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OFFICIAL NEWSLETTER

Volume 23 – Number 2March/April 2014

Patient acuity has increased due to more complex patient populations. This objective,quantitative tool is used to assign acuity ratings, adjust staffing ratios, assignappropriate skill mix, and balance workload to maximize safe, effective care.

A 148-bed community hospital, which is part of a large academic health system, has seenphysician specialists admit more complex patient cases to a 36-bed medical-surgical unitover the past few years. The usual census in the past included patients who had experiencedan appendectomy, hysterectomy, or cholecystectomy. Many of these patients are now dis-charged from the outpatient surgery service. Today, the population on this unit includespatients who have undergone a thoracotomy with placement of multiple chest tubes, multi-level spinal fusion, and laminectomy, patients recovering from cranio-neurosurgical proce-dures, and patients of prostatectomy and urologic reconstruction surgeries. The “overnightobservation” patients are now bariatric surgery patients with precise regimens to follow orbilateral mastectomy patients.

The nurses on this medical-surgical unit began to feel the impact of the increase inpatient acuity while their staffing ratios remained the same. They also felt an imbalance inworkload among the team at times when the assignments did not accurately reflect patientacuity nor balance the skill mix of the staff.

Charge nurses, who made the nurse-patient assignments for each 12-hour shift,attempted to balance the workload by using a subjective evaluation of patient acuity and theunit’s nursing skill mix. Assignments were often made under time-pressure and with limitedinformation. The staff nurses requested a more objective and equitable way of defining acuityratings to promote safer patient care. The unit’s Clinical Nurse Specialist and Nurse Managerwere supportive and felt it important to advocate for the nurses and their patients.

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INSIDE THIS ISSUENutrition to Improve Outcomes: Healthy to Undernourished: Post-Hospital Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Nursing Management of Constipation in the Medical-Surgical Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Strategies for Nurse Educators: Restructuring the New Nurse Orientation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Drug Update: NSAIDs: Is Naproxen the Safest Choice? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

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866-877-2676 Volume 23 – Number 2

Literature ReviewA literature search completed in

CINAHL® used the search termspatient classification, clinical assess-ment, and acuity score for the year2004 and forward. Articles were exam-ined for relevance to our setting andresources. For instance, methods usingproprietary software were reviewedfor concepts but not considered forimplementation.

Twigg and Duffield (2009) agreedthat nurse workload is difficult todefine and measure, yet necessary toensure adequate staffing for safe patientcare. They reviewed methods of deter-mining nursing workload that have beenused historically and agreed that itremains a complex process.

Brennan and Daly (2009) citedtools that have been used to determinepatient acuity, yet agreed that there isinconsistency in how acuity is definedand measured. They agreed that meas-urement of patient acuity should incor-porate patient severity of illness andnursing workload factors.

Tamburro, West, Piercy, Towner,and Fang (2004) found that the nursingacuity score for pediatric oncologyintensive care patients predicted sur-vival and affirmed the insight of thebedside nurse in assessing severity ofillness. Although their patient popula-tion was different, the acuity systemthey developed that used both clinicalseverity and nursing workload indica-tors provided guidance in the develop-ment of our tool. Friese, Earle, Silber,and Aiken (2010) related certain clinicalseverity scores to patient mortality.Brewer (2006) combined and refinedover 30 variables into 16 acuity charac-teristics. Our tool incorporated patientcharacteristics used by Brewer, such asrespiratory and cardiac management,isolation status, activities of daily living,and wound management. Brewer’smethodology of consolidating variableswas used to influence the design of ouracuity tool.

Rauhala and Fagerström (2004)discussed the RAFAELA system, amnemonic they created, comparing

Figure 1.Original 20 Categories and Final 10 Categories

patient acuity with nurse resources. TheRAFAELA system assigns points basedon care intensity for patient needs anduses the Professional Assessment ofOptimal Nursing Care Intensity Level(PAONCIL) tool, which establishesoptimal nursing intensity per caregiver.The RAFAELA system – used primarilyin Finland for outpatient departments,psychiatric nursing care, primary healthcare, and long-term or home care –was complicated to use and not appli-cable to our patient population.

DeLisle (2009) found that using anacuity tool representative of patientstatus and clinical intensity could beused to assist in equitable distributionof nursing workload. The acuity toolrated patients a Level I-V based onnursing time required to administerchemotherapy in an outpatient ambula-tory oncology unit. Although this wasnot our patient population, this infor-mation was helpful in considering clini-cal severity and nursing workload indi-cators in determining acuity and makingpatient assignments.

The literature was helpful in stimu-lating discussion about how to define

acuity, but a specific patient acuityassessment tool appropriate for ourmedical-surgical patient population wasnot found.

Using input from staff nurses, theauthors set out to develop a compre-hensive acuity assessment tool thatcould be used objectively and consis-tently by the staff. The intention was toutilize this tool to make appropriatepatient assignments and balance theunit workload to maximize safe, effec-tive patient care.

MethodThe authors held roundtable dis-

cussions that were open to all staff onthe unit over a period of severalmonths. Discussions included “whatdefines acuity” and “how to differenti-ate levels of acuity.” The team talkedabout what “counts” – illness of thepatient or how much nursing time isrequired to care for them or both.What about the psychological “work”of dealing with an anxious, upset, orconfused patient?

At first, the proposed acuity toolhad 20 categories (see Figure 1). Thenumber of categories and descriptors

Patient Acuity Toolcontinued from page 1

Academy of Medical-Surgical Nurses www.amsn.org

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were refined over a period of eightweeks by the researchers with inputfrom the nurses and manager. Throughdiscussions and continual assessment ofthe patient population, the team wasable to refine descriptors that identifieddifferent levels of acuity. After ten revi-sions, the final tool consisted of 10 cat-egories – six related to patient clinicalseverity and four related to nurseworkload (see Figure 2).

Using the tool, a typical, uncompli-cated postoperative patient was rated a2.A complex surgical patient with moreextensive care needs was a 3, and apatient at high risk for a decline in sta-tus or requiring frequent nursing careor assessment would have a 4 rating.Patients were rated a 2, 3, or 4 in eachof the ten categories. For example, inthe respiratory category, a stablelaparoscopic cholecystectomy patientmight need oxygen per nasal cannula at

2 liters per minute (lpm) for the first 24hours due to the carbon dioxide gasused to inflate the abdomen during theprocedure and would be identified as a2. A patient requiring oxygen supportabove 2 lpm per nasal cannula, perhapsdue to cardiac status would be a 3. Apatient with decompensating respira-tory status requiring a full-face oxygenmask would have a 4 rating.

ResultsContent validity was verified using

the input of the nursing staff and man-ager during the ten design and revisionmeetings. The resulting acuity tool waspiloted and validated for usability andfeasibility on all shifts at varying timesand days of the week. During thisphase, a total of 40 nurses assessed 183patients. Patients were scored in eachof the ten categories. Initially, rawscores were used and converted to an

overall acuity rating of 2, 3, or 4.Refinement of the tool showed that ascore of 3 for any category gave thepatient a final 3 acuity rating, and a 4score in any category gave a final 4 rat-ing. This refinement eliminated the needto perform mathematical calculationsand greatly reduced the complexity ofuse. Acuity ratings using the tool werethen compared to ratings assigned bycharge nurses using their traditional,subjective method.During the trial period, the chargenurses rated 51% of patients as 2 and49% of patients as 3 (none of thepatients received a 4). When nursesused the new tool for the samepatients concurrently, 32% of patientswere a 2, 53% were a 3, and 15% werea 4 rating (see Figure 3). These ratingsreflected the nurses’ perceptions oftheir patients’ acuity. There wasagreement among management and

Figure 2.Final Acuity Tool

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the researchers that nurses were notoverstating the number of high-acuitypatients.

ImplementationThe next phase was to implement

the new acuity tool. Beginning July 18,2011, each nurse rated his or herpatients’ acuity using the tool. Duringthis phase, 43 nurses rated 488patients. Data revealed that 51% of thepatients received an acuity rating of 2,38% received a 3 rating, and 12%received a 4 rating (see Figure 3). Data

collected using the objective toolshowed that our previous subjectivemethod failed to identify high-acuitypatients.

Acuity indicators were analyzed todetermine frequencies of occurrence(see Figure 4). The most frequentlyoccurring driver for a patient rating of4 was activities of daily living and isola-tion (for example, the care required fora paraplegic and a quadraplegic postop-erative patient due to nursing work-load). The second most common driverfor a 4 was wound/ostomy (for exam-

Figure 3.Results – Subjective, Validation, and Implementation

ple, a high-output ileostomy patientrequiring frequent monitoring of out-put volume, site leakage, and fluid/elec-trolyte imbalance). The top drivers foran acuity rating of 3 were activities ofdaily living, patient’s isolation status, andadmit/discharge/transfer.

The acuity ratings completed bynurses are now given to charge nursesto make the assignment for the oncom-ing shift. The typical nurse-patient ratioof 5:1 is adjusted to 4:1 if a nurse has apatient with a rating of 4. Novice nursesare assigned patients with acuity ratingsof 2 or 3, and assignments are balancedto distribute the unit workload (seeFigure 5).

DiscussionThis tool incorporates clinical

severity and nurse workload indicatorsto determine acuity and is used tomake patient assignments in alignmentwith appropriate skill mix and staffingratios. Nurses supported having anobjective tool to use in assessingpatient acuity to provide safe care,adjust staffing ratios, and balance unitworkload. Experienced nurses wereassigned higher acuity patients. Thechief nursing officer, operation adminis-trators, and nurse manager supportusing the new acuity tool to adjuststaffing ratios each shift according topatient needs.

The advantages of the tool aresimplicity, cost, and customization. Thetool does not require complex docu-mentation (i.e., any 4 is a 4) andrequires about ten seconds per patientper shift to complete. It does notrequire expensive information technol-ogy support. Finally, the tool is easilyadapted to the unique needs of anypatient population.

ConclusionsOur experience illustrates that the

use of the collaboration process bymanagement and staff nurses can leadto the development of an objective,quantitative acuity tool to assign patientacuity to medical-surgical patients. Thisunit used this tool to effectively deter-mine nurse-patient ratios and develop asafer nursing workload. Currently, theauthors are mentoring other units at

Figure 4.Drivers of Acuity by Category

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Figure 5.Sample Unit Assignment Based on Patient Acuity and Nurse Experience

our hospital to facilitate the develop-ment of an acuity tool for their patientpopulations.

ReferencesBrennan, C.W., & Daly, B.J. (2009). Patient acu-

ity: A concept analysis. Journal of AdvancedNursing, 65, 1114-1126.

Brewer, B.B. (2006). Is patient acuity a proxyfor patient characteristics of the AACNSynergy Model for Patient Care? NursingAdministration Quarterly, 30(4), 351-357.

DeLisle, J. (2009). Designing an acuity tool foran ambulatory oncology setting. ClinicalJournal of Oncology Nursing, 13(1), 45-50.

Friese, C.R., Earle, C.C., Silber, J.H., & Aiken,L.H. (2010). Hospital characteristics, clin-

ical severity, and outcomes for surgicaloncology patients. Surgery, 147(5), 602-609. doi:10.1016/j.surg.2009.03.014

Rauhala, A., & Fagerström, L. (2004).Determining optimal nursing intensity:The RAFAELA method. Journal ofAdvanced Nursing, 45(4), 351-359.

Tamburro, R.F., West, N.K., Piercy, J., Towner, G.,& Fang, H. (2004). Use of the nursing acu-ity score in children admitted to a pedi-atric oncology intensive care unit.Pediatric Critical Care Medicine, 5(1), 35-39.

Twigg, D., & Duffield, C. (2009). A review ofworkload measures: A context for a newstaffing methodology in WesternAustralia. International Journal of NursingStudies, 46, 132-140.

Kathy Chiulli, MSN, RN,CMSRN, was a Medical-SurgicalClinical Nurse Specialist, InpatientMedical-Surgical Units, Duke RaleighHospital, Raleigh, NC, at the time thisarticle was written.Jackie Thompson, MSN, RN,CMSRN, was a Stroke Coordinator,Duke Raleigh Hospital, Raleigh, NC, at thetime this article was written.Kristi L. Reguin-Hartman,BSN, RN, was an Education ResourceSpecialist, WakeMed Hospital, Raleigh,NC, at the time this article was written.

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