What does high acuity mean to you?

Daliadreamer · Mar 2, 2011

This is interesting, and I am eager to see what others have to say on this subject. I too, work on a hem/onc, renal floor with med/surg overflow. The acuity of the patients have come up numerous times recently due to an increase in census for the past 6 months. Most of us are now working 2-3 hours overtime because of the acuity of the patients and only one nurses aid on the floor.

In my opinion, acuity should be based on the mental status of the patient, their mobility status, and comorbidities. Family dynamics should also come into play, as we all know "that patient" with "that family" can take up most of your day. I'm sure there are many more reasons why a patient can have a higher acuity, but this is just my 2 cents.

SammiJoRNBSN · Mar 2, 2011

When I think of acuity, I think of how much time I am spending in the room providing care to the patient in regards to treatments, administering medications and all the misc. "lines" they may have.

When I did my preceptorship on a hem/onc unit, their acuity board was divided into like 6-10 different categories: level of dependence (self, ltd, ext, total), IV meds, psych issues, falls precautions, chemo, etc. each category was assigned a point value and anyone greater than like a 7 was considered to be higher acuity. They would then adjust the assignments as necessary.

I work on a sub-acute rehabilitation unit for all walks of life and recently we had a pt who had a trach, PEG, wound VAC, foley, fecal incontinence management system, and PICC. Mind you this person was non-responsive and a full code and the family was constantly on our butts. He had the MOST medications I have EVER seen to boot! Me and the other nurses on the unit literally spent almost 50% of our shift managing this person's care....and I have 11 other patients under our care!

annister · Mar 2, 2011

Thanks for your input. I'm having the same issues at work regarding high census and working late, compounded with inadequate staffing, a high employee turnover rate with a huge influx of new grads hired (and not yet chemo certified), and needless to say an overall low morale in reaction to the prior. I'd love to develop a way to not only influence patient assignments, but to increase the awareness of everyone during a given shift as to where potential problems may arise/who's door might be worth peeking into when passing by/which nurses could use a little extra help/yadda yadda. I don't think it could make anything worse, so I'm giving it a try.

msjellybean · Mar 2, 2011

I work heme/onc with general medical overflow and our (flawed) acuity system asks us to rank GI, neuro, skin, cardiac, respiratory, level of anxiety, medication response, frequency of VS measurement, overall life satisfaction, ability to complete ADLs, risk for infection, presence of family, and fluid balance on a scale from not compromised to severely compromised (with mild/moderate/substantial in between).

We have set criteria for what it takes to move from say, substantially compromised on meds to severely (chemo for example gets you a severe). Neutropenia earns you a substantially compromised for infection, neutropenia with positive cultures or fevers gets severe. And on so & so forth, for each point. I'm sure I'm missing a couple, since I'm not at work, but I think I hit the most important ones.

Acuity doesn't mean anything to me, because I could have a comfort care patient who ranks as a 7 (on the high end for us) -- but we're not doing anything for them. Meanwhile, I could have someone who is a 4 (low for us) who is climbing out of bed & isn't stable, yet they're still a 4.

MunoRN, RN · Mar 2, 2011

Staffing by acuity has two dimensions to it; acuity of medical condition and time consumption acuity. You'll find many definitions of staffing by acuity, such as that used by Magnet, to be only based on medical condition, which is really insufficient when trying to implement an acuity system to help guide staffing.

Medical acuity only takes into account medical diagnoses, and the severity/stability of those diagnoses. What that misses is that there can be huge differences in staffing requirements for the same medical acuity. Take two patients with a stable (not currently bleeding) lower GI bleed who are doing prep overnight for a colonoscopy in the AM (same medical acuity). One is 35, otherwise healthy, and fully ambulatory. The other is 375 pounds and a 2+ person assist to the commode. Those q 30 minute to 1 hour trips to the commode would require many more staff hours for patient 2 than patient 1, which really needs to be reflected in assessing staffing needs. In the end, whether or not I am having to spend and extra hour dealing with a complex medical situation, or helping a person to the commode over and over again, it's still an extra hour.

The main difference between medical acuity and labor time acuity is that a higher medical acuity requires more RN time, whereas a higher labor time acuity can be offset with either more RN's or CNA's.

I took this on as a project as well when I was on a tele floor. I found there are acuity rating systems out there (for purchase) that ask a series of questions and then give patients an acuity score. But what I found was that they just give a score of 1,2, or 3. It shouldn't take 2 pages of forms to come up with a score of 1,2 or 3, so we just came up with some basic definitions of each score and added another qualifier which is that 2 or 3 could be designated "RN intensive", meaning the patient was more of a higher medical acuity which would need to be reflected in the staffing.

As you point out, the advantage to this is not only to help make sure that the floor is staffing up when needed, but everyone knows who the busy patients are and what nurses have a heavier load than others and may need help (as well as which nurses have a lighter load and should offer help-which can also cause some problems).

tyloo · Mar 2, 2011

I would consider higher acuity patients based on medical/safety needs- high risk falls, isolated patients, patients with multiple lines/drains, patients with multiple IV abx and pushes, dependent, morbidly obese, restraints, incontinent, test prep, difficult family, wound care, blood transfusions, critical labs.

annister · Mar 2, 2011

To MunoRN, I Couldn't agree more. It seems that any system that doesn't take both labor intensity/frequency and medical condition/diagnosis into account would likely just require more effort and time from staff and end up being counterproductive. I notice that a lot of the requirements in my facility that were intended to benefit staff or patients (supposedly not just to make everything look good on paper) ultimately turn into more of a burden that inhibits me from actually caring for my patients. That in itself is not the problem, but the unwillingness of those capable of instituting such policies to admit that the current way is inadequate is what I find frustrating. I suppose I'm trying to put my money where my mouth is.

Our current method, which is used sporadically and unofficially, relies each nurse throwing out a 1,2, or 3 based on nothing other than individual perception. Problem is, a nurse with 30 years of experience probably has quite a different perception from a nurse with 30 days of experience. Not to mention the fact that a patient who requires a great degree of attention on night shift may very well be an "easy" patient on days or the reverse.

Up2nogood RN, RN · Mar 3, 2011

Our acuity tool is based on pt acuity but unfortunately not used for the staffing grid. It was explained to me though the other night it needs to be used effectively to justify the ratios we have now or it could be taken away.

I don't have a copy but it is based mainly on nursing interventions. It really isn't difficut to use, it's just a short form.

A pt with an insulin gtt is automatically a high acuity-doesn't matter if they're a walkie talkie. A pt on tele that needs mult interventions, anyone on an amiodarone gtt is rated a high or 3. A new radical neck with trach is a high but a pt with existing trach with lower interventions would be a medium.

I had 2 pts the other night that required hourly dilaudid pushes and I was told they were technically a high acuity according to our tool even though they were independent pts.

A new stable post op is a medium or 2. A walkie talkie but with pca and 2 abx pb's is a medium also.

A walkie talkie who would be discharged and on oral meds is a low or 1 unless they were a nut and consumed the nurses time for ridiculous reasons, than could be rated higher.

When acuity is based on interventions provided and documented it makes it easier to rate correctly and backs up/justifies the nurses.

sunnycalifRN · Mar 3, 2011

I work in ICU and a high acuity patient is what is commonly referred to as a "train wreck". Intubated with ARDS, FiO2 1.0, PEEP 15, PCV. Septic, on levo, vaso, dopa, epi gtts. Kidneys failing, on CVVHD. Often with 2 central lines to provide enough IV access; usually 12 - 15 gtts total.

ponytailman · Mar 3, 2011

I think most of the more seasoned nurses have similar ideas to what "high acuity" on there floor is whether mental,labor or crisis driven. To me often high acuity workload can become dangerous or unsafe because management often is slow to respond if they respond at all to help address the extra acuity. I am sure we all have had those days where there are too many issues and not enough eyes,ears hands and brains to deal with it.

steelydanfan · Mar 3, 2011

I've been casually working to create a tool for objectively measuring and classifying the current and anticipated acuity levels of the patients on my unit. I know that peoples' definitions of what constitutes a high acuity patient may differ vastly based upon numerous factors, and I don't want to create something that reflects only what I consider acuity to entail. I'm interested in hearing what other nurses believe influences a patients acuity, whether it is objective or subjective, or pertaining to the level of skill required, physical demand, knowledge, time consumption, a particular diagnosis, patient condition....whatever springs to mind when YOU think of acuity! It doesn't matter if you have evidence or an explanation to support your ideas, any input would be greatly appreciated.
Just for some background, I work on an inpatient hem/onc unit that includes med surg overflow as well as an increasing number of renal patients. I am well aware that programs exist to aid in this very thing, however, my hospital still uses paper charting, is by no means advanced in the way of electronic information utilization, and I am hoping to develop something to use as a guideline rather than a strictly interpreted system.
Thanks again in advance for any insight!

Basically. it really does not matter what you, me or the man in the moon considers to be a proper or reality based acuity scale. We punch them into a computer everyday, every shift, and our staffing matrixes are STILL based around numbers of pt's.

Want to sic the state on them, will probably do so soon.

What does high acuity mean to *you*?

What does high acuity mean to you?