Economics vs. Patient Acuity

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Information about Economics vs. Patient Acuity
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Published on April 24, 2008

Author: utep2008

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PRESENT RESULTS OF EVIDENCEEVIDENCE BASED PRACTICEBYMARIA M. MARQUEZ, BSN, RNNOVEMBER 13, 2007 : PRESENT RESULTS OF EVIDENCEEVIDENCE BASED PRACTICEBYMARIA M. MARQUEZ, BSN, RNNOVEMBER 13, 2007 DEFINE EVIDENCE BASED PRACITCE (EBP) : DEFINE EVIDENCE BASED PRACITCE (EBP) “A problem solving approach to practice that involves the conscientious use of current best evidence in making decisions about patient care. EBP incorporates a systematic search for and critical appraisal of the most relevant evidence to answer a clinical question along with one’s own clinical expertise and patient values and preferences.” Melnyk, B.M., & Fineout-Overholt, E. (2005) HISTORY OF EBP : HISTORY OF EBP Founded by Dr. Archie Cochrane Struggled with efficacy of HC Challenged the public Published landmark book criticized medical profession Strong proponent RCT’s Research reviews of evidence (all specialty areas) need be prepared rigorous systematic process HISTORY OF EBP CONT’D… : HISTORY OF EBP CONT’D… Influence~~Cochrane Center~~Oxford, England, 1992 Major Purpose~assist individuals in making well-informed decisions about healthcare By developing, maintaining, & updating SR of healthcare interventions Ensuring reviews available for the public ASKING & RESEARCHING A BURNING CLINICAL QUESTION IN PICO FORMAT : ASKING & RESEARCHING A BURNING CLINICAL QUESTION IN PICO FORMAT P= patient population of interest I = intervention of interest C= comparison of interest O= outcome of interest Does staffing an intensive care unit (P) based on a daily census (C) versus patient acuity (I) meet individualized patient needs (O) ? COLLECTION OF MOST RELEVANT BEST EVIDENCE TO ANSWER CLINICAL QUESTION : COLLECTION OF MOST RELEVANT BEST EVIDENCE TO ANSWER CLINICAL QUESTION Hierarchy of Evidence Level I thru Level VII Strongest level of evidence to the least strongest level of evidence 2 of the articles were Level IV 2 of the articles were Level V 1 article was a Level VII CRITICALLY APPRAISE THE EVIDENCE : CRITICALLY APPRAISE THE EVIDENCE Results of study Purpose of the study Are the results valid? Will the results of the study facilitate the care of the practitioner’s patients? “Matching nurse skill with patient acuity in the intensive care units: a risk management mandate” study : “Matching nurse skill with patient acuity in the intensive care units: a risk management mandate” study Aim to highlight need traditional concept of nursing skill mix reconfigured new concept of skill matching Patient acuity single indicator Comprehensive multifactorial approach Skill mix Recruit and retain nurses Nurse-staffing decision-making practices & their impact on patient outcome warrants further targeted research Rischbieth, A. Journal of Nursing Management, 2006 “EVIDENCE REPORT/TECHNOLOGY ASSESSMENT”QUALITATIVE OBSERVATIONAL STUDY/META-ANALYSIS : “EVIDENCE REPORT/TECHNOLOGY ASSESSMENT”QUALITATIVE OBSERVATIONAL STUDY/META-ANALYSIS Purpose of study: assess nurse to patient ratios & nurse work hours associated with patient outcomes in acute care facilities Patient outcomes and nurse staffing ratios (increase by 1 RN to patient ratio): decrease hospital-related mortality decrease failure to rescue decrease length of stay (LOS) “EVIDENCE REPORT” CONT’D… : “EVIDENCE REPORT” CONT’D… Pooled results Every additional FTE RN/patient day was associated with: 9% risk reduction hospital related mortality 16% reduction in surgical patients “EVIDENCE REPORT” CONT’D… : “EVIDENCE REPORT” CONT’D… Every additional patient per RN/shift was associated with: 7% increase relative risk of hospital acquired pneumonia 53% increase pulmonary failure 45% increase unplanned extubation 17% increase medical complications “EVIDENCE REPORT” CONT’D… : “EVIDENCE REPORT” CONT’D… Increase by 1 ICU FTE RN/patient day was associated with: 28% decrease of cardiopulmonary resuscitation 51% decrease unplanned extubation 60% decrease pulmonary failure 30% decrease hospital acquired pneumonia 24% shorter LOS PATIENT OUTCOMES & NURSE STAFFING HOURS : PATIENT OUTCOMES & NURSE STAFFING HOURS Increase total hours/patient day: decrease hospital mortality decrease failure to rescue decrease adverse events decrease death rate by 1.98% Pooled analysis (1 additional RN/patient day) 4% decrease hospital acquired pneumonia 11% pulmonary failure 9% unplanned extubation Other attributes Future research warranted to target specific questions, collect and analyze enough information to isolate effects nurse staffing levels By Minnesota Evidence-based Practice Center, Minneapolis, Minnesota For Agency for Healthcare Research and Quality “NURSE STAFFING, MODELS OF CARE DELIVERY, AND INTERVENTIONS”,OBSERVATIONAL, CASE CONTROL, COHORT STUDY WITH EXPERT OPINION : “NURSE STAFFING, MODELS OF CARE DELIVERY, AND INTERVENTIONS”,OBSERVATIONAL, CASE CONTROL, COHORT STUDY WITH EXPERT OPINION Aim of study to target safety problems of patient mortality and morbidity Nurse staffing decisions do not have scientific basis, based on economics Richer nurse staffing=better pt. outcome & increased skill mix: decrease UTI’s, thrombosis & pulm complications in surgical pts., pressure ulcer rate, pneumonia, post-op infection, nosocomial infection rate Further research needed for resources for research r/t nurses & nursing interventions “RELATIONSHIPS BETWEEN NURSE STAFFING AND PATIENT OUTCOMES”QUANTITATIVE DESCRIPTIVE CORRELATIONAL STUDY : “RELATIONSHIPS BETWEEN NURSE STAFFING AND PATIENT OUTCOMES”QUANTITATIVE DESCRIPTIVE CORRELATIONAL STUDY Purpose of study is to examine the relationship between hospital nurse staffing & patient outcomes While controlling for patient acuity Acuity level plays a crucial role between nurse staffing & patient outcomes “RELATIONSHIPS BETWEEN NURSE STAFFING” CONT’D… : “RELATIONSHIPS BETWEEN NURSE STAFFING” CONT’D… 3 indicators thought to be sensitive to nursing care: hours of care, nursing workload, nurse to patient ratio: 3 powerful predictors nosocomial infections Findings support for the context of implications that patient outcomes are correlated to organizational structure Effects on client outcomes require further research “…MEASURING NURSING CARE HOURS PER PATIENT DAY AND PATIENT OUTCOMES”RETROSPECTIVE ANALYSIS/CONVENIENCE STUDY : “…MEASURING NURSING CARE HOURS PER PATIENT DAY AND PATIENT OUTCOMES”RETROSPECTIVE ANALYSIS/CONVENIENCE STUDY Adequacy & appropriateness of nurse staffing Based on functionally outdated industrial models Common method of staffing nursing units or id staffing mix in hospitals “…MEASURING NURSING CARE HOURS/PATIENT DAY” CONT’D… : “…MEASURING NURSING CARE HOURS/PATIENT DAY” CONT’D… Identifying budgeted nursing care hours/pt day One suggestion~acuity levels Patient acuity systems (PAS) Patient classification systems (PCS’s) “…MEASURING NURSING CARE HOURS/PATIENT DAY” CONT’D… : “…MEASURING NURSING CARE HOURS/PATIENT DAY” CONT’D… Multifunctional assessments, actions, interventions Accurate standardized data Overcome obstacles-comprehensive multifaceted research efforts Evaluate current practice ***In the U.S. today, no single measure or process guides appropriate staffing levels in hospitals & acute care facilities*** INTEGRATE EVIDENCE/IMPLEMENT CLINICAL QUESTION : INTEGRATE EVIDENCE/IMPLEMENT CLINICAL QUESTION Collaborative effort If collaborative team in agreement, can the compelling evidence be integrated and implemented EVALUATE CHANGE : EVALUATE CHANGE How effective was the clinical decision? EBP II will allow the opportunity of exploration & implementation of interventions on clinical question & documentation of outcomes of care OUTCOMES USING FINK’S TAXONOMY : OUTCOMES USING FINK’S TAXONOMY OUTCOMES USING FINK’S TAXONOMY CONT’D… : OUTCOMES USING FINK’S TAXONOMY CONT’D… Objectives met (Cognitive) Identify what learned (Human dimension) Evaluate own practice to propose a clinical change and promote EBP (Caring) Research a process that will guide appropriate staffing levels in acute care facilities (Life long learning) New questions for future research surfaced (Application) Promote and embrace EBP (Integration) References : References Department of Nursing Graduate Studies Lehman College, City University of New York, USA. (2007). How many nurses are enough? A pilot study measuring nursing care hours per patient day and patient outcomes. Chia, Colombia, April, 7 (1). Melnyk, B.M., & Fineout-Overholt. (2005). Evidence-based practice in nursing & healthcare: a guide to best practice. Philadelphia; Lippincott Williams & Wilkins. Minnesota Evidence-based Practice Center, Minneapolis, Minnesota. (2007). Prepared for Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Evidence Report/Technology Assessment Number 151. Nurse staffing and quality of patient care. Rischbieth, A. (2006). Matching nurse skill with patient acuity in the intensive care units: a risk management mandate. Journal of Nursing Management,14 (5): 397-404. Seago, J.A., (1999). Chapter 39. Nurse staffing, models of care delivery, and interventions. University of California, San Francisco School of Nursing. Yang, K.P. (2003). Relationships between nurse staffing and patient outcomes. Journal of Nursing Research, 11 (3)

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