Design and Implementation of Hospital Automatic Nursing Management Information System Based on Computer Information Technology

Clinical nursing work fails to integrate various nursing tasks such as basic care, observation of patients' conditions, medication, treatment, communication, and health guidance to provide continuous and full nursing care for patients. Based on this, this paper uses the Internet of Things (IoT) technology to optimize the infusion process and achieve closed-loop management of medications and improve the efficiency and safety of infusion and medication administration by using a rational and effective outpatient and emergency infusion and medication management system. The system was built by applying wireless network, barcode technology, RFID, infrared tube sensing, and other technologies and was combined with actual nursing work to summarize application techniques and precautions. The application of this system will become a new highlight of medical informatization, improve patient experience, monitor infusion safety, enhance nursing care, reduce emergency medical disputes, improve patient satisfaction, and will create good social and economic benefits for the hospital.

Nonoccupational postexposure HIV prophylaxis in sexual assault programs: a survey of SANE and FNE program coordinators

This cross-sectional study describes sexual assault nurse examiner (SANE)/forensic nurse examiner (FNE) program practices related to HIV testing, nonoccupational postexposure prophylaxis (nPEP), and common barriers to offering HIV testing and nPEP. A convenience sample of 174 SANE/FNE programs in the United States and Canada was drawn from the International Association of Forensic Nurses database, and program coordinators completed Web-based surveys. Three fourths of programs had nPEP policies, 31% provided HIV testing, and 63% offered nPEP routinely or upon request. Using χ(2) and Fisher's exact tests, a greater proportion of Canadian programs had an nPEP protocol (p = .010), provided HIV testing (p = .004), and offered nPEP (p = .0001) than U.S.-based programs. Program coordinators rated providing pre- and/or posttest counseling and follow-up as the most important barrier to HIV testing, and medication costs as the most important barrier to providing nPEP. Our results indicate HIV-related services are offered inconsistently across SANE/FNE programs.

Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit

BACKGROUND

Effective collaboration and teamwork is essential in providing safe and effective care. Research reveals deficiencies in teamwork on medical units involving hospitalists.

OBJECTIVE

The aim of this study was to assess the impact of an intervention, Structured Inter-Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork.

METHODS

The study was a controlled trial involving an intervention and control hospitalist unit. The intervention, SIDR, combined a structured format for communication with a forum for regular interdisciplinary meetings. We asked nurses to rate the quality of communication and collaboration with hospitalists using a 5-point ordinal scale. We also assessed teamwork and safety climate using a validated instrument. Multivariable regression analyses were used to assess the impact on length of stay (LOS) and cost using both a concurrent and historic control.

RESULTS

A total of 49 of 58 (84%) nurses completed surveys. A larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05). Nurses also rated the teamwork and safety climate significantly higher on the intervention unit (P = 0.008 and P = 0.03 for teamwork and safety climate, respectively). Multivariable analyses demonstrated no difference in the adjusted LOS and an inconsistent effect on cost.

CONCLUSIONS

SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a hospitalist unit, yet no impact on LOS and cost. Further study is required to assess the impact of SIDR on patient safety measures.

Cost-effectiveness of the SEN-concept: Specialized Emergency Nurses (SEN) treating ankle/foot injuries

BACKGROUND

Emergency Departments (EDs) are confronted with progressive overcrowding. As a consequence, the workload for ED physicians increases and waiting times go up with the risk of unnecessary complications and patient dissatisfaction. To cope with these problems, Specialized Emergency Nurses (SENs), regular ED-nurses receiving a short, injury-specific course, were trained to assess and treat minor injuries according to a specific protocol.

METHODS

An economic evaluation was conducted alongside a randomized controlled trial comparing House Officers (HOs) and SENs in their assessment of ankle and foot injuries. Cost prices were established for all parts of healthcare utilization involved. Total costs of health care utilization were computed per patient in both groups. Cost-effectiveness was investigated by comparing the difference in total cost between groups with the difference in sensitivity and specificity between groups in diagnosing fractures and severe sprains. Finally, cost-effectiveness ratios were calculated and presented on a cost-effectiveness plane.

RESULTS

No significant differences were seen between treatment groups for any of the health care resources assessed. However, the waiting times for both first assessment by a treatment officer and time spent waiting between hearing the diagnosis and final treatment were significantly longer in the HO group. There was no statistically significant difference in costs between groups. The total costs were euro 186 (SD euro 623) for patients in the SEN group and euro 153 (SD euro 529) for patients in the HO group. The difference in total costs was euro 33 (95% CI: - euro 84 to euro 155). The incremental cost-effectiveness ratio was euro 27 for a reduction of one missed diagnosis and euro 18 for a reduction of one false negative.

CONCLUSION

Considering the benefits of the SEN-concept in terms of decreased workload for the ED physicians, increased patient satisfaction and decreased waiting times, SENs appear to be a useful solution to the problem of ED crowding.

The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units

BACKGROUND

Evidence that medical error is a systemic problem requiring systemic solutions continues to expand. Developing a "safety culture" is one potential strategy toward improving patient safety. A reliable and valid self-report measure of safety culture is needed that is both grounded in concrete behaviors and is positively related to patient safety.

OBJECTIVE

We sought to develop and test a self-report measure of safety organizing that captures the behaviors theorized to underlie a safety culture and demonstrates use for potentially improving patient safety as evidenced by fewer reported medication errors and patient falls.

SUBJECTS

A total of 1685 registered nurses from 125 nursing units in 13 hospitals in California, Indiana, Iowa, Maryland, Michigan, and Ohio completed questionnaires between December 2003 and June 2004.

RESEARCH DESIGN

The authors conducted a cross-sectional assessment of factor structure, dimensionality, and construct validity.

RESULTS

The Safety Organizing Scale (SOS), a 9-item unidimensional measure of self-reported behaviors enabling a safety culture, was found to have high internal reliability and reflect theoretically derived and empirically observed content domains. The measure was shown to discriminate between related concepts like organizational commitment and trust, vary significantly within hospitals, and was negatively associated with reported medication errors and patient falls in the subsequent 6-month period.

CONCLUSIONS

The SOS not only provides meaningful, behavioral insight into the enactment of a safety culture, but because of the association between SOS scores and reported medication errors and patient falls, it also provides information that may be useful to registered nurses, nurse managers, hospital administrators, and governmental agencies.

Summarizing benchmarks in the national database of nursing quality indicators using bootstrap confidence intervals

When summarizing the benchmarks for nursing quality indicators with confidence intervals around the means, bounds too high or too low are sometimes found due to small sample size or violation of the normality assumption. Transforming the data or truncating the confidence intervals at realistic values can solve the problem of out of range values. However, truncation does not improve upon the non-normality of the data, and transformations are not always successful in normalizing the data. The percentile bootstrap has the advantage of providing realistic bounds while not relying upon the assumption of normality and may provide a convenient way of obtaining appropriate confidence intervals around the mean for nursing quality indicators.

Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals

OBJECTIVE

This study describes the distribution of patient-to-registered nurse (RN) ratios, RN intensity of care, total staff intensity of care, RN to total staff skill mix percent, and RN costs per patient day in 65 acute community hospitals and 9 academic medical centers in Massachusetts.

METHODS

We conducted a retrospective secondary analysis of the Patients First database published by the Massachusetts Hospital Association for planned nurse staffing in 601 inpatient nursing units in the state for 2005 using a multivariate linear statistical model controlling for hospital type and unit type. Nursing unit types were identified as adult and pediatric medical/surgical, step down, critical care, neonatal level II, and neonatal level III/IV nurseries.

RESULTS

Medical centers had significantly higher case-mix index (1.72 vs 1.20, P < .001), longer lengths of stay (5.18 vs 4.19, P < .001), more beds (574 vs 147, P < .001), discharges (31,597 vs 7,248, P < .001), and patient days (161,440 vs 31,020, P < .001) compared with to community hospitals. Medical centers had significantly lower patient-to-RN ratios (3.22 vs 4.64, P < .001), higher nursing intensity and total nursing staff intensity (9.62 vs 7.43/11.75 vs 9.87, both P < .001), higher percent of RN to all staff mix (79% vs 71%, P < .001), and higher RN costs per patient day ($385 vs $297, P < .001) compared with to community hospitals. There were significant differences in adult med/surg units between community hospitals and medical centers for patient-to-RN staffing ratios (5.25 vs 4.08), nursing intensity (5.1 vs 6.2 hours daily), skill mix (67% vs 73% RN), and RN costs per patient day ($203 vs $248, all P < .001). There were no significant differences between the adult step-down units.

CONCLUSION

The significant differences between community hospitals and medical centers, unit type, as well as the high degree of variability in patient-to-RN ratios, nursing intensity, skill mix, and RN costs per patient day suggest that nursing resource expenditure at Massachusetts hospitals is complex and affected by case mix, unit size, and complexity of care.

Hospital nursing costs, billing, and reimbursement

Nursing intensity, estimated direct nursing costs, and daily billing were compared for 12 adult medical or surgical units at an academic medical center from January 1 to May 31, 2005 (22,649 patient days). Two main findings, nursing intensity and direct nursing costs, were highly variable within and across each of the study nursing units (mean 429 dollars, SD 160 dollars); direct costs of nursing care were significantly higher for private room rates compared to intermediate room per diem charges billed at a higher rate (441 dollars vs. 426 dollars, F 37.77, p < 0.001). The results demonstrate that the direct costs of nursing care are not aligned with current billing practices at this university hospital. The use of fixed room and board charges to account for nursing care in U.S. hospitals may be obsolete and an alternative nurse-centric costing, billing, and reimbursement model is proposed.

[Study for the decrease of errors in the records of hydric balances of critical patients admitted to an intensive care unit]

OBJECTIVES

Due to the results of the hydric balances, we believed that it did not adjust to the weight variations of the patients, that we should assure ourselves that the present recording method was a good reflection of the hydric changes of the patients and based on the diagnoses, interventions and results, the nurses of NANDA (North American Nursing Diagnosis Association), NIC (Nursing Interventions Classification) and NOC (Nursing Outcomes Classification) have suggested studying the errors in the records and how to reduce them without increasing work loads.

MATERIAL AND METHODS

Descriptive comparative study divided into two stages: a first one in which, on the one hand, we study the validity of our measurement systems by means of contingency tables, measurements of central tendency and dispersion, correlation (Pearson) and concordance (Bland-Altman (BA) and, on the other hand, we detect arithmetic errors in the records, and a second stage in which we analyze, by means of the Student's t test, the existence or not of significant differences between records without correction (WC), arithmetically corrected (AC) and arithmetically corrects and in measurement errors (ME) in all the patients admitted for 5 days (mean stay time) in our ICU. Confidence interval level was 95%.

RESULTS

We found significant variations in the real serum volume (+10%). We accept that perfusion pumps, graduated cups Coloplast bags, diuresis cage and weighing of absorbent material are great measurement systems. For this, r > 0.9979 and good differences of the means and confidence interval in the Bland-Altman analysis were found. We ruled out the subject assessment of volumes (large relative errors) and the diuresis bottles (r = 0.6986 and in mean BA of 21.593 cm3 and large dispersion of the differences). For the Uroway bags, we established a correlation curve (y = 4.0117x0.8292). We detected 64.0% (on 75 records) with arithmetic errors. In the Student's t analysis, we obtained: WC/AC, p = 0.654; AC/ME, p < 0.001; WC/ME p = 0.016 (significance level = 0.05).

CONCLUSIONS

We verified the existence of significant differences between the ME and the WC and AC.

Fight or flight? Disruptive behavior in medical/surgical services

The implementation of a clinical nurse specialist helped staff effectively manage disruptive patient behaviors and improve morale within an acute medical/surgical service.

[Multiple activities carried out by nurses at a hospitalization unit]

The study aimed at knowing the activities performed by nurses in internment units of ageneral hospital of Rio Grande do Sul, Brazil. The data have been collected by means of free observation per time sampling, semi-structured interviews and consultation on documents. The subjects were nurses who act in the internment units who were chosen at random. The results showed that the nurse coordinates the care, executes several procedures and provides infrastructure conditions for the development of the collective work. The nurse articulation capacity has been identified both in relation to the nursing team organization and in the organization of the hospital environment.

Differences and similarities between social work and nurse discharge planners

Historically the tasks involved in discharge planning have been a part of the practice of social work as well as the field of nursing. Based on this history and need for collaboration, a study conducted in 1998 measured the responses of 178 nurses and social workers who practiced discharge planning in 58 different hospitals in Alabama. According to the information gathered in this sample, it was clear that social workers as well as nurses continued to be important service providers in the area of discharge planning. Demographic data, work setting, caseload, and task difference were compared and significant differences were reported. This article makes recommendations for social work's participation in advocacy, policy, and outcome research in discharge planning.

Relationships among patient satisfaction, intent to return, and intent to recommend services provided by an academic nursing center

Patient satisfaction is an indicator and component of high quality care and service and the viability of academic nursing centers is dependent on patients' return visits and new patients' visits. The major purpose of this study was to determine patients' satisfaction with the quality of health care services provided by an academic nursing center. A secondary purpose was to determine the relationships among patient satisfaction, intent to return, and intent to recommend services. The study consisted of a convenience sample of 107 adult patients who responded to an investigator generated patient satisfaction survey. Findings indicated that 94 (87.8%) of the patients were satisfied. Stepwise regression analysis identified treatment with respect, the rating of care received, and the helpfulness of the person at the front desk as the strongest predictors of patient satisfaction. Correlation analysis revealed that patient satisfaction is highly correlated with intent to return and intent to recommend services (p < .01).

Measuring practice patterns among acute care nurse practitioners

OBJECTIVE

This initiative was designed to develop a reliable instrument to measure the activities of acute care nurse practitioners (ACNPs). A sound, standardized method for measuring ACNP productivity will assist nursing leaders and administrators to demonstrate the effectiveness and productivity of ACNPs in and across institutions and systems.

BACKGROUND DATA

Current research on ACNPs uses many different methodologies and research designs, and fails to provide standard definitions to measure practice patterns, making it difficult to generalize across settings.

METHODS

Advisory groups from 2 New York academic health science centers developed a survey that covered the demographic, educational, and employment characteristics of ACNPs, and a 20-item classification of advanced practice nursing activities. Sixty-one ACNPs completed surveys, a 58% response rate.

RESULTS

The survey found strong similarities at both institutions. ACNPs spend most of their time in 5 activities involving direct care and 4 activities within indirect care. Strong Cronbach alphas confirmed that the instrument was reliable.

CONCLUSIONS/IMPLICATIONS

The availability of a reliable instrument for measuring ACNP practice patterns provides administrators with a powerful tool to demonstrate the contributions of their ACNPs. In addition, a standardized method for data collection can contribute to healthcare workforce policy discussions.

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

OBJECTIVE

Patient classification systems are alternately praised and vilified by staff nurses, nurse managers, and nurse executives. Most nurses agree that substantial resources are used to create or find, implement, manage, and maintain the systems, and that the predictive ability of the instruments is intermittent. The purpose of this study is to compare the predictive validity of two types of patient classification instruments commonly used in acute care hospitals in California.

BACKGROUND

Acute care hospitals in California are required by both the Joint Commission on Accreditation of Healthcare Organizations and California Title 22 to have a reliable and valid patient classification system (PCS). The two general types of systems commonly used are the summative task type PCS and the critical incident or criterion type PCS. There is little to assist nurse executives in deciding which type of PCS to choose. There is modest research demonstrating the validity and reliability of different PCSs but no published data comparing the predictive validity of the different types of systems. The unit of analysis is one patient shift called the study shift. The study shift is defined as the first day shift after the patient has been in the hospital for a full 24 hours. Data were collected using medical record review only. Both types, criterion and summative, of PCS data collection instruments were completed for all patients at both collection points. Each patient had a before and after score for each type of instrument. Three hundred forty-nine medical records for inpatients meeting the inclusion criteria were examined.

RESULTS

The average patient age was 76 years, the average length of stay was 6.6 days with an average of 6.7 secondary diagnoses recorded. Fifty-five percent of the sample was female and the most common primary diagnosis was CHF, followed by COPD, CVA, and pneumonia. There was a difference in mean summative predictor score and the mean summative actual score of 1.57 points with the predictor score higher (P =.001; CI =.62--2.5). For the criterion instrument, 68.4% of the predictor criterion scores were in category 2 compared to 65.5% of the actual criterion scores. The criterion predictor agreed with the criterion actual score 45% of the time for category 1 patients, 87.3% of the time for category 2 patients, 77.1% of the time for category 3 patients and 72.7% of the time for category 4 patients, with an overall agreement between predictor and actual criterion scores of 79.9% (Kappa P <.001, indicating agreement is not by chance).

CONCLUSIONS

The most significant finding of this study is that there are virtually no differences in the predictive ability of summative versus criterion patient classification instruments. Using the same patients, both types of instruments predicted the actual score over 78% of the time.

Exploring the nursing minimum data set for The Netherlands using multidimensional scaling techniques

RATIONALE

To fulfil the need for a systematic collection of nursing data that give insight in nursing care and its benefits and costs, a nursing minimum data set (NMDS) has been developed and validated for Dutch general hospitals. A NMDS provides data describing the diversity in patient populations and variability in nursing activities that can be analysed in various ways.

AIM OF THE STUDY

To explore and compare the fundamental underlying dimensions describing patient problems and nursing interventions in Dutch general hospital wards.

METHODS

Data of predominantly nominal and ordinal measurement level that were collected with the NMDS for The Netherlands on 15 Dutch hospital wards underwent two consecutive steps: first, they were transformed into metric data by means of RIDIT (relative to an identified distribution) analysis; secondly, they were analysed by means of multidimensional scaling.

RESULTS

Multidimensional scaling techniques yielded a fairly good three-dimensional solution of the NMDS data. Hospital wards could be distinguished from each other on the basis of patient problems and nursing interventions most common on some wards but not on others. The core aspects underlying patient problems concerned dependency problems, life threatening problems and endogenous-exogenous problems, while discriminating nursing interventions were cure-care activities, internally-externally oriented activities and psychosocial-physical interventions.

LIMITATIONS

Not all types of hospital wards were represented, which limits the representativeness of the results for Dutch general hospitals. Furthermore, the patient sample size over the 15 wards was relatively small.

CONCLUSION

The constructs are consistent with NMDS findings in Belgium and findings from practice, which contributes to their content validity.

Patient satisfaction with nursing care at a university hospital in Turkey

Patient satisfaction is an important measure of service quality (SQ) in health care organizations. Patients' satisfaction and their expectations of care are valid indicators of quality nursing care. This article reports the results of a survey patient satisfaction with nursing care, administered by interview to 422 adults discharged from a university hospital in Turkey. The direct measurement of patient satisfaction with nursing care is a new phenomenon for this university hospital, and this was the first time that such an evaluation had been done in this particular hospital. In this study, SERVQUAL scale was used for determining patient satisfaction with nursing care. Weighted scores in dimensions of SERVQUAL were generally low, and there were statistically significant differences in means paired t-tests (p < .01). Sociodemographic characteristics of the patients (age, gender, education level) with regard to patient satisfaction were determined. Several statistically significant differences were found between the sociodemographic characteristics and weighted scores for dimensions of SERVQUAL (p < 0.5). According to results, the SQ gap scores for five dimensions were negative to meet expectations. The negative scores for tangibles, reliability, responsiveness, assurance, and empathy indicate areas needing improvement. In this hospital, results of this study support the need for nurses to take steps to improve patient satisfaction with nursing care.

Seeding information management capacity to support operational management in hospitals

There are vast amounts of regularly reported data in the information systems of hospitals, state and federal governments. The increase in accessibility offered by platforms such as the Health Information Exchange (HIE) in New South Wales (NSW) creates a new level of opportunity. Administrative data can also speak to clinical and managerial issues. The capacity to mine these data and use the information for improving quality and efficiency has not been well developed at the "coal face" of operational management. Whilst it has been both possible and useful to track utilisation of services to hospitals and patients as cost and volume, it has not been of interest to track these same data to the operational locus of care--the nursing unit, the operating room, the imaging department. With HIE-type systems, the information is now more readily available and operational managers know this. The challenge is to develop the interdisciplinary capacity to query administrative data to facilitate clinical and managerial decision-making. We report here a possible model of a systematic approach to developing this capacity and some of the results of equipping operational and clinical managers to study problems in their own work settings. These efforts have required no additional internal resources, while the payoffs have been considerable.

Arterial blood sampling practices in intensive care units in England and Wales

A postal survey of arterial blood sampling practices in 280 intensive care units throughout England and Wales found that very few measures are taken to reduce diagnostic blood loss in adult intensive care patients from arterial sampling. The average volume of blood withdrawn to clear the arterial line before sampling is 3.2 ml; subsequently returned to the patient in only 18.4% of intensive care units. Specific measures to reduce the blood sample size by the routine use of paediatric sample tubes in adult patients occurs in only 9.3% of intensive care units. In paediatric units, the average volume withdrawn was 1.9 ml and this was routinely returned in 67% of units. Some aspects of arterial blood sampling practices identified in this survey may contribute to iatrogenic anaemia in intensive care patients.

Achieving superior productivity

Hospitals need to analyze, develop, and implement realistic, effective productivity standards. The first step in a productivity analysis is to collect performance data for each hospital department. A workload measure should be assigned to every department. Comparing historical performance data for each department highlights problem areas. Gaining executive commitment and department manager acceptance is essential to productivity-improvement initiatives. Even in departments that experience a change in function, historical data can be used to monitor performance and determine where improvement is needed. A weighting system can be employed to capture historical data and establish a standard against which to measure future performance.

Sexual Assault Nurse Examiner programs in the United States

STUDY OBJECTIVE

We sought to provide a descriptive study of the Sexual Assault Nurse Examiner (SANE) programs and their characteristics in the United States.

METHODS

A confidential survey addressing patient and staff demographics, administration attributes, examination procedures, and medical and legal issues was mailed to SANE programs in the United States.

RESULTS

Sixty-one (66%) of 92 programs responded. More than half of the programs (32/58 [55%]) had been in operation for less than 5 years. Thirty (52%) of the 58 programs performed the initial sexual assault examination in hospital emergency departments. Written consent (57/59 [97%]) was obtained for the initial examination, and most (51/59 [86%]) programs used preprepared commercial sexual assault kits. Program directors were predominately registered nurses. All but one program mandated specific training requirements for their staff, with a median requirement of 80 hours. Procedures used for initial examinations varied; most offered pregnancy testing (56/58 [97%]), pregnancy prophylaxis (57/59 [97%]), and sexually transmitted disease (STD) prophylaxis (53/59 [90%]). HIV testing was not offered in 32 (54%) of 59 programs. Almost all programs used Wood's lamp (51/59 [86%]), colposcopes (42/59 [71%]), and photographs (46/59 [78%]) for documentation. Median time required per patient for initial examination and evidence collection was 3 hours (range, 1 to 8 hours). Follow-up is consistently offered to the survivor. Most programs (45/61 [74%]) could report the number of survivors treated, but few could provide information on survivor medical follow-up or the number of prosecutions by survivors and their outcomes.

CONCLUSION

This survey provided an overview of SANE programs. SANE programs are similar across the country with regard to staffing, training, STD and pregnancy prophylaxis, and documentation techniques. They are inconsistent in the use of STD cultures, HIV testing, and alcohol and drug screening. SANE programs were unable to provide data regarding survivor follow-up and legal outcomes. This information is essential to evaluate the programs' effectiveness and to improve performance. The need for better outcome data should be addressed to define success or failure of SANE programs.

[Client categorization: a tool to assess nursing workload]

BACKGROUND

Client categorization is a management tool that allows an objective and structured assessment of the care demands imposed by patients and nursing workloads.

AIM

To characterize the need for direct nursing care of patients admitted to a university hospital.

PATIENTS AND METHODS

During two months, all patients admitted to intensive, intermediate care units and general services were categorized, their need for nursing care and the time invested by nurses in their care was registered. All patients were classified as maximal, high, median or low risk and as independent, totally or partially dependent on nursing care. Considering four degrees of risk and three degrees of dependency, 12 categories of patients were defined.

RESULTS

Patients admitted to intensive care units were of maximal risk and totally dependent and required 1 nurse per 2.2 patients. Those admitted in intermediate care units required 1 nurse per 3.8 patients and those in general services, 1 nurse per 11.5 patients.

CONCLUSIONS

Client categorization is a reproducible method that determines a standard measuring unit to define nursing needs. This allows the comparison of workloads between different services within a hospital or between hospitals.

Reducing hospital inpatient lengths of stay

This article describes the importance of hospital length of stay as an indicator of health care efficiency and provides guidance concerning the development of data for length of stay reduction. It identifies variables involved in length of stay evaluation including the mean stay, median stay, and length of stay standard deviation. It describes how consistent length of stay data can be generated and analyzed for local populations and benchmark communities.

Longitudinal evaluation of professional nursing practice redesign

OBJECTIVES

The authors describe a 5-year study at a western university teaching hospital that evaluated the effect of organizational redesign on nurse job satisfaction, autonomy, and patient satisfaction.

BACKGROUND

Change in institutional status from public to private authority stimulated this hospital to map a new direction for professional nursing practice, to strengthen autonomy and job satisfaction while improving quality care outcomes. Evaluating redesign changes systematically provided significant longitudinal trended data to guide nurse executive actions.

METHODS

Phase-I evaluation, from 1992 to 1995, was a quasi-experimental design comparing pre- and poststudy outcomes of facilitator-led activities on units receiving interventions compared with control units. Of 12 outcome variables measured, 3 were sustained longitudinally into Phase II: nursing job satisfaction using the McCloskey Mueller Satisfaction Scale (MMSS), autonomy using Schutzenhofer's Scale, and patient satisfaction using the Picker Institute survey. Data were trended across units and departments over a 5-year period.

RESULTS

Phase-I results reported that control units held higher nursing documentation scores than the experimental units. There were no significant differences in aggregate nurse job satisfaction scores. Nurse autonomy scores significantly improved. Other results are reported descriptively. Phase II continued the evaluation, reporting no differences in nurse job satisfaction aggregate scores a decline in autonomy, and decreased patient satisfaction scores. There were significant differences by units and across departments.

CONCLUSIONS

Longitudinal evaluation provides significant data to guide nurse executives in an uncertain healthcare environment. Of theoretical interest is the absence of congruence in nurse job satisfaction and autonomy scores, suggesting more independence between these variables than previously reported.

Influences on nursing care volume

This study explores influences on nursing care volume per case in four DRGs and five hospitals. After accounting for the effects of length of stay, patient characteristics, and severity of illness, the direct effect of factors describing the nursing staff and hospital was assessed. Skill mix and standing orders each were significant in one or more DRGs, but there was no significant association between the volume of nursing care and occupancy or staff availability. The management and research implications of the findings are discussed.

Automation of patient dependency systems

One of the most challenging decisions in resource allocations in hospitals is: how to allocate nursing duties on the basis of patients' needs? Patient Dependency Systems, in different forms, can be used to provide information for staffing decisions and budgetary developments. That is why Patient Dependency Systems are emerging as powerful tools in hospital management. It is anticipated that their use will grow, as hospitals everywhere come under pressure to reduce cost and improve the delivery and quality of health care to patients. Experience has shown that manual Patient Dependency Systems lack the ability to process and provide information fast enough to handle crisis situations. In addition, manual calculations are inefficient and are not free from human errors. However, the utilization of current advances in computing technology can overcome these disadvantages. Patient Dependency Systems are suitable for automation since their essence is too complex to handle manually. Furthermore, it is essential to automate the Patient Dependency Systems because of their critical role and their inherent complexity. In this paper, the automation of Patient Dependency Systems is presented. The development of Patient Dependency Automated Systems is shown to provide reliable and valid methods for evaluating the needs of patients in terms of the nursing effort required.

The effectiveness of 'nursing beds': a review of the literature

A literature search was conducted to identify 'nursing led in-patient units' where the nurse is the designated leader of the clinical team. The review concentrates on studies which have attempted to measure the impact of nursing-led in-patient units and reviews both the methodology and outcomes. Three major bodies of work were identified. Lydia Hall's evaluation of the Loeb Center for Nursing and Rehabilitation (USA) is reviewed in some detail. This work was the model for 'nursing beds' at the two Oxfordshire Nursing Development Units (UK) in the 1980s. Studies evaluating these centres are reviewed and reports of similar UK units discussed. A third body of work evaluates a nurse-managed critical care environment. Common features include a case mix based on nursing need with nurses having authority to admit and discharge patients. While results are generally favourable, with improved patient independence, fewer readmissions, lower mortality and cost savings reported in some or all of the studies, all studies reviewed demonstrate the difficulties of applying an experimental model to real life clinical services. Methodological limitations render firm conclusions difficult. Techniques adopted from studies in field settings, the so-called 'quasi-experiment', are advocated as a remedy, as is further study of the process of care in investigating this model of care delivery.

Survey and critique of studies related to unlicensed assistive personnel from 1975 to 1997, Part 2

This article is part 2 of a descriptive integrated review of research on the use of unlicensed assistive personnel in nursing. Part 1, published last month, described the methods used to find and to critique 29 research articles; it included the conceptual model and the variables identified in the studies. Part 2 presents a synthesis of the 29 studies data conclusions, implications and recommendations.

Survey and critique of studies related to unlicensed assistive personnel from 1975 to 1997, Part 1

This descriptive integrated review of research on the use of unlicensed assistive personnel in nursing is presented in two parts. In this issue, part 1 describes the methods used to find and critique research related to unlicensed assistive personnel in nursing. It includes the conceptual model and findings related to the variables studied. Part 2 of this review, which is scheduled for publication in the next issue, will present research findings, conclusions, and recommendations.

Hospital activity. Barred facts

Barcode technology is applicable to a number of crucial management issues in the NHS, including internal efficiency, contract pricing and the effectiveness of care. Its enormous potential lies in the ability to record in detail over a number of dimensions such as time, staff group, patient type, and cost. But the effort involved is considerable. Projects have to be actively managed, users have to be willing participants and data has to be analysed. Where short cuts have been sought, projects have failed to deliver their full potential. The data is merely a means to an end, but a very powerful one. It brings together people who may normally work independently, and the process of collecting barcode data is a perfect mechanism for bringing together the patient, the professional and the purse strings.

Study provides comparative targets to help reduce costs of surgical procedures

Data Benchmarks: Cost and LOS benchmarks can help your organization target and reduce costs of surgical procedures. Setting up clinical pathways to improve quality and reduce costs requires good benchmarking data to zero in on the appropriate clinical services or procedures. This month's Data Benchmarks offers good comparative data on the most cost-intensive surgical procedures performed at U.S. hospitals.

South Dakota statewide Nursing Minimum Data Set Project

The elements of the Nursing Minimum Data Set (NMDS) were collected manually from 188 medical records in eight acute care facilities. These eight facilities represent 54 per cent of the beds in South Dakota. The purpose of the study was to describe discharge destination, nursing diagnoses, nursing interventions, and nursing resource utilization for patients with fractured femur with pinning. The sample was primarily female (69.1 per cent), with a mean age of 78.5 years. Most (84.0 per cent) patients were transferred to another facility, with 46.2 per cent going to extended care facilities. The most frequent nursing diagnoses were comfort (89.9 per cent) and physical mobility (59.6 per cent). Interventions were classified using the 16-category classification scheme developed by Werley and Lang. The most frequently recorded types of interventions were in the category of monitoring and/or surveillance (16.7 per cent of 7,555 interventions), whereas emotional support and/or counseling was much less frequent (3.0 per cent of 7,555). Discharge planning was the most frequent nursing intervention in the category of coordination and collaboration of care (54.8 per cent of 188 patients). Documentation systems have been structured to accommodate technical tasks on flow sheets, for example. Nursing resource utilization was the most difficult, and also presently the least meaningful, NMDS element to collect because each facility has different staffing, different patient classification systems, and no prescribed method for collecting these data. Manual data collection is time-consuming and expensive and therefore not recommended.

Survey of current practice patterns for percutaneous transluminal coronary angioplasty. SANDBAG Nursing Coordinators

BACKGROUND

The increasing complexity of coronary intervention has led to variations in current patterns of nursing practice for patients undergoing routine percutaneous transluminal coronary angioplasty. In preparation for a large study examining the effects of specific nursing practices on complications at the site of vascular access, we surveyed institutions participating in a randomized phase III trial involving 4010 patients to determine current patterns of practice.

OBJECTIVE

The purpose of this study was to determine the current patterns of nursing practice for patients undergoing percutaneous transluminal coronary angioplasty.

METHODS

An eight-page questionnaire was completed by 70 hospitals participating in the study titled Integrelin to Manage Platelet Aggregation to Prevent Coronary Thrombosis (IMPACT II).

RESULTS

The hospitals participating in this study have an average of 500 beds; 34% of the institutions do 500 to 1000 angioplasty procedures annually. At many sites (39%), heparin is infused for 12 to 18 hours after the intervention, but heparin is not infused at all in 31% of the hospitals studied. At 27% of the hospitals, arterial sheaths are removed 12 to 18 hours after angioplasty, and at 15% of the hospitals, sheaths are removed more than 18 hours after the procedure. Typically after angioplasty (36%), patients are transferred to an ICU, with a nurse-patient ratio of 1:2. Eighty-three percent of the hospitals use CareMAPs or care plans for standardization of care. Most hospitals (83%) require complete bed rest for patients who have had angioplasty, with the affected leg restrained to prevent mobility. Ninety-one percent of the hospitals reported continuing to treat the patient with bed rest for an additional 6 hours after the sheath is removed.

CONCLUSION

Comprehensive nursing standards of care based on well-designed clinical trials for patients after angioplasty are not available. In the second phase of our study, we hope to correlate nursing practices with clinical outcome data to improve further the care of patients who have had angioplasty.

Changes related to care delivery patterns

Nurse administrators, faced with a need to increase productivity and reduce costs in response to lower inpatient volumes and increased competition, are restructuring systems of care delivery. A survey of acute care hospitals was conducted to determine the extent of changes in nursing care delivery models, skill mix, assignment of non-nursing personnel to the nursing department, use of unlicensed assistive personnel, and registered nurse role changes in healthcare delivery systems employing unlicensed personnel.

Changing the admission process for elective surgery: an economic analysis

This study compared the costs of an inpatient elective surgical admission process with an outpatient based same day admission programme in patients undergoing laparoscopic cholecystectomy. The effect of this process change on annual surgical volume and case flow (number of procedures performed per surgical bed) in the year before the initiation of same-day method (1989/90) and subsequent to the widespread use of the process (1992/93), was also assessed. Costs incurred by 53 patients who underwent preoperative anaesthetic and surgical assessment as outpatients and were admitted as an outpatient on the day of surgery (SD Group) were compared with those incurred by 11 patients who entered hospital on the day before surgery and underwent anaesthetic and other assessments as inpatients (IP Group). Nursing, radiology, laboratory, operating room, rehabilitation and clinic costs were obtained for each patient. The remaining costs were not amenable to individual attribution and were assigned to each group as a percentage of the allocated costs. The cost per case in the SD Group was $360 less than in the IP Group, reflecting decreased nursing costs incurred by the SD Group. Between the period 1989/90 and 1992/93, the number of surgical beds declined 15.7%; however, surgical volume decreased by only 5.4%. Total case flow improved by 12.2%, that for elective and non-elective surgery increasing by 14.1% and 9.5%, respectively. Elective surgery, where same day admission was used, showed the greatest improvement in case flow. We conclude that a same day admission process reduces cost and serves to enhance hospital productivity.

Measurement of patient outcomes: data availability and consistency across hospitals

In a random sample of 20 hospitals, the availability and consistency of five patient outcome indicators were examined, including medication administration errors, patient falls, occurrence of new decubitus ulcers, nosocomial infections, and unplanned readmission to the hospital. The results indicate that information about only two outcome indicators--medication errors and patient falls--were collected consistently by the sampled hospitals. The findings are discussed in the context of implications for the study of patient outcomes research.

Requirement for nursing care services and associated costs in acute spinal cord injury

The purpose of this study was to analyze the requirement for professional nursing care and the nursing care costs for patients with acute spinal cord injury. This descriptive study used a convenience sample of 50 consecutively admitted spinal cord-injured (SCI) patients who agreed to participate. Trained data collectors interviewed patients daily, reviewed the chart and spoke with the patient's nurses, after which nursing diagnoses were determined and acuity calculated. The sample consisted of 26 quadriplegic (Q), 5 ventilator-dependent quadriplegic (V) and 19 paraplegic (P) SCI subjects. The median length of stay (LOS) was 16 days with an intensive care unit (ICU) LOS of 4 days. LOS in the intermediate unit was 11 days. Median hours of nursing care was 143 (translating to $2458) for the entire acute care hospitalization. Specific hours of care and consequent costs were determined for all three groups through both phases of care. Significant differences were found in the hours of nursing care required among the three groups (X2 7.18, df = 2, p < .03), even though no difference was found in the LOS. A nursing consumption ratio (hours of nursing care/hours of LOS) demonstrated that ventilator-dependent SCI patients required the greatest number of nursing care hours.

Managing with precision. A budgetary decision support model

In this era of intense competition for restrained healthcare resources, a sound financial system can provide the foundation for evaluating care requirements while balancing allocation and deployment of resources. The authors describe one nursing division's comprehensive budgetary decision support model. This model has enabled achievement of rigorous budgetary goals while maintaining high standards of quality. The budgetary decision support model was internally created; however, it is applicable and easily adaptable to any healthcare organization.