ADMINISTRATIVE POLICY AND PROCEDURE MANUAL

Transcription

1 ADMINISTRATIVE POLICY AND PROCEDURE MANUAL Title: DIVISION OF NURSING Policy No. NS7.82/GENERAL STAFFING PLAN Joint Commission Chapter/Section: Effective Date: 6/10 Page 1 of 18 Source (e.g. document, award, or committee, Publication Status: New I Revised X etc.): 7/91, 3/96, 11/98, 12/01, 11/04, Reviewed 11/ , 12/12, 11/13, 12/13 Cross-Referenced Policy No: NS7.81/GENERAL, NS7.37/GENERAL, NS7.19/GENERAL, NS7.61/GENERAL, NS7.72/GENERAL I. PURPOSE: To establish guidelines that ensures appropriate staffing levels for the provision of patient care. II. POLICY: It is the policy of Saint Peters University Hospital's division of nursing to provide quality patient care through the utilization of competent professional and non-professional staff. Competency is determined by the following: orientation Annual competencies (hospital wide & unit Specific). continuous in-servicing/education license/certification performance evaluation new technology I. STAFFING OVERVIEW The "ANA Principles for Nurse Staffing" (copyright 2005) are considered as the guiding principle for the provision of staffing and quality patient care. Some significant elements of these principles include: Nurse staffing patterns and the level of care provided should not depend on the type of payor. Staffing should be based on achieving quality of patient care indices. Appropriate staffing levels for a patient care unit reflect analysis of individual and aggregate patient needs. The specific needs of various patient populations should determine the appropriate clinical competencies required of the nurse practicing in the area. Organizational policies should recognize the needs of both patients and nursing staff.

2 It is the responsibility of the Nurse Manager, who is an RN, to manage the unit including staffing responsibilities. The staff are scheduled for 24 hour coverage by the Nurse Manager and schedules are maintained in the respective departments. The Unit staffing plan polices and procedures will be developed by the Nurse leader(s) in conjunction with the respective Director of Nursing and Vice President. Staffing decisions and recommendations are based on established staffing patterns which are benchmarked externally from regional, state and national organizations. Additional internal information used to support staffing decision includes: Average daily patient census 1: 1 Communication Approved budget Trended historical data Skill mix of staff State and federal regulations Patient outcomes Input from clinical staff nurses on a shift to shift basis Specialty nursing organizations recommendations Acuity Licensed nurses (RN or LPN) will provide 65% of all direct patient care. Minimal staffing requirements: when census or acuity suggests a reduction in staffing, there will be a minimum of2 RNs or 1 RN and 1 NA staffed at all times. Staffing patterns suggest necessary staff and adjustments are made based on direct communication between Nurse Managers, Charge Nurses, Nursing Supervisors and staff taking into consideration the above internal staffing information. Staffing is flexed up or down to meet the needs of the patients/unit. Final approval is conducted by the Vice President Patient Care Services/Chief Nurse Officer. The staffing plan uses registered professional nurses, licensed practical nurses, unlicensed assistive personnel (UAP), unit secretaries and other nursing staff members to meet patient care requirements for respective units. Staffing variances between suggested and actual staffing levels are evaluated continuously. When variances are foreseen, (i.e., vacations, planned leave of absence) coverage is provided through the use of per-diem, agency, and Saint Peter's University Hospital employees for voluntary overtime. The Nurse Manager and Director of Nursing collaborate in trying to meet the suggested staffing levels. In unforeseeable circumstances, (i.e. callouts, no shows, natural disaster or heavy census) Nursing Management is available via beeper and/ or cell phone to assist in covering staffing needs. Coverage is provided through the use of per diems, voluntary overtime, part-time, full-time, and agency. When all other reasonable efforts have been exhausted nursing leadership may be required to work additional hours. Page 2 of 18

3 All calls made to cover additional staffing needs on a daily basis are documented on the "call sheet". Documentation will be reflected on the date requested to cover, not the date of the call. In circumstances where the skill mix does not meet the established staffing guidelines, the Nurse Managers or Nursing Supervisor in conjunction with the respective Director of Nursing may utilize other members of the nursing team to help meet the established staffing guidelines. Ex. If the staffing matrix allows for 6 RN's and 4 UAP's, and the unit only has 5 RN's and 4 UAP's. An additional UAP may be utilized to maintain quality patient care. The staffing plan is evaluated annually or as needed by the Vice President of Patient Care Services/Chief Nurse Officer, Director(s) of Nursing, and unit Nursing Leader(s). Additionally, the annual staffing plan is reviewed in conjunction with the budgetary process. See Appendix A for department specific staffing plan. II. Unit based staff scheduling The Division of nursing recognizes that self scheduling is an important tool in helping nurses balance both their personal and professional lives. As a result, Saint Peter's University Hospital clinical nursing staff utilizes a self scheduling model for meeting unit based staffing requirements. Nurses are given a specified timeframe to complete the posted schedule worksheet. Once the time period has expired, nursing leadership will review the schedule to ensure it meets unit needs. All unit based schedules must be completed four weeks before the beginning of the new schedule. Once the schedule has been reviewed, the units nursing leadership will develop a needs list for vacant shifts. Nursing Leadership will then contact all per-diems or supplemental staff credentialed for their respective area(s). Once the units schedule is completed, it will be forwarded to the divisional director for either approval or denial. The Director will review and submit the unit schedule to the nursing office for assistance with covering any vacant shifts as needed. If Approved: The Divisional Director reviews the Department schedule and return to the Nurse Manager. Page 3 of 18

4 A copy of the department schedule will be posted two weeks before the beginning of the new schedule. If denial: The schedule will be returned to the unit(s) Nursing Leadership with comments for corrections. Once corrections have been made, the schedule must be resubmitted to the Nursing Director for approval. Vacation Time The unit( s) nursing leadership must manage vacation request throughout the year to prevent over/under staffing situations. The unit nursing leadership will determine vacation requests based on the needs of the unit. All requests for vacation must be submitted in writing via "vacation-holiday request form" (see attachment) to the unit(s) nursing leadership by the timelines outlined below. No more than two Registered Professional Nurses will be granted time off per shift at the discretion of nursing leadership. No more than two UAP's are off on days, one on evening and one on nights during a twenty-four hour period at the discretion of the unit(s) nursing leadership. If staffing does not permit the granting of requests, approval will be based upon alternate vacation time worked year to year, senority. Additionally, previous years vacation schedules will be reviewed. Any vacation schedule changes are at the discretion of the unit nursing leadership. Prime Time Summer: The period between June 15 and September 15, any vacation request for this period must be requested by March 1st. a) 12 hour employees may take no more than 6 vacation days. b) 8 hour employees may take no more than 10 vacation days. Manager must post approved vacation schedule by April 1 51 FaWWinter: The period between December 15 to January 3, any vacation requests for this period must be requested by September 30. Manager must post approved vacation scheduled by October 1st. a) No more than three days for 12 hour shifts and four days for 8 hour shifts. Page 4 of 18

5 Vacation requests submitted after April I or September 30, will be granted on a first come first serve basis. Non-prime time vacation requests must be submitted to the Nurse Manager four weeks prior to the beginning of the new schedule. Schedules should not be changed once posted, except in urgent or emergency situations at the discretion ofunits(s) nursing leadership in conjunction with Divisional Director's. For vacation requests that have been approved before a unit transfer or shift change is subject to review based upon unit staffing requirements and approval of the Management. Vacation requests for weekends normally worked may require a peer switch at the discretion of the Management. Holiday Requirement Part-time and Full-time staff is required to fulfill the following Holiday commitments: Memorial Day I Fourth of July- must work 1 of these holidays Labor Day I Thanksgiving - must work 1 of these holidays Christmas I New Years- must work 1 day and 1 eve of these holidays Must alternate holidays worked year to year. Previous years schedules will be reviewed. If staff is being cancelled on holiday, full-time and part-time employees will be given first choice. Any Holiday schedule changes are at the discretion of the Manager or designee. Sick Time The respective nursing unit's Manager or Nursing Supervisor must be notified of a sick call two hours before the start of a staff members shift. Once the nursing unit has been notified, it is the employee's responsibility to notify the respective unit(s) nursing leadership between the hours of8a-4p and the nursing supervisor for after hours and weekends. Sick days taken for a weekend shift will result in the employee having to make up the weekend. All staff will be subject to requirements of the human resources time and attendance policy# ER-2 Overtime Staff is expected to swipe in and out at the start and end of their scheduled shift, unless authorized to work additional time. Page 5 of18

6 All overtime must be approved by the divisional director and/or VP. Any employee that starts work early or leaves late must have authorization from the unit(s) nursing leadership and/or nursing director. The information must also be documented in the overtime book with the appropriate authorizing signatures. Unauthorized earlyflate swipes are not permitted as defined by HR policy and procedure # M-18. Agency StafTmg DEFINITION: A Supplemental staff member delivers patient care under the direction and supervision of the Nurse Management, in accordance with Saint Peter's University Hospital policy and procedures and job description for the contracted position. Agency staff is defined as either daily agency or travel nurses. I. The supplemental staff member will submit the following original documentation when reporting for orientation to the orientation coordinator. They will submit subsequent renewals before the date of expiration of the existing document. A. Current license as a Professional RN in New Jersey. B. Current BLS Certificate. C. Specialty Certificates (ACLS, CCRN, PALS, NRP) where applicable. D. Proof of employment at a state licensed agency which has a valid Contract with Saint Peter's University Hospital. E. Saint Peter's University Hospital or Agency Photo Identification. II. It is the responsibility of the agency to have available documented, evidence of the following in each nurse's personnel folder located at the agency. A. Current license as a Profession RN in the State of New Jersey. B. Current Malpractice Insurance ($1,000,000; $3,000,000). C. Current Cardio-Pulmonary Certification. D. Completed skills self-assessment checklist. E. IV certification F. Specialty area test if applicable or current certificates. G. Complete Health Record. H. Satisfactorily completed one year of clinical experience as a staff nurse. I. Satisfactory health examinations (including rubella, titer, tuberculosis screen). J. Yearly review competencies. K. Drug screening. III. The agency nurse is required to attend the Saint Peter's University Hospital Agency Orientation prior to working at Saint Peter's University Hospital, including but not limited to: A. Achieving a grade of85% on the Saint Peter's University Hospital Page 6 of 18

7 Pharmacology Examination. B. Review of Saint Peter's University Hospital's policies and procedures. C. Review of Saint Peter's University Hospital's job description. D. Information technology training. IV. The Nursing Office is responsible for: A. Maintaining personnel files at Saint Peter's University Hospital for each agency staff member. B. Coordinates completion of yearly evaluation for agency personnel, or as deemed necessary. C. Denying the supplemental staff agency nurse privileges when he/she fails to meet the established standards of Nursing Care required by The Division of Nursing. D. Coordination of supplemental staffing request in conjunction with the Divisional Director and Vice President Patient Care Services. V. Unit Nursing Leadership is responsible for: A. Orienting the supplemental staff member to the assigned unit. B. Providing patient care assignment and giving report on the assigned patient. C. Ascertain the competency of the nurse in order to assign patient care. VI. The Agency Staffing Member is responsible for: A. Report to the Nursing Office in proper nursing attire prior to each assignment. B. Signing the agency's payroll sheet and the Saint Peter's University Hospital Agency Sign-in book indicating the name, assigned unit, agency name and shift worked (Staffing Agencies Only). Swiping in/out via kronos payroll system on assigned unit (travel staff only). Travelers are guaranteed a contracted number of hours/shifts for a contracted period of time, generally thirteen weeks, but can be shorter or longer with the approval of all parties - the facility and the nurse. Travelers are guaranteed the specific shift that Saint Peter's University Hospital offers. Rotation to the off-shifts must be offered to the traveler prior to acceptance of the position. Once an assignment begins, the Saint Peter's University Hospital cannot change the shift that was offered without the traveler's consent. For example, if contracted to work 7am- 7pm, the facility cannot te11 the traveler upon arrival that there are no day shifts available; therefore one must work nights if one wants to stay on the Page 7 of 18

8 assignment. C. Reports to the unit(s) nursing leadership to: 1. Obtain assignment and patient report 2. Communicate any pertinent information regarding the patient's status. 3. Inform the charge nurse when leaving the unit. D. Follow all Saint Peter's University Hospital policies and procedures. E. Wearing a name tag denoting status. F. Reporting to duty on time for scheduled shift. VII. Agency staff are utilized based upon the needs of the unit. These staffing needs are identified by the unit(s) nursing leadership' /Director in conjunction with the Vice President. To request a traveler and/or extend a traveler contract the unit(s) nursing leadership must complete the appropriate form and forward to the divisional director. A review of the request will then be conducted by the divisional director and VP Patient Care Services. The nurse manager will receive notification of traveler request status within 1 day after meeting. Travelers are told during the initial phone interview that the following are requirements: floating to other units within their specialty refusal of an assignment within their division is grounds for immediate dismissal can be rotated to the off-shifts if it is part of the agreed upon contract During those times when a traveler is not needed, the traveler can be cancelled but must be offered additional hours within the same week that hours were cancelled to make up lost time. If the cancelled hours are not made up because Saint Peter's University Hospital has no hours to offer, Saint Peter's University Hospital will be charged and the nurse will be paid according to contractual agreement. This is called the "Low Census Clause" and is found in every travel agreement. The "Low Census Clause" has been in effect since 1998 per contractual agreement and it allows Saint Peter's University Hospital to cancel the nurse when the census drops, but it also gives the facility the ability to have the nurse make up the lost hours. In the event that Saint Peter's University Hospital recognizes a period of sustained low census (construction, decreased admission, etc.) it can choose to temporarily "loan" its traveler(s) to another facility, but the traveler must agree to the move. If the traveler does not agree, Saint Peter's University Hospital must give the nurse a thirty day notice to end the assignment. In case of illness or absence, the agency nurse must speak to Nurse Manager or Nursing Supervisor two hours before their assigned shift. Page 8 of 18

9 VIII. Performance Appraisals are a requirement for all agency/traveling nursing staff who perform patient care at Saint Peter's University Hospital. Performance Appraisals will be conducted in the following manner. 13-Week evaluated once during initial contractual period. The purpose of the Performance Appraisal is: 1. To uphold the identified standards of patient care according to the policies and procedures of Saint Peter's University Hospital Division ofnursing. 2. To verify that the nursing staff member adequately performs within their stated job description. 3. To offer constructive suggestions to improve patient care. 4. To comply with all regulatory Supplemental Staff standards. Performance Appraisal Process: 1. An agency representative will forward an evaluation form to the Nursing Office. 2. The Nursing Office will forward the evaluation to the appropriate Nurse Manager. 3. The unit(s) nursing leadership will complete the Performance Appraisal and attach required competencies and return to the Nursing Office. IX. Saint Peter's University Hospital can withdraw an offer to a traveler who hasn't yet started, but the withdrawal of an offer must be at least 30 days before the assignment begins and must be in writing. Saint Peter's University Hospital can also give notice to a traveler that the assignment must end prior to the original end date, but again, 30 days notice must be given to the nurse, in writing. As always, where there is cause to terminate a traveler due to poor performance, patient satisfaction issues, attitude, or negative behavior a traveler can be terminated immediately upon the completion of an investigation into the allegations related to the issue. The allegations must be submitted to agency in writing. Upon completion of the investigation, the agency and Saint Peter's University Hospital will make the decision to terminate services. PER DIEM NURSES Per-diem nurses at Saint Peter's University Hospital are required to work a minimum of 24 hours per month based upon unit needs which will include one weekend shift and 2 major holidays. weekends/holidays. Exceptions may only be made by the Divisional Page 9 of 18

10 Director or Vice President. In an effort to meet the ever changing needs of the nursing units, a per-diem nurse may be required to change their scheduled unit assignment when reporting for duty. The per-diem nurse will only be allowed to work and care for patients on respective units that he/she have demonstrated competency. Per-diem nurses must make arrangements for the scheduling of hours through the Unit Manager. The Nurse Manager will match the unit's specific staffing needs with the perdiem nurses. In case of illness or absence, the per-diem nurse must speak to the unit's Nurse Leader or nursing supervisor two hours before their assigned shift. Once the Nurse Manager has been notified, the per-diem nurse must then immediately notify the nursing office between the hours of 8a-4p or the Nursing Supervisor after hours/weekends. All per-diem nurses will be required to work 2 major holidays, one summer (Memorial Day, Fourth of July or Labor Day) and either Thanksgiving, Christmas or New Years Eve. Failure to comply with any of the requirements outlined above may lead to termination. Failure to adhere to the required amount of work hours, exclusive of Saint Peter's University Hospital cancellation in a 60-day period may result in termination. Evaluation process for all per-diems Evaluations are performed based upon the human resources performance appraisal policy #ER-6 A per-diem nurse's evaluation is completed by the unit(s) Nurse Managers(s) where the nurse has worked consistently. Resignation process for all per-diems All per-diem nurses are expected to submit their resignation in writing at least two weeks in advance of their last workday. Any per-diem nurse is automatically terminated if they fail to comply with all hospital and nursing requirements related to (1) competencies (2) immunizations (3) mandatory employee screenings,(4) professional licensure or certification, after 2 notices have been sent. In addition, it is the responsibility of the per-diem nurse to assure current up to date address and telephone information is on file in human resources and nursing administration. Staffmg adjustments: I. Cancelling of staff During times of changes to unit specific patient volumes, necessary adjustments to Page 10 of18

11 staffing will be completed to ensure quality patient care is provided. The Nurse Manager and/or supervisor will determine the need to adjust staffing through analysis of the following: Patient acuity Staff competency levels Unit census Staffing mix (ratio of RN to ancillary staff) Every attempt will be made to complete the staffing adjustment analysis 2 hours prior to the beginning of a respective shift. It is important to note, this analysis is conducted throughout the day. As a result, staffing adjustments can also occur during a scheduled shift with the exception of hospital defined holidays. Not more than half the staff on a holiday will consist of Per Diem/ Agency staff. When the need to adjust staffing is determined the following guidelines must be followed: )> Staff will be cancelled for all/or part of their scheduled shift. In the following order: a) staff schedule to work overtime (agency or full-time staff) b) Any part-time staff working additional hours over their budgeted hours c) Perdiem d) Full and part-time staff volunteering to be cancelled and take benefit time. e) Full and part-time staff volunteering to be cancelled and not utilize their benefit time. f) agency personnel If an employee has used their entire allocation of benefit time and the nurse is required to be cancelled, the unit(s) nursing leadership in conjunction with their Director ofnursing may approve time off without pay. Each nursing unit will maintain a log that outlines each staff member's name, job classification and the dates they were cancelled. The key goal of this log is to ensure that a fair and equitable rotation of staff does occur. II. Unit reassignment: When it becomes necessary to reassign nursing staff from one unit to another the following protocol must be followed: 1. When staffing levels exceed that required for the unit, reassignment of staff including per diems that have committed additional time will occur. A. Nurses will be reassigned to other units based upon the attached grids. B. Nurses who are reassigned shall not be in charge of a unit unless they have been oriented to charge on that unit. C. An employee on probation may not be temporarily reassigned until AFTER their 6 MONTH probationary period FROM DATE OF HIRE is completed. Page 11 of18

12 D. An employee on orientation to a new area will not be temporarily reassigned, unless employee consent is obtained. E. The Charge Nurse in the assigned unit will designate an appropriate resource for the reassigned nurse. F. Every effort will be made by Nursing Leadership to maintain primary float areas. In the event of an emergency changes to the primary float areas may be necessary as determined by Nursing Leadership. G. Nurses will not be reassigned to more than one unit per shift (if a Nurses is returned to his/her home unit during the shift, this will count for only one reassignment). H. Every attempt will be made to minimize a double pull situation. I. Nurses will be floated to another unit on a Holiday for emergency situations (i.e. sick calls, increased acuity exceeding staffing guidelines, the nurse volunteers to be temporarily reassigned). J. When reassigned: every attempt will be made to provide an optimal assignment, provide orientation to the unit (see orientation checklist), and be provided with a resource nurse. 2. If reassignment is not necessary, adjust unit staffing levels based on job category. Personnel will be flexed to home in the rank order listed below. Part time includes weekend incentive and seasonal staff. Staff members that are flexed may be asked to work a partial shift. Staff may be asked to flex in 4 hour and then 8 hour increments, i.e., (7a-11 a or 7p-11 p) depending on unit needs exclusive of oncall time. See page 11 regarding flexing order. 3. Maintain a flex log on each unit listing the staff in each of the categories cited above listed in order of date of hire. Flex staff within each category based on last time flexed. Record the date a staff member has been flexed in the log for the staff member. An even rotation among all categories will occur once the first round of flexing has occurred, except for those employees working beyond their commitment. 4. Determine what category of staff (i.e., RN, LPN, NA, NUS) will be flexed, depending on acuity. 5. Determine if staff flexed home are taking holiday time, vacation time, or time without pay. 6. Where possible, provide a two-hour cancellation notice for all shifts. 7. When nursing resources are determined to be significantly below the planned NHPPD target, Nursing Administration may: Shift Rotation: - Supplement staffing with per diem/float or overtime staff. - Utilize agency staff if necessary. 1. No RNILPN will rotate after 10 (ten) years of continuous service at Saint Peter's Page 12 of18

13 University Hospital. 2. As of April 1, 1994, continuous service applies to that service accrued within the job classification; i.e., prior service as a nursing unit secretary does not apply toward the ten-year requirement. 3. Any RN who accrued a ten year length of service in any nursing job category prior to April 1, 1994, will be grandfathered into the prior no rotation policy. 4. LPN's who have more than 10 (ten) years longevity may credit that time to the ten year no rotation rule. 5. In the event of a crisis (unexpected LOA) all staff regardless of years of service WILL be asked to rotate. Approved by: ~zr tgnature ~~ Chief Nursing Officer Title Director- Women & Children's Division Title Director- Adult Acute Care Services Director- Emergency Department Director-Perioperative Services Date ~; ~ ll..s. I 7/9) Supersedes Date(s): 3/93, 3/94, 3/95, 3/96, 11198, 12/01, 11104, 11/05, 1108, 12/09 Reviewed Date: 3/93, 3/94,3/95, Revised Date: 3/96, 12/01, 11104, 11105, 1108, 11109, 6/10, 4111,12/12, 12/13 NS Page 13 of18

14 Med/Surg 8 Critical Care Division FloatiDS Guidelines Adult Critical Care Floatiag GuideUnaa PACU Pre Holding G u.a [::::1 6 II ICU II <====> 6.a.a II TELE II II ICU II.a II MED/SURG II MedfSurg Floatiag GuideUnaa May be reassigned among each other I Orthopedics II ~ II Oncology II ~ II Metabolic II ~ I Surgical I ~ II Renal II ~ II TELE II Page 15 of 18

15 Women 8 Cblldren's Division J1oatiDJ! Guidelines I PICU/Peds II I NICU II I NBN I I NBN I c:::::> I NBN I I PICU I <==::::> I PEDS I I'. PEDS I n n I SCN I I SCN I I L&D II <==::::> 1 1 4G 1 11 II M/B n I L&D/PET I I L&D/PET I ~ I [ft. ;;) I c:::::> I M/B I I M/B =>@] I NBN n Page 16 of 18 I SCN I

16 Orientation Checklist Scope of service Tour of the unit to include orientation to:./ Clean Utility Room./ Dirty Utility Room./ Food and Nutrition Station./ Code Cart./ Medication room./ Nursing Station./ Environment of Care including fire extinguisher location, fire pull station, and emergency exit(s) Medications frequently given on the unit with associated side effects Nursing protocols based on patient population Specific equipment utilized for patient population Page 17 of18

17 Appendix A P ACU Staffing Plan 1. The daily coordination of P ACU activities is the responsibility of the P ACU Nurse Manager. 2. The P ACU will be staffed by Registered Nurses at all times. A staggered work shift will be utilized to provide adequate coverage from Monday through Friday and from 0800 to 1630 on Saturday. 3. There will be two nursing assistants assigned to the unit; one will cover the hours of and one from There will be one nursing assistant/nursing unit secretary from Two licensed nurses, one of whom is an RN competent in Phase I Post - Anesthesia Nursing, will be present whenever a patient is recovering in Phase I. 6. Staffing is based on patient acuity and census as well as the guidelines set for by ASP AN (American Society of Peri-Anesthesia Nurses). 7. Staffing during Phase I of recovery will be as follows: Class 1 :2 - One Nurse to Two Patients Who Are: a. One unconscious, hemodynamically stable with a stable airway, over the age of 8 9 years; and one conscious patient, stable and free of complications b. Two conscious patients, stable and free of complications c. Two conscious patients, stable, 8 9 years of age and under; with family or competent support staff present Class 1:1 - One Nurse to One Patient: a. At the time of admission, until the critical elements are met b. Unstable airway: Examples of unstable airway include but are not limited to the following: i. Requiring active interventions to maintain patency such as manual jaw life or chin life or an oral airway ii. Evidence of obstruction, active or probable, such as gasping, choking crowing, wheezing, etc. iii. Symptoms of respiratory distress including dyspnea, tachypnea, panic, agitation, cyanosis, etc. c. Any unconscious patient 8 years of age d. A second nurse must be available to assist as necessary Class 2:1 - Two Nurses to One Patient: a. One critically ill, unstable, patient Page 18 of 18