“That baby could have died. We need to fix our dangerously understaffed NICU.”
Part of a series: COVID-19 — Nurses’ Notes from the Front Line
by Teresa Rowe, RN
Twenty years ago — before we were designated as an approved neonatal intensive care unit (NICU) by California Children’s Services, and back when we rarely had an infant who needed to be on a ventilator — my hospital asked the California Department of Public Health (CDPH) for a “program flexibility,” which allowed management to schedule too few RNs on the floor caring for these most vulnerable patients.
Fast forward 20 years — we now have a state-of-the-art NICU where every single baby admitted to the unit is extremely high-risk, requiring intense NICU-level care. During those same 20 years, the hospital also drastically slashed the schedules of support staff like Nurses’ Aides, Monitor Techs and Unit Secretaries. Yet CDPH still renews that staffing waiver every year, allowing our hospital to understaff the NICU.
It’s unbelievably dangerous for our tiny patients.
Many of our patients are on ventilators. The endotracheal tubes used on infants are uncuffed, which means there’s an extremely high risk that a distressed baby will pull the tube out. And this is even more dangerous now because our once “open bay”-type unit now has individual private rooms, where our patients aren’t as visible. And like I said, the hospital doesn’t staff us with a Monitor Tech.
California established its minimum nurse-to-patient ratios in 2004. Depending on the level of care a baby requires, ICU Nurses should have one or two patients at the most. The program flexibility allows the hospital to give us three or even four patients each.
I’ve been an RN for 13 years. I planned to major in business at college. Then my mom got cancer and I became very interested in everything that went into her care. She died when I was only 19. I wanted to learn why she got sick, why she died, so I switched majors. After graduating, I went right into the NICU and have been here ever since. I love my job. Technology allows us to do so much for these babies. They wouldn’t survive without it. Not only do we keep them alive, but most go on to have good, strong, healthy lives. Babies are very resilient.
But, of course, it’s touch and go in an ICU. They require constant care and monitoring. And it’s impossible to provide them with the attention they need when the hospital intentionally understaffs us.
Our patients are often intubated, on ventilators. They are sometimes in pain. They need constant consoling. The have IVs. They need feeding. Some interventions need our attention every 10 minutes.
You give me an additional infant, and suddenly all my tiny patients are at risk.
Also, because we’re so understaffed, we can’t always be available to help our colleagues with the many procedures that require two RNs.
Like the time I had a baby with pertussis. He would turn blue from his intense coughing spells. I had to frequently suction him to his clear airways. The baby was in an isolation room on another floor. I was by myself with no NICU resources on that floor. No Nurse Aide. No Respiratory Therapist. At one point when I checked on him, he was having a really bad coughing fit. The mom was there with me. He started to code. I got equipment to bag the baby and I had to have that terrified mom go out and search for help. If the baby coded, I couldn’t do it alone. Typically, a Respiratory Therapist operates the bag while the RN does the chest compressions. A second RN would be pulling up meds. All three have to work together simultaneously. Luckily, the mom found a Respiratory Therapist in the hospital and we were able to bring the baby back.
That baby could have died. We need to fix our dangerously understaffed NICU.
Recently, there were two of us on duty, plus our Charge Nurse. I had one baby on high-flow oxygen. The other Nurse had a similar case, plus another baby. A mom walked in with pre-term twins, one of whom she’d learned would likely not live after birth. The Charge Nurse needed my help with this difficult delivery. There are always supposed to be two RNs in our unit at all times, but we had to leave my colleague alone with all three of the other babies.
As usual, there was no tech, no unit secretary, no aide — no support for the Nurse left alone.
We delivered the twins. The Charge brought the baby back to our unit to provide comfort care to the infant, who lived about an hour. I took the other twin, who went immediately on a ventilator. That baby should have been a “one-to-one” ratio — my only patient. As I tended to that baby, my colleague fed my other patient — the baby who was on the high-flow oxygen. When I went to check on that baby as soon as I could, she had pulled out her feeding tube and projectile vomited all over the crib. That baby could have choked while I was with the twin, unable to look in to know that there was an issue.
Again, we have no support staff. No monitor techs. No one entering the newborns into the computer. No one printing the bands. No one calling the pharmacy, calling radiology for x-rays, sending labs.
One night, a mom walked in and delivered preemie triplets. They were only 27 weeks and all three had respiratory distress requiring interventions. One of them ended up being my patient. All of us working that night already had full caseloads. We just all pitched in and did round-robin. But it was insane. Usually, babies are fed on a schedule, but the schedule was thrown out and we fed them when we could.
A colleague shared with me what happened on her shift the other day. There were two RNs on duty, plus a Charge Nurse. The Charge had to leave the floor to attend to a C-section, leaving the two RNs alone, without any support staff. The phone was ringing off the hook, but there wasn’t anyone to answer phones or open the locked doors of the unit for visitors. One RN had two babies, one of whom was in an isolette (a clear plastic enclosed crib) with an umbilical catheter and on oxygen. The other RN had two babies on oxygen that required her to be in full PPE with an N95. One of her babies started having a dangerously low heartbeat and resulting low blood oxygenation and required intense intervention. At the same time, the first RN was attending to her baby with the umbilical catheter, applying pressure to a line she’d just pulled. Suddenly, an unfamiliar alarm went off in the second RN’s other room, but neither RN could leave their babies. About 30 seconds later, the floor manager and the Charge Nurse ran by. The baby had an episode while in the mother’s arms. She couldn’t get anyone’s attention, because no one was there. She was panicking (rightfully so) and pulled the code button on the wall. It’s difficult for parents to get our attention in the new unit, because there aren’t any call lights.
On top of all of this, the hospital often uses the dangerous “buddy system” to provide us with lunches and breaks, where one RN is left to watch over a colleague’s patients during their break, because there’s not enough staff on the floor to provide safe coverage. When that happens, a nurse can be left in the unit with up to six patients by themselves.
It’s impossible to safely care for all of our patients this way. Let alone give the kind of individualized care and parent education that we were trained to provide. The kind of care we long to provide. The kind of care that babies and new parents deserve.
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RNs like Joe support California Assembly Bill1422 — the proposed “Patients’ Right to Know” law, which would expose hospitals’ dangerous practice of sidestepping nurse-to-patient ratio regulations.