How to determine patient acuity

  1. Does anyone know of any guidelines for determining patient acuity? I'm sure we can all pretty much do it in our heads, but I'm actually looking for documented recommendations. Without some kind of formal guideline, patient acuity can be left open to wide interpretation and manipulated to managemental desires.
  2. Visit Pudnluv profile page

    About Pudnluv

    Joined: Oct '08; Posts: 589; Likes: 1,436
    Registered Professional Nurse; from US
    Specialty: 20 year(s) of experience in ED


  3. by   mama_d
    We used to have a section of our flowsheet that we filled out, tallied up, and depending on the total the patient rated a 0-5 on acuity. Zero basically never happened. Five would indicate that they should be on step-down at least. It had categories like number of IV pushes/piggybacks, restraints, tube feeds, skin issues, etc. Honestly, they never staffed to acuity, so I don't know why they ever did it. They said initially that they were going to, but everyone knew they never would. It finally got phased off of the flow sheets after about two years.
  4. by   BookwormRN
    Our hospital uses the MESH system for acuity levels. Of course, nothing is perfect, but at least we have something other than ratios to go by. I've added the link below.
  5. by   GrumpyRN63
    We have one somewhere, and use to actually complete them on every shift, but as we were told my our manager it doesn't infuence our staffing ratio, so we don't bother
  6. by   mpccrn
    i worked at a place that was trying to come up with an accuity scale. they had people actually follow us around and time every task required for a was a complete joke and made no difference in how staffing was was still staffing by number, not accuity.
  7. by   HonestRN
    Here are some basic guidelines for rating acuity. Patients are rated on a scale of 1-4 based on some of the following:

    Level 1: VS X 1, A&O,independent care, 1-2 PO meds, saline lock, room air, 1-2 closed incisions OTA, no procedures

    Level 2: VS X 1 and Orthostatic BP X 1, Fluid restrictions, 1 PRN med, 3-5 scheduled PO meds, 1-2 schedule SQ/IV meds, PCA, Labs X 1, O2 per NC or simple mask, O2 sats X 1, tele w/o changes, NG/G or J tube, chem strips X 1, simple drsg change<5 min, simple drain, foley care

    Level 3: Assess X 3, Neuro checks q 4 hrs. VS X 2, Orthostatic BP X 2, Oral care X 1, 3-4 3 emisis, TPN/Lipids, aspiration precautions, 2 PRN meds, 6-10 scheduled PO meds and/or crushed meds, 3 scheduled SQ and/or IV meds, 2 IV sites, Blood products <2, meds that require assessment before giving (cardiac etc), trach O2/O2 via face mask, O2 titration/O2 sats X 2, Low RR, suctioning X 1-2, trach care X 1, prep for surgery/post procedure checks, freq tele changes with stable pt, chem strips X 2, drsg change 5-10 min, multiple/complex drains/monitor > tubes q 1-3 hrs, Post op bleeding, osotomy care, detox precautions, restraint alternatives, assist with elimination X 3-4, straight cath X 1, ck urine output q 4 hours, specimen collection X 2

    Level 4: Assess >/= 4, Neuro cks >/= 4, VS > 2, Orthostatic BP X 3, ADL complete care, emesis >/= 5, oral care X 2, total feed, aspiration precautions, 2 PRN meds, > 10 PO meds, 4 scheduled SQ and or IV meds, 2 IV sites/lines, Meds crushed or per PEG/FT, multiple blood products >/= 2, detox protocol, lab intrerpetation >/= X 2, mech ventilation, cont or intermittant POX/O2 sats > X 2, Suctioning > 2, Trach care > 2, frq tele changes with interventions, chem strips > 2, dressing changes > 15 min or X3 or >/= 2 assist, osotmoy irrigation, freq alarm cks > 2 hrs, DT's, pt wanders, isolation precautions (contact, droplet, neutropenic etc), sitter, assist with elimination >/= 5, insert or poss foley insert, incontinent care X 2, bowel incontinence with freq loose stools, >/= 2 assist with BR, BSC or bedpan, IV insert X 2

    These are basic guidelines and can be tweaked for any unit.
  8. by   Pudnluv
    Thank you. Those are pretty good. Based on those guidelines, how would you staff your unit?
  9. by   HonestRN
    Quote from Pudnluv
    Thank you. Those are pretty good. Based on those guidelines, how would you staff your unit?
    Would depend on how many pt's at what levels. Increased high levels, more staff. A nurse with a level 4 couldn't reasonably be expected to take on as many pt's as a nurse with levels 1 or 2.
    Last edit by HonestRN on Nov 6, '08 : Reason: spelling
  10. by   Pudnluv
    Most of our patients rate a level 4 according to your scale. All our tele patients are q4 hour vs. We do have have some level 2 and 3 and rarely level 1. Currently are nurse to patient ratio is 6:1 on days with a target 4:1, eves 9:1 with a target of 6:1 and nights 10:1 with a target of 7:1. Many of the nurses have been there for at least 1 year, our newest for about 6 months. Most have at least 5 years on the floor.
  11. by   HonestRN
    Sounds to me that you have to beef up your staff and staffing levels.

    Remember those are just guidelines and you can adjust the requirements as needed and desired for your particular unit
  12. by   Pudnluv
    Thank you for the info. We are currently working on ways to improve our staffing, we just need some tangible info. Where do you get your guidelines from?
  13. by   uscstu4lfe
    we have a computer system that we log into. it asks a series of questions about each patient that we have, and based on our responses, it determines acuity. that information is then automatically sent to staffing, where appropriate staffing ratios are determined.
  14. by   HouTx
    This is really a very interesting subject, and it all hinges on how you define nursing. Actually, I used to develop these types of systems as a consultant & it paid very well.

    Most 'acuity systems' are simply laundry lists of tasks -- like the one outlined by a previous poster. These tasks certainly add to the workload, but they don't completely reflect the work of nursing.

    Workload and Intensity are actually 2 separate issues when it comes to staffing. You can have a 'high task' patient (comatose) but most of the the work could be handled by a nurse assistant. On the other hand, you could have a new diabetic - completely ambulatory and self care, but with extremely high teaching and emotional support needs - high intensity - that requires a LOT of RN time.

    Of course, acuity systems also fail to account for the ADT 'noise' (admissions, discharges & transfers) that are very time consuming. We all know you can start & end the shift with 4 patients, but the ones you ended up with are not the ones you started with!

    All in all, I don't think that there is any task list that can replace good old nursing judgement. I am a proponent of 'prototype' acuity systems that consider both workload and acuity. But they need to be coupled with additonal workload attached to the ADT.

    It's no wonder that so many hospitals have just given up and rely on ratios.