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Best Practices for Staffing: Acuity vs. Census

Best Practices for Staffing: Acuity vs. Census. . Lauren Bachman, Heath Chrisianson , Sylvia Davis, Heidi Kidd, Eric Stuemke. Summary of Evidence What does it all mean?

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Best Practices for Staffing: Acuity vs. Census

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  1. Best Practices for Staffing: Acuity vs. Census •  Lauren Bachman, Heath Chrisianson, Sylvia Davis, Heidi Kidd, Eric Stuemke • Summary of Evidence • What does it all mean? • Nurse tracking call light systems are an underutilized tool that can be used to effectively communicate patient needs among the interdisciplinary team, (Lucero, Ji, Cordova, & Stone, 2011) • There is a need to have a universal acuity tool, (Harper & McCully, 2007). • There is an association between acuity based staffing and improvements in patient safety, (Twigg, Duffield, Bremner, Rapley, & Finn, 2011). • Nursing satisfaction is related to patient acuity, nursing workload, and understaffing (McGillis & Kiesners, 2005). • Universal system for collection of nurses involved in patient care (Mark & Harless, 2011). • A standardized acuity system needs to be developed, tested, and implemented widely in hospitals and adopted by researchers (Mark & Harless, 2011) • Patient satisfaction is related to nurse staffing and the availability of hospital support services. (Bacon & Mark, 2009) • High acuity increases workload due to understaffing. Fixing staffing would decrease the workload per patient (Acar, 2010). • Patient acuity scoring systems and distance scoring systems can be used to estimate total workload of nurses, (Acar, 2010). • Units cannot use a minimum nurse patient ratio alone, a number of factors must be incorporated to determine an appropriate patient to nurse ratio, including patient acuity, skill mix, nurse competence, nursing process variables, technological sophistication (Lang, Hodge, Olson, Romano, & Kravitz, 2004). • There is a lack of support offered in the literature for specific minimum nurse patient ratios ,(Lang, Hodge, Olson, Romano, Kravitz, 2004). • The use of acuity tools alone is not sufficient to determine adequate staffing requirements, (Hayes & Ball, 2012) BACKGROUND • Patient Classification Systems have been utilized since the 1960’s without standardization or consensus (Harper & McCully, 2007). • With a combination of increasing health costs, decreasing nurse satisfaction, a lack of communication tools, and staffing shortages; acuity tools can appropriately coordinate staff with patient needs (Twigg, Duffield, Bremner, Rapley, & Finn 2011). • Low nurse-to-patient ratios are related to lower rates of adverse patient outcomes (Harper & McCully, 2007). • “Patient classification systems and acuity tools allow managers and administrators to predict staffing needs and more accurately control nurse-to-patient ratios” (Harper & McCully 2007) • RESULTS • Evidence Answers Original Question • Research was inconclusive related to our original question. At this time there is a continued need for establishing a universal acuity rating tool. Additional experimentation, and possibly a meta-analysis of previous research is needed. • Not Found in Evidence • There was no universal tool for patient acuity measurement found in the literature search. • SEARCHABLE QUESTION • What are the best practices for staffing adult inpatient acute care units regarding patient census and patient acuity? • Databases Searched • CINAL & PUBMED • Suggestions for Future Research • Meta-analysis of all currently available acuity tools. • Unit specific measures of acuity should be considered in development of future acuity staffing tools. • A patient acuity tool should be developed, and measured against patient outcomes. • For addition information please contact: • University of Anchorage • School of Nursing (907) 786-4550 • CONCLUSIONS • Nurse leadership should pay careful attention to seeking buy in from staff nurses and other interdisciplinary members (Harper and McCully, 2007). • Each unit should seek out workable acuity tools, and implement them within their specific environment (Heede,Diya, Lesaffre, Vleugels, & Sermeus, 2008).

  2. Best Practices for StaffingAcuity vs. CensusUniversity of Alaska Anchorage NS400 Heidi Kidd, Sylvia Davis, Eric Stuemke, Heath Christianson, and Lauren Bachman

  3. Background & Significance • Patient Classification Systems have been utilized since the 1960’s without standardization or consensus (Harper & McCully, 2007). • With a combination of increasing health costs, decreasing nurse satisfaction, a lack of communication tools, and staffing shortages; acuity tools can appropriately coordinate staff with patient needs (Twigg, Duffield, Bremner, Rapley, & Finn 2011). • Low nurse-to-patient ratios are related to lower rates of adverse patient outcomes (Harper & McCully, 2007). • “Patient classification systems and acuity tools allow managers and administrators to predict staffing needs and more accurately control nurse-to-patient ratios” (Harper & McCully 2007)

  4. Searchable Question • What are the best practices for staffing adult inpatient acute care units regarding patient census and patient acuity?

  5. Information Technology, Nurse Staffing, and Patient Needs (Lucero, Ji, Cordova, & Stone, 2011) • Retrospective Exploratory, Level IV • FTE RN’s on an orthopedic surgical unit N=34 • Convenience Non-Random Sample • Admissions increased response times more than discharges • Tracking call light study demonstrated the busiest times of day • Nurse staffing was adjusted accordingly Strengths Readily available data & use of existing technology Application to clinical practice Weaknesses All patient calls (needs) were assumed equally important

  6. Acuity Systems Dialogue and Patient Classification System Essentials (Harper & McCully, 2007) • Descriptive Level VI Evidence • N = 15 RN’s on a Medical-Surgical Unit • Author’s Patient Classification System Employed 5 Criteria • Medications, Complicated Procedures, Education, Psychosocial Issues, and Complicated IV Medications. • Criteria yielded a level 1-4 patient acuity rating • The PCS tool was well received by nurses with 77% rating it as an effective voice for nurses in communicating about their patients Strengths Use of staff nurses input to develop PCS tool 5 rating concepts evaluate time & frequency required for interventions Includes education & psychosocial considerations Weaknesses Small Sample Size No clear recommendation on how to use tool to make specific assignments

  7. The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data. (Twigg et al., 2011) • Interrupted time series using retrospective analysis. Level IV • Three adult tertiary teaching hospitals that received 88.9% of the staffing increases • All patient records (N = 236,454) and nurse staffing records (N = 150,925) . • Measurements taken pre implementation, transitional period and post implementation. • Significant decreases in the rates of nine nursing-sensitive outcomes following implementation of NHPPD Strengths Large sample size Extensive patient and nurse staffing records Weaknesses DRG’s not consistent through time California did not produce similar results

  8. A narrative approach to understanding the nursing work environment in Canada (McGillis et al., 2005) • Qualitative . Level VI. • Purposive sampling from eight randomly selected hospitals. • 8 nurses from 8 different acute care units • Revealed three key themes: patient acuity, workload, and understaffing as effecting quality of work environment Strengths Themes dominated conversations and were interrelated Weaknesses Group size was preselected & no mention of data saturation

  9. Adjusting for Patient Acuity in Measurement of Nurse Staffing (Mark and Harless, 2011) • Cross Sectional and Longitudinal, Level IV • Sample 579 hospitals in 13 states from 2000 to 2006 • Purpose to examine if CMI can substitute for NIW • CMI=Case Mix Index High CMI =more care • NIW = Nursing Intensity Workload Strengths Descriptive Statistics with simple correlation analysis Large sample size Weakness NIWs provide a true estimate of Patient needs CMI doesn’t reflect acuity. CMI only for Medicare patients No distinction between inpatient and outpatient employee Level IV Study

  10. Benchmarking nurse staffing levels: the development of a nationwide feedback tool (Heede et al., 2008) • Retrospective analysis of cross-sectional data, Level IV • Sample 690,258 inpatient days for 298,691 patients from 1637 acute care nursing units in 115 hospitals • Feedback tool developed based on satistical model • Spearman rank correlations from 0.91-0.99 • High reliability and validity for tool developed Strengths Inter-rater reliability 78.8 % Random selection of patients data Weakness Data assumes units within hospitals are correlated Aim of study to report not predict staffing Feedback tool only available online Level IV evidence

  11. Organizational Effects On Patient Satisfaction In Hospital Medical Surgical Units (Bacon, C.T. & Mark, B., 2009) • Single, correlation study, level IV • Random sample • Included 2720 patients and 3718 RNs in 286 medical-surgical units in 146 hospitals • Investigated the relationship of patient satisfaction with floor staffing and support services. Strengths Patient acuity is used as a variable Weaknesses Sampling bias is a potential problem. Variables used (patient acuity and work complexity) are difficult to operationalize.

  12. A Decision Model for Nurse-To-Patient Assignment (Acar, I., 2010) • After-only Comparative Design, level IV. • 40 RN’s on General Medical Unit. Approximately 100 12-hour shifts observed. • Models for staff assignment included maximizing patient acuity and minimizing RN distance traveled during a shift, or minimizing the maximum workload assigned to a nurse. Results compared to the Charge Nurse’s manual assignments’ resulting workload Strengths Initially planned to study nurses in NICU, and realized generalizability may be limited. Switched the study to a General Medical Unit. Weaknesses Study took place in one hospital, which may limit generalizability.

  13. Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes (Lang et al., 2004) • Level V • Systematic review of descriptive/correlational studies • Sample: 43 research studies on acute care, rehabilitation, or psychiatric hospitals • Patient acuity, skill mix, nurse competence, nursing process variables, technological sophistication, and institutional support of nursing should be considered when setting minimum nurse staffing requirements, and not a minimum nurse-patient ratio alone. Strengths Former nurse with 15 years experience as a medical reference librarian performed the literature search Weaknesses 49% of studies analyzed hospital-level data, rather than nursing-unit-level data. Include data from ICUs, which have different staffing patterns and different patient characteristics

  14. Achieving safe staffing for older people in hospital(Hayes & Ball, 2012) • Level VI • Mixed Methods (quantitative from a 2 survey method) • Nurses who worked on older people’s wards (n=240) • The use of acuity tools alone is not sufficient to determine adequate staffing requirements. • During periods of high patient acuity, charge nurses must have instant access to additional nursing resources. • Charge nurses should also have access to senior clinical support and leadership from nurse experts. Strengths Royal college of Nursing’s (2012) guidance and recommendations can be used by nurses at all levels Multiple focus groups with front-line nurses Workshops & discussions w/ invited gerontological nurses Weaknesses Focused on older people’s ward’s in the U.K. Focused groups not randomized, may introduce bias

  15. Stake Holders • Facility Administration/Accounting • Insurance Companies/Third Party Payer • Nurse Leadership • Nurse Educators • Staff Nurses • Patient Care Technicians/CNA’s • Patients-(Outcomes)

  16. Summary of Evidence • Nurse tracking call light systems are an underutilized tool that can be used to effectively communicate patient needs among the interdisciplinary team(Lucero, Ji, Cordova, & Stone, 2011). • There is a need to have a universal acuity tool (Harper & McCully, 2007). • There is an association between acuity based staffing and improvements in patient safety(Twigg, Duffield, Bremner, Rapley, & Finn, 2011). • Nursing satisfaction is related to patient acuity, nursing workload, and understaffing (McGillis & Kiesners, 2005). • A standardized acuity system needs to be developed, tested, and implemented widely in hospitals and adopted by researchers (Mark & Harless, 2011) • Patient satisfaction is related to nurse staffing and the availability of hospital support services. (Bacon & Mark, 2009)

  17. Summary of Evidence • High acuity increases workload due to understaffing. Fixing staffing would decrease the workload per patient (Acar, 2010). • Patient acuity scoring systems and distance scoring systems can be used to estimate total workload of nurses (Acar, 2010). • Units cannot use a minimum nurse patient ratio alone, a number of factors must be incorporated to determine an appropriate patient to nurse ratio, including patient acuity, skill mix, nurse competence, nursing process variables, technological sophistication (Lang, Hodge, Olson, Romano, & Kravitz, 2004). • There is a lack of support offered in the literature for specific minimum nurse patient ratios (Lang, Hodge, Olson, Romano, Kravitz, 2004). • The use of acuity tools alone is not sufficient to determine adequate staffing requirements (Hayes & Ball, 2012).

  18. Results Evidence Answers Original Question • Research was inconclusive related to our original question. At this time there is a continued need for establishing a universal acuity rating tool. Additional experimentation, and possibly a meta-analysis of previous research is needed. Not Found in Evidence • There was no universal tool for patient acuity measurement found in the literature search.

  19. Future Research • Meta-analysis of all currently available acuity tools. • Unit specific measures of acuity should be considered in development of future acuity staffing tools. • A patient acuity tool should be developed, and measured against patient outcomes.

  20. Plan of Implementation • A meta analysis should be performed. • Focus groups, comprised of stake holders, should conduct a literature review. • Unit specific acuity tools would then be implemented. • Pre-implementation data should be measured against post-implementation data in relation to pre-defined patient outcomes.

  21. Conclusions • Nurse leadership should pay careful attention to seeking buy in from staff nurses and other interdisciplinary members (Harper and McCully, 2007). • Each unit should seek out workable acuity tools, and implement them within their specific environment (Heede,Diya, Lesaffre, Vleugels, & Sermeus, 2008).

  22. References Acar, I. (2010). A decision model for nurse-to-patient assignment. Western Michigan University. Bacon, C.T. & Mark, B. (2009). Organizational effects on patient satisfaction in hospital medical surgical units. Journal of Nursing Administration, 39(5), 220-227. Harper & McCully. (2007). Acuity systems dialogue and patient classification system essentials. Nursing Administration Quarterly, 31(4), 284-299 Hayes, N. & Ball, J. (2012). Achieving safe staffing for older people in hospital. Nursing Older People 24(4), 20-24. Heede, K. V., Diya, L., Lesaffre, E., Vleugels, A., & Sermeus, W. (2008). Benchmarking nurse staffing levels: The development of a nationwide feedback tool. Journal of Advanced Nursing, 63, 607-618.

  23. References Lang, T.A., Hodge, M., Olson, V., Romano, P.S., & Kravitz, R.L. (2004). A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. JONA, 34(7/8), 326-337. Lucero, R.J., Ji, H., de Cordova, P.B., & Stone, P. (2011). Information technology, nurse staffing, and patient needs. Nursing Economics, 29(4), 189-194. Mark, B. A., & Harless, D. W. (2011, March/April). Adjusting for patient acuity in measurement of nurse staffing. Nursing Research, 60(2), 107-113. McGillis Hall, L., & Kiesners, D. (2005). A narrative approach to understanding the nursing work environment in Canada. Social Science & Medicine, 61(12), 2482-2491. doi: 10.1016/j.socscimed.2005.05.002 Twigg, D.I., Duffield, C., Bremner, A., Rapley, P., & Finn, J. (2011). The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data. International Journal of Nursing Studies, 48(5), 540-548.

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