The Relevance of Patient Acuity Scales in Clinical Settings

Patient Acuity Scales

Literature Review

According to DiClemente (2018), nurses have a moral as well as professional obligation to ensure that patient have access to the best possible level of care. This could be achieved via the deployment of a wide range of ideals, systems and tools. Patient acuity could be conceptualized as one of the most instrumental patient classification systems (Garcia, 2017). In the words of the author, acuity comes in handy in efforts to “project how many nursing care hours are needed to optimize patients’ ability to improve” (Garcia, 2017, p. 477). Studies conducted in the past have clearly demonstrated that patient acuity scales have a positive impact on not only patient outcomes, but also patient satisfaction. Further, the said scales help increase staff satisfaction and decrease staff burnout.

Patient acuity does not have an assigned definition. What this means is that in the past, various definitions have been offered by multiple authors in an attempt to define this particular concept. Connor, LaGrasta, Gauvreau, Porter, O’Brein, and Hickey (2019) observe that the lack of a clear and straightforward definition of patient acuity, and thus identification its key attributes, has largely stifled the effective application of acuity measurements and tools in clinical settings. Brenan and Daly (as cited in Goh, Ang, Chan, He, and Vehvilainen-Julkunen, 2018), in their attempt to offer a concise definition to the concept, indicate that patient acuity could be conceptualized as “the physical and psychological status of the patient and is described as the measurement of the patient’s illness severity and the intensity of nursing care required” (694). This is the definition of patient acuity that will be embraced in this context.

There are quite a number of factors that could affect nurse satisfaction. Some of the factors that have been highlighted in the past include, but they are not limited to, resource adequacy, the organizational policies in place, interactions between co-workers, autonomy, etc. According to Carlisle, Perera, Stutzman, Brown-Cleere, Parwaiz and Olson (2020), past studies that have reviewed data related to nurse satisfaction indicate that adequate staffing and proper assignment of tasks also has a positive impact on the ability of nurses to enjoy their roles. For this reason, there exists a valid reason to embrace systems and standards that ensure that nurses are not overwhelmed by tasks and that patient assignments are equitable. This could be achieved by scoring patient needs using data sourced from the relevant workload indicators and patient characteristics (from a clinical perspective). A patient acuity tool could come in handy in these efforts. Further, it should also be noted that in as far as staff satisfaction is concerned, Firestone-Howard, Gonzalez, Dudjak and Rader (2017) make a finding to the effect that nurse-to-nurse communication as well as perceived professional autonomy are greatly enhanced by patient acuity tool. More specifically, in the words of the authors, their findings indicate that “the utilization of the PAT has the potential to result in an improvement of nurse satisfaction and perceptions that patient assignments are all equitable” (Firestone-Howard, Gonzalez, Dudjak and Rader, 2017, p. E13). This is more so the case given that according to Minnick et al. (as cited in Firestone-Howard, Gonzalez, Dudjak and Rader, 2017), the perceptions that nurses have of an increase in workload are affected by the nature as well as design of the work environment. In this context, the nature and design of the work environment could be in relation to not only events deemed non-routine, but also case difficulty. It would be prudent to note that patient acuity scales have been associated with greater ability to quantify (as well as promote equitability in) RN assignments.

When it comes to patient satisfaction and outcomes, it would be prudent to note that the same is affected by a wide range of factors. The said factors are inclusive of, but they are not limited to, diagnosis quality, decisions made with regard to treatment, as well as strategies put in place to monitor care. One often overlooked factor in as far as patient outcomes is concerned is nurse stuffing levels. According to Garcia (2017), available evidence indicates that patient outcomes could also be impacted by appropriate staffing. Inappropriate staffing could result in greater workload. Firestone-Howard, Gonzalez, Dudjak and Rader (2017) make an observation to the effect that workload greatly impacts patient outcomes. According to the authors, developing greater understanding of the relevance of workload in as far as patient outcomes are concerned would be instrumental in efforts to chart how workload is influenced by patient acuity tools. For instance in a study conducted by Cimiotti et al. (as cited in Firestone-Howard, Gonzalez, Dudjak and Rader, 2017), it was found that there was a significant correlation between the rate of surgical site as well as urinary tract infections and patient-to-nurse ratio. More specifically, as per these findings, surgical site as well as urinary tract infections increase with an increase in patient-to-nurse ratio. Further, findings from another study by Mitka (as cited in Firestone-Howard, Gonzalez, Dudjak and Rader, 2017) indicate that healthcare institutions report less readmissions following an improvement in nurse staffing ratios. Lee, Cheung, Joynt, Leung, Wong, and Gomersall (2017) also point out that their study findings clearly demonstrate that increased workload/staffing ratio (even for a single day) is linked to significant increase in death risk among patients who are considered critically ill. More specifically, the authors point out that their findings are aligned with the findings of previous studies which link increased mortality to high workload/staffing ratios. It is also important to note that according to Carlisle, Perera, Stutzman, Brown-Cleere, Parwaiz and Olson (2020), there is plenty of evidence to indicate that the safety of care at the unit level is often impacted upon by nurse staffing ratios. With this in mind, it would be prudent to note that the deployment of patient acuity tools could have a positive impact in as far as workload is concerned – thereby resulting in improved patient outcomes. Indeed, in the words of Firestone-Howard, Gonzalez, Dudjak and Rader (2017), “utilizing a patient acuity system, it is possible to increase the levels of staffing efficiency and effectiveness in the hospital setting, thereby resulting in increased quality of care by deploying the appropriate nursing staff for patient care” (E6). This is an assertion further advanced by Garcia (2017) who point out that there is need for nurse leaders keen on attaining optimal staffing practices to embrace the utilization of real-time acuity data.

Numerous other studies have also established that staffing decisions impact patient outcomes. In a study seeking to establish whether high nurse staffing ratios or workload resulted in adverse outcomes among patients who were critically ill, Lee, Cheung, Joynt, Leung, Wong, and Gomersall (2017) made a finding to the effect that there was significant decrease in survival odds following the exposure of patients considered critically ill to excessive workload/nurse staffing ratios. It is important to note that workload could be quantified in various ways. According to Lee, Cheung, Joynt, Leung, Wong, and Gomersall (2017), workload – which is often linked to patient numbers – could also be thought of in terms of the clinical interventions deployed by nurses. Nurse managers could find themselves in a tight corner when making decisions that relate to the further promotion of patient outcomes and appropriate staffing levels. For instance, Lee, Cheung, Joynt, Leung, Wong, and Gomersall (2017) point out that some could struggle with the question of whether or not to admit patients to the ICU when there are available beds, but the staffing levels are inadequate. This, according to the authors, is more so the case given that in such a scenario, admitting more patients to the ICU could have a negative impact on the wellbeing of those patients already in the ICU. Further, a scenario such as this, as the authors indicate, raises “questions about whether ICUs should be staffed on the basis of actual workload rather than number of patients and conversely, whether bed capacity should be determined by actual nursing workload and staffing rather than physically empty beds…” (Lee, Cheung, Joynt, Leung, Wong, and Gomersall, 2017, p. 6). Patient acuity tools could come in handy as decision making aids on this front. This is particularly the case given that they make use of various workload indicators as well as clinical patient characteristics to come up with a patient score – effectively helping to tackle concerns revolving around unbalanced nurse-patient assignments. This is an assertion further advanced by Goh, Ang, Chan, He, and Vehvilainen-Julkunen (2018) who are of the opinion that nursing workload management tools, such as a patient acuity tool, are of great relevance in the effective setting of priorities related to patient care. Thus, the authors are convinced that this is a tool that could be of great relevance to nurse managers. According to Goh, Ang, Chan, He, and Vehvilainen-Julkunen (2018), when patient acuity is high, there is need to ensure that more nurses are available to ensure that patients access competent care. Thus, according to Harper and McCully (as cited in Goh, Ang, Chan, He, and Vehvilainen-Julkunen, 2018), “nurses score patients’ acuity ratings according to predefined patient care needs” (698).

Lee, Cheung, Joynt, Leung, Wong, and Gomersall (2017) are categorical that their findings (i.e. in relation to the central role that nurse workload/staffing ratios play in the enhancement of patient outcomes – specifically in relation to patients who happen to be critically ill - could have “significant implications for nurse staffing in Intensive Care Units, suggesting that staffing should be based on workload, not just patient numbers” (7). Findings of this nature help to further demonstrate the relevance of patient acuity tools in efforts to address crucial issues revolving around nurse-patient assignments. This is more so the case given that as DiClemente (2018) points out, “balancing nurse-patient assignments continues to be a challenge within healthcare organizations” (355). For is reason, the authors are categorical that one of the most effective approaches that could be deployed in this endeavor is the deployment of a subjective acuity strategy. This is an assertion further supported by Welton (as cited in DiClemente, 2018) who indicates that one of the best ways to improve patient outcomes is ensuring that patient have access to quality care. This, according to the author, could be accomplished by well-planned patent acuity assessment as well as ideal nurse-patient assignment. Nguyen (as cited in DiClemente, 2018) also observes that after the deliberate consideration of acuity, nurse managers can accurately establish the needed care level following the assessment of the various needs of patients at the individual level. There are a wide range of factors that could impact the needed level of care for each patient. Some of these factors, according to DiClemente (2018) are the psychological needs of patients, the patient’s family dynamics, the instruction level required for the patient, the complexity of patient care procedures, etc. According to the authors, these factors play a huge role in the determination of each individual patent’s amount of nursing care. As a consequence, the relevance of assessing patient acuity cannot be overstated in efforts to make nursing assignments reasonable and more effective. Carlisle, Perera, Stutzman, Brown-Cleere, Parwaiz and Olson (2020) are also of the opinion that there is need to individualize staffing needs to patient needs. In the words of the DiClamente (2017), acuity tools “help nurses succeed in promoting the best patient outcomes… a standardized tool allows nurses not only to communicate patient needs, but also communicate their own needs” (387). Goh, Ang, Chan, He, and Vehvilainen-Julkunen (2018) also observe that patient acuity tools come in handy in nursing workload management. In essence, effective management of nursing workload results in increased staff satisfaction as well as better patient outcomes.