Staffing Nurses and Refactoring A Hospital Layout

A few days ago I talked about the number of nurses that it takes to take care of a patient in an Intensive Care Unit (ICU). I want to expand on that a little more, based on my experience being married to an ICU nurse during "times like these".

A quick recap - for most ICUs, the typical ratio in a single shift is 1 nurse for every 2 patients. For certain situations, this could jump to a single nurse for every patient. When you factor in 24/7 coverage, this comes out to somewhere between 2.5 nurses to 5 nurses per patient (or bed).

Vanderbilt's Medical Intensive Care Unit, has 35 beds with a 1:2 (ideally) ratio. Based on the 2.5 or 5 nurse / bed ratio, this means that MICU should have somewhere between 88 and 175 nurses that work in a given week, if the unit is full.

For a stepdown unit, the ratio is closer to 1:4. For example, Vanderbilt's Medical Cardiac Stepdown unit (which is where MICU patients usually end up) has 37 beds with a ratio of 1:4. This means they optimally would be scheduling 47 (or more) nurses to cover 37 full beds for a week.

Enter COVID-19

When COVID-19 hit, and it looked like the hospital would need to handle more patients, they started to move some rooms around. MCE8, where the Medical Cardiac Stepdown unit was located, got moved to elsewhere in the hospital. The rooms were re-purposed to be a dedicated COVID unit. The choice to move it to MCE8 appears to be two-fold. First, it is located within a short distance from the MICU, making it easy to transfer patients. Secondly, the rooms are equipped with the right hardware:

MCE8 patient rooms have built-in features such as dual ports for fluids suctioning and delivery of medical gases, allowing the unit to accommodate intensive care beds as needed. As of April 2, the unit had 27 standard floor beds, complemented by 10 newly installed intensive care beds.

Not all rooms in a hospital would have some of these "built-in" features, meaning converting more rooms would have an increasing level of difficulty (see TMC in Houston, and their Phase 2 / Phase 3 - maybe Phase 2 covers rooms that can be quickly converted, I am not sure though).

From what I have heard from my wife, the ratio of ICU to step-down (10:37) has fluctuated some, with some of the standard floor beds being converted to ICU beds.

Let's get back to nurse staffing for a bit. In its documented configuration from April, MCE8 had 10 ICU beds and 27 step down beds. That means 25-50 ICU nurses, and 34 stepdown nurses would be needed per week. If that has shifted to 20:17, that means 50-100 ICU nurses and 22 stepdown nurses, and if that unit were converted entirely to ICU beds, they would need 93-186 ICU nurses.

Back at the top, I said that a fully occupied MICU would need 88-175 ICU nurses. If MCE8 is fully converted to ICU beds, that unit is already larger than the existing MICU.

Nurses are not Robots

Nurses are not units of production that can be rapidly repurposed from one type of nursing to another. Nurses are very smart, but the skills do vary quite a bit between different units. There are different technologies (ex: ventilators, ECMO and CRRT) that are used in ICUs. ICU patients can be on more complicated IV medication mixes. My wife received training for ECMO and CRRT, but it was something she learned over the course of days, and had the opportunity to practice before there was a crisis.

So, when COVID hit, and her hospital opened up a dedicated COVID unit, they staffed it with the nurses that knew how to best treat patients with the symptoms of this particular disease. The sickest COVID patients have symptoms that mirror severe cases of the flu, pneumonia, ARDS, and other respiratory problems. These kinds of patients typically end up in the MICU. So in addition to nurses from the CDRU (a special group of nurses with additional training formed in response to the 2014 Ebola outbreak), that unit is staffed primarily with the existing nurses from MICU.

The MICU still sees a lot of other patients - flu, pneumonia, respiratory issues have not gone away. So, when my wife goes to work, she is usually joined by a lot of travelers (contractors) and nurses who have come from other parts of the hospital. Because there is still a lot unknown about COVID, hospitals are taking the nurses who have the most experience with those kind of symptoms and putting them in the dedicated COVID unit, and then back-filling their ICU positions with contractors and nurses from other units.

When Things Get Worse

What happens then when dedicated COVID units are full, and normal ICUs are full? Thankfully with many elective surguries being cancelled, other parts of the hospital are more empty than normal, so you can re-purpose staff from those areas to work in the ICU. But, as things "open up", you need those nurses back in their normal homes. You can start bringing in more contractors (expensive).

If things get really bad, you have to let the staffing ratio slip - maybe have one nurse per three beds, or more. But when that happens - patients do not get the attention they would normally get. If a nurse is already busy tending to the medical needs - IV's, vital checks, responding to alarms, moving patients so they don't get bedsores, and all of the other 100's of things they do throughout their shift - going to a situation where they have to take care of more patients means less work per patient can be done.

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