Staffing - Due 3-8 - Question 1

Angie:

• Nurse to patient ratios would be helpful

• They exist for in-patient, but it's more of a guess for outpatient

Pam:

• Acuity tool can be a great way to see whether or not additional staff are needed

• Painstaking review of previous visits, ranking 1-5, how they changed over time; tried to do a calculation based on the proposed time to see how well it would match up to FTEs

• This was how they made a proposal for new staff--looking at acuity retrospectively

• What are the key components of an acuity tool? Would it be possible for institutions/centers to pick and choose elements?

Val:

• Facility hasn't found an acuity tool that works for them

• Didn't reflect what was happening in actuality

• Knows that there are tools out there that might work, keep looking

• Previously has been helpful and beneficial to use acuity tools--good for charge nurses, but also good for staff nurses to see how each patient fits in the puzzle and understand the assignment better

Amanda:

• Anecdotally, via networking, larger institutions have stopped using an acuity tool

• Wasn't working for them--nurses could have an acuity has high as 30 or 35

• Not just the agent

• The acuity tool in use at Morristown has helped gain needed staff--started with 6, now have 15 or so nurses

• Not just about planning the day, also about planning the future

• Could there be a tool to level the complexity of a patient?

• Institutions might be looking for acuity tools, especially if it's more reflective of reality

• Can we figure out how to make an acuity tool with value added?

• Patient/treatment factors

• Different regimens, if first time getting an infusion that might cause a reaction vs. the eighth time

• How to account for those differences?

• Charge nurses looking at different acuity levels for patients, higher acuity that might have a reaction split among the staff who are working

• Staff is split across locations based on acuity--try to make it as fair as possible across locations

• Try to make it so nurses have equal number of high acuity patients when they get their assignments and spread throughout the shift

Amanda:

• Same at Morristown

• Try to make it fair, doesn't always work

• Try to keep the acuity assignments fairly level

• Acuity tool at Morristown based on Cleveland Clinic article

• Levels 1 - 5 (5 is hardest)

• Levels don't go above 5, but they should

• Just because the acuity is 1 doesn't actually show the patient situation/complexity

Val:

• Rarely would a nurse get two new starts/new infusions

• Supervisor the day before can impact it

• Try to give a cushion of time in case there is a reaction whenever possible, banking on an issue 30 minutes to an hour in

Gigi:

• Unpredictable things--on paper it looks good, well-planned, but a level 1 can end up taking more time than someone who is a level 5

• Back and forth communication between nurses taking care and a charge nurse helping out--"Let me know if there's a cancelation or an add-on"

Christina:

• Attempted to create float pool for RNs, but the floats get tired of floating and when a permanent position opens up they move into that

• Hard to keep float nurses on--even offered $1 more an hour to keep them in the float position to incentivize

• Has worked for one of the nurses, but also the type of nurse who likes things to be different every day, likes to be busy (hard to find)

• Seven locations throughout Las Vegas

• Not enough nurses in the float, they will have to pull full-time nurses from centers with lower acuity or less busy sites

• Try to utilize per diem RNs--at the mercy of when they're available to work

• Float nurse designated to west side of city, but floated to all locations during orientation so she would feel comfortable floating there

Amanda:

• Do float nurses have trouble grasping the work flow if they float and aren't at a site full time?

• Amanda has spoken to float nurses who have trouble with that.

• Difficult for a site that is heavier--worried they might not acclimate to the areas they might be assigned to

Gigi:

• Has also seen that float nurses want a "home base"

• Instead of a pure PRN, two full-time floater employees; trained for infusion and that is where they're used

• Float across any of the sites (wish they had 6 of them)

• If there is a call-off at a site at a site with 2 or 3 RNs, the charge (float?) nurse can go where they're needed

• Theoretically could go into the clinical space, but pretty much 100% of the time they're filling in for infusion (across 18 centers)

Angie

• Front desk then has to ask a lot of questions about scheduling

Gigi:

• Staggered start times

• Mix of full-time and part-timers

• Ask for part-timers to give extra shifts for high acuity days

• Patient treatment schedule

• Try to level-load the week

• No matter how many templates they give the scheduling team or how many times they review, they can't get 50 patients across the board

• 82 patients today, 75 tomorrow

• Never really know how to staff--have to do staffing by the week, but that isn't practical or preferable

• Normally have 12 nurses scheduled

• Might need 12 on Monday but 7 on Wednesday

• On-call to handle increased need?

• Staggered staffing? Nurses working 7-7, 7:30-5:30, 7-5

• Nurses coming in 10-6? Could be something to explore because of how inundated they get around that time

• Fridays and Mondays are the heaviest days, ask per diems for extra shifts

• Too high of a patient load/acuity so then the front desk can't schedule unless it's through

• Blood/blood products done at the same site

• Pharmacy and lab--how do we schedule, staff, bring patients in

• Have to account for pharm and lab, too

• If staffing for 6 nurses to start at 7:30, the pharmacy and lab can't accommodate all starting at the same time

• Sites that do transfusion--dependent on lab/pharmacy as well as blood banks

Pam:

• Are pediatric centers usually different from adult centers? Are adults and children treated at the same center?

• A possible consideration--overall maybe tackle adult infusions

• Considerations may be the same, but if everyone is working with adults it might be good to keep the focus on adults

Val:

• Both are separate and ne'er the twain shall meet

• Apples to oranges

Gigi:

• Also separate

Angie:

• Pediatrics/family dynamics

Gigi:

• Sometimes it's not the patient who requires the most care--it can be the caregivers if the patient is elderly

• Sometimes older patients bring caregivers who are just as physically ill/mobility issues, etc.

• Not sure who to turn to first in that case

Gigi:

• Mix of staffing -- RN, MAs, LPNs

• Level of experience of people in unit

• Overall operational risk

• What are the responsibilities?

• Is there a cross-over between infusion and clinic?

• Links between acuity and intensity of patient care

Angela

• Size of infusion center is another big factor

• Satellite campuses

• Some have few chairs, others have many chairs

• If someone is sick or quits, nurses have to travel to get to other sites

• Size/safety

• How many people do you need to ensure patient safety?

Becky:

• Also run outpatient ambulatory infusion service with the medical oncology infusion service

• Has presented its own set of challenges

• Have to trade/borrow staff back and forth

• Completely different referral processes, EMRs, schedules

Susan:

• Typical day--so many add-ons

• Much different depending on volume, but can have as many as 7-10 add-ons in a day

• Can alter assignment needs

• Hard to plan assignments even in the best of circumstances

• Assigning add-ons gets very chaotic.

Amanda:

• Same at Morristown

• 9:30-11:30 11 phone calls in a row

• MWF patients have to wait 2 hours because the clinic is behind

• The schedule can look nice and planned out, but outside factors affect that

• May or may not have enough staff, but the outside factors create significant issues

• The 10-2 hour scrambling

• Trying to get a lunch, support peers to get assignments done

• 7-9 hour in the morning hanging around waiting for patients

• 3-7 hours hanging another drug or taking everything down

Angie:

• Mix chemo

• Chart review

• What are the duties outside of patient care?

• Types of patient care?

• Heavy clinical trials

• Outpatient transplants

• One on one carries

• Quantify those things before even considering other

• Institutional model

• Facilities trying to go back to traditional model with only nurse staffing, no supportive personnel

• Is there anything hindering us to get different roles to help out with patient cares

• Those will all play into the different roles in staffing