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Safer Nursing Care ToolImplementation Resource Pack2014

1 Settingthecontext............................................................................................ 2

2 IntroductiontotheTool.................................................................................... 4

3 AbriefoverviewoftheTool.............................................................................. 5

4 Howisacuityanddependencymeasured?...................................................... 7

5 ExampledatacollectionTools.......................................................................... 8

6 HowdoIensurethataccuratedataarecollected?........................................ 11

7 Whatnursesensitiveindicatorsarealliedtoacuityanddependency?.......... 12

8 Howtousethemultipliers............................................................................... 13

9 Occupancy....................................................................................................... 14

10 Toptipsfromthepilotandfieldtestsites...................................................... 14

11 Frequentlyaskedquestions............................................................................. 15

12 WhocanIcontactifIneedhelp?.................................................................... 16

13 References....................................................................................................... 17

Table of Contents

*TheShelfordGroupisanorganisationcomprisingtheChiefExecutivesoftenoftheleadingNHSmulti-specialtyacademichealthcareorganisationsinEngland.

TheChiefNursesofeachoftheseNHSTrustsbelongtoaSub-Groupoftheorganisationandtheymeeteverytwomonthstosharebest-practice,benchmarkandworktowardsimprovingstandardsinnursing.

Executive National LeadsProfessorKatherineFentonOBE,ChiefNurse,UniversityCollegeLondonHospitalsNHSFoundationTrustandProfessorHilaryChapmanCBE,ChiefNurse,SheffieldTeachingHospitalsNHSFoundationTrust

National Lead Nurses on behalf of Executive Leads:AnnCasey,SeniorNurseN&MEstablishments,UniversityCollegeLondonHospitalsNHSFoundationTrust,ChristineBryer,SeniorNurse,SheffieldTeachingHospitalsNHSFoundationTrustandSueSmith,DirectorofNursing,PatientSafety&Quality,NorthTeesandHartlepoolNHSFoundationTrust.

Validating the Tool and Developing the MultipliersDrKeithHurst,IndependentResearcher/Analyst;Editor,InternationalJournalofHealthCareQualityAssurance

DepartmentofHealthSupportfororiginalversionoftool:RosMoore,thenNursingOfficerDHEngland&Wales

Pilot sites• UniversityHospitalSouthampton

NHSFoundationTrust

• BartsHealthNHSTrust

• UniversityHospitalsCoventryandWarwickshireNHSTrust

• Guy’sandStThomas’HospitalNHSFoundationTrust

• HammersmithHospitalsNHSTrust

• King’sCollegeHospitalNHSFoundationTrust

• UniversityHospitalsofLeicesterNHSTrust

• OxfordUniversityHospitalsNHSTrust

• UniversityCollegeLondonHospitalsNHSFoundationTrust.

Field Test Sites original version• NHSScotland

• NewhamUniversityHospitalNHSTrust

• SheffieldTeachingHospitalsNHSFoundationTrust

• WhippsCrossUniversityHospitalNHSTrust

• Winchester&EastleighHealthcareNHSTrust.

Updating sitesTheShelfordgroupofHospitals*consistingofthefollowing:

• CambridgeUniversityHospitalsNHSFoundationTrust

• CentralManchesterUniversityHospitalsNHSFoundationTrust

• Guy’sandStThomas’HospitalNHSFoundationTrust

• ImperialCollegeHealthcareNHSTrust


• TheNewcastle-upon-TyneHospitalsNHSFoundationTrust



• UniversityCollegeLondonHospitalsNHSFoundationTrust

• UniversityHospitalsBirminghamNHSFoundationTrust

andAUKUHhospitals.

• AshfordandSt.Peter’sHospitalsNHSFoundationTrust

• UniversityHospitalsCoventryandWarwickshireNHSTrust

• WhippsCrossHospital,London,partofBartsHealthNHSTrust

Acknowledgements

1

Background and descriptionEnsuringwehavetherightstaff,withtherightskillsintherightplaceisActionArea5withinCompassioninPractice(NHSCB2012).Thisemphasisestheneedfordevelopingevidence-based,patientneed-drivenstaffinglevelsinallcaresettings.ThestrategyalsoadvocatesthatthereisatwiceyearlypublicBoardleveldiscussiontoratifyandagreenursestaffinglevelsinadultin-patientandacuteadmissionsunits.

TheSaferNursingCareTool(SNCT)isonemethodthatcanbeusedtoassistChiefNursestodetermineoptimalnursestaffinglevelsinadultin-patientandacuteadmissionsunits.

TheSNCTis:

• Anevidencebasedtoolthatenablesnursestoassesspatientacuityanddependency,incorporatingastaffingmultipliertoensurethatnursingestablishmentsreflectpatientneedsinacuity/dependencyterms.

• AppropriateforuseinanyacutehospitalwithintheUK(althoughfurtherworkisunderwaytorefinethetoolforuseinparticularclinicalenvironments,seesectiononongoingdevelopmentofthetool)

• UsedinconjunctionwithNurseSensitiveIndicators(NSI)suchaspatientfallsandpressureulcerincidence,whichcanbelinkedtostaffing

• AbletosupportbenchmarkingactivityinorganisationswhenusedacrossTrusts.Thiswillfacilitateconsistentnurse-to-patientratiosinlinewithagreedstandardsacrosssimilarcaresettingsinEngland.

Developing and validating the toolThetoolwasvalidatedbyDr.K.Hurst,(thenbasedattheUniversityofLeeds).ThisincludedrecalibratingthetoolusingtheUKNursingDatabase,whichatthattimeincluded1,000bestpracticewards(thoseachievingapre-determinedqualityrating)andsome119,000nursinginterventionsdeliveredtoalmost2,800patientsin14caregroupsovertwoyears.

TheSNCTtoolwastestedinTeachingandDistrictGeneralHospitalsinEnglandandacrossNHSScotland,toconfirmthatthetoolwaseasytouse.

1. Setting the context for using the Safer Nursing Care Tool

In2012theShelfordChiefNursesGroupcommissionedanexpertworkinggroupincludingDr.KeithHursttoreviewthetool,itsdefinitionsandmultiplierstoensuretheSNCTisstillcurrentandapplicable.Afullreviewwasundertakentakingintoconsiderationchangessuchas:

• Theageingpopulation’simpactoninpatientdependencyandacuity;

• Rapidthroughputandshorterpatient-stays;

• DecreasingRegisteredNursedirect-caretimeandthecorrespondingriseinsupportworkerdirectcaretime.

• Newrolesandsupportstaff;e.g.Band4NursingAssistants*andBand1-3housekeepers

Thisrequiredthatthedualscoringexercisewasrepeated.40,000dualassessmentswereundertakeninOctober2012usingtheUKNursingDatabaseandSaferNursingCareTooltoupdatethestaffingMultipliers.

Thestaffingmultipliers(nursingresource)werealsoupdatedforuseinAcuteAdmissionsUnits(AAU).Almost1,600AAUpatientsweredualassessedin2013usingtheUKNursingdatabaseandSNCT.Over1,100hourswerespentobservingnursingactivityandpatientcarein46AAUsrecordingalmost42,000nursingandsupportstaffinterventionsonwardsthatpassedapredeterminedqualityassessment.ThishasproducedtheAAUspecificstaffingmultipliers.

Using the tool in conjunction with other methods to increase assuranceNursingworkloadandtheabilitytoprovidegoodcareisinfluencedbymanyvariablesincludingpatientacuityanddependencyandotherissuesknowntoinfluencenursingworkloadmorelocally;e.g.:

• Theclinicalmodel

• Thelabourmarket

• Staffcapacityandcapability,seniorityandconfidence

• Organisationalfactors;i.e.supportroles,supportexternaltotheward,wardlayout

• SeniorSister/ChargeNursesupervisorytimeandleadershipcapability

2*includesHCAs/AssistantPractictioner

Nonationalworkforcetoolcanincorporateallfactorsandsocombiningmethods(triangulation)isrecommendedtoarriveatoptimalstaffinglevels.ThisshouldincludequantitativeassessmentssuchasthoseencapsulatedintheSNCTandothermorequalitativeandprofessionaljudgementmethodstoincreaseconfidenceinrecommendedstaffinglevelsandprovidebalancedassurance.

TheRoyalCollegeofNursingreport(RCN2010)alsoadvocatestriangulatingdifferentmethodsforcalculatingnursestaffinglevels.Appendix1summarisesothermethodsavailabletohelpdeterminenurseestablishments,whichcanbeusedfortriangulationpurposes.

Are we getting the results we want? Monitoring Nurse Sensitive IndicatorsLinksbetweenpatientacuityanddependency,workload,staffingandqualityhavebeenestablishedinrecentyears.Evidenceintheliteraturelinkslowstaffinglevelsandskillmixratiostoadversepatientoutcomes(Raffertyetal.2007;NPSA2009).

MonitoringNurseSensitiveIndicators(NSIs)suchasinfectionrates,complaints,pressureulcersandfallsisthereforerecommendedtoensurethatstaffinglevelsdeterminedinthewaysdescribedabove,deliverthepatientoutcomesthatweaimtoachieve.WithintheSNCTthesedataareconvertedintoarateper1,000occupiedbeddays,thusallowingconsistentcomparisonacrosswardsandTruststohelpensureoptimumstaffinglevels.

IftheNSIsareadversethenstaffinglevelsrequirepromptreviewtotestiftheinitialrecommendationsremainappropriate.Itisimportanttoexcludefactorsthatmaycompromiseworkforcenumbers,suchashighturnover,sickness,leaveorunfilledvacancies.

Alternatively,theremaybeotherfactorsthatcompromiseworkforceefficacyincludingcompetence,inadequateleadership,poormoraleandpoorcompliancewithgoodpracticeallofwhichwillrequireredressthroughotheraction.

Ongoing development of the toolTheadult/AcuteAdmissionsUnittoolisnotvalidatedforuseinChildren’s/YoungPeople’swards.Thismodeliscurrentlybeingdevelopedfortheseareasandwillbereleasedwhenavailable.

Thetoolisalsobeingfurtherdevelopedtobetterreflectthecomplexitiesofcaringforolderpeopleinacutecarewards;thisversionisalmostreadyforuse.

Additionally,workhasbeencommissionedandisinprogresstodevelopasimilartoolforuseinAccidentandEmergencyDepartments.

DrRuthMay,RegionalChiefNurse,NHSEngland,(MidlandsandEast)leadstheimplementationofActionArea5andlearningfromtheexperienceinNHSScotland,workisunderwaytodevelopSNCTforuseinothercaresettings-Community,MentalHealthandLearningDisabilitiesinthefirstinstance.

Shelford Chief Nurse Group

May2014

3

Appendix 1: Methods available to calculate staffing requirements (Hurst, 2003)

The Professional Judgment model (Telford method)Simpletouseandtakesintoaccountclinicalstaffviewsbutisseentobesubjective,hasnoevidence-baseandisnotsensitivetoworkloadintensity.

Staff to Bed ratioSimpletouse,allowsbenchmarkingbutassumesthatbasestaffinglevelsareaccurateandreflectpatientneedandisinsensitivetochangesinworkload.

Activity Monitoring (GRASP )Usescareplans/carepathwaysandrelatednursingtimebutistaskoriented,canbetimeconsuming(togatherdata/undertakeworkloadstudies)andmayrequiresupportfromcommercialsystems

Nursing hours per patient day (NHPPD)ThismethodiswidelyusedintheUSAandAustralia.Itcalculatesthenumberofnursesandnursingassistantsrequiredinrelationtoactivitylevels.

Regression Methods (Teamwork)Commercialsystemsareavailableandhavebeenusefulwhereworkloadpredictionsarepossible,butisnoteasilyunderstoodbynursesandthereisanunderlyingassumptionthatallwardsareefficientandeffective.

Alloftheabove,usedincombination,provideevidencetoensurethatstaffinglevelsandpatientoutcomesarecorrelated.

TheSaferNursingCareToolhasbeendevelopedtohelpNHSHospitalstaffmeasurepatientacuityand/ordependencytoinformevidence-baseddecisionmakingonstaffingandworkforce.Thetool,whenalliedtoNSIs,willalsooffernursesareliablemethodagainstwhichtodeliverevidence-basedworkforceplanstosupportexistingservicesortodevelopnewservices.

Thisbookletoffersbriefguidanceforpeopleusingthetoolinpractice.

Itincludes:

• Abriefoverviewofthetool

• Howacuityand/ordependencyaremeasured

• Howtoensurethataccuratedataarecollected

• WhatNurseSensitiveIndicatorswillbealliedtoacuityand/ordependencymeasurement

• Howtousenursingmultiplierstosupportprofessionaljudgement

• WhatcanbelearnedfromthepilotsitesandFrequentlyAskedQuestions(FAQ)

• Howtogethelporsupportifneeded.

2. Introduction to the Tool

TheSaferNursingCareTool(SNCT)isbasedonthecriticalcarepatientclassification(Comprehensive Critical Care, DH 2000).Theseclassificationshavebeenadaptedtosupportmeasurementacrossarangeofwards/specialties.ThefullSNCTisoutlinedbelow.

Safer Nursing Care Tool (SNCT)

3. A brief overview of the Tool

Levels of Care Descriptor

Level 0 (Multiplier =0.99*, adult in-patient wards / 1.27* AAU)

Patientrequireshospitalisation

Needsmetbyprovisionofnormalwardcares.

Care requirements may include the following

• Electivemedicalorsurgicaladmission

• Mayhaveunderlyingmedicalconditionrequiringon-goingtreatment

• Patientsawaitingdischarge

• Post-operative/post-procedurecare-observationsrecordedhalfhourlyinitiallythen4-hourly

• Regularobservations2-4hourly

• Early Warning Scoreiswithinnormalthreshold.

• ECGmonitoring

• Fluidmanagement

• Oxygentherapylessthan35%

• Patientcontrolledanalgesia

• Nerveblock

• Singlechestdrain

• Confusedpatientsnotatrisk

• Patientsrequiringassistancewithsomeactivitiesofdailyliving,requiretheassistanceofonepersontomobilise,orexperiencesoccasionalincontinence

Level 1a (Multiplier =1.39*, adult in-patient ward/1.66* AAU)

AcutelyillpatientsrequiringinterventionorthosewhoareUNSTABLEwithaGREATERPOTENTIALtodeteriorate.


• Increasedlevelofobservationsandtherapeuticinterventions

• Early Warning Score-triggerpointreachedandrequiringescalation.

• Post-operativecarefollowingcomplexsurgery

• Emergencyadmissionsrequiringimmediatetherapeuticintervention.

• Instabilityrequiringcontinualobservation/invasivemonitoring

• Oxygentherapygreaterthan35%+/-chestphysiotherapy2-6hourly

• Arterialbloodgasanalysis-intermittent

• Post24hoursfollowinginsertionoftracheostomy,centrallines,epiduralormultiplechestorextraventriculardrains

• Severeinfectionorsepsis

5

Levels of Care Descriptor

Level 1b (Multiplier = 1.72*, adult in-patient ward/2.08* AAU)

PatientswhoareinaSTABLEconditionbutaredependantonnursingcaretomeetmostoralloftheactivitiesofdailyliving.


• Complexwoundmanagementrequiringmorethanonenurseortakesmorethanonehourtocomplete.

• VACtherapywhereward-basednursesundertakethetreatment

• PatientswithSpinalInstability/SpinalCordInjury

• Mobilityorrepositioningdifficultiesrequiringtheassistanceoftwopeople

• ComplexIntravenousDrugRegimes-(includingthoserequiringprolongedpreparatory/administration/post-administrationcare)

• Patientand/orcarersrequiringenhancedpsychologicalsupportowingtopoordiseaseprognosisorclinicaloutcome

• PatientsonEndofLifeCarePathway

• Confusedpatientswhoareatriskorrequiringconstantsupervision

• Requiresassistancewithmostorallactivitiesofdailyliving

• Potentialforself-harmandrequiresconstantobservation

• Facilitatingacomplexdischargewherethisistheresponsibilityoftheward-basednurse

Level 2 (Multiplier = 1.97* adult in-patient ward/2.26* AAU)

Maybemanagedwithinclearlyidentified,designatedbeds,resourceswiththerequiredexpertiseandstaffinglevelORmayrequiretransfertoadedicatedLevel2facility/unit

• Deteriorating/compromisedsingleorgansystem

• Postoperativeoptimisation(pre-opinvasivemonitoring)/extendedpost-opcare.

• Patientsrequiringnon-invasiveventilation/respiratorysupport;CPAP/BiPAPinacuterespiratoryfailure

• First24hoursfollowingtracheostomyinsertion

• Requiresarangeoftherapeuticinterventionsincluding:

• Greaterthan50%oxygencontinuously

• Continuouscardiacmonitoringandinvasivepressuremonitoring

• DrugInfusionsrequiringmoreintensivemonitoringe.g.vasoactivedrugs(amiodarone,inotropes,gtn)orpotassium,magnesium

• Painmanagement-intrathecalanalgesia

• CNSdepressionofairwayandprotectivereflexes

• Invasiveneurologicalmonitoring

Level 3 (Multiplier = 5.96*, adult in-patient ward/5.96* AAU)

Patientsneedingadvancedrespiratorysupportand/ortherapeuticsupportofmultipleorgans.

• Monitoringandsupportivetherapyforcompromised/collapseoftwoormoreorgan/systems

• RespiratoryorCNSdepression/compromiserequiresmechanical/invasiveventilation

• Invasivemonitoring,vasoactivedrugs,treatmentofhypovolaemia/haemorrhage/sepsisorneuroprotection

6

Truststaffcollectdataatthesametimetoenablebenchmarkingacrossparticipatingorganisations.Acuityanddependencymeasurementcurrentlytakesplaceatleasttwiceyearly(JanuaryandJune).Overtime,itisanticipatedthatthisacuityanddependencymeasurementwillidentifyseasonaltrendsinresponsetochangingdemographicsandhealthcareneeds.Ultimately,thisevidencebasewillsupportworkforceplansfornursingthatshouldaccuratelypredictandenableresourcestobeidentifiedtosupportnursingestablishmentsthatmeetpatientandserviceneeds.

Acuityanddependencymeasurementmustbeconsistent.Itisessentialtoensurethatallrelevantdataarecollectedduringthesameperiod.Datashouldbecollectedoneverypatientonparticipatingwards/unitsat1500hrs,dailyMondaytoFridayfor20daysasaminimum.Qualitycontrolisfundamentaltoensuringarobustapproachtodatacollection.(Howtoensurethataccurate,qualitycontrolleddataarecollectedisoutlinedinsection6.)Thiswillallownursingstafftounderstandnotonlythelevelsofpatientsonwards,butalsoenablethisinformationtobealliedtootherkeydataincluding:

Nurse Sensitive Indicatorsarequalityindicatorslinkedtonursingcare.Theyinformnursesofgoodandpoorpatientoutcomes,enablinggoodpracticetobesharedandpoorpracticetoberectified.(Seesection7)

Patient Flow informationiscollectedtoenablenursesresponsiblefornursingworkforcereviewstoconsiderissuessuchasthroughput,includingnumbersofadmissions,discharges,transfers,wardattenders,deathsandtransfersawayfromtheward/department,occupancyandstaffinglevels.Themultipliersaccountfornormalpatient-flowlevels,howeverwhenthereisahighthroughputofpatients,anadditionalstaffingupliftmaybeconsideredappropriate-seeexampleinsection11.

NurseSensitiveIndicatorsandpatientflowalliedtoacuityanddependencysupportprofessionaljudgementandenableappropriatenursingestablishmentsformeetingthepatients’needstobeagreed.

ThedatacollectiontoolusedisincludedaspartofthisresourcepackforusebyTruststaff.Ascreenshotofasampledatabaseisalsoincluded.TruststaffmayprefertoworkwiththeirITdepartmentstafftodevelopanelectronicversionofthedatabase.

4. How is acuity anddependency measured?

7

5. Example data collection Tools

Ward .................................... Date

Bed No Level Comment Bed

No Level Comment

1 15

2 16

3 17

4 18

5 19

6 20

7 21

8 22

9 23

10 24

11 25

12 26

13 27

14 28

Patient Flow

Admissions Discharges

Transfer In Transfer out

Deaths Ward attender

Escorts on site Escorts off site

RMN specials:

Completed by

Name ........................................................................ Signature

Verified by ................................................................. Signature

Question 1: Ward Name

Question 3: Acuity Score

Question 5: Staffing

Question 6: Completed by

Question 4: Patient Flow

Question 2: Date

D D M M Y

Bay Bed 0 1a 1b 2 3

1 1

1 2

1 3

1 4

1 5

1 6

2 1

2 2

2 3

2 4

2 5

2 6

3 1

3 2

3 3

3 4

3 5

3 6

4 1

4 2

4 3

4 4

4 5

4 6

Room 1

Room 2

Room 3

Room 4

Please complete for the previous 24 hours 15.00 - 15.00

Please complete for the previous night, current morning and evening shift

RegisteredRegistered Bank / Agency

Unregistered Bank / Agency Unregistered

Admissions

Transfers in

Ward attenders

Escorts on site

Name Signature

Discharges

Transfers out

Deaths

Escorts off site

5 hour

6 hour

7.5 hour

10 hour

12 hour

Other

Date

Division

Ward

A&D level

Patient flow information

Drop down box

Drop down box

SUBMIT

0

1A

1B

2

3

Admissions Discharges Category of staff Early / Day Late Night

Transfers in Transfers out Permanent RN

Ward attender Deaths Permanent NA

Escort on site Escorts off site Agency RN

Comments Agency NA

Bank RN

Bank HCA

RMN Special

Data collected by: Verified by:

Example of a database screen

Red RulesQualitycontrolisthekeytosuccessfuldatacollection.Thesesimplestepswillensureaconsistentapproachacrossparticipatingwards:

1 Nominatesomebodytoqualitycontrolthedatacollection.ThismaybeaPracticeFacilitator,amemberofyourCriticalCareOutreachTeamoraseniormemberofthecorporatenursingteam.

2 Identifynomorethanthreeleadersperwardtocompletethescoringdailyforthedurationofthedatacollectionperiod.

3 ThethreeleadersshouldincludetheSisters/ChargeNurses.IfnoSister/ChargeNurseisavailable,anominatedmemberofstaffshouldbeagreedwiththeSeniorNursefortheDirectorate.

4 ThedatacollectionshouldtakeplaceatleasttwiceperyearinJanuaryandJune

5 DatashouldberecordedoneverypatientfromMondayuntilFridayforatotalof20daysasaminimum.

6 Acuityanddependencydatashouldbecollectedforeachpatientineachbedat1500hrs,aspartofabedtobedwardroundreview.

7 Wherepaperbaseddatacollectionisutilised,datacollectionformsshouldbestoredinafolderontheward/unittoawaitcollection/inputtotheelectronicsystem.

8 Patientflowdatashouldbecollectedforthe24-hourperiodleadingtothedatacollectiontime;e.g.,alladmissions/dischargesbetween1500hrsthatdayand1500hrsthepreviousday.

9 NurseSensitiveIndicatordatacanbecollectedretrospectivelybyaseniornurseordirectlypulledfromtheelectronicincidentreportingsystem.

10 Datasheetsshouldbecollectedweeklyfromparticipatingwards/departmentswherecentraldataentrymanagementsystemsareinplace.

11 Datashouldbeenteredontothedatabaseasspeedilyaspossibleaftercollectionorwherethisiscompletedelectronicallyfollowyourlocalpolicybasedontheseprinciples.

12 FeedbackresultstoSistersandChargeNurses,Matrons,DirectorsofNursingandoperationalmanagementteamsassoonaspossible.

6. How do I ensure thataccurate data are collected?

11

NurseSensitiveIndicators(NSIs)refertoqualityindicatorsthatcanbelinkedtonursestaffingissues,includingleadership,establishmentlevels,skill-mixandtraininganddevelopmentofstaff.Thisinformationcanbeusedtofurthersupportwardstaffingrequirementsidentifiedthroughacuityanddependencymeasurement.TheNSIsusedwithinthisprojecthavebeenidentifiedasservicequalityindicatorswithspecificsensitivitytonursinginterventions.

Official ComplaintsOfficialcomplaintsaboutnursing/midwifery/carestaffreceived(per1,000occupiedbeddays)identifyingthethreeareasof:

• Communication

• ClinicalCare

• Attitude

Drug Errors• Actualdrugerrorswherenursingwastheprimarycause,notincludingnear

missesper1,000occupiedbeddays.

Infection• IncidenceratesofMRSAbacteraemiaper1,000occupiedbeddaysand

Clostridium Difficileper1,000occupiedbeddays.

Slips, Trips & Falls• Numberofslips,tripsorfallsper1,000occupiedbeddayscausedprimarily

bynursingerror.

Pressure Ulcers• Incidenceofhospitalacquiredpressureulcersper1,000occupiedbeddays.

Nutrition• Numberofpatientshavinghadnutritionalscreeningper1,000occupiedbed

days.

• PercentageofwardsthathaveimplementedprotectedmealtimespolicywithintheTrust.

7. What nurse sensitive indicators are allied to acuity and dependency?

12

Multiplierscanbeusedtosetnursingestablishmentsalliedtoacuityanddependencymeasurement.Themultipliersagreedforeachlevelofpatientsonin-patientwardsare:

8. How to use the multipliers

13

Level of Care Adult In-Patient wards Acute Admissions Units

Level0 0.99*WTEperbed 1.27*WTEperbed

Level1a 1.39*WTEperbed 1.66*WTEperbed

Level1b 1.72*WTEperbed 2.08*WTEperbed



Number of patients /level of care

Adult in-patient ward Acute Assessment Unit

12patientsatLevel0 0.99x12 = 11.88 1.27x12=15.24

7patientsatLevel1a 1.39x7 = 9.73 1.66x7 = 11.62

8patientsatLevel1b 1.72x8 =13.76 2.08x8 =16.64

1patientatLevel2 1.97x1 = 1.97 2.26x1 = 2.26

Total 37.34 WTE 45.76 WTE

*thisincludesa22%upliftforannualleave,studyleaveetc.

Forexample,ifa28-beddedwardhas12patientsatLevel0,7patientsatLevel1a,8patientsatLevel1b,and1patientatLevel2,atotalof37.34WTEnursingstaffwouldberequiredforanadultin-patientwardOR45.76WTEforanAcuteAdmissionsUnit.

Thisfigureisabaselineagainstwhichtosetnursestaffinglevels.Two28-beddedwardsmayhavedifferentactivity.Onemayhavefewadmissions,dischargesorwardattenderswhereasanothermayhavemany.Professionaljudgementisrequiredtoensurethatestablishmentsareadjustedappropriatelyunderthesecircumstances(Seeexampleinsection11).

Basedon130,000WardSister/ChargeNurseactivitiesobservedin1,414wards,20%oftheirshiftisspentonmanagerial/administration/coordinatingwork,andthistimeisincorporatedintothemultipliers.Intheorythisequatestoonedayperweek.However,somemanagersallowahigherpercentageandthereforeadjustmentmayberequiredtothetotalestablishmenttoensurethisreflectsthelocallyagreedallowanceforSeniorSister/ChargeNursesupervisorytime.

NurseSensitiveIndicatorscanalsobeusedatthisstagetoascertaintheimpactofacuity,dependencyandactivityonqualityoutcomes.

Occupancyiscalculatedbyobtainingthenumberofavailablebeddaysandthenumberofbeddaysused(thelatteriscalculatedbyaddingtogetherthetotalbedsassignedanacuity/dependencyscoreandarethereforeoccupied)asfollows:

Numberofbeddaysusedx100

Numberofbedsavailable

Forexampleifawardhas420beddaysavailableand400beddaysareused,theoccupancyratecalculationis:400x100=40,000dividedby420=95%occupancy

ThissectionaimstoprovideusefultipstosupportsuccessfulimplementationofSNCTscoringinyourTrust.

PreparationItisessentialthatstaffarepreparedandtrainedtoundertaketheacuityanddependencyscoring.

CommunicationMeetwithSisters/ChargeNursestoexplaintheprocessandreasonsformeasuringacuityanddependency.Iftheydonotunderstandthereasons,theymaybesuspiciousandreluctanttoparticipate.

EnsurethattheExecutiveBoard,GeneralManagersandClinicalDirectorsareengagedandunderstandthepotentialimplicationsofimplementingthistoolacrosstheorganisation.

Quality ControlQualitycontrolbytrainedindividual(s)atacorporatelevelwillensurethatthetoolisappliedconsistentlyacrossallwards/units.

Data InputDatainputcanbetimeconsuming.InputfromtheInformationTechnology(IT)departmentwithanominatedcontactpersonmaybeabletosupportthisaspectoftheproject.

FeedbackWardstaffwelcometimelyfeedbackonthelevelsofacuity/dependencywithintheirarea.

9. Occupancy

10. Top tips from the pilotand field test sites

14

Q If I have had a Level 1b patient in my bed for the last 18 hours and a Level 0 patient has just been admitted to that bed, do I score at Level 0 or Level 1b?

A Scoreforthepatientthathasoccupiedthebedforthelongesttimewithinthelast24hours;inthiscaseatLevel1b.

Q When looking at activity, do I include potential discharges?

A Noyoushouldincludeactualactivitynotpredictedorpotentialactivity.

Q I have just measured acuity for the second time and there is a big change in acuity. How can these data be used as evidence to show that we need more staff?

A Thismaybeananomaly.Itisnotadvisedthatthesedataareusedtoshowtrendsuntilithasbeencollectedanumberoftimes.Pilotsitestaffhavebeencollectingacuitydatasince2005andmaybewillingtosharetheirfindingswithyoutoenablecomparisonstobemade.Itisalsoimportantthatdataaretriangulatedwithotheroutcomes.

Q How do I score empty beds?

A Thesearenotgivenascoreunlessthepatienthasonlyjustgonehome.

Q How do I score a patient whose dependency has changed in the last 24 hours?

A Scoreapatientatthehighestleveltheyhavebeenintheprevious24hours.Donotscorethempredicatively.i.e.ifhe/sheisintheatrethenscorethemastheywerebeforetheywentforsurgery.

Q How do I score if there is a patient in the bed waiting to go home and another waiting to go into it?

A Scorethepatientstillinthebedasyoucannotpredictwhattheotherpatientwillbelike.

Q I have a lot of ward attenders who return for dressing changes - how should I capture this?

A Themultipliersallowforanormallevelofactivity.Wherethewardactivityexceedsthis,professionaljudgementneedstobeapplied.Asimplewayofcalculatingthiswouldbe-iftherewere12patientsattendingthewardeachdayandthedressingtakesonehourofnursingtimetocompletethiswouldrequirethefollowingequation(assumingthatthepatientisLevel0)

No.ofpatientsx1hour÷24(tocalculatethenumberperday)x0.99=

Therefore12x1÷24=0.5x0.99=0.49WTE

11. Frequently asked questions

15

TheShelfordGroupisanorganisationcomprisingtheChiefExecutivesoftenoftheleadingNHSmulti-specialtyacademichealthcareorganisationsinEngland(thesearelistedbelow).TheChiefNursesofeachoftheseNHSTrustsbelongtoaSub-Groupoftheorganisationandtheymeeteverytwomonthstosharebest-practice,benchmarkandworktowardsimprovingstandardsinnursing.

• CambridgeUniversityHospitalsNHSFoundationTrust

• CentralManchesterUniversityHospitalsNHSFoundationTrust

• Guy’sandStThomas’NHSFoundationTrust

• ImperialCollegeHealthcareNHSTrust


• TheNewcastleuponTyneHospitalsNHSFoundationTrust



• UniversityCollegeLondonHospitalsNHSFoundationTrust

• UniversityHospitalsBirminghamNHSFoundationTrust

12. Who can I contact if I need help?

16

London and the South of EnglandAnnCaseySeniorNurseN&MEstablishmentsUniversityCollegeLondonHospitalsNHSFoundationTrust

Tel:02034472412

Email:[email protected]

North of England and ScotlandChristineBryerSeniorNurseSheffieldTeachingHospitalsNHSFoundationTrust

Tel:01143052158

Email:[email protected]

DepartmentofHealth(2000)Comprehensive Critical Care:A Review of Adult Critical Care Services.London:DH

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13. References

17

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