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Adaptation of Patient Acuity Tools to Improve Patient Care in an Inpatient Setting

Jason Keller

Delaware Technical Community College

Nursing Informatics NUR410

Melissa Brown

February 11, 2024

Adaptation of Patient Acuity Tools to Improve Patient Care in an Inpatient Setting

Advancements in healthcare has taken our lives to new levels of health and wellbeing for

individuals. Despite the overall increase in lifespan and potential long healthy life, people are

also becoming sicker which brings a downfall of increasing patient acuity and the care that every

individual needs. Patient acuity is getting increasingly complex for the healthcare professionals,

especially nurses, working on the frontline. Throughout the development of nursing as a career,

the going trend was to push the work onto the nurses. It was understood that they can handle

everything that was given. Although nurses are considered the eyes and ears of healthcare, they

are continuously pushed beyond their limits when it comes to patient workload. Nurses are

unceasingly burdened by not only the number of tasks they have to complete during a shift, but

they also have to monitor, and tend to every patient’s immediate and comfort needs. This

includes additional tasks that take up time like heating up food, fetching items like blankets, and

other tasks that can take up additional time that can be focused on more pressing needs for their

other patients they are responsible for. All of these tasks alone can and will take up an entire shift

without even including time for important documentation. The informatics topic that was chosen

for this class is a look and potential change that nursing care patient ratio based on patient acuity

may have a more beneficial impact versus a set number of patients a nurse has in a given shift.

Also, we will look at the potential adaptation of a patient acuity software system and how that

benefits not only the staff and patients, but the organization as well.

As this topic has been researched a lot within the last decade, a typical conclusion

summarized best by Karen DiClemente, is that having an “accurate assessment of patient acuity

followed by appropriate nurse-patient assignments is critical to ensure patients receive the best

quality care and, in turn, the best clinical and overall outcomes” (DiClemente, 2018). In a study
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within a 32-bed medical-surgical/cancer care unit, despite the eventual lack of participation of

the study by the staff on the unit, that conclusion was resulted. The unit decided to standardize

patient acuity and develop a tool to create nurse-patient assignments. Existing models of patient

acuity were taken from the organization and were researched deeper with the help of the nurses

on the unit in a post shift survey. With this gathered data of scoring patient’s acuity after every

shift, a tool was created to quantify the level of care an individual patient requires and patient

assignments were created via the data. As stated earlier, the lack of staff participation was key to

not following through with the program but another important area was addressed as a result.

Discharges were significantly more frequent with the implementation of the acuity study. In

another study, researchers wanted to define the link between patient acuity scores to nursing shift

assignments and see if it increased workload balance, achieve equitable nursing assignments, and

how it impacts job satisfaction. A sample size of 64 nurses were essentially given assignments

based off patient acuity or not and then researchers measured the amount of job satisfaction each

nurse had as a result. The study concluded that “[Patient acuity tools] increases nurses'

satisfaction and serves as managers' voice for important staffing decisions like recruitment,

assignment distribution, employing new staff, and improving quality of care” (Al-Dweik et al,

2019). Though studies haven’t truly measured the outcomes of nursing assignments based on

patient acuity, we can deduct from many other studies of the subject that the benefits can and will

be far more beneficial once implemented permanently.

As with any potential implemented change, there could be concerns of ethical and legal

issues. Several nursing ethical and legal issues could be addressed with this topic alone, but one

big one stands out. That would be provision three of the nursing code of ethics. This states that

the “nurse promotes, advocates for, and protects the rights, health, and safety of the patient”
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(American Nurses Association, 2015). The area specifically would be the protection of the rights

of privacy and confidentiality. Within the study, the use of handwritten forms of patient

information could come into play. “The nurse has a duty to maintain confidentiality of all patient

information, both personal and clinical” (ANA, 2015). For example, should a patient have a

medical condition that he or she does not want exposed, but it is important to know this for the

understanding of how much care they require, then a nurse could be faced with a difficult

decision as to include specific information as requested by the acuity tool. What if that document

gets dropped in the hallway and all the patient’s information’s are exposed? There must be

accountability within the given task at hand or have the process of gathering this information

more thought out.

The patient management system based on numbers alone is failing as hospitals are seeing

dramatically increasing number of admission rates. Nurse-to-patient ratios are at dangerous

levels in which not only results in missed care opportunities but can result in significant safety

issues for patients including but not limited to falls with injury and sentinel events. There must

be accountability from staffing, as well as the unit coordinators to look into how much actual

workload a patient adds to a nurse’s shift. Sure, some charge nurses on a couple units take into

consideration the amount of work each patient requires, but that’s only for a specific oncoming

shift. As we all understand, nursing informatics can be a key to address the situation by

incorporating information that is given and utilizing newer technologies today.

Every inpatient hospital has their own policies and procedures in order to admit patients

to be treated and assign them to a unit of care. The process of assigning patients in a medical

and/or surgical unit can be an arduous task for a charge nurse who is responsible to make up the

nursing assignments for the oncoming shift. There will always be a nurse or two that won’t be
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happy with their assignment, missed opportunities of care, and worst-case scenario being a

sentinel event. All of this has the potential due to heavy patient acuity. Sure, this can be kind of

solved by the charge nurse assuming the acuity of a patient based off their diagnosis, but that still

does not give a complete answer. As you can see from the workflow below, the current method is

generic and based off just patients being a number. Keep in mind, other processes (i.e., upgrading

patients) are kept off to simplify and make it easier to read.

Current Patient Assignment Workflow

The current patient assigning process is based off basic informatics. When a

patient arrives to the ED, they are triaged accordingly to their condition. At this point, nothing is

established as far as the amount of care, other than just a “number”. As the patient is diagnosed,

plan of care is established to be admitted to the hospital, they are sent to one of three areas as you
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can see in the diagram. The ICU and Transitional ICU take patients that are critical and urgent in

which is kind of based off acuity as they need closer monitoring. These units, the nurses only are

allowed to have a maximum of 3 to 4 patients. Once the patients are cleared for downgrading,

the patients are then sent to either Stepdown or Floor Bed units. This is where assignments based

off acuity change need to take place. The nursing coordinator will pick an open room following

minimal guidelines (isolation, male/female, etc). Sure the patient may need less monitoring, but

their acuity hasn’t changed.

A solution to this issue would be to incorporate assigning patient acuity from the

admission point and continuing throughout their stay. A software program can be used by many

hospital staff including physicians, nurses, and more to assess the overall acuity level of each

patient. Not only does this software compute patient acuity, but it also manages nurse’s

schedules, and adequately provides assignments to make workload spread out evenly.

New Patient Assignment Workflow

Once again in this model, other processes are kept off for better understanding. The model

emphasizes and creates more interagency collaboration between all healthcare staff who oversee

patients. It stresses the need to adjust patient acuity as they progress through the hospital system

as well as each day and every shift. Ideally, as the average patient becomes more medically

stable, the lower their acuity prior to discharge. Utilizing this type of patient assignment tool is

understood to be beneficial for the patients, nurses, other healthcare staff, and to the

organization. On the side of the nurses, having a say in patients’ acuity which will determine an

equal and fairly distributed workload is something every nurse can agree upon. This will

contribute to decreasing nurse burnout from being overworked and an increase in overall job

satisfaction. The patients benefit tremendously in which the nurse will be able to provide better

and more focused care due to the increased amount of time available. This will then generate

better patient health outcomes with a bonus of shorter length of stay for the organization. Finally,

with the length of stay decreased, the hospital will see a significant financial gain as patients will

get healthier quicker and add the ability to cycle in new patients more frequently than before.

The idea of nursing based off patient acuity is that of it not only benefits the nurse, but

also the patients much more as they will receive more of the care they deserve and need. Going

back to the article written by Kimberly DiClemente, she recognizes that “nurses are obligated

professionally and morally to provide the best possible care, and they can do so more effectively

with appropriate assignments and distribution of workload” (DiClemente, 2018). As patient

populations are increasing, nursing workforce is decreasing, and patients requiring more care,

there hasn’t been a more urgent time for hospitals that are flirting with and/or past max capacity

to implement this change.

Patient Acuity Software Application Use Implementation Policy

I. PURPOSE: The purpose of this policy is to improve patient care by providing

adequate nurse to patient workloads based off patient acuity.

II. POLICY: Understanding of patient acuity workflow must be demonstrated by all

healthcare staff involved in patient care.

III. PROCEDURE:

a. Patient arrives in the Emergency Department and triaged accordingly.

b. Patient is assessed by all medical staff involved in the care for the patient.

i. Hospitalist determines plan of care, determines overall patient acuity

for hospital stay, and assigns patient to a specific unit of care based on

their condition.

ii. RN assesses the patient’s acuity for nursing care and enters all data

into the patient acuity software.

iii. Nurse Coordinator assigns patient to empty room/bed in one of these

three areas.

1. Coordinator utilizes the patient acuity tool to prevent acuity

overload.

c. Units of Care

i. ICU and TCU: Patient is admitted and treated within designated unit

of care.

1. All staff involved in the treatment and care of patient will

continually update patient acuity software.

a. Nurse reports to the charge nurse during each shift

about the patient’s acuity during charge report.

b. Charge nurse assigns patients to nurses for oncoming

shift according to acuity to create equal patient

workload.

2. Once patient can be downgraded, nurse coordinator will assign

patient to empty room/bed carefully considering patient acuity

and current nurse’s workload.

ii. Stepdown and Floor Bed: Patient is admitted and treated

1. All staff involved in the treatment and care of patient will

continually update patient acuity software.

a. Nurse reports to the charge nurse during each shift

about the patient’s acuity during charge report.

b. Charge nurse assigns patients to nurses for oncoming

shift according to acuity to create equal patient

workload.

iii. Any changes in patient condition resulting in patients being sent to

other units must continue to follow new protocol on patient acuity.

IV. RESPONSIBILITIES:

a. All healthcare staff must adhere to strict HIPAA compliance when accessing

and utilizing patient acuity software.

b. When entering data within the patient acuity software, healthcare must adhere

to the same level of responsibility as when being documented in the EMR.

References

Al-Dweik, G., & Ahmad, M. (2019). Matching Nursing Assignment to Patients' Acuity Level:

The Road to Nurses' Satisfaction. Journal of nursing measurement, 27(1), E34–E47.

https://doi.org/10.1891/1061-3749.27.1.E34

Allen, S. (2018). The nurse-patient assignment process: What clinical nurses and patients think.
MEDSURG Nursing, 27(2), 88-82.
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.

American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-

excellence/ethics/code-of-ethics-for-nurses/

DiClemente, K. (2018). Standardizing Patient Acuity: A Project on a Medical-Surgical/Cancer

Care Unit. MEDSURG Nursing, 27(6), 355–387.

Juvé-Udina, M. E., González-Samartino, M., López-Jiménez, M. M., Planas-Canals, M.,

Rodríguez-Fernández, H., Batuecas Duelt, I. J., Tapia-Pérez, M., Pons Prats, M.,

Jiménez-Martínez, E., Barberà Llorca, M. À., Asensio-Flores, S., Berbis-Morelló, C.,

Zuriguel-Pérez, E., Delgado-Hito, P., Rey Luque, Ó., Zabalegui, A., Fabrellas, N., &

Adamuz, J. (2020). Acuity, nurse staffing and workforce, missed care and patient

outcomes: A cluster-unit-level descriptive comparison. Journal of nursing management,

28(8), 2216–2229. https://doi.org/10.1111/jonm.13040

Leary, A., & Punshon, G. (2019). Determining acute nurse staffing: a hermeneutic review of an

evolving science. BMJ open, 9(3), e025654. https://doi.org/10.1136/bmjopen-2018-

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