A comparison of two patient classification instruments in an acute care hospital

Multivariate analysis of early surgical management factors affecting posttraumatic penoscrotal avulsion injury: a level I trauma center study

Background

To conduct an accurate evaluation of patients presenting with posttraumatic penoscrotal injuries, and to formulate a treatment algorithm based on this assessment.

Methods

We conducted a retrospective chart review study. Patients with penoscrotal defects admitted to our level I trauma center from 2017 to 2019 were evaluated. The Braden scale score was used for wound evaluation and the Korean patient classification system (KPCS) was used for assessment of severity. Univariate and multivariate analyses were performed for potential risk factors associated with early surgical management.

Results

In total, there were 58 male patients, and the average Braden scale score was 12.08 ± 2.54, with the scrotum (36.20%), and the penile shaft (32.76%) being popular sites for injuries. The wounds requiring surgical treatment were 20.68% (n = 12), with local flaps (33.33%) being most commonly used. The significant predictors of advanced wounds which required surgical treatment were old age (p = 0.026, odds ratio [OR] 8.238), orthopedic combined injuries (p = 0.044, OR 1.088), intubation (p = 0.018, OR 9.625), restraint (p = 0.036, OR 0.157) and blood transfusion (p < 0.001, OR 2.462).

Conclusion

In multiple trauma patients, penoscrotal defects caused by high-speed trauma are an important matter of concern. Specifically, patients with combined skeletal injuries or requiring respiratory care were prone to advanced wounds. We proposed a five-category algorithm to manage such patients, which included severity of the patient’s condition, respiration, hemodynamic status, comorbidity, and immobilization. Additionally, inter-departmental cooperation and active intervention by plastic surgeons is needed for the comprehensive treatment of such injuries.

Trial registration This study was performed in line with the principles of the Declaration of Helsinki. The study and all its protocols were approved by the institutional review board of Ajou Medical Center (approval no. AJIRB-MED-MDB-17-254). The need for informed consent was waived by the institutional review board of our hospital due to the retrospective design of the study.

Taking nurse staffing research to the unit level

This summary of currently published literature explores gaps that explain why translation of nurse staffing research into clinical practice has been difficult.

Measuring agreement between healthcare survey instruments using mutual information

BACKGROUND

Healthcare researchers often use multiple healthcare survey instruments to examine a particular patient symptom. The use of multiple instruments can pose some interesting research questions, such as whether the outcomes produced by the different instruments are in agreement. We tackle this problem using information theory, focusing on mutual information to compare outcomes from multiple healthcare survey instruments.

METHODS

We review existing methods of measuring agreement/disagreement between the instruments and suggest a procedure that utilizes mutual information to quantitatively measure the amount of information shared by outcomes from multiple healthcare survey instruments. We also include worked examples to explain the approach.

RESULTS

As a case study, we employ the suggested procedure to analyze multiple healthcare survey instruments used for detecting delirium superimposed on dementia (DSD) in community-dwelling older adults. In addition, several examples are used to assess the mutual information technique in comparison with other measures, such as odds ratio and Cohen's kappa.

CONCLUSIONS

Analysis of mutual information can be useful in explaining agreement/disagreement between multiple instruments. The suggested approach provides new insights into and potential improvements for the application of healthcare survey instruments.

Hospital mortality and optimality of nursing workload: A study on the predictive validity of the RAFAELA Nursing Intensity and Staffing system

BACKGROUND

Patient classification systems have been developed to manage workloads by estimating the need for nursing resources through the identification and quantification of individual patients' care needs. There is in use a diverse variety of patient classification systems. Most of them lack validity and reliability testing and evidence of the relationship to nursing outcomes.

OBJECTIVE

Predictive validity of the RAFAELA system was tested by examining whether hospital mortality can be predicted by the optimality of nursing workload.

METHODS

In this cross-sectional retrospective observational study, monthly mortality statistics and reports of daily registrations from the RAFAELA system were gathered from 34 inpatient units of two acute care hospitals in 2012 and 2013 (n=732). The association of hospital mortality with the chosen predictors (hospital, average daily patient to nurse ratio, average daily nursing workload and average daily workload optimality) was examined by negative binomial regression analyses.

RESULTS

Compared to the incidence rate of death in the months of overstaffing when average daily nursing workload was below the optimal level, the incidence rate was nearly fivefold when average daily nursing workload was at the optimal level (IRR 4.79, 95% CI 1.57-14.67, p=0.006) and 13-fold in the months of understaffing when average daily nursing workload was above the optimal level (IRR 12.97, 95% CI 2.86-58.88, p=0.001).

CONCLUSIONS

Hospital mortality can be predicted by the RAFAELA system. This study rendered additional confirmation for the predictive validity of this patient classification system. In future, larger studies with a wider variety of nurse sensitive outcomes and multiple risk adjustments are needed. Future research should also focus on other important criteria for an adequate nursing workforce management tool such as simplicity, efficiency and acceptability.

The oncology acuity tool: a reliable, valid method for measuring patient acuity for nurse assignment decisions

BACKGROUND AND PURPOSE

Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments.

METHODS

Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events.

RESULTS

Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls.

CONCLUSIONS

The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.

Nursing workforce planning: insights from seven Malaysian hospitals

In 2010, the Royal College of Nursing asked: 'What is the optimal level and mix of nurses required to deliver quality care as cost-effectively as possible?' This question implies there is a relationship between staffing levels, quality of care and financial efficiency. This paper examines the relationship between the staff budget, the number of staff required to achieve a target level of care and the actual number of staff employed in seven hospitals in Malaysia. It seeks to critically evaluate local challenges arising from staff budgeting/planning procedures, identify general issues that apply beyond Malaysian healthcare institutions and, finally, to propose a model that combines finance, staffing and level of care.

Determining nurse staffing needs: the workload intensity measurement system

OBJECTIVE

To develop a prototype nursing workload intensity measurement system (WIMS).

BACKGROUND

Current nurse staffing was determined based on a development. The predetermined nurse-to-patient ratio of a measurement system in the present work environment was deemed essential.

METHODS

The study was conducted in a 1500-bed acute care hospital in Singapore. A questionnaire was designed to identify critical indicators for workload measurement. Nineteen wards were observed over a period of 1 week on day shifts. The WIMS was developed using regression modelling.

RESULTS

Nursing time required for a low-acuity ward increased from 90.5 to 177.1 hours per day. The WIMS was developed using nursing diagnoses as critical indicators of workload. The model (WIMS) yield R(2) values ranging from 0.615 to 0.736 across the six key disciplines, rendering it a model with relatively good predictive ability of nursing time required.

CONCLUSION

In such a rapidly changing work environment, workload measurement systems should be reviewed periodically. The WIMS was developed as a potential methodology for measuring staffing needs.

IMPLICATION FOR NURSING MANAGEMENT

Workload predictions should de-link patient dependency with acuity status as both do not correlate, as evidenced by this study.

Time in care for older people living in nursing homes

In order to measure actual care needs in relation to resources required to fulfill these needs, an instrument (Time in Care) with which to evaluate care needs and determine the time needed for various care activities has been developed with the aim of assessing nursing intensity in municipal care for older people. Interreliability (ICC = 0.854) of time measurements (n = 10'546) of 32 nursing activities in relation to evaluated care levels in two nursing homes (staff n = 81) has been determined. Nursing intensity for both periods at the two nursing homes comprised on average a direct care time of 75 (45%) and 101 (42%) minutes, respectively. Work time was measured according to actual schedule (462 hours per nursing home during two weeks). Given that the need for care was high, one must further investigate if the quality of care the recipients received was sufficiently addressed.

Measuring the intensity of nursing care: Making use of the Belgian Nursing Minimum Data Set

BACKGROUND

The Belgian Nursing Minimum Data Set (B-NMDS) is a nationwide registration of 23 nursing activities. It was developed for the measurement of nursing care in acute hospitals. It is used to support healthcare management & policy decision making such as hospital financing and nurse staffing decisions.

OBJECTIVE

To develop a measure of the intensity of nursing care based on information that is available in the B-NMDS. DESIGN-SETTING-PARTICIPANTS: Retrospective analysis of the B-NMDS from all Belgian acute hospitals (n=115) for the year 2003. The sample included 690,258 inpatient days for 298,691 patients that were recorded from 1637 acute care nursing units.

METHODS

The 23 nursing activities were synthesized into one new latent variable by PRINQUAL analysis. This variable was evaluated as a measure of nursing care intensity using key characteristics of the San Joaquin patient classification system, which was designed to measure the intensity of nursing care.

RESULTS

The main NMDS component from the PRINQUAL analysis accounted for 26.8% of the variance. The distribution of inpatient days over all four San Joaquin categories is: 11.1% (self-care); 40.4% (average care); 30.8% (above average care); 17.7% (intensive care). In 97.5% of the nursing units the intensity of nursing care score of the B-NMDS (main NMDS component) followed the ordinality of the San Joaquin classification system. Furthermore, the San Joaquin categories alone explained more variability--70.2% in the intensity of nursing care measure (main NMDS component) than did other determinants, such as department type, age, diagnostic-related groups (DRG) and severity of illness, hospital type and hospital size together.

CONCLUSION

The B-NMDS is an instrument that produces a measure of the intensity of nursing care in acute hospitals.

Assessing patient's care requirements: a comparison of instruments

The purpose of this study was to compare two patient classification instruments developed in different countries, Perroca's (Brazil) and the Beakta (Sweden) systems and to investigate if both instruments equally assess patients' care requirements. The survey sample comprised 85 patients from a university hospital in southeast Sweden. Statistical analysis used Spearman's correlation and Kappa. The Spearman's correlation coefficient for total scores and classifications were 0.83 and 0.80, respectively (P-value < 0.01). The level of agreement between the instruments related to the different care categories pointed to an overall kw of 0.60 (95% CI: 0.50-0.71). The findings indicate a high degree of association between the total scores and patient classification assessment using the Beakta and Perroca systems and also a moderate level of agreement between the two instruments in the different care categories. There are few surveys that compare classification instruments between countries making it difficult to know to what extent cultural differences influence measurement approaches.

Toward near real-time acuity estimation: a feasibility study

BACKGROUND

Patient acuity estimation provides the basis of the nursing workload determination. It is critical to estimate patient acuity in real-time to capture a patient's need for nursing care more consistently and accurately.

OBJECTIVES

To explore the feasibility of using patient data documented in an electronic nursing flowsheet in computerized nursing decision making; that is, near real-time acuity estimation.

METHODS

Decision algorithms to determine values of acuity indicators using the flowsheet data were developed based on input from experienced nurse decision-makers and implemented as a rule-based system (RBS) with the Java Expert Shell System provided in Protégé. The RBS was tested with randomly selected patient data by comparing the observed agreements with previously recorded nurses' decisions.

RESULTS

The observed agreements varied. The agreement rates exceeded 60% in nine indicators and the RBS tended to agree more on assigning false values. No consistent association was observed among the agreement rates, number of observations, and number of data items included in the study. The agreement rates increased slightly when the values determined by the RBS were aggregated following the nurses' time frame. The agreement rates were higher than chance agreement in the majority of the indicators included in this study.

CONCLUSIONS

Two major factors that influenced the accuracy of the RBS were noted:limitations in source data and incompleteness of decision rules. Replicating the study with more complete data sets and enhanced decision rules was identified as the next step.

5-20: a model of minimum nurse-to-patient ratios in Victoria, Australia

AIM

This study presents a critique of a new model of minimum nurse-to-patient ratio and considers its utility alongside established Patient Dependency Systems.

BACKGROUND

Since 2001 legislation mandating minimum nurse-to-patient ratios has been enacted throughout large public hospitals in the state of Victoria, Australia. The Victorian model mandates minimum staffing of five nurses to 20 patients in acute medical and surgical wards. In conjunction with this approach, Patient Dependency Systems are employed to anticipate short-term resource needs.

KEY ISSUES

Although this legislation has been successful in attracting nurses back into the public sector workforce, no published empirical evidence exists to support specific ratios. In addition, neither ratio nor Patient Dependency Systems approaches account for the critical influence of skill mix on hospital, employee, or patient outcomes.

CONCLUSION

There is an urgent need for further research that specifically examines relationships between models of staffing, skill mix and quality outcomes.

Care needs of residents in community-based long-term care facilities in Taiwan

AIM

The purpose of this study is to gain an understanding both of the characteristics of residents who receive the services of nursing assistants and the service intensity (service tasks, service time and cost) of nursing assistants as a means of developing a patient classification based upon resource consumption.

BACKGROUND

Most people in Taiwan send their disabled older family members to community-based long-term care facilities instead of nursing homes because they are much cheaper, and because they are generally closer to their homes, making visits more convenient. Nursing assistants make up the largest group of personnel in long-term care facilities. To determine resource use, both the service time and the actual activities performed for a resident by nursing assistants need to be assessed and this will help to develop a patient classification system to predict resource use and patient outcomes.

METHODS

A descriptive survey method was used to identify the tasks performed by nursing assistants in community-based long-term care facilities in Taiwan. Nursing assistants were recruited from 10 long-term care facilities in the Shihlin and Peitou Districts of Taipei City. Thirty-four nursing assistants and 112 residents participated in this study.

RESULTS

Findings showed that each nursing assistant spent 5.05 hours per day doing direct service care, which is much higher than the 2.08 hours for nursing assistants in the United States. Among service tasks provided by nursing assistants, personal care consumed 35.1% of their time. Non-complex treatments were second (33.3%). Skilled nursing and medical services were third (31.6%). The service intensity required of nursing assistants was strongly related to the residents' activities of daily living and their needs.

CONCLUSION

Complex nursing procedures are normally provided by Registered Nurses in nursing homes and consumed almost as much of the nursing assistants' time as did personal care activities in this study.

RELEVANCE TO CLINICAL PRACTICE

It is suggested that a training program for nursing assistants, especially for foreigners in community-based long-term care facilities, should be mandated to assure the quality of service.

Nursing time allocation and other considerations for staffing

The purpose of this project was to evaluate how nursing staff on the telemetry unit at Merle West Medical Center, a rural Pacific northwest community medical center in the USA, spend their time on selected nursing tasks, and how they believed staffing and patient acuity levels could best be determined. A self-report survey tool was developed, piloted and administered. Of the tasks that were listed in the survey, registered nurses (RNs) reported spending 39% of their time performing tasks that RNs only can perform. RNs reported spending 12% of their time performing activities that certified nursing assistants (CNAs) could perform alone and 49% of their time was spent on tasks that both RNs and CNAs must perform. Results from the quantitative portion of the survey indicated that RNs may not be used efficiently due to task overlap. Administering a modified survey which includes a balance of direct and indirect patient care tasks, as well as only those tasks that are truly performed frequently, will increase the relevance of the results.