42 Pediatrics is an 18-bed inpatient unit located on the fourth floor in the North Tower of UF Health Shands Hospital. The unit consists of eighteen private, laminar air flow rooms including two negative pressure-flow rooms. Bedside monitoring capabilities include continuous pulse oximetry, EKG, respiratory rate, and non-invasive blood pressure. Patients can be centrally monitored at the nursing station for continuous pulse oximetry, and remotely monitored for EKG by 44 Pediatrics.
Family centered care is provided to patients on the unit, allowing for one parent to be with their child 24 hours per day. A family resource room is available on the unit for families to congregate, and access information, or communicate via internet. A family room, sponsored by Ronald McDonald® House, located on the 10th floor, offers a place for families to relax, prepare and eat meals, contact family members, and sleep. Showers and laundry facilities are, also, available to families on the 4th floor.
Description of Patient Populations
Unit 42 Pediatrics is primarily an Oncology/Hematology unit. Patients are admitted with a variety of hematological, oncological, immunological, malignant, metabolic and genetic disorders, as well as for stem cell transplantation and treatment of pre/post transplant complications and chemotherapy. Types of transplants include: autologous, syngeneic, allogeneic, or matched-unrelated donor transplants in the form of cord blood, peripheral blood stem cells (PBSC), or bone marrow. The ages of the patients served are newborn to young adults. The average daily census is 11.95 patients per day with an average length of stay of 3.9 days. The unit is operational 24 hours per day, 7 days per week.
Nursing care is directed toward the prevention and treatment of transfusion, chemotherapy, and/or stem cell transplant complications by focusing on assessment, nursing diagnosis, outcome identification, planning, treatment, and evaluation of patients requiring inpatient care. Nursing care activities include: comprehensive care of all body systems, assessment and treatment of comfort (pain, nausea/vomiting, temperature imbalance), treatment of fluid and electrolyte abnormalities, administration and management of intensive medication therapies (antibiotics, antivirals, antifungals, growth factors, chemotherapy, immunoglobulins, immunosuppressants, biological response modifiers, and blood products), and early intervention and treatment of common complications/side effects of transplant/chemotherapy including: mucositis and bowel changes, myelosuppression, graft versus host disease, hemorrhagic cystitis, veno-occlusive disease, tumor lysis syndrome, and sepsis. Nurses also provide ongoing education to the patient and their family/caretakers.
Health Care Team
The Medical Director is appointed by the chairman of the Department of Pediatrics. The Medical Director is board certified in Pediatric Hematology/Oncology. The Division of Pediatric Hematology/Oncology consists of attending physicians, fellows, physician assistants, and nurse practitioners. Patients are cared for by a multidisciplinary team consisting of the attending physician, fellow, residents, interns, physician assistants, nurse practitioners, medical students, registered nurses, patient care assistants, transplant coordinators, pharmacists, child life specialist, respiratory therapists, physical therapists, occupational therapists, social workers, case managers, registered dieticians, chaplains, patient and family services representatives, and the Arts in Medicine and Footprint programs. Collaboration is fostered by weekly referral meetings attended by medical staff, nurses, pharmacists, protocol/research nurses, and transplant coordinators. There are also multidisciplinary daily rounds on the inpatient unit. Registered nurses and patient care assistants provide bedside nursing care. Support Techs provide clerical support for the direct patient caregivers. The registered nurse is responsible for guiding the care of the patient based upon their individualized plan.
The nursing management structure for the unit consists of a Nurse Manager and Clinical Leader. The management team provides training experiences to maintain staff competency as defined by the unit and role specific job descriptions, and the departmental education plan. A Unit Assistant provides administrative support to the unit management team and functions under the direction of the nurse manager.
Nursing care is based on the total patient care nursing delivery model (as described in the Hospital Plan for Nursing Care) with co-worker assistance. The patient care assistant (PCA) is assigned under the direct supervision of a registered nurse (RN). Unit clerical coverage is provided 24 hours/day. Skill mix is 85% RN and 15% PCA. The predominant staffing ratio of nurses to patients is 1:3 on all shifts, and assigned 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 descried in the Hospital Plan for Nursing Care. Patient bed assignments are made by the CN and are based upon patient safety concerns, patient/family requests, monitoring capabilities, and skills required. Patients requiring 1:1 observation as a result of personal safety concerns are assigned a personal safety care attendant, which is supplied through the central staffing office.
The staffing plan is based on a budget of 12.42 HPPD, 8.69 HPWI and acuity of 1.35 and adjusted for the skill mix as identified above. The Nurse Manager or designee, in accordance with the Hospital Plan for Nursing Care and the nursing policy, determines the need for extra shifts/overtime. Adjustments to staffing each shift are reflected by targeted staffing projections, unit census, and acuity of the classified patients (Quadra-Med Classification System). Patient care assignments made by the Charge Nurse take into account:
- Complexity of the patients condition
- Number and type of isolated patients
- Experience level of staff
- Previous days’ assignment to facilitate continuity of care
- Frequency of monitoring, and technological or pharmacological support
- Unit geography and location of assigned patients
- Competency level of supplemental and float staff
- Skill mix
- Complexity of patient and family needs
- Unit activity
The unit scheduling committee is responsible for developing the staff schedules for the unit. Requests for Scheduled Paid Time Off (PTO) are reviewed individually and take into account the staffing needs of the unit. Employees submit their requests for time off in conjunction with the Bid Shift calendar dates. Requests are limited to 2 RNs, and 1 ST and 1 PCA per shift. The following criteria is utilized to determine awarding request for time off: 1) date of PTO request, 2) amount of PTO taken in the past year, and 3) seniority. Requests are granted only if minimum staffing numbers are maintained. Staff is encouraged to trade shifts for day to day PTO requests after the deadline for scheduled requests has occurred. Schedule trades should not incur overtime.
Staff is granted time for educational programs by requesting Education Leave or administrative time for unit projects, attending departmental or hospital committees or councils, etc. Mandatory programs sponsored by the unit are given during shift hours or staff is paid to attend. Staff is paid for attending staff meetings. Staff attendance at meetings, education offerings, and other activities are coordinated so that patient care coverage is continuous.
The Nurse Manager/designee makes decisions concerning overall adjustments for staffing, including the need for extra shifts or overtime, according to unit census and acuity in accordance with the Hospital Plan for Nursing Care. When additional staff is required, the Central Staffing Office is notified and additional staff may be sent, floated or scheduled. If census and/or acuity are decreased, the Central Staffing Office will be notified of float availability, or the staff may be utilized for unit activities such as quality monitoring, performance improvement initiatives, educational programs, in-services, etc. If floating is not required, the staff, may be granted time off per request or on a rotating basis.
Addendum: Plan for Unit Coverage
When no CSO or Float help is available, the CN triages staff & patients in conjunction with the Nurse Manager/designee:
- Can assignments be adjusted as acuity allows?
- Can patients be relocated to facilitate assignments?
- Are schedule manipulations possible; evaluate numbers for the week,
- Is staff available to work additional hours? 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,
- Utilize on call staff if available,
- Evaluate status & abilities of orientees,
- Evaluate role CN can take in meeting staffing needs,
- Request Nursing Coordinator for assistance outside the usual float pool, e.g. STAT RN,
- Request unit management team to staff.
- Collaborate with Nurse Manager/Nursing Coordinator of unmet staffing needs if above measures have not been able to meet the patients’ requirements.