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Discussion

Acuity based nursing

(note - if you get bored w/ my rambling, scroll to the bottom. The last two paragraphs have questions)

Our unit (and possibly soon to be hospital) is starting something new. We're taking the acuity level of our patients and staffing accordingly. Our unit consists of 40 beds. We are called "Adult Intermediate", and we are pretty much the dumping ground of the hospital. Our floor is an Intermediate / Stepdown unit specializing in Vascular, Trauma, and we take trach-vent patients. We are the only floor outside of an ICU that is allowed to take vented patients, and trach patients are RARELY seen on other units (we have been open for 2 years, now, and I have heard of less than 3 incidences that trachs have been on other floors). Because of the way our unit is set up, we have 2 Pixis rooms, 2 clean and soiled utility rooms, and 1 main equipment room. We obviously share resources like a 12-lead EKG machine, bladder scanner, etc. We are also a unit that is composed of single bed units.

This all being said, with the demographics of our patients (MANY ortho, TONS of LONG stay patients, etc) we have a TON of total care patients. Our manager fought tooth and nail to get us to the point where we can do acuity staffing for not only nursing but also nursing aids. We apply a number to each of our patients that represents their acuity. It's a fairly simple scale that is as follows:

1- Walkie talkie. Person that gets up to the restroom and back by themselves, no running IV's minus maybe a maintenance fluid, person that can feed self, bathe, etc. (aka a person that isn't going to be in the hospital long)

2- Patient up with minimal assist, but assist is needed. Able to wash up mostly by self with maybe one minimal assist. Fairly independent, but needs to have staff in the room to get up.

3- Patient that is up with 2 assist or max assist. Patient that has many IV's, tube feed, etc., patient that gets up to the chair via lift, but is able to assist with things like turns, can help minimally with cleaning, is a feed, etc.

4- Total care patient. Patient is unable to help with bathing, feeds, etc. Vented patients. Patient that may get up with the lift, but is a difficult person to get into the chair properly r/t to no ability to assist.

Not only does this make it MUCH simpler to make assignments (make the numbers as close to another person's as possible and you have a fair assignment!), but when our TOTAL number gets too high, we qualify for an extra RN, a few extra NA's, etc. We've actually gotten to the point where if our numbers call for "X" amount of nurses and we don't have them, we are able to call people from home and see if they want some OT.

This has worked SO well in our favor so far, and from what I hear they are going to do it hospital wide via computer. This in addition to hourly rounding is the admin's hope that we have a winning combo of adequate staff levels for units that need them!

The reason I'm posting this is to ask simply: Has anybody seen something like this before? Does it sound like something similar they've seen in their hospitals? How long have you been doing it, and how well is it working?

I can see the ability to have a fair amount of abuse, but I'm hoping that this isn't the case. I hope it goes smoothly, and I hope the transition for the rest of the hospital is great. Eventually when the units that have very low acuity call in they're down an RN, but a unit that is exceptionally heavy calls and says they're short as well, they can redistribute more according to acuity than to "well they asked first" or "that unit always gets people so let's let them go elsewhere" like it seems like our hospital has done in the past.

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    Staffing by acuity looks and sounds great in theory. I have yet to see it work in reality. Even when the numbers call for extra staff "no one is available", staff tends to pad the numbers to TRY to get more help and in the end it is obvious that staffing is done by ratio....

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    Staffing by acuity is nothing new. And I guarantee you that the higher ups will find a way to tweak it to keep your staff numbers down. I'm sure that you're already aware of how they've bastardized staffing by census.

    Know this and know it now: everything in health care is driven by dollar signs. More dollars in and fewer dollars out is the only directive and they don't care how they achieve it.

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    We are also an intermediate unit. Seems no one has really defined what type of pts can be on this type of unit. We came up with a 3 point scoring system. Under each point value, we descibe the characteristics of that pint value. For example a 3 is multiple dressings, freq suctioning (more than q half hour), multiple stools, q 1 hour urine or vitals for a period of time, very large pt, stuff like that. A #2 would be suctioning, say every 1 hour, some dressings, confused, q2 hour vitals. I don't have it with me, but we are going to try to base our staffing on that. Our pts are considered ICU pts in smaller hospitals. Wonder where you are located? Are you a teaching institution? Seems like you are also on a type of general care floor design if you are 40 beds. We are 20 beds, just like the other ICUs in my hsopital. We are an academic institution. I'd be willing to dialogue and maybe we can both benefit. Let me know.

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    A process to 'match' staffing to patient has always been the Holy Grail of nursing . . .

    The problem with most acuity systems is that they are only based on physical workload - like that of the OP. Accepting a system like that one means that we think nursing is only task-based physical labor (workload). There's another dimension of acuity that is not being considered... the 'intensity' of the care needed.

    For instance - what about a 'walkie talkie' that has been newly diagnosed with a very serious illness - requires an enormous amount of emotional support, teaching, etc? Obviously, providing an adequate amount of nursing care for this patient is going to require a lot of time - most likely by an RN. But this is not factored in to most acuity systems. And on the opposite side of the spectrum; what about a comatose but stable patient? Lots of workload, but low level of intensity mean that most of the care could be delivered by a CNA. So - I don't think any acuity system is worth a darn unless it includes both workload & intensity.

    Also - most systems are based on the premise that nurses are completely interchangeable - a new grad is equivalent to an experienced nurse. In actuality, this is never the case. So, how can we account for this? Do we count the newbie as only 50% in terms of workload???

    Food for thought . . .

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    I used to work at a state hospital back east that had a great system for estimating acuity levels. It basically allotted a reasonable number of minutes to each common task, ie total bath with bed change - 60 minutes, hanging an iv med (pre-mixed on a lock or running iv) - 3 minutes, an admission - 45 minutes. It was simplified by a point system, each point equalling a specific number of minutes. The individual patient kardexes held a chart of common procedures and the points assigned to them, nurse just circles the relevant tasks.

    Each shift, the charge would go thru the kardex and update/add up the number of points for each patient, add 'em up and communicate that number on the written supervisor's report we submitted each shift. Supes then used the info to staff the oncoming shift.

    There were shortcomings, for sure ... there was seldom enough slack in the system to make up for sudden changes in unit acuity, so it was really a measure of the baseline workload and so worked better for more chronic units than for something really fast-changing like ICU or acute med-surg.

    But I worked weekend nights for about 4 years with this system. My unit was a mix of chronic and acute ... and could change on a dime. I found it a PITA to do all that math every shift, but it was remarkably accurate even when the unit was more acute.

    I think that, for fast-changing settings like acute care, there is no system that will predict all the variables and be able to react in a timely way. Here's where your supervisors' competence and the availability of extra staff comes into play. If the supe has no-one to move around, her ability to respond to sudden changes in acuity is really limited.

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    • Author
    A process to 'match' staffing to patient has always been the Holy Grail of nursing . . .

    The problem with most acuity systems is that they are only based on physical workload - like that of the OP. Accepting a system like that one means that we think nursing is only task-based physical labor (workload). There's another dimension of acuity that is not being considered... the 'intensity' of the care needed.

    For instance - what about a 'walkie talkie' that has been newly diagnosed with a very serious illness - requires an enormous amount of emotional support, teaching, etc? Obviously, providing an adequate amount of nursing care for this patient is going to require a lot of time - most likely by an RN. But this is not factored in to most acuity systems. And on the opposite side of the spectrum; what about a comatose but stable patient? Lots of workload, but low level of intensity mean that most of the care could be delivered by a CNA. So - I don't think any acuity system is worth a darn unless it includes both workload & intensity.

    Also - most systems are based on the premise that nurses are completely interchangeable - a new grad is equivalent to an experienced nurse. In actuality, this is never the case. So, how can we account for this? Do we count the newbie as only 50% in terms of workload???

    Food for thought . . .

    One of the most beautiful thinkgs about our hospital is that it ha one of the best orientation systems I think I've ever seen. When I graduated, I went to two places to interview (the only ones to call back) - the current place I work, and Cleveland Clinic. I went to the clinic first. When I asked how long orientation was for new grads, my honest to gosh answer for and ICU setting was 2-3 weeks. MY hospital was 6 months training (with a preceptor) and then 6 months of "resourcing" where you're on your own, but you have a specific person that you can ask questions, but really as always everybody helps out... after the first 6 months you're ready for the big time and are able to do anything on your own. Therefore a "new grad" has 6 months of experience and its a beautiful thing indeed!

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