Patient acuity score: Staffing plan
Deeparani1, Lydia Annie2
1Deputy Nursing Superintendent, Kauvery Hospital, Radial Road, Trichy
2Chief Nursing Officer, Kauvery Hospital, Radial Road, Trichy
What is a Nursing Workload Acuity Tool?
Acuity, defined as the individual patient’s need for nursing care, is being measured can inform the level of care, nurse staffing, and the nurse-to-patient assignment.
Acuity scoring challenges the traditional way of patient assignment and the tool helps nursing charge to plan patient assignment unbiased and level of nursing staff, their privilege and competency and workload she has to render to patient will be taken in to account quantitatively.
Incorporation of nursing workload in acuity-based staffing
Acuity based staffing gives clear picture with the structured tool, and helps in quantitative measurement on Nursing Workload that allows nursing leaders to make assignments Make sure high acuity patients assigned evenly across the nursing care team based on their levels
- Identify unusual patient care needs that might require a different level of staffing than is expected to be available for the next shift. e.g. Isolation patients, Chemo administration etc.
- Patient Workload (how much care is needed)
- Complexity of Care (the measure of staff nurse skill/Work load of nurses needed to provide care)
- Continuity of Care (assignment of same caregivers – with correlation to patient outcomes)
Unit and institutional factors, which includes;
- Physical layout of the floor – Small cubicle, Deluxe ward, General ward, Triple/Double sharing
- Existing support including nursing assistance/Patient care assistant and other supporting services
Stocking of supplies and other resources including Medicines/Crash cart/ BM equipment, bed capacity, availability of other resources used for direct patient care.
ANA modified tool
| Category | 1: Stable Patients | 2: Moderate Risk Patient | 3: Complex Patient | 4: High-Risk Patient |
|---|---|---|---|---|
| Assessment | Q4H Vitals Alert and oriented | Q2H Vitals with altered MEWS score | - Q2H Vitals - Delirium/altered mental status | Unstable Vitals (determined by ordered parameters) |
| Respiratory | Stable on room air | Oxygen < 2L via NC | - Oxygen > 2L via NC - Tracheostomy | - Oxygen via mask - Can’t maintain secretions independently |
| Pain Management | Pain well managed with Per oral or IV medication with every 4 hr | - Patient-controlled analgesia/nerve block - Nausea/Vomiting | Q2H Pain management | Uncontrolled pain with multiple pain devices (IV, Patch, Epidural, etc) |
| Complicated Procedures | - Naso Gastric tube feeding - Rectal tube/ostomy - Transfer: incoming & outgoing - Routine blood sampling and blood glucose checks | - Moderate care patient (turnQ2/incontinent episode < 3 per shift, assist with >50% ADLS) - Restraints - Pre-operative care - New admission (Golden hour completion) - Tracheostomy care - Wound care by nursing - Q4h blood sampling/ Q1h Blood glucose checks (i.e Hyperkalemia & Hypoglycemia Protocol) - Procedures off the unit(CT Scan) | - Hemodynamic instability - Bleeding precautions (i.e. Heparin gtt) - Post-surgical (i.e. instability requiring multiple interventions upon arrival to MDCCU) - Active bedside procedures (i.e. CVC, Art. line, Chest tube, Paracentesis, Lumbar puncture) - Colostomy care, PICC line care, Chemo port care, Catheter care, Central line care, Drain care | - Ventilated (i.e. High Fio2 and PEEP) - Severe shock state (i.e. Hemorrhagic, Septic Cardiogenic, anaphylactic shock) - Post code (first 12 hr) - Active life-threatening conditions |
| Complicated IV Medications | - POCT - Blood glucose normal | - TPN, PEG feed - Routine/stable blood products administration - Routine electrolyte replacement (< replacements with subsequent lab draws per shift) | - Frequent concentrated electrolyte replacements (> 2 replacements) - 1 unit of blood transfusions - Heparin protocol - Blood draws from PICC - Dialysis - Chemo drug administration | - Thrombolytic therapy - Multiple/critical blood product administration (i.e. > 3 products per shift) - Administration of chemo drugs |
| Nurses Workload Indicators | ||||
| Education | Standard | - New meds/side effects - Inability to comprehend - Communication barrier (i.e. Language/Sensory) | - Discharge today - Multiple comorbidities > 3 consults on the case - New Diagnosis - Pre/Post-procedure | End-of-life care |
| Isolation | - Independent in ADLS - Standard precaution | - Assist with ADLs - Two-person assist for out of bed - Isolation (Contact, Enteric) | - Turns Q2H - Bed rest - Respiratory Isolation | - Paraplegic or quadriplegic - Total care (lifts) |
| Admit/Discharge/Transfer | - Stable transfer - Routine Discharge | Discharge to an outside facility | - New admission - Complex discharge - Discharge to hospice/palliative care | - Complicated post-operative cases - Transfer to higher level care |
| Safety/Vulnerability | No Risk | High-risk patient with vulnerability | - High-risk patient with vulnerability to Fall, Pressure ulcer, DVT - Sensory deficits (Visually, Hearing impaired etc) | - Highly agitated - Restraints |
| Wound, Ostomy, Continence | - QD/BID dressing - Wounding vac - One-person assist to bathroom/bedpan | - Ostomy /rectal tube - Enema - Bowel preparation - Incontinent Bowel and Bladder | - TID/complex dressing by RN - High output ostomy - Multiple wound vacs | - Active drainage, change >30 min or > TID - Q1H toilet needs |
| Medication Administration | Patient receiving one to two medicines | Patient receiving two and more medicines and IV infusion | Patient receiving high-end antibiotic and multiple infusion | Chemo and High alert medication, High Concentrated medicines (KCL, Albumin, 3%Nacl), administration with multiple lines |
| Patient Score | 01 to 11 | (12-22) Two or more = 2 | (23-33) Any 1 = 3 | (Above 34) Any 1 = 4 |
Each patient is scored on a 1-to-4 scale
| S No | Description of the Tool | Score interpretation |
|---|---|---|
| 1 | Stable patient | 01 to 11 |
| 2 | Moderate risk patient | (12-22) Two or more =2 |
| 3 | Complex patient | (23-33) Any 1 =3 |
| 4 | High-risk patient | (Above 34) Any 1 =4 |
Nurse: Patient Assignment based on acuity score
| Category | Score | Nurse:Patient Ratio |
|---|---|---|
| Stable patient | 1–11 | 1:4 |
| Moderate-risk patient | 12–22 | 1:2/1:3 |
| Complex patient | 23–33 | 1:1/2:1 |
| High-risk patient | >34 or new admission | 2:1 |
Assess the patient for each of the level categories related to the core, care plan issues. Patient assignments allocated to nurses according to the Acuity and Maximum workload outlined below.
Benefits of Acuity based nursing Positive clinical and operational outcomes linked to acuity-based staffing include:
- Decreases in mortality, adverse outcomes & length of stay.
- Maximizes patient and nursing outcomes
- Improves operational outcomes. ´ Improves nurse & patient satisfaction.
- Improves the financial outcome of an organization.
- It is an evidence base approach to staffing needs and manpower budgeting
Implementation of staff plan (example)
| Date | shift | No. of. Pt | Critical level of Pt | Score | Special Procedures | Assigned nurse | Level | Nurse Patient Ratio |
|---|---|---|---|---|---|---|---|---|
| Special Assignment | Morning Staff Name | Pull in (from) | Pull Out (to) | Deployment | No | Criticality Legend |
|---|---|---|---|---|---|---|
| Day off | Ventilator | |||||
| SL | Non-ventilator | |||||
| CL | BiPAP/HFNC | |||||
| Comp. Off | Tracheostomy | |||||
| EL | Isolation | |||||
| Maternity leave | Barrier nursing | |||||
| - | Vulnerable | |||||
| - | Post-op | |||||
| - | Neutropenic patients |
Conclusion
Acuity-based staffing is a model that allocates resources to patients based on their needs, rather than just the number of patients. It is a way to improve patient outcomes, manage costs, and improve organizational excellence.
Here are some benefits of acuity-based staffing:
- Improved patient outcomes
- Acuity-based staffing can decrease mortality and adverse outcomes like infections, falls, and pressure ulcers.
- Cost savings
- Acuity-based staffing can reduce costs; decrease overtime hours, and lower costs per case.
- Better distribution of nurse talent
- Acuity-based staffing can help ensure that the most critically ill patients’ are assigned to experienced nurses.
- Improved employee satisfaction
- Acuity-based staffing can increase employee satisfaction and retention.
- Acuity-based staffing models are patient centre, flexible, equitable, and cost-effective. They can help identify when team members are overburdened, reallocate resources as needed, and balance staff workload
References
- Kidd M, Grove K, Kaiser M, Swoboda B, Taylor A. A new patient-acuity tool
- promotes equitable nurse-patient assignments. American Nurse Today. 2014;9(3):1-4.
- Andrea Ingram, BSN, RN-BC, and Jennifer Powell, BSN, RN “Patient acuity tool on a medical-surgical unit”, North Carolina.
- Chiulli KA, Thompson J, Reguin-Hartman KL. Development and implementation of a patient acuity tool for a medical-surgical unit. Academy of Medical-Surgical Nurses. 2014; 23(2):1,9-12.
- CAHO – Acuity Based Staffing.
