Medical Intensive Care/Intermediate Care — Unit 11-4

Unit UF 11-4 ICU/IMC, is a 24-bed inpatient adult medical intensive (ICU) and intermediate (IMC) care unit located on the eleventh floor in the North Tower.  The unit consists of large private ICU capable rooms including four negative isolation rooms. Monitoring of patients includes 24 Philips IntelliVue MX750 bedside monitors each capable of monitoring ECG, NIBP, invasive pressure monitoring, temp, CO2 monitoring and oxygen saturation. Additional monitoring capability for invasive pressures monitoring and continuous cardiac output via Edwards Flo Trac/EV1000 monitoring.  All monitoring parameters are transmitted via hardwire to the central station having capability to print ECG strips using a strip printer and other parameters using a laser printer. UF 11-4 ICU/ICM provides treatment for patients requiring complex stabilization and care. Care is provided 24 hours per day 7 days per week.

Description of Patient Populations

UF 11-4 ICU/IMC provides intensive care nursing for high-risk medical patients. Common diagnoses of patients include respiratory failure (i.e., COPD exacerbation, asthma, cystic fibrosis, pneumonia and COVID pneumonias), non-invasive and invasive multi-system failure / sepsis, GI bleed, infectious diseases, endocrine dysfunction including diabetic ketoacidosis, post cardiac and respiratory arrests, and cancer.  Patients on this unit include adults and older adults.  Average length of stay in the 11-4 ICU/IMC is 5-7 days. Patients are admitted from the Emergency Department, referred from other hospitals, patients transferred from med-surg units requiring a higher level of care or who have had a worsening in condition, and patients requiring complex cardiovascular or pulmonary management and intervention.  A team of healthcare workers, admitting Attending physicians, Fellows, Residents and Interns as well as specialists as requested by the medical teams, nurses, social workers and ancillary personnel work together to provide this excellent care and service.

Nursing Care

Nursing care is based on the total patient care delivery model with co-worker assistance that is focused on the assessment, diagnosis, treatment, evaluation, and monitoring of the critically ill adult patient.  Special emphasis is placed on the use of critical thinking in the ongoing assessment of the ICU and IMC patient populations. Nursing activities include hemodynamic (arterial, central venous pressure, pulmonary artery pressures, intra-abdominal pressures, arterial and venous oxygenation and capnography) monitoring, rhythm interpretation, fluid and electrolyte monitoring, vasoactive and inotropic therapy, respiratory management in both mechanically- ventilated and spontaneously-breathing patients, postoperative recovery, specialized wound care, nutritional therapy, medical management, rehabilitation initiation, and comfort/palliative care measures as indicated.  Patient and family education and emotional support related to the patient’s condition and treatment is an essential element in the nursing care provided. Nurses utilize a multi-disciplinary plan of care to deliver consistent goal directed care.  Patient and family education and discharge planning are also important components of nursing care delivered in the unit.

Health Care Team

The Medical Director of UF 11-4 ICU/ICM is a physician who is board-certified in pulmonary medicine.  The faculty and residents provide 24-hour medical care of the ICU patients 7 days per week.  Scheduling of rotations is maintained through the Department of Medicine. Multidisciplinary, comprehensive care of patients and families is provided by medicine, nursing, social work services, case management, pastoral care, food & nutritional services, pharmacy, rehab services, cardiopulmonary services, and other health care providers as indicated by the patient’s health status and identified needs.

Nursing Leadership for the unit includes registered nurses in the positions of Nurse Manager and Clinical Leader. The Department of Nursing staff is provided training experiences to attain and maintain competence as defined by the unit and role specific job descriptions and departmental education plan. Monitor support techs are responsible for monitoring telemetry alarms, providing clerical support for the direct patient caregivers, and function as a unit-based mobility team encouraging and assisting with early mobility. The Registered Nurse is responsible for guiding care of the patient based upon the individualized plan.  Nursing care delivered by Patient Care Assistants is coordinated under the direction of the Registered Nurse. 

Staffing Plan

Nursing care on UF11-4 ICU/IMC is based on the total patient care delivery model (as described in the Hospital Plan for Nursing Care) with coworker assistance. Unit support tech coverage is available 24 hours a day. Skill mix is RN 100%.  Each RN is assigned 1-2 ICU patients. On all shifts, the Charge Nurse (CN) is available to all staff for consultation and assistance in providing patient care.  Patient care assignments are made each shift by the CN, as described in the Hospital Plan for Nursing Care.  Patient bed assignments are made by the CN and are based upon patient safety concerns, monitoring capabilities, and skills required for care delivery. Additional unit-based considerations for staffing needs include:

  • Complexity of the patient’s condition (frequency of procedures, emotional needs, physical care needs)
  • Technology required
  • Relevant safety and infection control issues
  • Previous day’s assignment to provide continuity of care
  • CSO/float RN’s will not be assigned patients who are outside their competency/skill level
  • Patient transport requirements

The staffing plan is based on a budgeted ADC of 12.78, HPPD 26.06, HPWI of 6.2, and acuity of 2.59 and adjusted for the skill mix as identified above.  Adjustments to staffing are reflected in the Targeted Staffing projections defined by staffing grid loaded into the Shift Wizard scheduling system. Additional staffing needs are met as described in the Hospital Plan for Nursing Care. The Nurse Manager or designee, in accordance with the Hospital Plan determines the need for extra shifts/overtime for nursing care.

In the event of an emergency such as severe weather conditions or other disaster, the minimum amount of staff required to safely operate up to 75% capacity would be 12 Registered Nurses and 1 Support Tech.

Requests for Paid time off (PTO) will be reviewed on a case by case basis and will consider the staffing needs of the unit. 

Staff attendance at meetings, education offerings, Council meetings and other activities are coordinated so that patient care coverage is continuous.  Staff is granted time for educational programs by requesting Administrative Leave for off unit continuing education activities.  Mandatory programs sponsored by the unit are given during shift hours or staff is paid to attend.

Staffing Decision Points

When assessing staffing at “break points” take into consideration the following:

  • Planned admissions (hospital to hospital transfers)
  • Skill level of staff
  • Acuity of pts (#of 1:1’s and borders)
  • Available resources (stat nurse, management team members)
  • Float for 4-8 hours only and reassess
    • Notify Nursing Coordinator if workload changes to negotiate clinical support.

1:3 Patient Ratio for IMC

1:2 Patient Ratio for ICU

1:1 Patient Ratio for Higher acuity ICU

  1. Unstable hemodynamic, frequent titration of multiple drips
  2. Post arrest hypothermia patients may be paired depending on acuity of patient
  3. Massive GI Bleed of Massive Transfusion of patient
  4. CRRT unless stable and could be paired with a more stable patient in close proximity
  5. Patients requiring specific drug desensitization per order set
  6. Some DKA patients

Addendum:  Plan for Unit Coverage

  • When no CSO or Float help is available:
  • Can assignments be adjusted to pair patients as acuity allows?
  • Are 1:1’s due to unit geography? Can patients be moved to facilitate pairing?
  • Are schedule manipulations possible; evaluate numbers for the week.
  • Contact staff who may be interested in extra worktime.  Ask what shifts they are willing to cover, work extra, or switch to.
  • Ask current staff if they are willing to stay and work extra/overtime.
  • Evaluate orientees ability to come off orientation or operated in an expanded role with their preceptor.  This can only be considered if the orientee has been on the unit greater than eight weeks (for inexperienced nurses) or greater than a week (ICU experienced nurses). 
  • Evaluate whether the charge nurse is capable of coming into the numbers.
  • Ask Nursing Coordinator for help outside of our usual float pool – do we have med/surg boarders and a MS nurse can manage, same with IMC float nurses. 
  • If all possible resources have been evaluated and implemented to the best of your ability, notify on call unit management team member.

Updated January 24, 2022 JB

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Jennifer Zimmerman, RN, explaining to a parent and her daughter how to use a bedside asthma action plan.