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Improving staffing and nurse engagement in a neuroscience intermediate unit.

ABSTRACT

The neuroscience intermediate unit is a 23-bed unit that was initially staffed with a nurse-to-patient ratio of 1:4 to 1:5. In time, the unit's capacity to care for the exceeding number of progressively acute patients fell short of the desired goals in the staff affecting the nurse satisfaction. The clinical nurses desired a lower nurse-patient ratio. The purpose of this project was to justify a staffing increase through a return on investment and increased quality metrics. Methods: This initiative used mixed methodology to determine the ideal staffing for a neuroscience intermediate unit. The quantitative section focused on a review of the acuity of the patients. The qualitative section was based on descriptive interviews with University Healthcare Consortium nurse managers from similar units. Design: The study reviewed the acuity of 9,832 patient days to determine the accurate acuity of neuroscience intermediate unit patients. Nurse managers at 12 University Healthcare Consortium hospitals and 8 units at the Medical University of South Carolina were contacted to compare staffing levels. Discussion: The increase in nurse staffing contributed to an increase in many quality metrics. There were an 80% decrease in controllable nurse turnover and a 75% reduction in falls with injury after the lowered nurse-patient ratio. These 2 metrics established a return on investment for the staffing increase. In addition, the staffing satisfaction question on the Press Ganey employee engagement survey increased from 2.44 in 2013 to 3.72 in 2015 in response to the advocacy of the bedside nurses.

Keywords: nurse engagement, progressive care, staffing ratios, step down

The neuroscience intermediate unit (NIU) is a 23-bed unit that opened in 2009 to provide care for a mix of routine and intermediate neuroscience patients. Intermediate patients have a higher acuity, and at many institutions, these patients would be housed in intensive care units (ICUs). Intermediate patients can be classified as step-down patients or progressive care patients. The NIU maintains a consistent case mix index (CMI). Case mix index assigns a dollar value to diagnosis-related groups and a relative acuity. The CMI is computed by the Centers for Medicare and Medicaid Services to measure how resource intensive it is to care for a patient population. The Centers for Medicare and Medicaid Services 2016 CMI of the NIU was 2.6511. The CMI in 2014 was 2.6763 and then 2.5888 in 2015. The NIU provides bedside telemetry, intracranial pressure monitoring, arterial blood pressure monitoring, serial neurological checks, and titration of cardiac and vasoactive medications such as nicardipine, labetalol, and diltiazem. Nurses care for critically acute patients after receiving tissue plasminogen activator (tPA), monitor and maintain lumbar and external ventricular drains, and are required to accompany critical care patients to tests and procedures. When the NIU opened, it staffed 7 nurses including a free-floating charge nurse. This allowed 5 nurses staffed at a nurse-patient ratio of 1:4 and 1 nurse to be staffed 1:3 to care for the most critical patients. The free-floating charge nurse cared for the post-tPA patients who require neurological checks every 30 minutes. As time passed, there were more intermediate patients than projected. This required nurses to have staffing ratios of 1:5 to allow more nurses to be assigned 1:3 ratios to care for intermediate patients. The staffing ratio resulted in dissatisfaction among the nursing staff. The purposes of this project were to better classify the intermediate status of NIU patients and to increase the allotted full-time equivalents to provide NIU patients with the appropriate level of care.

An extensive literature search revealed minimal research in this area. A 2002 article stated that the ideal staffing in a progressive care unit should be 1:4. (1) Another study found that step-down units have a staffing ratio of 1:4.79, based on 406 surveyed nurses. (2) However, the first article is greater than 5 years old, and neither article factors in the acuity of the neuroscience population because the literature for step-down units is based primarily on surgical or cardiac units.

Design and Methodology

The initiative used mixed methodology to capture the intermediate status of the NIU patients and determine the ideal staffing when comparing with units at similar institutions. The project analyzed retrospective quantitative InterQual data. InterQual status is a method of using predetermined qualifiers to establish patient acuity and the resources needed to care for the patient. In addition, the initiative used qualitative data through a series of descriptive interviews with managers at the Medical University of South Carolina (MUSC) and similar University HealthSystem Consortium (UHC) units. The nurse manager organized the interviews into an internal and external summaries of executives.

Data Collection and Measurement

The project reviewed the InterQual criteria for 9832 patient days to establish the true intermediate status of NIU patients. The nurse manager contacted 12 nurse managers at UHC hospitals and 8 units at MUSC to determine the appropriate staffing levels. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores are externally bench-marked against the average HCAHPS scores as reported on the HCAHPS Webpage. The turnover is internally benchmarked against NIU using American Nurses Credentialing Center (ANCC) definitions. The annual Press Ganey employee engagement scores determine the nurse satisfaction. The falls with injury are benchmarked against the National Database of Nurse Quality Indicators (NDNQI) averages.

Results

The nurse manager conducted interviews for the external and internal summaries of executives. The interviews included 12 UHC hospitals and 8 units at MUSC. To create the summaries, the nurse manager polled the unit managers to discover her staffing ratio and capabilities within her unit's scope of practice. The 14 capabilities polled were intracranial pressure monitoring, arterial blood pressure monitoring, central venous pressure monitoring, hourly neurological checks, management of external ventricular drains, management of lumbar drains, post-tPA monitoring, post-operative craniotomy monitoring, postoperative transsphenoidal monitoring, care of subarachnoid hemorrhage patients starting at day 5, titration of labetalol, nicardipine, diltiazem, and esmolol. The internal summary of executives showed that other units at MUSC performed only 2 of the 14 polled capabilities. Two of the 8 units operate lumbar drains, and three of the units can titrate diltiazem drips. Twelve of the NIU's capabilities are exclusive to the NIU for non-ICUs at MUSC. The external summary of executives yielded that the NIU is the most comprehensive unit of its kind and that it has the capability to care for a sicker population. The summary also provided that most similar units staff nurses at a ratio of 1:3. However, 33% of these comparable units are extensions of the UHC hospitals' neuroscience ICUs, and they only have between 3 and 6 step-down beds. The others are surgical or cardiac step-down units. These units are contrasted against the NIU being a separate unit with their own staff and resources. The external summary of executives for the 12 UHC units is displayed in Table 1.

The initiative reviewed patient InterQual criteria for 15 months from February 2012 to April 2013. The review of the InterQual criteria and accommodation codes yielded the fact that more than 50% of NIU inpatient stays are intermediate. The Centers for Medicare and Medicaid Services reported that CMI remained comparable for 2012 and 2013. They were 2.7295 and 2.6626, respectively.

On the basis of the data presented and the comparisons with similar UHC hospital units, MUSC's staffing committee revised the NIU staffing matrix to increase the budgeted nurse full-time equivalents by 4.2. This allowed for 5 nurses to be staffed 1:3 and care for intermediate patients and 2 nurses to be staffed 1:4 and care for the floor status patients. This change contributed to a measured increase in staff satisfaction. Before the staffing matrix change in 2013, the staffing satisfaction question on the Press Ganey employee engagement survey scored 2.44. The score increased to 3.20 in 2014 with the implementation of the new staffing matrix. In 2015, this question garnered a score of 3.72.

After the NIU implemented the staffing increase, there was a marked increase in the NIU HCAHPS scores. Between 2013 and 2014, 9 of 11 questions garnered a significant increase. The question about the willingness of a patient to recommend the NIU saw no change at 87.32% for both years. The question polling the responsiveness of staff was the only question that saw a decrease between 2013 and 2014. This score decreased from 75.48% to 69.44%. One possible factor in this decrease is that the sample size for this question saw a decrease from n = 218 in 2013 to n = 75 in 2014. The HCAHPS composites are displayed in Figure 1. (3)

The increase in staffing also correlates with a decrease in falls with injury. The 2013 quarter 2 NDNQI step-down benchmark for falls with injury was 0.57. In the 2 quarters before the rollout, the NIU scored from 0.49 to 0.5. This number rests below the benchmark, which is an accomplishment. After the staffing increase, the falls with injury decreased from one per quarter to one per year for the next 2 years. With a national average of 0.72 in the NIU NDNQI comparison group, the NIU scored 0.49 for two of the quarters and zero for the remaining 6 quarters. It is estimated that current inpatient falls with injury cost $13 316. (4) By reducing falls with injury by 75%, there is a huge cost savings and decrease in length of stay. Even if there had been only 1 fall per quarter, the annual savings at a 75% reduction would be a savings of $39 398 annually for the 3 prevented falls with injury.

The decline in turnover established a return on investment. Replacing and training nurses are a costly endeavor. Evaluation of the cost of nursing turnover yields an average cost of $36 900 to $58 400. (5,6) In addition, there is an 8.5% national nurse vacancy rate, which makes it increasingly difficult to hire experienced nurses. (5) This leaves many positions filled by new graduate nurses whose training is longer and reaches the upper range of the $36 900 to $58 400.

The MUSC evaluates turnover with the ANCC definition of controllable turnover. The ANCC considers controllable turnover to be a resignation because of an aspect that the employer controls. (7) This number shows the turnover created by controllable factors. In the 4 quarters leading up to the change in staffing ratio, there was 1 event of nurse controllable turnover per quarter. In the 5 quarters after the change in the staffing ratio, there was 1 event of controllable nurse turnover. The proper staffing of the NIU led to an 80% decrease in controllable turnover. If one assumes the cost of $58 400 per new nurse, then that is a savings of $233 600. The average nurse in the NIU earns an hourly rate of $27.50, and this rate extrapolated for the additional 4.2 full-time equivalents applied to the NIU is $240 286 annually. The total cost of the increased staffing based on the decreased controllable turnover was $6686 a year or $129 a week. However, if one couples this with the decrease in falls, then there is an annual savings of $33 262.

In addition, caring for these patients in the NIU frees up ICU beds and saves the organization money. The current bed charge for an ICU bed is $3593 per day compared with the daily room charge for an NIU bed that is $2734 if the patient is coded as an intermediate patient. That is a difference of $859 per bed per day. This number extrapolated that, for a 23-bed unit during a year, that is a savings of $7 211 305 in bed costs alone. That figure does not account for discharges and admissions, which would significantly increase the total savings from bed costs.

Discussion

Neuroscience nurses experience unique challenges caring for their patient population. Frequent neurological evaluation and monitoring coupled with often confused patients makes this population unique from other areas of the hospital. It is essential for neuroscience units to be staffed appropriately to offer specialized care through skilled assessments that recognize subtle changes and decline in a patient's condition. This article shows how neuroscience nurses leveraged their role as part of the healthcare team to enhance an innovative and cost-effective staffing model designed to care for poststroke patients in an NIU. The implications of this model are paired with the advocacy of neuroscience nurses who increased the full-time equivalent on the unit to allow for improved staffing and patient outcomes. Standards have not been set in the staffing of an NIU, and this article seeks to start a national dialogue between similar units to standardize the care of neuroscience patients.

[FIGURE 1 OMITTED]

The increase in staffing resulted in an increase in many quality metrics. Updating the NIU staffing matrix increased staff satisfaction and contributed to the NIU being designated the first non-ICU Beacon-designated unit in South Carolina. These gains are worth the budgetary increase as justified by the return on investment. Further longitudinal research on other inpatient units should be completed to externally validate the findings of this study. Possible limitations to this study are the 1-group quasi-experimental design because there was neither a control group nor a comparison group. The other UHC hospitals were already staffing their NIUs at a ratio of 1:3. Although many of the UHC hospitals in the external summary of executives do not have standalone neuroscience step-down units, the reported surgical and cardiac units were comparable with generated statistical data for the purpose of this study. The minimal evidence of staffing step-down units in the literature warrants further exploration into the appropriate staffing of step-down units. It is paramount that nurses are staffed at safe levels to not only increase satisfaction but also increase overall patient safety. The higher CMI of these units increases unit and hospital revenue, but the onus exists to ensure proper staffing ratios. Proper staffing ratios increase patient safety, nurse satisfaction, and patient satisfaction. Further studies could contribute to the use of mixed methodology in establishing optimal staffing levels and improving patient safety.

References

(1.) Lewis PS, Latney C. Achieve best practice with an evidence-based approach. Nurs Manage. 2002;33(12):24-30. doi:10.1097/00006247-200212000-00010.

(2.) Choi J, Staggs VS. Comparability of nurse staffing measures in examining the relationship between RN staffing and unit-acquired pressure ulcers: a unit-level descriptive, correlational study. Int J Nurs Stud. 2014;51(10):1344-1352. doi:10.1016/j.ijnurstu.2014.02.011.

(3.) Hospital Consumer Assessment of Healthcare Providers and Systems. Summary of HCAHPS survey results April 2014 to March 2015. http://www.hcahpsonIine.org/Files/December_2015_Summary_Analyses_Survey_Results.pdf. Accessed June 13, 2016.

(4.) Wong CA, Recktenwald AJ, Jones ML, Waterman BM, Bollini ML, Dunagan WC. The cost of serious fall-related injuries at three midwestern hospitals. Jt Comm J Qual Patient Saf. 2011;37(2):81-87.

(5.) Nursing Solutions Inc. 2016 National healthcare retention & RN staffing report. http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/NationalHealthcareRNRetentionReport2016.pdf. Accessed June 13, 2016.

(6.) Lewin Group. Evaluation of The Robert Wood Johnson wisdom at work: retaining experienced nurses research initiative. http://www.rwjf.org/content/dam/farm/reports/evaluations/2009/rwjf41981. Accessed June 13, 2016.

(7.) American Nurse Credentialing Center. Demographic data collection tool (DDCT) question text and associated help text. http://www.nursecredentialing.org/DDCT-QuestionGuide. Accessed June 13, 2016.

Questions or comments about this article may be directed to Charles Nadolski, BSN RN SCRN CNRN CSRN, at nadolski@musc.edu. Medical University of South Carolina, Charleston, SC.

Pheraby Britt, ADN RN SCRN, is Clinical Nurse, NSICU, Medical University of South Carolina, Charleston, SC.

Leah C. Ramos, MSN RN CCRN-K NE-BC, is Nursing Director, Medical University of South Carolina, Charleston, SC.

The authors declare no conflicts of interest.

Copyright [c] 2017 American Association of Neuroscience Nurses
TABLE 1. External Summary of Executives From UHC Hospitals Unit
Capabilities

                           MUSC   UHC         UHC         UHC
                           NIU    Hospital 1  Hospital 2  Hospital 3

Nurse-patient ratio        1:3-5  1:3         1:3         1:3
Monitoring capabilities
  1. Intracranial          Yes    No          No          No
     pressure
  2. Arterial line         Yes    Yes         No          No
  3. Central venous        Yes    Yes         Yes         No
     pressure
  4. q1-hour neuro         Yes    Yes         Yes (time   No
     checks                                   limited)
Patient population
  1. External ventricular  Yes    Yes         No          Yes
     drains
  2. Lumbar drain          Yes    Yes         Yes         No
  3. Post-tPA              Yes    No          No          Yes
  4. Postoperative         Yes    Yes         No          Yes
     craniotomy
  5. Postoperative         Yes    No          No          No
     transsphenoidal
  6. SAH post bleed day 5  Yes    No          No          No
Cardiac drips
  1. Labetalol             Yes    No          No          No
  2. Nicardipine           Yes    Yes         No          Yes
  3. Diltiazem             Yes    Yes         Yes         No
  4. Esmolol               Yes    No          No          No

Unit Capabilities          UHC         UHC         UHC
                           Hospital 4  Hospital 5  Hospital 6

Nurse-patient ratio        1:4         1:2-3       1:3
Monitoring capabilities
  1. Intracranial          No          No          Yes
     pressure
  2. Arterial line         No          No          Yes
  3. Central venous        No          No          Yes
     pressure
  4. q1-hour neuro         No          No          No
     checks
Patient population
  1. External ventricular  No          Yes         Yes
     drains
  2. Lumbar drain          Yes         Yes         Yes
  3. Post-tPA              No          No          No
  4. Postoperative         No          No          No
     craniotomy
  5. Postoperative         No          No          No
     transsphenoidal
  6. SAH post bleed day 5  No          No          No
Cardiac drips
  1. Labetalol             No          No          No
  2. Nicardipine           No          No          No
  3. Diltiazem             At times    No          Yes
  4. Esmolol               No          No          No

Unit Capabilities          UHC         UHC         UHC
                           Hospital 7  Hospital 8  Hospital 9

Nurse-patient ratio        1:3-4       1:3         1:3
Monitoring capabilities
  1. Intracranial          No          No          Yes
     pressure
  2. Arterial line         Yes         Yes         No
  3. Central venous        Yes         No          No
     pressure
  4. q1-hour neuro         No          Yes         No
     checks
Patient population
  1. External ventricular  Yes         Yes         Yes
     drains
  2. Lumbar drain          Yes         Yes         Yes
  3. Post-tPA              No          Yes         No
  4. Postoperative         Yes         Yes         Yes
     craniotomy
  5. Postoperative         No          Yes         Yes
     transsphenoidal
  6. SAH post bleed day 5  No          Yes         No
Cardiac drips
  1. Labetalol             Yes         No          No
  2. Nicardipine           Yes         Yes         Yes
  3. Diltiazem             Yes         Yes         Yes
  4. Esmolol               No          Yes         No

Unit Capabilities          UHC          UHC          UHC
                           Hospital 10  Hospital 11  Hospital 12

Nurse-patient ratio        1:3          1:3          1:3-4
Monitoring capabilities
  1. Intracranial          No           Yes          Yes
     pressure
  2. Arterial line         Yes          Yes          Yes
  3. Central venous        Yes          Yes          Yes
     pressure
  4. q1-hour neuro         No           Yes (time    No
     checks                             limited)
Patient population
  1. External ventricular  No           Yes          Yes
     drains
  2. Lumbar drain          Yes          Yes          Yes
  3. Post-tPA              No           Yes          No
  4. Postoperative         Yes          At times     Yes
     craniotomy
  5. Postoperative         No           No           Yes
     transsphenoidal
  6. SAH post bleed day 5  No           Yes          Yes
Cardiac drips
  1. Labetalol             No           Yes          No
  2. Nicardipine           No           Yes          No
  3. Diltiazem             Yes          Yes          Yes
  4. Esmolol               No           Yes          No

Unit Capabilities          % of UHC
                           Hospitals

Nurse-patient ratio
Monitoring capabilities
  1. Intracranial          33
     pressure
  2. Arterial line         58
  3. Central venous        58
     pressure
  4. q1-hour neuro         25
     checks
Patient population
  1. External ventricular  75
     drains
  2. Lumbar drain          92
  3. Post-tPA              25
  4. Postoperative         58
     craniotomy
  5. Postoperative         25
     transsphenoidal
  6. SAH post bleed day 5  25
Cardiac drips
  1. Labetalol             25
  2. Nicardipine           50
  3. Diltiazem             75
  4. Esmolol               25

This table displays the capabilities and staffing ratios of similar
units at 12 UHC hospitals in a summary of executives and shows that the
NIU has more capabilities and that it has been caring for more acute
patients with a higher nurse-patient ratio.
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Title Annotation:CLINICAL NURSING FOCUS
Author:Nadolski, Charles; Britt, Pheraby; Ramos, Leah C.
Publication:Journal of Neuroscience Nursing
Article Type:Report
Date:Jun 1, 2017
Words:3236
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