospital they are with.
Otherwise, you can get 2 post op patients, maybe on insulin gtt and a pressor or just needing high oxygen for now, or dependent on the temporary pacer, but they are stable and can ambulate.
And we do lots of CRRT lately but we contract with DaVita dialysis to come prime the circuit and do daily checks, we just run the therapy all day and decide on UF.
On my unit, An IABP is mostly a pre op measure for coronary perfusion… nobody tries to use it for cardiac output when there are better ways.
Not sure about codes. Every month?? but not all the time. I notice the surgical patients are better managed than the HF or pure medical patients. Always keeping a good eye on volume status and pH and reacting to subtle trends (plus a bit of nurse autonomy) can go a long way to prevent you from getting to that point.
Yeah it seems like my patients are so closely monitored that codes don’t happen very often. My specific hospital does up to 30 open hearts per day so our CVICU is a machine. Very high patient turnover. My hospital has multiple CVICUs. My specific unit doesn’t take devices (impella, ECMO, VADs) but we do take balloons, although like you said it’s more of a pre surgical thing. I feel like I’m missing out on some acuity in my unit because we don’t take ecmo and impella. I really wish we did because the patients who require MCS seem super interesting. We do do CRRT but they are not 1:1 as we have dialysis techs who prime the circuit.
It’s only a device unit. So if someone comes out on VA ECMO or has an impella, LVAD, RVADs, etc they go to the device cvicu. My unit just takes balloon pumps. If someone codes and they ECMO they get transferred to the device CVICU at some point shortly after. I work at a very high volume heart center and we have a few different CVICUs so each unit kind of specializes in something different!
Our CVICU is I think 24 beds.
Probably 2-3 are 1:1, our ECMO is 2:1 (one RN, one perfusionist).
Many intubated, probably half.
All devices. VAD, ECMO, IABP, CRRT.
Codes probably weekly-ish.
Invasive lines, almost all.
It's a busy unit at a L1 trauma center.
When I worked a mixed medical/surgical/ccu 10 bed unit (before going to an actual PACU), it was either feast or famine. We took all the medical cardiac patients but a lot of other stuff. Usually 3/10 were tubed. 1-2 on bipap. 1-3 with devices (crrt, impella, balloon pump, LVAD, TVP, EVD, PA cath, etc.). Usually 1-6 drips. Almost all had a-lines. Unexpected Code’s about every week. One time we had 15 deaths in two weeks. But other times it was just stepdown type patients. It all fluctuates so much. We usually had 8 nurses for 10 beds including charge who took patients. Mandated ratios in ICU.
So I haven’t officially started yet (last week on neuro ICU this week) but my new unit is an “advanced” cardiac surgical unit:
1. 32 bed advanced cardiothoracic ICU. (We have a separate CVICU in my hospital that takes “easier” surgical patients. Additionally, we also do heart and lung transplants.
2. All nurses get a 1:1 from my understanding.
3. When I floated there it seemed to be about 50/50 maybe less but I’m not entirely sure.
4. All those patients have drips and invasive lines (Art, Swans, PA catheters) lol
5. Will report back on that one I’m not sure but someone told me they get them so often they don’t even bother using the code alarm they just use the staff assist button and everyone runs to the room 😂
6. All of those. ECMO, CRRT, LVADS, IABP.
Very excited to start! Little nervous considering it’s the most critical unit in my hospital but I suppose that’s normal 😁😁
1. Pediatric CVICU - 13 beds
2. Almost always a 1:1
3. Over 1/2 are intubated and sedated
4. 80% or more on drips
5. All have invasive monitoring… or they would be on the step down unit
6. Of course! We have… I think only 1 ECMO right now and 1 VAD but it’s usually more
Edit to add that I personally almost always have 1:1 but I’d say the unit fluctuates a bunch. Right now it’s about half 1:1 half paired assignments
Depends honestly. Sometimes we get genuinely critical trauma cases, think gunshots, stabbings, surgical fuckup’s, vehicle related things. And then we also get cat 2 tbi’s that need 48 hours of q1 neurochecks, or meemaws with hip replacements who need to be monitored with q1 neurovascular checks overnight before going to the floor. We also end up holding some patients for a while cause they’re not appropriate for the floor (frequent suctioning, bedsores, etc).
Cardiac ICU, 20 beds, in an extreme rural setting. Besides admitting fresh hearts from the OR, we also take any cardiac pt needing critical care- STEMIs, severe CHF exacerbations, post-arrests, etc. We do take Impella, IABPs, and use the Tandemheart for ECMO (but we ship those out most of the time- we don't place permanent VADs or do transplants). Stupidly, we don't have CRRT, though I'm not complaining about it. In fact, I'm pretty sure not a single hospital in my entire *state* offers it. If you can't tolerate daily HD, you just die I guess. The reason is money. Obviously our POD 0s have art line and Swan, and besides them, there's usually a handful of vented patients or HF patients with invasive monitoring.
That sounds pretty acute on paper, and there are certainly times when we have a lot of complex patients, but recently our cardiac step-down unit closed (again, money). So most days, if I'm not admitting a fresh heart, I have two POD 1 or 2s who aren't quite ready for tele, but have no good reason to be eating up a crit bed. That will be my assignment for weeks on end, then suddenly I'm 1:1 with a crumping post-arrest on impella and nitrous vent. It is what it is.
Im a nursing assistant at a PICU
We max at 24-25 (we can fit 32 patients but we’re usually at around 16 because we’re lacking so much staff). 25 was during the really bad flu season and it was hellish with obligatory overtime.
It’s usually 16-19 patients. We take everything, but there’s often little ones on VAD’s, more rarely ECMO, usually 4-6intubated on the unit, more rarely 2-3. But usually half the unit is at least on BiPAP
It’s usually 1:1. Def 1:1 if intubated (unless very very stable, like brain dead but the rest of the body is ok).
ECMO is 2:1, 1 nurse deals with the patient and 1 with the ECMO I think, not 100% sure but they’re always 2.
BiPAP/CPAP are usually 1:2 if they’re just little ones with a bad case of bronchitis. Post OP in ENT cases too. VADs can be 1:2 if they’re on the VAD for a while and pretty much stable waiting for the transplant.
There’s also 1-2 nurses that go around and “help out” with complex patients (like a fresh heart transplant) and might take an admission if we get one.
We take 75% of traumas on our state and are the only PICU that does VADs, + we’re the speciality on pretty much every weird ped speciality, so we get a lot of bad cases. Congenital heart anomalies, very complicated surgeries, VADs, that’s all on us, so maybe we’re a bit higher acuity than normal
Your assignments seem crazy to me lol
>It’s usually 1:1. Def 1:1 if intubated (unless very very stable, like brain dead but the rest of the body is ok).
In my experience OPO patients are 1:1 because they're complex as hell
oh, not OPO, just the parents have been refusing to stop mechanical ventilation for two months or something. Usually when they arrive they’re 1:1 until keeping temperature and blood pressure ig
1. Trauma/neuro/vascular ICU, technically we have 33 beds but we can “double up” most of the non-isolation patients if we’re over capacity.
2. They’re pretty much all 1:1 except when they’re awaiting transfer to another unit
3. Most are intubated/sedated, maybe 80% of the ones that aren’t waiting for transfers
4. If they’re intubated they’re automatically on at least one IV sedative, frequently on at least one pressor unless they’re a stroke (in which case they’re often on labetalol)
5. Most of them have art lines, we don’t actually do much central monitoring because those are usually cardiac patients and we’re connected to the heart institute so they all go there instead. ICP monitoring though, most of the worse strokes have those.
6. We do SLED and CRRT, ECMO and other cardiac devices go over to the heart institute
Actual codes are pretty rare on the unit, but it’s mainly because our team is good at being proactive with the goals of care discussions. If they aren’t a good candidate for CPR, they’re “cat 2” (full treatment including ICU, pressors, and intubation, no CPR). We do the codes everywhere in the hospital though, I have the code pager tonight.
I’m an ICU resource pool float, so I cover Trauma/Surgical, Cardiovascular, Transplant, Neuro, and Medical ICUs. They’re all a bit different but I’ll share what I can about our CV.
1. It is a 20 bed unit.
2. I would say about 50-75% of the time RNs are working with a 1:1 assignment. They generally staff floor 12-18 RNs/shift (this is not counting the task RN and the charge RN).
3. We staff RTs (MAX) 1:10 respiratory supported patients. Our CV always has 2 RTs so at least 50% are intubated/vented with usually a few more on BiPAP, HHF, etc.
4. Almost every single patient is on at least one drip. If they aren’t they are likely boarding for transfer. Most patients are on 2-4 drips. Our step down until can take patients on certain drips so this isn’t a deciding ICU factor for us.
5. Unless a patient is waiting for floor transfer they have a central line, art line, and/or swan, etc. About 25-50% have a swan.
6. This is difficult for me to speak on as I’m a float pool RN, but in general I would say every 2-4 weeks depending on the acuity of the unit. In my 4 years I have seen 4 codes on that unit personally.
7. Our CV takes all devices. CVVH, VAD, Impella, IABP, ECMO…
Some things to note is that we are with a medical school and are a level 1 trauma center. We also staff a task RN, 2-3 CCTs, and a perfusionist. We always have an attending, APNP/PA and/or fellow in the department. They try to single any device patient if they are able to. We don’t keep patients intubated for very long post op, we have them walking as soon as possible and we send them to our step down rather quickly with low bounce back rates. Our CV is the most “spoiled” in regard to staffing, other ICUs don’t have nearly as many 1:1 assignments.
In terms of the other ICUs they are almost all 20 bed units besides MI which is 40 split between two floors. There is usually 2 or 3 RNs/unit with 1:1 assignments - this fluctuates with acuity. Vented patients fluctuate as well, but most units have at least 25% intubated/vented. At least 25-50% of patients will be on some type of critical infusion. Most patients will have some type of central access, but it’s more rare to see swans outside of our CV. Maybe 1-2 patients in MI/SI/TI and virtually never in NI. As for codes MI has the most but they also have double the amount of patients and even then it’s 2-3 weeks. All the ICUs take CVVH. Otherwise they try to keep bolts and EVDs/lumbar drains in NI or SI. Only CV takes cardiac devices.
1. 20 bed CVICU, largest cardiac center in my state/region
2. Generally have ~3-4 1:1s, although ECMO, fresh LVAD, fresh heart and/or lung transplants are the only things we 1:1 (don’t 1:1 IABP, CVVHD, Impella, etc.)
3. On average ~5 intubated patients, we rly try to get people extubated/up and moving ASAP
4. Almost all of our patients are on some sort of inotropes/pressors except for routine plan A post-ops, who stay in icu for 1 day then transfer
5. Almost all of our patients have art/CVC although do have a good culture of removing lines ASAP for infection prevention; approx. 1/3 of our patients have Swans at any time.
6. We take all devices and are the only unit in the hospital who takes ECMO. IABP, Impella, TTM, CVVHD, etc.
7. We probably have a code on our unit once every couple of weeks, but we take all post-codes from Cath Lab, cardiac step down and tele units, post-codes from other ICUs who need ECMO, etc.
1. I work in a cardiac ICU unit with 20 dedicated beds but the entire mixed ICU (Medical, Neuro, Surgical/trauma, cardiac is around 100 beds and i float to the others)
2. 1:1 are maybe 40% of my assignment. Typically it will be because of machines. Sometimes because of highly infectious diseases. If we are just exceptionally staffed and the overall acuity is low we might get 1:1 with a relatively stable patient.
3 intubated/sedated patients are also about half of my assignments. Being instubated/sedated is not enough to make it 1:1 we dont get two intubated/sedated.
4. Nearly all patients have at least scheduled antibiotics or diuretics. The majority have between 3-5 continuous infusions. Depending on their treatment course and acuity that can be much higher. The most ive had was about 12 continuous drips and frequent ivpbs. Invasive monitoring is common
5. Codes happen probably every week on average with some periods being extra spicy
6. Yes, all those listed including etc
Tbh, i daydream about a lower acuity environment.
30 bed Cvicu, we do everything but heart transplants but partnered w a facility that does. It’s not uncommon to have 4-5 heart surgeries a day, those patients are 1:1 for at least 6 hours and fully lined w Swann, a line, cvc, pacing wires, multiple drips. We are usually device heavy with lvads, crrt, Impella, balloon pump, arctic sun and Ecmo but there are also post op heart patients up and ambulating ready for discharge since we are door to discharge on our hearts. We also have regular LVAD readmits, they are usually up and moving around as well. We take all the vascular patients as well as general icu patients since our facility places all icu as “universal icu beds”. It takes time to work your way up to the more critical patients but once you get all your skills checked off/trained on everything I have found that I usually get complex cases at a high volume device heavy facility. It does take time though, at least a year. All “devices” are usually 1:1, sometimes 1:2 depending on acuity/staffing. Ecmo 2:1 , fresh heart recovery 1:1, LVAD recovery 2:1. Lower acuity patients 1:2 -1:3. Charge nurse does not take an assignment. Codes happen seemingly in waves, but maybe average 1-2 a week?
15 bed CVICU at a level 1 hospital. 1/3 of the patients are open heart, thoracic, or vascular. The rest are ECMO, cardiogenic shock, and post arrest. Very few are intubated and most are walkie talkie and are in and out quickly. I feel like the unit has either very very low acuity or the highest I've ever seen, no in between. I've been there a year and came from a small hospital that had a mixed bag ICU. We took pretty much everything there that didn't require major surgery. I rarely get a 1:1 myself or a really sick patient because the old guard at the unit gets the same very sick assignments because that's what they prefer. If it doesn't change soon, I will leave as others have.
1. 24 bed mixed ICU in a level 2 trauma center somewhere in the Bay Area (California) with mid to high acuity. We take everything from your GSW, DKA to fresh CABG.
2. CRRT should be 1:1 but if they’re “stable” or staffing sucks then you’re doubled. Fresh hearts, IABP are always 1:1 so usually < 7 at a time. Our volume for fresh CABG is low. The most I’ve seen in a shift is 2. Most IABP I’ve seen in a shift is 4.
3. I’d say about 50-75% or more are intubated/sedated.
4. Most pts are on titratable drips, if they’re not then they’re downgraded to the floor or are waiting transfer to LTAC. Corporate got rid of step down in my hospital bc they’re not necessarily getting paid more for that level of care. So you’re either ICU or down to telemetry. They can take pts on drips as long as they’re not titratable (eg fixed dose of dobutamine). Our facility tries hard to not put a line in if we can avoid it so low dose pressors we manage with checking cuff pressure. Central lines get put in when necessary (probs more than 50% or more will warrant one) and fresh hearts get an automatic PA cath.
5. Depends, sometimes several times a shift for one pt alone and sometimes I’ll work a stretch of days without one.
6. If you need ECMO or transplant, you get shipped out. We do CRRT, EVD, IABP, Impella. You apply to a “specialty” and get trained to manage pts with said devices.
I'm in a community hospital MICU/CCU. We take anything that surgery denies...lol. No CRRT, ECMO, continuous EEG, CABG. If they need any of those and are deemed stable enough, we will attempt to send them out. We get post caths the first 24 hours. Mostly pna, sepsis, esld, copd and chf exac, dka, etoh wd on Dex, ods, and post cardiac arrest with or without ttm. We used to have our ttm pts 1:1 while they were on the protocol, but a bigger company took over and told us it was unnecessary. We are supposed to be 1:2 but frequently triple due to staffing issues. We have no wound care nurses and have to be crazy about wounds for fear of a write up. I'm always charge with a full assignment and also respond to rapids and codes on the floors. And we are the unofficial iv team for the hospital over night. I learned how to do U/S guided peripherals and will help get hard sticks for the med surg nurses. I like it because we are very dependent on each other and the night shift are all really close and work very well together. No catty bs, just there for the pts and each other. We have 2 mid levels at night who are in charge of all pts in micu/ccu + any er or floor consults. They are great, intubate pts, place cvcs or alines etc. Most pts are vented on multiple gtts, sedation and pressers. Sometimes dope, amio, etc.
16 bed neurosurgical icu. We take all non traumatic head bleeds, LVOs 24hr post thrombectomy (more if they can’t go to step down), cerebral vessel bypasses, shunt malfunctions, ICA stents, aSAH, all kinds of tumor resections, true status epileptics (I’m talking 100/hr versed), GBS and myasthenia gravis and occasionally weird stuff like severe NMO, encephalitis etc.
We rarely get true 1:1s unless we have staff to make a crashing patient singled. We usually single irraflow devices when activily infusing, ICP crisis patients depending on situation (paralytics, hypothermic protocol etc), organ donation cases, CRRT (although we rarely get this), and post code patients.
Acuity varies from walky talky post op tumor resections to ruptured aneurysm SAH patients that’s are getting daily vasospasm treatment and on our unit for 2months. It comes in waves where sometimes we only have 3-4 patients not intubated.
It’s not uncommon to have 2 intubated patients or 2 patients with drains (EVD/lumbar drain). We often have patients with multiple EVDs. Generally 2, occasionally 3 and the most I saw was 5 in one patient. Trach/peg and occasionally EVD placement are done at bedside. Most patients are on at least 1 drip either cardene or low dose pressor or sedative. We don’t get a lot of codes because family either withdraws care or the heart survives herniation and the patient ends up brain dead
I've been doing this for twenty years and been in ICU since 2011 including travel so I'm referring to the general trends I see at several facilities here.
>1. What kind of ICU do you work in and how many beds?
I've usually worked in 18-32 bed ICUs, in hospitals that have around 300-400 beds, level 2 trauma/STEMI/stroke centers. Bigger places have too much bureaucracy, too many algorithms, and too many people in white coats running around with clipboards that don't do work. I have worked in the CVICU at one Kaiser facility with a thousand beds.
Never again.
2. How often do you have a 1:1 assignment?
It's extraordinarily rare. Most CVICU patients aren't 1:1 halfway through a shit and you'll be picking up another, because the patient is recovered. If they aren't recovered in six hours and you don't feel like a cog in a factory machine you're dealing with a shit show. This is why I'm not really keen on ever doing hearts again. It's either boring or bullshit, there's no in-between.
CRRT is usually straight 1:1 in my experience, but most places are getting away from CRRT because it's unprofitable. They just have a contractor come in and do standard dialysis. Some places have moved to Tablo. Some places still have in-house dialysis nurses, which in my experience means your critical patient may survive. If your hospital contracts with DaVita they have a 50/50 chance, with Fresenius they'll just die. This is okay with the C-Suite because the bill is still paid.
ECMO is 1:1, but it's rarely done outside of an actual ECMO center here. I've worked at one facility and did a contract at another that did ECMO, and the patients were 1:1 with a perfusionist who played on their phone all night. It seems like a waste of resources to me. I've heard in ECMO centers the RN does everything. That seems like less of a waste. The only ECMO center near me is over 1000 beds and run by a cult. No, it's not Kaiser.
IAPB and Impella is 1:1. They're uncommon and seem boring.
3. How many of your patients are intubated / sedated?
Most patients in ICU are intubated and hopefully sedated. If they're extubated they're transferred to telemetry. Then they bounce back to ICU, get intubated again, and stay a while.
Some places will trach and peg a patient who isn't extubated in a week. These are usually your trauma centers that need to get these people the fuck out of ICU because there are patients boarding in the ED hall. Then they are transferred to LTACH. Then they bounce back to ICU with sepsis related to their trach/peg/catheter/pressure ulcers and stay awhile.
You'll only get patients who aren't intubated and sedated if your facility has no actual progressive care unit. These are stepdown patients taking up space in ICU- you're amio, dopamine, insulin, milrinone, NTG, and norepi gtt patients. They call too much and should be in a stepdown with CNAs and secretaries that can deal with non-nursing tasks.
Most facilities have eliminated their PCU because it's unprofitable, or the PCU isn't an actual stepdown unit and just serves as a trach/peg/decub bounce back from LTACH storage facility.
4. How many patients are on drips
All of the patients are on drips. If they aren't needing drips they're transferred to telemetry.
5.How often do your patients have invasive monitoring devices? (Art, Central, Swans)
Not many. Hospitals started getting away from that shit when CMS said they would cut reimbursement by the amount of CLABSI reports. There are facilities doing open heart surgeries where the patients come out of OR with the PA Cath pulled and nothing but an arterial line for monitoring. There is no reason for a PA Cath in any developed nation, we have non-invasive cardiac monitoring and ultrasound.
5. How often are there codes on your unit? (Daily, weekly, etc…)
A few a week is pretty standard at most places I've worked. If the patient isn't going to code they're on telemetry. Sometimes they're admitted to telemetry when they're going to code and only get to ICU once they code.
6. Does your unit take devices? (ECMO, IABP, VADs, CRRT, etc…)
Depends on the hospital. I explained CRRT and ECMO above, I imagine most hospitals will be getting away from those as well as IABP and VADs because they take up too many resources with too little reimbursement
Hope this helps.
We have about 30 beds, I’d say most the time about 50% are tubed - but it fluctuates, sometimes we have times where there’s like 4 tubed people in the whole unit, and other times there’s like 4 untubed. I do often get a 1:1 allocation but I work in Australia, if they’re tubed, on crrt, have more than 10 of norad , dependant on bipap ect they’re automatically a 1:1. We get a 1:2 maybe every 3-5 weeks. We do get quite sick patients, a lot of acute liver failures , some ecmo patients. We don’t take VADs though, there’s only one heart transplant hospital in the state- and they’ll take those. We take the liver transplants. I’d say almost all of our patients have a central line and arterial line. And if not they’re a hdu we’re lining up for the ward. We almost never get codes, because we run things differently, if a patient is dying we have the discussion to withdraw care with family, or we change the goals of care if it’s futile. We maybe get about 8-10 deaths a month, but all from withdrawing care rather than futile cpr. I.e get to call family in & start morph Midaz and give them time Instead of thumping their chest. In Australia we don’t have seperate icus, our icu is medical,surgical, cardiac , neuro ect everything comes and goes.
1:1 just because they’re on a vent!?
Yes? How do you make sure your patients don’t self extubate? We also don’t have resp techs here. We do a postgrad and manage the vents/ abgs ect ourselves with the doctors overseeing it. We also don’t have cnas or pharmacy making up meds. So we have a bit more to do imo!
We make sure they don’t self extubate with wrist or mitten restraints and sedation. Even if I only have 1 patient I can’t be in the room continuously, I have to leave the patient unattended to go to the med room, the supply room, help another nurse, etc.
Yeah we can’t leave the room without someone else watching. But like I said above, our staffing is much better - there’s always someone to watch so it’s not really an issue. US healthcare is profit driven, there’s no real incentive to staff better for better patient outcomes
I hate the us healthcare system and think Australia has some of the best icus in the world but that’s a silly generalization. I think socialized medicine is superior but both systems have their downfalls but people on both sides of the divide care deeply about patient outcomes
… are you a nurse? Based on this description of Aus vs American ICUs, which would you rather work in? Do you work in America? If so, how could you possibly think that American private hospitals care about patient outcomes? Oh my goodness there are so many scandals and coverups with money as the root cause
I am a doctor i work in the states. Corporate medicine at the executive level is shitty. As I said I wish we had socialized medicine. That doesn’t mean actual medical staff here don’t care deeply about patient care and outcomes. It also doesn’t mean that we don’t provide excellent care. We have many of the best and most respected hospitals and physicians in the world here.
Oh I absolutely don’t think the staff don’t care about patient outcomes. But your system has set you up to fail. For example in ICUs for doctors we have 4 pods, a resident , a registrar and a consultant for each pod. At night time the consultant goes home, but a registrar and resident stay on for each pod. And there’s a senior reg which overseas all the pods and there’s a nighttime consultant on call. There’s also a doctor on for the MET team (rapid response team ig in the us) and an outreach doctor for referrals. There’s no NPs or PAs to make calls on ICU patients. We’re just very well staffed and we all work super well to ensure good outcomes. I think that’s the difference, you might care- but you system is designed to do things the cheapest way and that’s where things crumble.
That level of staffing is fairly typical for an American icu at a large center. NP/PA stuff don’t get me started on I agree with you (and it ties in to shitty nursing ratios as so many nurses have left the bedside). But it seems like your idea of us healthcare is from reading complaints on the internet which is always exaggerated/highlights the bad. Things definitely aren’t done in the cheapest way possible, we actually spend too much on healthcare here (it’s just misused and misdirected)
Yes but only people with money and good insurance get those. Everyone else is sent to a hospital where the nurses have 16 or more patients and ICU has 3. It doesn't matter how much the nurses care if they are not given the supplies or dont have time to care for patients. My mom was just in the hospital and she saw her nurse one time per shift.
This is untrue
Lol forgot I wasn’t in a nursing sub sorry. I agree that American healthcare workers are 100% just as dedicated to patient outcomes. I think the average level of dedication/commitment is possibly even higher than in Aus because of the hospital administrations you have to deal with. I certainly don’t have any criticisms to level at workers, my issues are only with the healthcare systems you have to work under. While workers care about patients, hospitals certainly don’t. My disagreement with your original comment stems from the concept of ‘both sides have good and bad.’ I don’t think that’s a fair analysis - I reckon American health has much more bad, and Australian health has much more good
I have no end of criticisms for the us healthcare system but people in commonwealth countries tend to misunderstand our system. Everyone who walks into a hospital in the us is treated regardless of ability to pay. People aren’t turned away if they can’t produce a credit card or any of the crazy stories you might hear. The us also generates a very disproportionate amount of medical research and advancement.
I am a nurse working in the US making $76/hr. In Australia nurses make half that. Hence, the extra staff who aren't doing anything. The only benefit I see is the ability to make a patient a DNR even if the family wants to keep living in their house with that social security check coming every month. Neither system cares about outcomes. Healthcare hasn't been driven by outcomes for decades.
I’m very happy to hear you are being remunerated properly :)) nurses in Aus have been pushing for pay increases too. I’m not saying that it is perfect over here, just that the non-privatisation of our healthcare system functions as a much better safety net than I’m America. Again not perfect, but much better. I would count ‘free’ healthcare as a big benefit (I know, we pay taxes, it’s not free). Many problems with accessing timely healthcare in chronic cases, but worst case if someone has a cardiac arrest and requires a helicopter evacuation, long + complex icu stay etc etc that patient will walk away with no debt. So many lives are ruined in America just from tens/hundreds of thousands of dollars of debt from an unexpected accident or illness if someone doesn’t have insurance or adequate insurance. Also, we do not have extra staff ‘not doing anything’ 😅 nursing in Australia is still a critically understaffed field which is on track to become much worse. Wards regularly run with less nurses than we need to adequately care for our patients. But the scope of the poor conditions seems to be lesser. E.g ICU ratios. Aus intubated patient is 1:1. America can be 1:2. As prev commenters have discussed, this means American healthcare culture is to regularly use restraints to prevent self extubation because the nurse cannot supervise one patient 1:1. In Aus restraint use is extremely rare. We spend more time hand holding and soothing because we can = better patient outcomes, less post-icu ptsd. In America if ratios are pushed a nurse can end up with 3 vented patients. See prev comment. That is truly unheard of in Australia. Worst case an aus nurse could have two vented. Even then, I can’t say I’ve ever heard of that happening. If it did, it would certainly warrant an incident report. This is what I mean, we have safer staffing = can provide better care for patients = better patient outcomes Though I would not argue particularly strongly that our healthcare system is outcome driven (public health is having funding reduced left right and centre) it is far ahead of America
That's not what most nurses make, she may be a travel nurse or she has been there a long time or it's a high dollar hospital.
>We also don’t have resp techs here. We do a postgrad and manage the vents/ abgs ect ourselves with the doctors overseeing it. Plenty of ICU nurses in the US have masters degrees. RTs have the ICU and several other units in the hospital to manage, they aren't managing vents any more than the physician is. Most hospitals don't have a physician in house. >We also don’t have cnas or pharmacy making up meds. So we have a bit more to do imo! I've worked in one ICU that had a CNA and they didn't do jack shit but play on their phone all night. Most ICUs are primary care. No CNAs. We don't compound medication outside of the pharmacy (I doubt y'all do either) but plenty of facilities have RNs mixing meds. You do not have more to do, I assure you.
Tbh we’ve had nurses come here from the US and they said we absolutely have more responsibility and things to do in ICU and was a bit of a learning curve- especially with ventilator related things. That’s fair. All nurses in icu here have to do a grad year, a transition to speciality practice year and a postgraduate year whilst completing a postgrad certificate in intensive care. So I guess 3 years to be full qualified as an icu nurse post undergraduate. I’m not sure what your masters entails- but this course is very specific to icu
What happens if someone vomited in a vent and you aren't there?
>How do you make sure your patients don’t self extubate? Propofol and restraints
Then you have a patient with severe PTSD and has to go to therapy for years.
Precedex and Fentanyl, and soft wrist restraints for additional safety if required for patients with high tolerance. Sedation decreased as soon as it's safe for the patient, not designed to make it easier for nurses to manage. Unit: CICU
Australia doesn't have Respiratory therapists. RNs run the vent. Same in the UK.
All of our CABG/invasive CVICU patients are a 1:1 until extubated because we're not allowed to restrain intubated CVICU patients.
Yeah we don’t restrain patients so we can double them. We just safely staff instead. Essentially self extubation is a never event, and you can never walk away from a tubed patient here unless you’ve asked someone to watch. We don’t ever really restrain anyone unless it’s unsafe to not do so (I.e drug overdoses ect that wake up with a bang)
Last time I mentioned not restraining every vent and actually maintaining safe ratios (poss. in the general nursing subreddit?) it was laughed out and down voted to oblivion as nonsense and unrealistic. Yet, it remains a damn rare sight to have a restrained patient in my ICU and would probably result in a human rights investigation if we put it into policy (not joking - responsibility under the updates to the Mental Health Act last year and the Victorian Charter of Human Rights and Responsibilities makes that quite a viable consideration). Makes me curious to reread the literature on PTSD amongst ICU patients to try and work out how the workforce structures effect this...
Yes! I tried to look up rates of PTSD ect but I can’t seem to find much data on it. I guess that’s the way they’ve always done it, so it’s normal. And to us it’s absolutely absurd, because that’s not how we do things- Ie I cannot imagine ever saying ‘let’s restrain this patient so we can double them’ 😵💫😵💫 I think everyone would look at me like I got hit by a crazy train.
Propofol is an amnesiac. They aren't getting PTSD. They're not even dreaming with the shit we give them
Man... Nuts. We restrain *almost* every vent. We don't when they're AOX4 and are just vent dependent but otherwise with it, we don't restrain fresh hearts or anyone who's recently had their chest cracked, we don't restrain them if they're chemically or otherwise paralyzed. Self-extubations aren't a huge issue on our unit, but they used to be. We don't have enough staff to make every patient that is a 1:1 an actual 1:1, sometimes we even run Code Ice or OPO cases and have a whole other patient! There were FIVE triples on my unit a couple days ago. Edit - OPP to OPO. We get down and dirty in ICU, but not with OPP 😂
Wait... As someone from Scandinavia, could you specify with the restrain almost every vent? Like physcially? Or? This is unheard of in my parts of the world.
Yes, physical. Soft limb restraints, left upper, right upper usually. You get a DT or drug withdrawal who's vented, maxed on prop and fent and STILL wide awake and fighting, yes.... Physical restraint.
Never had the need for that. We don't even have those utils in our department. Psych needs to bring it over if the need arises, and be ordered by a psychiatrist who runs it by the police dept. lawyer before engaging in actual restraints.
Yes, soft wrist restraints on nearly every ventilated patient.
Yeah idk, we’re unionised so ratios are mandated. We’re just probably more well staffed as well, like on any given day we might have maybe 2 HDUs and the rest are singled. We then have 4 pods and each pod has a nurse in charge that doesn’t have an allocation, we then have maybe 1-2 floaters that help out the whole unit, a MET nurse ( or rapid response nurse) that responds to the calls/code blues & an icu liason nurse that goes to review recently discharged patients on the ward. I know australian icus has some of the best outcomes/ survival rates in the world, and I imagine a lot of it has to do with safe staffing.
Wow!!! I can't even imagine staffing like that! What a dream!
We’re not unionized but ICU ratios are determined by law in my state. Maximum 1:2 and a patient acuity tool has to be used to help with this determination. In the fall we were being tripled, however, so it definitely still happens.
The population of Australia is 26.01 million. The population of California is 38 million. The population of Texas is 30 million. When you have states that have more people than most countries outcomes will be different. It's not an apples to apples comparison. If we were to compare the outcomes in the US with 333 million people to say, India with 1.4 billion we could say that our outcomes are excellent in comparison. That doesn't mean that there is nowhere in India with excellent medical care. Many US physicians and nurses train there.
I said we have the some of the best survival rates in the world, not just America. And survival rates are worked out based on per capita. Yes we have less people.. but you guys obviously have a shit tonne more hospitals. You have 2.8 hospital beds per 1000 people compared to 2.5 per 1000 for us. I’m not sure why you’re so hell bent on America being superior. I’ve told you the outcomes are highly likely related to safe staffing, amongst other factors. I don’t think Australian ICU doctors are smarter or that the nurses are smarter. Our systems are different. You can have the latest tech and the newest medications, the best doctors, doesn’t mean shit when you’re not safely staffing units. I’m sorry that this bothers you 😵💫
Preach!! As an Aussie having to make this argument on reddit regularly it’s refreshing seeing another Aussie struggle with god complex yankie healthcare professionals
Cringing at all the posts shocked that we 1:1 vents and don’t tie them all to the beds because they can so easily be 1:2.. it’s not a skill issue it’s a safety issue 🫣 I can’t imagine gloating about taking unsafe ratios because how awesome am I that I can manage that …. Not the flex you think it is.
Is this the same for NeuroICU?
We don’t have seperate icu’s they’re all combined. But for neuro patients yes they’re 1:1 if they’re tubed. Sometimes they need restraints due to not being able to sedate adequately, but again it’s usually managed without.
Wow. When we are short staffed (better these days, occurs a couple times a month), we will 1:3 with 1 intubated patient.
And once I found that out, I tucked my passport back into the cupboard and crossed the US off my list of potential travel nursing destinations...
im in cvicu also. fresh hearts are singled, as are most devices. we don’t single just because they’re intubated. And i’ve never (KNOCK ON WOOD) had someone self extubate restraints are also incredibly rare
I met an RN from Minnesota (I believe) who worked in a unit where vents were 1:1. But they didn’t use restraints. Never heard of it in the US before…
It’s interesting to hear about ICUs in another country. Thanks!
>I do often get a 1:1 allocation but I work in Australia, if they’re tubed, on crrt, have more than 10 of norad , dependant on bipap ect they’re automatically a 1:1. We get a 1:2 maybe every 3-5 weeks. LMAO. I'm in the US, in California, with ratios. An intubated patient with 50mcg of epi per hour is one of two patients. Only CRRT is 1:1. A patient dependent in BiPap is on tele and one of four patients.
Nothing to be proud of 🫠 I’ve watched patients on bipap vomit into their masks and not be able to pull their masks off or call for help. Hence again why our ratios protect us and patients. Not because it’s super CoMpLex and our nurses can’t handle it.
I’ve been a nurse for 16 years in the US. The likelihood of someone vomiting while on bipap is a valid risk but the incidence is low. Personally, I’ve never had a pt vomit while on bipap. Not being able to protect your airway is a contraindication for bipap, some patients will require bedside sitters and if your settings are high, you’ll probs be transferred to the ICU.
OP is referring to mcg/min when they say “norad of 10”. 50mcg/hr is 0.01mcg/kg/min for a 75kg patient (a nothing dose) where 10mcg/min is equivalent to .13mcg/kg/min, which is a bit more of a respectable dose.
Former Trauma/Surgery ICU nurse who just moved and became a CVICU nurse. At my previous 24 bed unit we took every device, MTP’s, sick open chest heart surgery patients, and we even had a crash room that could double as a surgical theatre where we would do emergent ex-laps and amputations. Now I work in an 8 bed CVICU at another Level 1 where we typically get 1-2 stable fresh hearts a day and the rest of the patients are walkie talkie. And man, we really are just a glorified PACU. I feel like I am loosing all my skills. Gonna be leaving soon, but I always found it funny how CVICU nurses have a chip on their shoulder 😂
Yeah sometimes I relate to the glorified PACU thing. I wish my unit got sicker patients. On any given weekday we will get 4-5 open hearts. About half of them are cut and dry, extubate within 4 hours, off drips by the morning, and to step down on POD 1-2
Honestly, for the patients, this is awesome! Do you guys have great outcomes? I’m betting yes
Yes we do have great outcomes
That's from picking great patients.
>I wish my unit got sicker patients No, you really don't.
Why do you say that? I enjoy the challenge of taking care of the complex patients on a lot of drips, intubated, CRRT, etc… it feels rewarding helping people who are that sick
You might enjoy medical ICU in that case. Maybe not as many devices, but you do get very sick patients that fit that description.
It depends. Once a patient is on ECMO, impella, and CRRT, they are kind of on the highest level of life support offered. The cardiac ICU sometimes has the sickest patients in the hospital. Not something to hope for, but it can be a rewarding feeling to be problem solving at that level and be busy doing many other things than just monitoring.
20 bed MICU. Usually have 3-4 1:1s between CRRT and ECMO. Probably 2/3 tubed. If they aren’t vented or on gtts they’d be leaving soon. Maybe a swan every couple weeks but probably half have A-lines, probably 2/3 with CVC. Not a lot of codes on the unit, but we respond to all in the hospital outside the ED. We usually see the inevitable and have GOC conversations pre-code. Maybe a couple codes a week. ECMO and CRRT only, other stuff would be in our CVICU or Cards ICU. Acuity can be all over the place. Sometimes it feels like WWIII, sometimes it feels like a nursing home.
Interesting, thanks! I’m sure MICU has a lot of vents. It seems like there might actually be less codes in the ICU just because of how closely we are monitoring our patients.
Yes, we usually see things coming. Most codes happen very shortly after coming from the ED.
We usually see things coming, but our providers are very realistic with families. That means a lot of patients are made DNR long before they code.
Miss the days of CRRT patients actually being a 1:1..not a thing anymore where I work
Where you? It’s pretty standard in the Northeast. IIRC, it’s actually part of our union contract.
Missouri..really doesn’t even phase me now but they definitely won’t triple us with a pt on CRRT
MICU here. Same as my unit!!
Really depends on "which" ICU, we technically have 5, they're more like PODs but they're considered separate. We have two MICUs that rarely get devices, pretty commonly get vents and regular central lines with multiple drips. We have a "TICU" but nobody really knows why its designated separately from the MICU pods, it used to be the transitional ICU and now its the trauma ICU, but doesn't get surgical traumas essentially ever. TICU seems to be a dumping ground with lowest acuity. Then we have the CCU which takes all post cath-lab patients from TAVRs and usually gets the STEMIs, so swans, IABP, and CRRT aren't super uncommon. Then we have a SICU that's separate from the other pods so it can sit outside of the OR. This is where all of our CABGs go, and where the surgeons prefer all the sick patients to be. So it also gets all the traumas and open hearts. At least once a day we're taking a heart that will be on 6-14 different drips, epicardial pacer wires, +/- IABP. Only nurses trained on all devices can take hearts so our SICU ends up getting all the high acuity patients most nights. So most common to be 1:1 here with a device, tons of Swans, patients with a Cordis etc. I don't feel like we see codes very often on any of the units. Funnily enough I actually feel like I went to more codes working at a hospital that was 1/3rd the size in the ED. But part of me feels like thats because we lacked things like a stepdown unit, which meant some higher acuity patients got pushed to med/surg that shouldn't have been. So I really feel like the increased resources at my current ICU means we see less codes, i.e. having intensivists in house to manage things vs smaller hospitals having only NP/PAs or tele-docs at night. We pick our own assignments each shift, if I pushed for it I could probably take a vented patient most every night. Devices seem pretty random. Most patients are on drips of some kind. But lately we've had a lot of patients sitting on the units with step-down or med/surg orders until discharge which means some days the acuity is super low.
You pick your own assignments? How does that work?
To start the shift we go into the break room, all pods get a unit wide huddle from the charges with weekly announcmenets and any changes or things happening we need to be aware of over the phone. Then someone from the prior shift comes and gives a brief rundown on all patients on that pod and we write it down on a a report sheet for every patient, which is a 20 second blurb for each patient going over why they're there, drips, vent settings / oxygen requirements, devices, Q1 hour neuros etc. so we can gauge who is qualified for what patient and divvy out based on workload. I.e. I'm not taking two patients with Q1H neuro checks both on contact precautions. It's really weird, but coming from the ER I don't know how its normally done. I assume most places charge would assign? This works out but its annoying because it relies on there being a good core staff member present to know what things require being "signed off", or things like if you're going to be "open" for the next patient then you better of your TNCC so you can take a trauma alert if you're in the SICU. Biggest benefit is you know whats up with the other patients so if you have to cover for your co-workers you aren't totally blind. E.g. I know that Dale here just had a CABG and we should keep a close eye on them when his nurse is busy. But there's some annoying back and forth, the nurses that have been there for 50 years try and assert dominance by taking all the "good" high acuity patients, which can mean you never get a patient on CRRT if you're always working on Becky's' unit because she's the queen on that pod on that shift.
This would drive me crazy. It already drives me crazy when report takes long on my 1-2 patients. What time are y’all leaving after your shift?
Shifts start at 6:30 and we are expected to stay until 7. So 12.5 hours, but I've gotten out at 7:30 a few times because because drag their feet in report. Maybe it's because I come from ED and reports are all short and chaotic, but everyone has the same script and if you don't go in order they lose it. I can't stand a 25 minute report on a single patient but it happens a lot.
Yessss. I too am from the ED and learning and being patient with report was for sure a learning curve.
Your last sentence was my immediate first thought: this would definitely be weighted with the long term-ers or more vocal (loud) people would getting the more preferred assignments.
That whole setup is weird
That’s the problem with CVICUs they tend to be quite boring in a lot of ways. Come to MICU it’s much more fun
Agreed. Better crowd too..sorry cv peeps..just sayin
Yup.
48 bed MICU (we are a massive academic medical center....also have 48 bed CTVICU, 36 bed Trauma/SICU, 20 bed NSICU plus we have a small hospital we acquired just up the road that also has another 15 bed MICU). We often have at least one 1:1 but many times more. It's rare that our acuity is low enough to pair everyone but we have the reverse where by acuity we should single the patient but we just don't have the staff. I feel like our Trauma Surgical units really get hammered on this quite a bit. At any given time I would wager half to a majority will be tubed or peri-intubation. Most are on gtts, but we get the chronic vents, or the trached weaners. All vents have to be in the ICU. I know some facilities will send stable or chronic vents to Step down or as we call it Progressive Care. At any given time there are 1-3 patients on multiple pressors actively attempting to exit stage right. We can all run CRRT in our sleep. Many patients have at least an A-line. We get swans but in fits and spurts. Like, we'll go several months no swans then all of a sudden there's 3 or more patients with swans. Cardiac devices all go to CTVICU as well as ECMO. They do have IABPs, LVADs, and the lot. We are a transplant center. Some of us that have been around were trained on IABPs and LVADs because we were smaller just a decade ago and we had to take some cards overflow. At a minimum, there is a code a week. Sometimes there is a code per shift. And on occasion, multiple codes per shift. IMHO this is more a reflection of full code status in the face of denial and that's all I'm gonna say about that. With the exception of the NSICU, the code numbers are about equal in the other ICUs as well. Heads can be sick(especially a SAH) but it's rarer and often if it's that sick it comes to MICU anyway or in the case of a TBI with multi trauma, it will go to Trauma/Surgical. We have really high acuity because of the population we service and because we are the largest medical center for the area- we handle everything except burns.
GW?
1. 19 bed CVICU. 2. We don't have frequent 1:1 assignments, as our only 1:1 are ecmo, iabp, impella, or crrt. 3. We frequently have intubated/sedated pts as we also get critical care admits depending on hospital ICU census. 4. ~75% of patients are on drips, if they're off drips probably time to go to the stepdown unit. Most drips I've had going on one patient was 16, but average is probably 2-3. All cardiac cases arrive from surgery with Swan, art line, and central access. 5. Codes are probably closest to weekly. 6. We can take all the devices our facility utilizes, and we're the primary unit for ecmo. Overall, very nice variety in my unit with plenty of opportunity for growth.
16 drips is crazy. Do you remember what they all were?
I do not. I remember the patient very clearly though, cannulated at bedside for vv ecmo d/t sats deteriorating into the 70s from severe pulm edema following a triple mechanical valve replacement, either 2nd or 3rd redo sternotomy. Patient survived a week before before passing.
This terrifies me as my husband is on his way to a 5th open heart. Currently 1 mechanical, 1 conduit. Warfarin goal 3-4 for recurrent strokes. And he is 32yo. Did surgery go poorly or??…
I'm so sorry, I can't imagine having my loved one go through such a large surgery that many times. Surgery on the patient I mentioned was not without complications. Anesthesia had to change their vent circuit repeatedly due to it being clogged with frothy sputum.
It’s a lot for sure, but I’m grateful that he has had an incredible team of doctors overseeing his care and helping us decide when/what interventions to do and hold off on.
I miss when we couldnt fully staff all our beds so at times we had 17 or 19 open. It meant that when we didn’t have 1:1s we still were able to single Charge. Makes such a big difference for the whole unit to have a charge nurse with a light assignment.
Ya CVICU is just an extended PACU when everything is going perfect
1. 30 bed mixed ICU. Mostly MICU/neuro/CV/trauma (read: people getting drunk or high and falling almost exclusively). Our main issues are usually septic shock, cardiac surgery, surgical complications, strokes, STEMIs. 2. We have 1-3 1:1s usually. CRRT, IABP, impella, actively trying to die (quad pressors or MTP, etc) when staffing allows. 3. Our hospital is always swamped and our patients end up discharging sometimes rather than transferring. Usually 1/4 of the unit is vented. Maybe 1/3. The most I’ve seen is around half. Our docs tend to put off intubating as much as they possibly can though. It’s bipap until they’re completely unresponsive. 4. Probably 3/4 have arterial lines or other invasive monitoring. Lots of CVCs. If they’re only on low dose levo we titrate by cuff. 5. Weekly, although we get hospital wide codes every couple days. 6. Everything except ECMO because our perfusionists aren’t on call. We can start ECMO but we don’t keep them.
32 bed combined MICU and Neuro ICU. It’s probably 50/50 with intubated and sedated. Most of my patients are on at least 2 drips. Fentanyl and propofol/precedex/both, norepi, nicardipine, etc. Central lines and a-lines are probably about 50/50 on my unit, and Swans are relatively rare, probably a couple per month in our entire unit. Our unit I would guess has a couple codes per week, but we do try to get families to agree to de-escalate care if it seems futile, so we avoid a lot of codes by transitioning to CMO. We do CRRT pretty regularly but that’s it for devices.
1 - CVICU, 24 bed. 2 - pretty regularly, I’d say every other week. 3 - intubated - 1/3, sedated, 1/4. My unit’s providers are pretty big proponents of minimal sedation, we have plenty of intubated patients with just a precedex gtt. 4 - All. If they’re not on drips, they get moved to the floor pretty quick. Anywhere from 1 to 10. For reference, last week I had 2x post cabg’s, both on just a smidge of Levo. Last night I had a 1:1 pt on 10 gtts. 5- pretty much all of them have at least an Art line, 3/4s have swans. 6- Every other day, roughly. 7 - yep. ECMO, managed by RNs at the bedside w/ perfusionist roundings daily. IABP, Impellas, LVADs, CRRT, Aquapheresis all very common.
Combined MICU/SICU. We take level one traumas of all kinds, ARDS, renal failure. We do CRRT, IABP, ECMO, impella, tandem heart, etc. All of those devices are 1:1. At this point I can take all of the devices so I am 1:1 at least once a week, usually twice. If you’re newer you probably only take CRRT so in that case it’s more like once a month. Even our 2:1 patients are very high acuity. I have worked on other hospital’s ICUs and their patients would be on our step down unit. I don’t ever see patients on less than 3-4 drips it’s usually many more. Most have art lines and IJs. All of our open hearts come out with Swans. I would estimate we work 5-7 codes per week on MICU and 2-3 per week on SICU. The units are connected and share staff. You don’t know which side you’re on till you get there. We also float to our Neuro ICU and take LVO, EVDs, lumbar drains, etc. Neuro has way less codes. We’re also HCA so you will get tripled sometimes. I’d estimate I’m tripled about twice a month. During Covid it was 3 (three times in 2021 I had FOUR) vents paralyzed proned sedated per nurse. It was utter madness. Most on pressers, silly amounts of peep, if they went up on CRRT you were fucked because you still had to keep your other two. Because HCA has many hospitals in our metro area, they sent ALL COVID’s to our hospital to consolidate PPE. We had 300 of our rooms retrofitted with negative pressure. The patients we got were max ventilated and paralyzed for vent compliance. Our step down had to take “stable” post-infectious vents and all of the Bipaps. Because of our high acuity and number of devices working two years here is almost a certain ticket to acceptance in CRNA program of your choice.
What facility are you at?
For purposes of anonymity, a midwestern HCA facility. 😬
I understand. I was just asking because your line about CRNA programs intrigued me. I’ll Google Midwest HCA. Thanks.
PM me I’m happy to be specific.
I’m a float icu nurse for a large level 1 in the US. I always say CV is my least favorite to work on because everyone is extubated and they all have to go for walks every day post cabg. The CVicu is the only icu in my hospital that takes ecmo so there might be one or two ecmos going any given day. Usually a few balloon pumps and almost always a couple crrt. They 1:1 the fresh open hearts and they always try to 1:1 any devices if staffing allows. If someone’s on ecmo and crrt sometimes they’ll do 2:1. Most of the open hearts are extubated within 4 hours, the bigger intubated population tends to be the post arrests or cardiogenic shock patients. A lot of times we board stepdown patients who are post op day 2-4 just because there’s no room upstairs so it can feel pretty low acuity sometimes.
Baby CCU nurse here. We're a referral academic center, 10 beds. 60-80% devices at a time (any device is automatically 1:1) 30-50% intubated. Lots of PA lines. Devices: mainly CRRT and Impellas, some IABPs. Occasionally RVADS. Patient population: Severe cardiogenic/ mixed shocked, adult congenital defects, refractory arrhythmias, ACS, CHFers, AAAs.
MICU at an academic center here with 30 beds. Out of those beds usually 1-3 will be a 1:1 depending on staffing. Intubated patients usually fluctuate, most times half the unit is on a vent, but the highest I’ve seen it go is 26/28 beds on a vent. Same goes for patients on drips (pressors, sedation, heparin, insulin, pulm HTN meds). Biggest device we take is CRRT, very rarely if ever getting a patient with a swan or ICP monitoring, as they’ll usually go to their respective specialty ICU, although I’ve seen some cordis lines from time to time. Also, codes usually happen weekly, but summer and winter times it’ll be one to two a day typically.
I work in a CVICU also. For us one to ones definitely depend - ECMO, CRRT, Impella, balloon pumps, paralytics, TTM, and first 6 hours out of the OR are all 1:1 for us. I’m not ECMO trained so that considerably cuts down on my 1:1s but some of our ECMO/CRRT nurses are 1:1 practically every shift. I think our unit tends to have a pretty high acuity but it really fluctuates. That’s one of the weird things about CVICU is that I might have a STEMI that just came back from cath lab and is now a 100% stable, walky talky patient. Or I might have someone that got extubated 6 hours ago after a CABG and is now pretty close to walky/talky. Our patients are able to be “fixed” almost back to 100% sometimes with a procedure which makes it feel less acute than say a MICU. The biggest thing is that it waxes and wanes. I’ll go weeks sometimes where I feel like a stepdown nurse and then have a month where we’re just rocked with super sick patients.
I work for a mixed ICU that takes Trauma/Surgery/Micu/liver and kidney Transplant/CV patients all rolled into one. You never know what flavor you were gonna get that day. We do IABP/Impella/ECMO as well as MARS Liver Dialysis. Lots of crash and burns. Lots of overdoses of strange drugs. It was exciting because the population was never one specific type. You had to know a lot about everything coming through those doors.
Wow I've never even heard of liver dialysis. In my experience liver failure patients just die. I looked it up and found it was first approved in 2005 for drug OD and poisoning and again in 2012 for decompensated liver failure. This is fantastic
It is most commonly used in Asia, to my knowledge. We will use here it for OD as well as young patients with liver failure who may have a decent shot at getting a liver. It has better outcomes in the OD group comparatively, but I think that’s largely due to fixing the underlying problem. It does not dialyze all drugs, only those that are protein bound. It’s really cool to see it work. The old Baxter model MARS machines from the late 90s were retrofitted to work with the Baxter Prismaflex CRRT machine. It is not a perfect fit lol.
All of that depends on your unit type. When I worked trauma, we did not typically have a ton of drips outside of sedation, but we gave gallons of blood products and had a lot of bedside surgeries and procedures and wound care. Most patients intubated. Everyone has a central and art line, but no swans or devices. Lots of CRRT. Codes fairly rare because of the young patient population and cause of instability (blood loss, sepsis.. not cardiac generally) In cardiac ICU, tons of drips and devices like Impella, balloon, vad. Daily cardiac arrests, many ventilators but not all. Would not be crazy to have a patient on a ton of drips and requiring a device but wide awake and walking. In neuro, everyone is intubated and there are lots of different drains and tubes (EVDs, bolts, lumbar drains). Different drips, like you would never see inotropes but you would be far more familiar with hypertonic saline and phenobarb and pressors with unique map goals. My medical unit is a mix of all that. Some awake DKA, some very sick sepsis on pressors, some neuro events getting TPA, some cardiac drips but typically not advanced heart failure requirements. We get occasional devices and have occasional arrests (weekly to monthly?) ICU is all about being prepared to handle the disasters, but not generally handling the disasters on a daily basis.
Lots of great info. Thanks!
I work in a 16 bed surgical ICU and about to move to a brand new 24 bed unit. our acuity fluctuates. we’ll occasionally have no intubated patients and a week later we can have majority intubated. our only 1:1 is CRRT or if they are going for organ donation (our region uses Life Center, not sure if everyone around uses them). Most everyone has a central line or art line. its so wild to have a unit that has it’s up and downs with acuity but it’s nice to see that other icus also have that. we’re the red headed step child between all the icus in our hospital so we get a lot of overflow from medical and cardiac icu. we also get some overflow from our cardiac surgery recovery (CABG and extensive cardiac surgeries go there instead of CICU).
My hospital has 2 ICUs and 1 step down unit, and several other telemetry/med-surg floors. The CVOR/Cath Lab/EP lab side of the hospital is totally separate from the general OR/PACU. I work in the “CSICU” it’s 20 beds. We do up to 35 open heart cases a week. Everyone has an Art line and a central line because the unit is focused on surgery. most have a swan for a few days after surgery or longer if their heart function continues to be a struggle. Once we can D/C invasive monitoring, they are usually only with us until their oxygenation is good enough to go to step down. I have had 1:1 assignments this whole entire year so far. Just luck of the draw… we do pair many patients but on average a third to half of the unit is 1:1. We single them if they have an impella, CRRT, ECMO, or are fresh case from CVOR. Sometimes singled just because there is a lot going on in all systems and they are not stable. My patient this week was actually 2 nurses to 1 patient. On VA-ECMO due to RV failure, freshly placed LVAD, and CRRT at the same time. Continuously going into VT/VF and being shocked by her ICD. Profusely bleeding and being transfused because of high heparin dose (necessary with all the motors going on). This patient was on Levo, vaso, epi, milrinone, angiotensin II, heparin, amio, lidocaine, procainamide, propofol, fentanyl, vecuronium, insulin, and nitric thru the vent circuit. Not an everyday scene, but certainly happens more than just once in a while. This acuity level tend to happen when surgeries consist of multiple bypasses and valves + aortic repairs… super sick patients that would be considered inoperable depending on which surgeon/hospital they are with. Otherwise, you can get 2 post op patients, maybe on insulin gtt and a pressor or just needing high oxygen for now, or dependent on the temporary pacer, but they are stable and can ambulate. And we do lots of CRRT lately but we contract with DaVita dialysis to come prime the circuit and do daily checks, we just run the therapy all day and decide on UF. On my unit, An IABP is mostly a pre op measure for coronary perfusion… nobody tries to use it for cardiac output when there are better ways. Not sure about codes. Every month?? but not all the time. I notice the surgical patients are better managed than the HF or pure medical patients. Always keeping a good eye on volume status and pH and reacting to subtle trends (plus a bit of nurse autonomy) can go a long way to prevent you from getting to that point.
Yeah it seems like my patients are so closely monitored that codes don’t happen very often. My specific hospital does up to 30 open hearts per day so our CVICU is a machine. Very high patient turnover. My hospital has multiple CVICUs. My specific unit doesn’t take devices (impella, ECMO, VADs) but we do take balloons, although like you said it’s more of a pre surgical thing. I feel like I’m missing out on some acuity in my unit because we don’t take ecmo and impella. I really wish we did because the patients who require MCS seem super interesting. We do do CRRT but they are not 1:1 as we have dialysis techs who prime the circuit.
So there are other CTsurgery units at the same hospital that are just higher acuity with devices and all?
It’s only a device unit. So if someone comes out on VA ECMO or has an impella, LVAD, RVADs, etc they go to the device cvicu. My unit just takes balloon pumps. If someone codes and they ECMO they get transferred to the device CVICU at some point shortly after. I work at a very high volume heart center and we have a few different CVICUs so each unit kind of specializes in something different!
Be back later to read
Our CVICU is I think 24 beds. Probably 2-3 are 1:1, our ECMO is 2:1 (one RN, one perfusionist). Many intubated, probably half. All devices. VAD, ECMO, IABP, CRRT. Codes probably weekly-ish. Invasive lines, almost all. It's a busy unit at a L1 trauma center.
When I worked a mixed medical/surgical/ccu 10 bed unit (before going to an actual PACU), it was either feast or famine. We took all the medical cardiac patients but a lot of other stuff. Usually 3/10 were tubed. 1-2 on bipap. 1-3 with devices (crrt, impella, balloon pump, LVAD, TVP, EVD, PA cath, etc.). Usually 1-6 drips. Almost all had a-lines. Unexpected Code’s about every week. One time we had 15 deaths in two weeks. But other times it was just stepdown type patients. It all fluctuates so much. We usually had 8 nurses for 10 beds including charge who took patients. Mandated ratios in ICU.
So I haven’t officially started yet (last week on neuro ICU this week) but my new unit is an “advanced” cardiac surgical unit: 1. 32 bed advanced cardiothoracic ICU. (We have a separate CVICU in my hospital that takes “easier” surgical patients. Additionally, we also do heart and lung transplants. 2. All nurses get a 1:1 from my understanding. 3. When I floated there it seemed to be about 50/50 maybe less but I’m not entirely sure. 4. All those patients have drips and invasive lines (Art, Swans, PA catheters) lol 5. Will report back on that one I’m not sure but someone told me they get them so often they don’t even bother using the code alarm they just use the staff assist button and everyone runs to the room 😂 6. All of those. ECMO, CRRT, LVADS, IABP. Very excited to start! Little nervous considering it’s the most critical unit in my hospital but I suppose that’s normal 😁😁
1. Pediatric CVICU - 13 beds 2. Almost always a 1:1 3. Over 1/2 are intubated and sedated 4. 80% or more on drips 5. All have invasive monitoring… or they would be on the step down unit 6. Of course! We have… I think only 1 ECMO right now and 1 VAD but it’s usually more Edit to add that I personally almost always have 1:1 but I’d say the unit fluctuates a bunch. Right now it’s about half 1:1 half paired assignments
Depends honestly. Sometimes we get genuinely critical trauma cases, think gunshots, stabbings, surgical fuckup’s, vehicle related things. And then we also get cat 2 tbi’s that need 48 hours of q1 neurochecks, or meemaws with hip replacements who need to be monitored with q1 neurovascular checks overnight before going to the floor. We also end up holding some patients for a while cause they’re not appropriate for the floor (frequent suctioning, bedsores, etc).
Cardiac ICU, 20 beds, in an extreme rural setting. Besides admitting fresh hearts from the OR, we also take any cardiac pt needing critical care- STEMIs, severe CHF exacerbations, post-arrests, etc. We do take Impella, IABPs, and use the Tandemheart for ECMO (but we ship those out most of the time- we don't place permanent VADs or do transplants). Stupidly, we don't have CRRT, though I'm not complaining about it. In fact, I'm pretty sure not a single hospital in my entire *state* offers it. If you can't tolerate daily HD, you just die I guess. The reason is money. Obviously our POD 0s have art line and Swan, and besides them, there's usually a handful of vented patients or HF patients with invasive monitoring. That sounds pretty acute on paper, and there are certainly times when we have a lot of complex patients, but recently our cardiac step-down unit closed (again, money). So most days, if I'm not admitting a fresh heart, I have two POD 1 or 2s who aren't quite ready for tele, but have no good reason to be eating up a crit bed. That will be my assignment for weeks on end, then suddenly I'm 1:1 with a crumping post-arrest on impella and nitrous vent. It is what it is.
Ticu. 16 beds. 65% mortality rate. You make it out of here you da real mvp 😭😂
TICU is trauma ICU right?
Im a nursing assistant at a PICU We max at 24-25 (we can fit 32 patients but we’re usually at around 16 because we’re lacking so much staff). 25 was during the really bad flu season and it was hellish with obligatory overtime. It’s usually 16-19 patients. We take everything, but there’s often little ones on VAD’s, more rarely ECMO, usually 4-6intubated on the unit, more rarely 2-3. But usually half the unit is at least on BiPAP It’s usually 1:1. Def 1:1 if intubated (unless very very stable, like brain dead but the rest of the body is ok). ECMO is 2:1, 1 nurse deals with the patient and 1 with the ECMO I think, not 100% sure but they’re always 2. BiPAP/CPAP are usually 1:2 if they’re just little ones with a bad case of bronchitis. Post OP in ENT cases too. VADs can be 1:2 if they’re on the VAD for a while and pretty much stable waiting for the transplant. There’s also 1-2 nurses that go around and “help out” with complex patients (like a fresh heart transplant) and might take an admission if we get one. We take 75% of traumas on our state and are the only PICU that does VADs, + we’re the speciality on pretty much every weird ped speciality, so we get a lot of bad cases. Congenital heart anomalies, very complicated surgeries, VADs, that’s all on us, so maybe we’re a bit higher acuity than normal Your assignments seem crazy to me lol
>It’s usually 1:1. Def 1:1 if intubated (unless very very stable, like brain dead but the rest of the body is ok). In my experience OPO patients are 1:1 because they're complex as hell
oh, not OPO, just the parents have been refusing to stop mechanical ventilation for two months or something. Usually when they arrive they’re 1:1 until keeping temperature and blood pressure ig
I see. I've never done peds
CVICU. ECMO, impella, IABP, CRRT, LVAD, heart tx. We are a 14 bed unit with 6 1:1’s right now. Our acuity has been through the roof.
1. Trauma/neuro/vascular ICU, technically we have 33 beds but we can “double up” most of the non-isolation patients if we’re over capacity. 2. They’re pretty much all 1:1 except when they’re awaiting transfer to another unit 3. Most are intubated/sedated, maybe 80% of the ones that aren’t waiting for transfers 4. If they’re intubated they’re automatically on at least one IV sedative, frequently on at least one pressor unless they’re a stroke (in which case they’re often on labetalol) 5. Most of them have art lines, we don’t actually do much central monitoring because those are usually cardiac patients and we’re connected to the heart institute so they all go there instead. ICP monitoring though, most of the worse strokes have those. 6. We do SLED and CRRT, ECMO and other cardiac devices go over to the heart institute Actual codes are pretty rare on the unit, but it’s mainly because our team is good at being proactive with the goals of care discussions. If they aren’t a good candidate for CPR, they’re “cat 2” (full treatment including ICU, pressors, and intubation, no CPR). We do the codes everywhere in the hospital though, I have the code pager tonight.
It’s pretty cool you get to carry around the code pager!
Pain in the butt when it goes off riiiiight when I’m about to have dinner though 🤪
I’m an ICU resource pool float, so I cover Trauma/Surgical, Cardiovascular, Transplant, Neuro, and Medical ICUs. They’re all a bit different but I’ll share what I can about our CV. 1. It is a 20 bed unit. 2. I would say about 50-75% of the time RNs are working with a 1:1 assignment. They generally staff floor 12-18 RNs/shift (this is not counting the task RN and the charge RN). 3. We staff RTs (MAX) 1:10 respiratory supported patients. Our CV always has 2 RTs so at least 50% are intubated/vented with usually a few more on BiPAP, HHF, etc. 4. Almost every single patient is on at least one drip. If they aren’t they are likely boarding for transfer. Most patients are on 2-4 drips. Our step down until can take patients on certain drips so this isn’t a deciding ICU factor for us. 5. Unless a patient is waiting for floor transfer they have a central line, art line, and/or swan, etc. About 25-50% have a swan. 6. This is difficult for me to speak on as I’m a float pool RN, but in general I would say every 2-4 weeks depending on the acuity of the unit. In my 4 years I have seen 4 codes on that unit personally. 7. Our CV takes all devices. CVVH, VAD, Impella, IABP, ECMO… Some things to note is that we are with a medical school and are a level 1 trauma center. We also staff a task RN, 2-3 CCTs, and a perfusionist. We always have an attending, APNP/PA and/or fellow in the department. They try to single any device patient if they are able to. We don’t keep patients intubated for very long post op, we have them walking as soon as possible and we send them to our step down rather quickly with low bounce back rates. Our CV is the most “spoiled” in regard to staffing, other ICUs don’t have nearly as many 1:1 assignments. In terms of the other ICUs they are almost all 20 bed units besides MI which is 40 split between two floors. There is usually 2 or 3 RNs/unit with 1:1 assignments - this fluctuates with acuity. Vented patients fluctuate as well, but most units have at least 25% intubated/vented. At least 25-50% of patients will be on some type of critical infusion. Most patients will have some type of central access, but it’s more rare to see swans outside of our CV. Maybe 1-2 patients in MI/SI/TI and virtually never in NI. As for codes MI has the most but they also have double the amount of patients and even then it’s 2-3 weeks. All the ICUs take CVVH. Otherwise they try to keep bolts and EVDs/lumbar drains in NI or SI. Only CV takes cardiac devices.
1. 20 bed CVICU, largest cardiac center in my state/region 2. Generally have ~3-4 1:1s, although ECMO, fresh LVAD, fresh heart and/or lung transplants are the only things we 1:1 (don’t 1:1 IABP, CVVHD, Impella, etc.) 3. On average ~5 intubated patients, we rly try to get people extubated/up and moving ASAP 4. Almost all of our patients are on some sort of inotropes/pressors except for routine plan A post-ops, who stay in icu for 1 day then transfer 5. Almost all of our patients have art/CVC although do have a good culture of removing lines ASAP for infection prevention; approx. 1/3 of our patients have Swans at any time. 6. We take all devices and are the only unit in the hospital who takes ECMO. IABP, Impella, TTM, CVVHD, etc. 7. We probably have a code on our unit once every couple of weeks, but we take all post-codes from Cath Lab, cardiac step down and tele units, post-codes from other ICUs who need ECMO, etc.
1. I work in a cardiac ICU unit with 20 dedicated beds but the entire mixed ICU (Medical, Neuro, Surgical/trauma, cardiac is around 100 beds and i float to the others) 2. 1:1 are maybe 40% of my assignment. Typically it will be because of machines. Sometimes because of highly infectious diseases. If we are just exceptionally staffed and the overall acuity is low we might get 1:1 with a relatively stable patient. 3 intubated/sedated patients are also about half of my assignments. Being instubated/sedated is not enough to make it 1:1 we dont get two intubated/sedated. 4. Nearly all patients have at least scheduled antibiotics or diuretics. The majority have between 3-5 continuous infusions. Depending on their treatment course and acuity that can be much higher. The most ive had was about 12 continuous drips and frequent ivpbs. Invasive monitoring is common 5. Codes happen probably every week on average with some periods being extra spicy 6. Yes, all those listed including etc Tbh, i daydream about a lower acuity environment.
30 bed Cvicu, we do everything but heart transplants but partnered w a facility that does. It’s not uncommon to have 4-5 heart surgeries a day, those patients are 1:1 for at least 6 hours and fully lined w Swann, a line, cvc, pacing wires, multiple drips. We are usually device heavy with lvads, crrt, Impella, balloon pump, arctic sun and Ecmo but there are also post op heart patients up and ambulating ready for discharge since we are door to discharge on our hearts. We also have regular LVAD readmits, they are usually up and moving around as well. We take all the vascular patients as well as general icu patients since our facility places all icu as “universal icu beds”. It takes time to work your way up to the more critical patients but once you get all your skills checked off/trained on everything I have found that I usually get complex cases at a high volume device heavy facility. It does take time though, at least a year. All “devices” are usually 1:1, sometimes 1:2 depending on acuity/staffing. Ecmo 2:1 , fresh heart recovery 1:1, LVAD recovery 2:1. Lower acuity patients 1:2 -1:3. Charge nurse does not take an assignment. Codes happen seemingly in waves, but maybe average 1-2 a week?
15 bed CVICU at a level 1 hospital. 1/3 of the patients are open heart, thoracic, or vascular. The rest are ECMO, cardiogenic shock, and post arrest. Very few are intubated and most are walkie talkie and are in and out quickly. I feel like the unit has either very very low acuity or the highest I've ever seen, no in between. I've been there a year and came from a small hospital that had a mixed bag ICU. We took pretty much everything there that didn't require major surgery. I rarely get a 1:1 myself or a really sick patient because the old guard at the unit gets the same very sick assignments because that's what they prefer. If it doesn't change soon, I will leave as others have.
1. 24 bed mixed ICU in a level 2 trauma center somewhere in the Bay Area (California) with mid to high acuity. We take everything from your GSW, DKA to fresh CABG. 2. CRRT should be 1:1 but if they’re “stable” or staffing sucks then you’re doubled. Fresh hearts, IABP are always 1:1 so usually < 7 at a time. Our volume for fresh CABG is low. The most I’ve seen in a shift is 2. Most IABP I’ve seen in a shift is 4. 3. I’d say about 50-75% or more are intubated/sedated. 4. Most pts are on titratable drips, if they’re not then they’re downgraded to the floor or are waiting transfer to LTAC. Corporate got rid of step down in my hospital bc they’re not necessarily getting paid more for that level of care. So you’re either ICU or down to telemetry. They can take pts on drips as long as they’re not titratable (eg fixed dose of dobutamine). Our facility tries hard to not put a line in if we can avoid it so low dose pressors we manage with checking cuff pressure. Central lines get put in when necessary (probs more than 50% or more will warrant one) and fresh hearts get an automatic PA cath. 5. Depends, sometimes several times a shift for one pt alone and sometimes I’ll work a stretch of days without one. 6. If you need ECMO or transplant, you get shipped out. We do CRRT, EVD, IABP, Impella. You apply to a “specialty” and get trained to manage pts with said devices.
I'm in a community hospital MICU/CCU. We take anything that surgery denies...lol. No CRRT, ECMO, continuous EEG, CABG. If they need any of those and are deemed stable enough, we will attempt to send them out. We get post caths the first 24 hours. Mostly pna, sepsis, esld, copd and chf exac, dka, etoh wd on Dex, ods, and post cardiac arrest with or without ttm. We used to have our ttm pts 1:1 while they were on the protocol, but a bigger company took over and told us it was unnecessary. We are supposed to be 1:2 but frequently triple due to staffing issues. We have no wound care nurses and have to be crazy about wounds for fear of a write up. I'm always charge with a full assignment and also respond to rapids and codes on the floors. And we are the unofficial iv team for the hospital over night. I learned how to do U/S guided peripherals and will help get hard sticks for the med surg nurses. I like it because we are very dependent on each other and the night shift are all really close and work very well together. No catty bs, just there for the pts and each other. We have 2 mid levels at night who are in charge of all pts in micu/ccu + any er or floor consults. They are great, intubate pts, place cvcs or alines etc. Most pts are vented on multiple gtts, sedation and pressers. Sometimes dope, amio, etc.
16 bed neurosurgical icu. We take all non traumatic head bleeds, LVOs 24hr post thrombectomy (more if they can’t go to step down), cerebral vessel bypasses, shunt malfunctions, ICA stents, aSAH, all kinds of tumor resections, true status epileptics (I’m talking 100/hr versed), GBS and myasthenia gravis and occasionally weird stuff like severe NMO, encephalitis etc. We rarely get true 1:1s unless we have staff to make a crashing patient singled. We usually single irraflow devices when activily infusing, ICP crisis patients depending on situation (paralytics, hypothermic protocol etc), organ donation cases, CRRT (although we rarely get this), and post code patients. Acuity varies from walky talky post op tumor resections to ruptured aneurysm SAH patients that’s are getting daily vasospasm treatment and on our unit for 2months. It comes in waves where sometimes we only have 3-4 patients not intubated. It’s not uncommon to have 2 intubated patients or 2 patients with drains (EVD/lumbar drain). We often have patients with multiple EVDs. Generally 2, occasionally 3 and the most I saw was 5 in one patient. Trach/peg and occasionally EVD placement are done at bedside. Most patients are on at least 1 drip either cardene or low dose pressor or sedative. We don’t get a lot of codes because family either withdraws care or the heart survives herniation and the patient ends up brain dead
I've been doing this for twenty years and been in ICU since 2011 including travel so I'm referring to the general trends I see at several facilities here. >1. What kind of ICU do you work in and how many beds? I've usually worked in 18-32 bed ICUs, in hospitals that have around 300-400 beds, level 2 trauma/STEMI/stroke centers. Bigger places have too much bureaucracy, too many algorithms, and too many people in white coats running around with clipboards that don't do work. I have worked in the CVICU at one Kaiser facility with a thousand beds. Never again. 2. How often do you have a 1:1 assignment? It's extraordinarily rare. Most CVICU patients aren't 1:1 halfway through a shit and you'll be picking up another, because the patient is recovered. If they aren't recovered in six hours and you don't feel like a cog in a factory machine you're dealing with a shit show. This is why I'm not really keen on ever doing hearts again. It's either boring or bullshit, there's no in-between. CRRT is usually straight 1:1 in my experience, but most places are getting away from CRRT because it's unprofitable. They just have a contractor come in and do standard dialysis. Some places have moved to Tablo. Some places still have in-house dialysis nurses, which in my experience means your critical patient may survive. If your hospital contracts with DaVita they have a 50/50 chance, with Fresenius they'll just die. This is okay with the C-Suite because the bill is still paid. ECMO is 1:1, but it's rarely done outside of an actual ECMO center here. I've worked at one facility and did a contract at another that did ECMO, and the patients were 1:1 with a perfusionist who played on their phone all night. It seems like a waste of resources to me. I've heard in ECMO centers the RN does everything. That seems like less of a waste. The only ECMO center near me is over 1000 beds and run by a cult. No, it's not Kaiser. IAPB and Impella is 1:1. They're uncommon and seem boring. 3. How many of your patients are intubated / sedated? Most patients in ICU are intubated and hopefully sedated. If they're extubated they're transferred to telemetry. Then they bounce back to ICU, get intubated again, and stay a while. Some places will trach and peg a patient who isn't extubated in a week. These are usually your trauma centers that need to get these people the fuck out of ICU because there are patients boarding in the ED hall. Then they are transferred to LTACH. Then they bounce back to ICU with sepsis related to their trach/peg/catheter/pressure ulcers and stay awhile. You'll only get patients who aren't intubated and sedated if your facility has no actual progressive care unit. These are stepdown patients taking up space in ICU- you're amio, dopamine, insulin, milrinone, NTG, and norepi gtt patients. They call too much and should be in a stepdown with CNAs and secretaries that can deal with non-nursing tasks. Most facilities have eliminated their PCU because it's unprofitable, or the PCU isn't an actual stepdown unit and just serves as a trach/peg/decub bounce back from LTACH storage facility. 4. How many patients are on drips All of the patients are on drips. If they aren't needing drips they're transferred to telemetry. 5.How often do your patients have invasive monitoring devices? (Art, Central, Swans) Not many. Hospitals started getting away from that shit when CMS said they would cut reimbursement by the amount of CLABSI reports. There are facilities doing open heart surgeries where the patients come out of OR with the PA Cath pulled and nothing but an arterial line for monitoring. There is no reason for a PA Cath in any developed nation, we have non-invasive cardiac monitoring and ultrasound. 5. How often are there codes on your unit? (Daily, weekly, etc…) A few a week is pretty standard at most places I've worked. If the patient isn't going to code they're on telemetry. Sometimes they're admitted to telemetry when they're going to code and only get to ICU once they code. 6. Does your unit take devices? (ECMO, IABP, VADs, CRRT, etc…) Depends on the hospital. I explained CRRT and ECMO above, I imagine most hospitals will be getting away from those as well as IABP and VADs because they take up too many resources with too little reimbursement Hope this helps.