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OFFICIAL NEWSLETTER

Volume 23 – Number 2 March/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, assign appropriate 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 seen physician specialists admit more complex patient cases to a 36-bed medical-surgical unit over the past few years. The usual census in the past included patients who had experienced an appendectomy, hysterectomy, or cholecystectomy. Many of these patients are now dis- charged from the outpatient surgery service. Today, the population on this unit includes patients 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 “overnight observation” patients are now bariatric surgery patients with precise regimens to follow or bilateral mastectomy patients.

The nurses on this medical-surgical unit began to feel the impact of the increase in patient acuity while their staffing ratios remained the same. They also felt an imbalance in workload among the team at times when the assignments did not accurately reflect patient acuity 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 the unit’s nursing skill mix. Assignments were often made under time-pressure and with limited information. The staff nurses requested a more objective and equitable way of defining acuity ratings to promote safer patient care. The unit’s Clinical Nurse Specialist and Nurse Manager were supportive and felt it important to advocate for the nurses and their patients.

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INSIDE THIS ISSUE

Nutrition 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

CNE

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… Israel, R.J. (2008). Subcutaneous methylnaltrexone for treatment of opi- oid-induced constipation in patients with advanced illness: A double-blind, random- ized, parallel group, dose-ranging study. Journal of Pain and Symptom Management, 35(5), 458-468.

Rao, S. (2009). Constipation: Evaluation and treatment of colonic and anorectal motility disorders. Gastrointestinal Endoscopy Clinics of North America, 19(1) 117-139.

Rao, S.S., & Go, J.T. (2009). Treating pelvic floor disorders of defecation: Management or cure? Current Gastroenterology Report, 11(4), 278-287.

Rao, S.S., & Go, J.T. (2010). Update on the man- agement of constipation in the elderly: New treatment options. Clinical Interventions in Aging, 5, 163-171.

Sakharpe, A., Lee, Y., Park G., & Dy, V. (2012). Stercoral perforation requiring subtotal colectomy in a patient on methadone maintenance therapy. Case Reports in Surgery. doi:10.1155/2012/176143

Tack, J., & Müller-Lissner, S. (2009). Treatment of chronic constipation: Current phar- macologic approaches and future direc- tions. Clinical Gastroenterology and Hepatology, 7(5), 502-508.

Tack, J., Müller-Lissner, S., Stanghellini, V., Boeckxstaens, G., Kamm, M., Simren, M., … Fried, M. (2011). Diagnosis and treat- ment of chronic constipation – A European perspective. Neurogastro- enterology & Motility, 23(8), 697-710.

Additional Reading Higgins, D. (2006). How to administer an

enema. Nursing Times, 102(20), 24.

Literature Review A literature search completed in

CINAHL® used the search terms patient classification, clinical assess- ment, and acuity score for the year 2004 and forward. Articles were exam- ined for relevance to our setting and resources. For instance, methods using proprietary software were reviewed for concepts but not considered for implementation.

Twigg and Duffield (2009) agreed that nurse workload is difficult to define and measure, yet necessary to ensure adequate staffing for safe patient care. They reviewed methods of deter- mining nursing workload that have been used historically and agreed that it remains a complex process.

Brennan and Daly (2009) cited tools that have been used to determine patient acuity, yet agreed that there is inconsistency in how acuity is defined and measured. They agreed that meas- urement of patient acuity should incor- porate patient severity of illness and nursing workload factors.

Figure 1. Original 20 Categories and Final 10 Categories

Tamburro, West, Piercy, Towner, and Fang (2004) found that the nursing acuity score for pediatric oncology intensive care patients predicted sur- vival and affirmed the insight of the bedside nurse in assessing severity of illness. Although their patient popula- tion was different, the acuity system they developed that used both clinical severity and nursing workload indica- tors provided guidance in the develop- ment of our tool. Friese, Earle, Silber, and Aiken (2010) related certain clinical severity scores to patient mortality. Brewer (2006) combined and refined over 30 variables into 16 acuity charac- teristics. Our tool incorporated patient characteristics used by Brewer, such as respiratory and cardiac management, isolation status, activities of daily living, and wound management. Brewer’s methodology of consolidating variables was used to influence the design of our acuity tool.

Rauhala and Fagerström (2004) discussed the RAFAELA system, a mnemonic they created, comparing patient acuity with nurse resources. The RAFAELA system assigns points based

Patient Acuity Tool continued from page 1

Special Issue of MedSurg Matters! to Focus on Education

The July/August issue of MedSurg Matters! will have an emphasis on nursing education. Explored topics will include: educa- tion initiatives based on the Institute of Medicine's Future of Nursing report, collaborative learning and the professional growth of student nurses, and emerging roles for nurses after health care reform. Keep an eye on your mailbox this summer for this exciting theme issue.

Academy of Medical-Surgical Nurses www.amsn.org

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on care intensity for patient needs and uses the Professional Assessment of Optimal Nursing Care Intensity Level (PAONCIL) tool, which establishes optimal nursing intensity per caregiver. The RAFAELA system – used primarily in Finland for outpatient departments, psychiatric nursing care, primary health care, and long-term or home care – was complicated to use and not appli- cable to our patient population.

DeLisle (2009) found that using an acuity tool representative of patient status and clinical intensity could be used to assist in equitable distribution of nursing workload. The acuity tool rated patients a Level I-V based on nursing time required to administer chemotherapy in an outpatient ambula- tory oncology unit. Although this was not our patient population, this infor- mation was helpful in considering clini- cal severity and nursing workload indi-

cators in determining acuity and making patient assignments.

The literature was helpful in stimu- lating discussion about how to define acuity, but a specific patient acuity assessment tool appropriate for our medical-surgical patient population was not found.

Using input from staff nurses, the authors set out to develop a compre- hensive acuity assessment tool that could be used objectively and consis- tently by the staff. The intention was to utilize this tool to make appropriate patient assignments and balance the unit workload to maximize safe, effec- tive patient care.

Method The authors held roundtable dis-

cussions that were open to all staff on the unit over a period of several months. Discussions included “what

defines acuity” and “how to differenti- ate levels of acuity.” The team talked about what “counts” – illness of the patient or how much nursing time is required to care for them or both. What about the psychological “work” of dealing with an anxious, upset, or confused patient?

At first, the proposed acuity tool had 20 categories (see Figure 1). The number of categories and descriptors were refined over a period of eight weeks by the researchers with input from the nurses and manager. Through discussions and continual assessment of the patient population, the team was able to refine descriptors that identified different levels of acuity. After ten revi- sions, the final tool consisted of 10 cat- egories – six related to patient clinical severity and four related to nurse workload (see Figure 2).

Figure 2. Final Acuity Tool

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Using the tool, a typical, uncompli- cated postoperative patient was rated a 2.A complex surgical patient with more extensive care needs was a 3, and a patient at high risk for a decline in sta- tus or requiring frequent nursing care or assessment would have a 4 rating. Patients were rated a 2, 3, or 4 in each of the ten categories. For example, in the respiratory category, a stable laparoscopic cholecystectomy patient might need oxygen per nasal cannula at 2 liters per minute (lpm) for the first 24 hours due to the carbon dioxide gas

used to inflate the abdomen during the procedure and would be identified as a 2. A patient requiring oxygen support above 2 lpm per nasal cannula, perhaps due to cardiac status would be a 3. A patient with decompensating respira- tory status requiring a full-face oxygen mask would have a 4 rating.

Results Content validity was verified using

the input of the nursing staff and man- ager during the ten design and revision meetings. The resulting acuity tool was

Figure 3. Results – Subjective, Validation, and Implementation

piloted and validated for usability and feasibility on all shifts at varying times and days of the week. During this phase, a total of 40 nurses assessed 183 patients. Patients were scored in each of the ten categories. Initially, raw scores were used and converted to an overall acuity rating of 2, 3, or 4. Refinement of the tool showed that a score of 3 for any category gave the patient a final 3 acuity rating, and a 4 score in any category gave a final 4 rat- ing. This refinement eliminated the need to perform mathematical calculations and greatly reduced the complexity of use. Acuity ratings using the tool were then compared to ratings assigned by charge nurses using their traditional, subjective method. During the trial period, the charge nurses rated 51% of patients as 2 and 49% of patients as 3 (none of the patients received a 4). When nurses used the new tool for the same patients concurrently, 32% of patients were a 2, 53% were a 3, and 15% were a 4 rating (see Figure 3). These ratings reflected the nurses’ percep- tions of their patients’ acuity. There was agreement among management and the researchers that nurses were not overstating the number of high- acuity patients.

Implementation The next phase was to implement

the new acuity tool. Beginning July 18, 2011, each nurse rated his or her patients’ acuity using the tool. During this phase, 43 nurses rated 488 patients. Data revealed that 51% of the patients 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 tool showed that our previous subjective method failed to identify high-acuity patients.

Acuity indicators were analyzed to determine frequencies of occurrence (see Figure 4). The most frequently occurring driver for a patient rating of 4 was activities of daily living and isola- tion (for example, the care required for a paraplegic and a quadraplegic postop- erative patient due to nursing work- load). The second most common driver

Figure 4. Drivers of Acuity by Category

Academy of Medical-Surgical Nurses www.amsn.org

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

for a 4 was wound/ostomy (for exam- ple, a high-output ileostomy patient requiring frequent monitoring of out- put volume, site leakage, and fluid/elec- trolyte imbalance). The top drivers for an acuity rating of 3 were activities of daily living, patient’s isolation status, and admit/discharge/transfer.

The acuity ratings completed by nurses are now given to charge nurses to make the assignment for the oncom- ing shift. The typical nurse-patient ratio of 5:1 is adjusted to 4:1 if a nurse has a patient with a rating of 4. Novice nurses are assigned patients with acuity ratings of 2 or 3, and assignments are balanced to distribute the unit workload (see Figure 5).

Discussion This tool incorporates clinical

severity and nurse workload indicators to determine acuity and is used to make patient assignments in alignment with appropriate skill mix and staffing ratios. Nurses supported having an objective tool to use in assessing patient acuity to provide safe care, adjust staffing ratios, and balance unit workload. Experienced nurses were assigned higher acuity patients. The chief nursing officer, operation adminis- trators, and nurse manager support using the new acuity tool to adjust

staffing ratios each shift according to patient needs.

The advantages of the tool are simplicity, cost, and customization. The tool does not require complex docu- mentation (i.e., any 4 is a 4) and requires about ten seconds per patient per shift to complete. It does not require expensive information technol- ogy support. Finally, the tool is easily adapted to the unique needs of any patient population.

Conclusions Our experience illustrates that the

use of the collaboration process by management and staff nurses can lead to the development of an objective, quantitative acuity tool to assign patient acuity to medical-surgical patients. This unit used this tool to effectively deter- mine nurse-patient ratios and develop a safer nursing workload. Currently, the authors are mentoring other units at our hospital to facilitate the develop- ment of an acuity tool for their patient populations.

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

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

Brewer, B.B. (2006). Is patient acuity a proxy for patient characteristics of the AACN Synergy Model for Patient Care? Nursing

Administration Quarterly, 30(4), 351-357. DeLisle, J. (2009). Designing an acuity tool for

an ambulatory oncology setting. Clinical Journal 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 surgical oncology 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 of Advanced 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 of workload measures: A context for a new staffing methodology in Western Australia. International Journal of Nursing Studies, 46, 132-140.

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

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