Saturday, September 26, 2009

Question to All My L&D Nurse Readers!!!

Things have been super busy/crazy/insane at work these last several months (welcome results of winter "coziness"!) and it has led us night shift people to think about our staffing situation. I'm asking for your advice/input/ideas!! My question is...how are you staffed on your units? What have you found that works best and what doesn't? How do you handle putting nurses on call? Any suggestions would be MORE than appreciated!!

A little bit about our unit...

We are a 17-bed L&D unit for both labor/delivery and antepartum. We average between 320-340 deliveries a month during most of the year, closer to 300-320 during the winter. We don't have a separate antepartum unit/rooms nor a triage area. We have 17 rooms that we use for all of the above. We triage/labor/deliver then after 2hr recovery move patients to postpartum.

We have 2 OR's and then 4 separate PACU rooms for our 2hr C/S recoveries before we move them to postpartum. Our L&D nurses do both vag and C/S deliveries, and then we are are the ones who are responsible for moving them to postpartm (a good 30minute process). Unless we have to we don't usually have both a C/S recovery and triages out on the floor. If we take a C/S back we're "in the back" until that recovery is over.

We have NICU nurses staffed in our well-baby nursery and the NICU "admit" nurse comes to all our deliveries to catch our babies.

We have one charge nurse who is over L&D/postpartum/NICU and our Women's & Children's unit (usually an extension of M/B but can also take GYN surgeries/peds patients). The charge nurse doesn't do patient care.

We are usually staffed 4:1 antepartums, 2:1 or more often 3:1 labor patients and whoever can handle it takes the next patient that walks through the door. If we have Mag patients we are usually 2:1 as along as they're somewhat stable, sometimes have a mag patient + a labor or something else.

Our L&D nurses can all float to mom/baby and if we're OK on labor and M/B is short then we get floated. None of the M/B or NICU nurses float to L&D.

Our core staffing is minimum of 3RN's. Most of the time we're staffed with 4-5RN's/night. If we're lucky we'll have 6 or 7. We usually have 2-3 scheduled cervidils on the weeknights plus a 0730 C/S that comes @ 0530. Day shift usually brings in between 10-12 RN's. If the day charge nurse thinks we are overstaffed for the night shift someone (rotates by dates or requests) is put "on call." If we need the "on call" person during the shift they have to be there within 30min of being called. If you get "called in" before the shift is half over (0100) it's time-and-a-half 'till 0100, and if you come in extra it's time-and-a-half.

9 comments:

  1. Wow that sounds busy! I'm hoping you get some helpful responses! The 2:1/3:1 to laboring moms is interesting (not unexpected though). I wonder if that's the most usual situation? I'd be really interested to know what other nurses' ratios are...

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  2. We do about 400 births per month, and over 1000 triage/outpatient visits per month. Needless to say, we are a very busy unit.
    We have 14 LDR rooms, 8 triage beds, 3 ORs, 4 PACU beds. Antepartum is a separate unit, unless the patient is high acuity, then she is on L&D with us.
    PACU time is 30-45 minutes after a c/s. Recovery time after a vag birth is 1-2 hrs. Our unwritten goal is to get the beds turned over as soon as we can when it's super busy, because we have people lined and up and waiting for the beds.
    Staffing - 10-12 RNs on days, 8-10 RNs on eves, 6-7 RNs on nights. All scheduled c/s are done between 0730-1300. Inductions: 4 inpatient inductions scheduled on day shift if there are 3 c/s. If there are 4 c/s, then only 3 inpatient inductions. We can have up to 6 scheduled outpatient procedures on day shift (NST, OCT, PG gel, cytotec, version). There are always many more outpatient/triage visits added on to that as the day goes by.
    Evening schedule: up to 2 inpatient inductions, 3-4 outpatient procedures. Nights do not get inductions or procedures scheduled. Not enough nurses on nights, and many overflow of patients from days and evenings.
    Charge nurse covers L&D, OR, PACU, and triage. She takes a light assignment and is included in staffing numbers.
    Each RN is required to call for a 2nd RN for each vaginal delivery. Sometimes there is no one available to 2nd at a delivery. But we try our hardest to have someone there to 2nd for the actual birth itself - even if the 2nd RN cannot stay for more than a few minutes to help out with the post birth clean up and charting/patient care.
    All RNs are expected to circulate or do baby care and recovery room for c/s. Many RNs can also scrub for c/s. We mainly use our OB techs for scrubbing though.
    Staffing ratios: depends on what's going on in the unit. We try to stick to the AWHONN guidelines as much as possible. We also have a computer program that figures out our staffing for us. It's a guideline though - the charge nurse has discretion on whether to call in the on call staff, or send staff home on call.

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  3. I tried to comment, but my comment must be too big. Got an error message :-(

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  4. Hi there! I am not a nurse (although would love to be) however had a question. You quoted, "We average between 320-340 deliveries a month during most of the year, closer to 300-320 during the winter." What is the reasoning behind that? Any ideas? I have Oct, April and 2 June babies. I love your blog and read it often! :o)

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  5. I work in a much smaller unit, we have 8 LDRP's, we always have 2 nurses/shift. One nurse does L&D, one nurse does mother/baby. We all rotate between the two. We also always have a CNA scheduled and an on call RN. If we have 2 inductions/C-sections or more scheduled, we get a 2nd nurse on call. We also have the antepartums on our unit. We do have 2 overflow rooms that we can put postpartum pts in (not labor pts as they don't have the capability of the central fetal monitor). We never have more than 2 labor pts at a time (this is the national staffing standard - you wouldn't have a leg to stand on if you ended up in court and it was found that you had more than 2 labor pts at a time.) If we have a pt on MgSO4 in labor, that is always 1:1. After delivery and she is stable, we might have one other mom and baby but never more than that and only if we are busy and have several moms and babies. I have worked in much larger units and love this job the best of any of the L&D's that I have worked in.

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  6. Hi Birthday Nurse! I read your blog often and love it. My input may not be very helpful since the hospital I work at does a considerable higher number of deliveries. We're one of the busiest if not the busiest in the country with 19,000 deliveries a year.

    In any given day we do around 30-60 deliveries and have anywhere from 30-45 nurses on staff including the charge nurses.We have about 50 labor rooms and 25 high risk rooms. Our labor rooms are organized into "pods" with 6 rooms to each pod making a total of 8 pods. There is a team leader for each pod who doesn't take patients. They are there to help out the 3 nurses assigned to that pod and watch over paitents if the primary nurse is doing and epidural or delivery. We never take any more than 2 labor patients ever and never any more than 3 antepartum. Our high risk/antepartum unit is seperate.

    We usually have anywhere from 15-20 scheduled c/s with 6 Or's and 10 PACU areas. If we take a c/s back then we basically take them and help the circulating RN prep, give report and then come back to our original assignment.

    We have a seperate charge nurse for each area(OR, High risk, LDR's) including a charge nurse over everything. For vaginal and c/s deliveries we have surgical techs that scrub in and assist, there are never 2 RN's in any delivery unless there's some problem. The scrub techs do all of the baby stuff and there are usually 1-2 scrub techs assigned to each pod and that works out very well as far as deliveries go because the RN's don't get caught up doing baby care and they can assume care of their other patients asap.

    When we come in for our shift we are assigned to one part of the unit and thats where you stay the whole shift, for instance if your name is in high risk then you wont have labor patients, you'll only have high risk patients that day in that specific area. There's usually about 10 Pitocin inductions in the am and about 10-18 cervidil/cytotec inductions for nighttime. Hope maybe this was possible helpful in some way.

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  7. Hello! I work in a 14 bed L&D unit, and we have a 6 bed triage area and a separate 12 bed antepartum unit. We usually do about 20 deliveries each day, but recently we've been extra busy. There are about 10-11 L&D nurses on the day shift plus one nurse who can be called in if needed, but that includes the charge nurse, a triage nurse, a float nurse, and a nurse who floats to APU if needed. In L&D, we typically have 2 laboring patients, and we usually keep both patients until one is complete and ready to start pushing. We might also have a mag recovery patient and a laboring patient or two mag recovery patients. If we start the shift with one laboring patient, it's only because that patient is already 8-9 cms or because we're about to be assigned an admit from triage or an induction. Nursery nurses are not present at our deliveries, but we call NICU to be at any c-section, vacuum or forceps (rare) delivery, meconium, non-reassuring strips if they're bad enough, etc. After each delivery, the float nurse or another nurse who is available tries to come help with the immediate baby stuff of APGARs and vitals. Sometimes no extra nurse is available, so we balance mom and baby ourselves. If one of our patients is getting an epidural, someone will watch our other patient during the procedure and for the 30 mins following it. We recover our own patients for an hour after delivery, and we are 1 on 1 during that time. The recovery is in the room with mom and baby for vaginal deliveries, and it's in PACU with just mom if it's a c-section. If APU has more than 6 patients, an L&D nurse is sent up to help the APU nurse. The APU nurse to patient ratio is 6:1. We never float to postpartum, nursery, or help in the MFM unit for testing.

    1 of my shifts from this past week (busier than the norm!)
    2 vaginal deliveries and recoveries, baby nurse for a delivery, a c-section of twins and PACU recovery, and an admission/Pitocin induction at the end of the day

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  8. Hello, I'm searching for nursing related blogs like mine http://nursingcrib.com and I stumbled your site, nice blog!. I hope you could also include me in your blogroll.

    By the way, you have a very good writing skills here. Keep up the good work.

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  9. I work in a 15 bed L&D, with a 5 bed triage unit, 4 bed ATU,3 OR's and 4 bed recovery. We staff 8-11 on nights and 7-12 on days. We do around 400 deliveries a month. Although Sept this year was crazy and our total was 507.We have a level III NICU. Nicu only attends our vag deliveries if there is complications such an no pnc, mec, preterm... Otherwise, it's the RN and ST. We have 1 hour long recoveries for vag deliveries and c-sections. Transport is called to transport to out MB unit. We also staff MB when things are busy, but no one is able to come help us. We are 1:1 with deliveries and recoveries. Staffing is 2:1 with any other pt. Babies stay with mom for up to 1 hour and then they go to nursery. No one under the age of 16 is allowed with mom and mom can only have 3 people in the room at a time, but may switch out as often as they like.

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