What is the recommended protocol for float nursing surveillance?

Float Nursing Surveillance Protocol

Float nurses assigned to intensive care units (ICUs) or monitored stroke units require structured surveillance protocols with close supervision, mandatory competency verification, and restricted patient assignments to prevent medical errors and ensure patient safety.

Core Principle: Restrict Float Nurse Use in Critical Care Settings

Maintain an appropriate nurse-to-patient ratio and actively restrict the use of float nurses in ICUs whenever possible. 1 Observational studies demonstrate that minimizing float nurse presence in ICU settings is associated with reduced infection rates and improved patient outcomes 1. For stroke units specifically, weekend staffing ratios below 3.0 registered nurses per 10 beds resulted in significantly higher 30-day mortality (15.2% vs 11.2%) 1.

Mandatory Staffing Ratios

When float nurses must be deployed:

• Monitored beds (ICU/stroke unit): Maintain minimum 1.5 full-time equivalent nurses per bed on 24-hour duty rota 1
• High-dependency patients: Ensure 1:2 nurse-to-patient ratio maximum 1
• Non-monitored stroke beds: Maintain 0.5 full-time equivalent nurses per bed 1

Float Nurse Competency Requirements

Before assignment to critical care areas, float nurses must demonstrate:

• Documented education and training specific to the receiving unit's patient population 2
• Competency verification by the receiving unit manager for assigned patient acuity level 2
• Familiarity with unit-specific protocols including emergency equipment location, alarm systems, and communication procedures 2

Surveillance Protocol for Float Nurses

Patient Assignment Restrictions

Assign float nurses only to the most stable patients within the unit, reserving higher-acuity patients for permanent ICU/stroke unit staff 2. Float nurses should never be assigned patients requiring:

• Active titration of vasoactive medications
• Immediate post-thrombolysis monitoring (first 24 hours)
• Ventilator management
• Complex arrhythmia monitoring requiring immediate interpretation

Mandatory Surveillance Elements

Float nurses must perform the five key surveillance attributes 3, 4:

1. Systematic data collection every 15-30 minutes initially, then hourly based on patient stability 1
2. Pattern recognition through comparison of current vital signs to baseline trends 3
3. Coordinated communication with permanent unit staff about any parameter changes 3
4. Anticipation of instability by recognizing early warning signs 4
5. Rapid decision-making with immediate escalation to experienced staff 3

Specific Monitoring Requirements for Stroke Patients

Float nurses caring for stroke patients must monitor:

• Neurological assessment: NIHSS or simplified assessment every 2-4 hours 1
• Temperature: Minimum 4 times daily for 72 hours, treating >37.5°C (99.5°F) 1
• Blood glucose: Finger-stick minimum 4 times daily for 72 hours, treating >180 mg/dL 1
• Blood pressure: Every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours post-thrombolysis 1
• Cardiac monitoring: Continuous for minimum 24-72 hours 1
• Oxygen saturation: Continuous monitoring 1

Technology-Assisted Surveillance

Implement automated surveillance systems rather than relying solely on manual monitoring 5. Automated Early Warning Systems reduce rapid response team deployment time by an average of 291 minutes and decrease hospital length of stay by 4 days 5.

• Mobile pagers/devices that display rhythm strips when alarms activate 6
• Multiple monitor screens strategically placed throughout the unit 6
• Wireless telemetry systems to reduce infection risk 6

Supervision and Support Structure

Buddy System Implementation

Pair each float nurse with a permanent unit nurse who serves as immediate resource for questions and rapid escalation 2. The permanent nurse should:

• Perform initial patient assessment together with float nurse
• Review unit-specific protocols and emergency procedures
• Remain available for immediate consultation
• Verify documentation accuracy

Mandatory Check-ins

ICU charge nurse or stroke unit coordinator must directly assess float nurse's patients at minimum every 2 hours 2. This includes:

• Reviewing vital sign trends and surveillance data
• Verifying appropriate interventions for abnormal findings
• Confirming accurate documentation
• Providing real-time education on unit-specific practices

Communication Protocols

Escalation Pathways

Float nurses must have clear, written escalation protocols for specific clinical scenarios 2:

• Immediate notification (within 5 minutes) for: neurological deterioration, new arrhythmias, systolic BP >220 or <100 mmHg, oxygen saturation <90%, temperature >38.5°C
• Hourly updates to charge nurse regarding patient status
• Direct communication with attending physician for any parameter outside predetermined ranges

Handoff Requirements

Structured handoff using SBAR format (Situation, Background, Assessment, Recommendation) when float nurse's shift ends 2. Include:

• Complete vital sign trends over shift
• Any surveillance concerns or pattern changes noted
• Pending tasks or anticipated problems
• Specific patient vulnerabilities

Quality Assurance Measures

Documentation Requirements

Float nurses must document:

• All surveillance activities with timestamps 3
• Clinical decision-making rationale for interventions 4
• Communication with permanent staff regarding patient concerns 2

Incident Reporting

Mandatory reporting of near-misses or adverse events involving float nurses to identify system vulnerabilities 2. Analysis should focus on:

• Adequacy of orientation and training
• Appropriateness of patient assignment
• Effectiveness of supervision structure
• Need for protocol modifications

Critical Pitfalls to Avoid

• Never assign float nurses to immediate post-thrombolysis patients (first 24 hours) requiring intensive BP monitoring every 15-30 minutes 1
• Never rely on float nurses for complex arrhythmia interpretation without immediate verification by permanent staff 2
• Never assume float nurse competency without documented verification specific to the receiving unit 2
• Avoid alarm fatigue by ensuring clear protocols for alarm response and using technology that displays rhythm strips on mobile devices 6
• Do not use float nurses during periods of maximum unit census when supervision capacity is already strained 1