Pediatric Echocardiography by Work Relative Value Units: Is Study Complexity Adequately Captured?

BACKGROUND: Present resource-based relative value unit (RVU) assignment for echocardiography is based on Current Procedural Terminology (CPT) codes, which do not incorporate complexity of diagnosis, time spent for image acquisition, or interpretation of echocardiograms. The objective of this study was to determine whether CPT-based RVU assignment accurately reflects physician effort in performing and interpreting pediatric echocardiographic examinations. METHODS: Cardiac complexity category (CCC) and physician time for study interpretation of 123 echocardiograms (June to September 2013) were prospectively assigned. Categories included (1) focused effusion/function evaluation, (2) normal anatomy/focused preterm infant studies, (3) acquired heart disease, (4) congenital heart disease excluding single ventricles, (5) single ventricles including heterotaxy syndrome, and (6) hearts on mechanical support. Subsequently, a random sample of echocardiograms (March to August 2013) were retrospectively analyzed, and each study was assigned a CCC and an extrapolated median interpretation time (MIT) on the basis of prospective data collection. Assigned work RVUs based on CPT codes were recorded. Comparisons were made between CCC and time for study interpretation, work RVUs, number of images acquired, and total scan time. RESULTS: A total of 933 echocardiograms were analyzed: 198 (21%), 174 (19%), 98 (11%), 359 (35%), 84 (9%), and 20 (2%) studies in CCCs 1 to 6, respectively. Total scan time, MIT, number of images, and work RVUs were different among CCCs (P < .0001). However, among the more complex studies (CCCs 2-5), work RVUs were similar, while number of images obtained and MIT were different (P < .001). Correlation analysis showed no association between work RVUs and CCC, total scan, or number of images per study. Compared with older patients, work RVUs of studies in children <2 years of age were lower, while all other markers of study complexity were higher (P < .05). CONCLUSIONS: Current CPT-based assignment of work RVUs does not discriminate study complexity and physician effort. The results of this study highlight the need for a refined system that accurately assesses physician effort in pediatric echocardiography.

Prediction of care burden of patients undergoing haemodialysis: development of a measuring tool.

BACKGROUND: The ageing of the population and new options for therapy have led to an increase in the number of patients undergoing dialysis. Rising costs in health care and new financial structures impose funding constraints on dialysis departments and force the departments to deploy nurses more efficiently. Therefore, predicting the nursing time spent on the care of patients is important. OBJECTIVE: Development of a classification tool to predict the burden of nursing care of patients undergoing dialysis. DESIGN: Observational study. PARTICIPANTS: 242 patients on dialysis in 12 centres. MEASUREMENTS: The time spent on nursing care within predefined areas, including patient independence, vascular access, psychosocial support, dialysis complexity, communication and specific nursing actions, was measured by observers. Average times and their standard deviations (SD) were calculated. Variation of patient characteristics was analysed. RESULTS: The average care time required for the four routine investigated domains, namely independence, vascular access, psychosocial support and dialysis complexity, was 59.23 (SD = 24.30) minutes per treatment per patient. CONCLUSION: Our study shows that it is possible to predict the burden of nursing care of patients undergoing dialysis by means of a classification model.

The RAFAELA system: a workforce planning tool for nurse staffing and human resource management.

The RAFAELA system was developed in Finland during the 1990s to help with the systematic and daily measurement of nursing intensity (NI) and allocation of nursing staff. The system has now been rolled out across almost all hospitals in Finland, and implementation has started elsewhere in Europe and Asia. This article describes the system, which aims to uphold staffing levels in accordance with patients' care needs, and its structure, which consists of three parts: the Oulu Patient Classification instrument; registration of available nursing resources; and the Professional Assessment of Optimal Nursing Care Intensity Level method, as an alternative to classical time studies. The article also highlights the benefits of using a systematic measurement of NI.

[Evaluation of interventions intended to reduce psychosocial work stress. Proposal for a classification scheme]. / Evaluation von Maßnahmen zur Verringerung psychosozialer Arbeitsbelastungen. Vorschlag eines Kategorisierungs- und Punkteschemas.

Evidence for the effectiveness of measures aiming to reduce psychosocial work stress is sporadic. This is contradictory to the requirement identified by the German Social Security Code (SGB VII) that interventions constitute the most important method of maintaining and improving employees' health. Reasons for this can be seen in the complexity of the subject and methodological issues concerning scientific standards. In addition, agreed quality standards are nonexistent for the evaluation of intervention measures. For this reason, a synopsis of existing audit and evaluation schemes was performed, thus, resulting in refined and adapted quality standards for intervention measures aiming to reduce psychosocial work stress. The quality criteria presented in this paper comprise aims, effectiveness, and facilitators, each being composed of several indicators. The criteria are designed as quality indicators which translate the outcome of an evaluation into quality figures. The process is transparent and offers a rational basis for communication, planning, and decision-making in health promotion.

Estimating nursing intensity and direct cost using the nurse-patient assignment.

BACKGROUND: This study examines the feasibility of using the nurse-patient assignment (NPA) to calculate direct nursing hours and costs for each inpatient-day. The NPA data are collected at every hospital and therefore represent a readily available information source that can establish the intensity and economic value of nursing care at US hospitals. METHOD: Direct nursing care hours for each patient were collected twice a day using an existing nursing intensity database at a single university hospital between January 2004 and June 2005 for a total of 11,582 patient-days. Nursing intensity was also calculated for each shift using the NPA. Mean unit and hospital nursing hours were calculated and compared with the direct nursing care hours using ordinary least squares regression. RESULTS: For the day shift, the NPA estimate explained 77.2% (r2 = 0.772) of the variance of patient-level nursing intensity. Unit and hospital mean estimates of nursing intensity had lower r of 0.574 and 0.456, respectively. The night-shift NPA, unit, and hospital r2 estimates were 0.824, 0.633, and 0.579, respectively. CONCLUSION: The use of the NPA can provide a robust and easy method to calculate nursing intensity for individual patients using assignment data available in nearly all care settings. The NPA estimate can be used to allocate direct nursing time and costs for each patient within the hospital billing system and can also be used in pay-for-performance or for benchmarking nursing intensity within and across hospitals.

[A new method for the determination of human energy expenditure]. / Nowa metoda wyznaczania wydatku energetycznego czlowieka.

BACKGROUND: Work physiology besides providing the theoretical background for occupational medicine, is also concerned with performing practical research. The research is aimed at setting numerous physiological criteria for the assessment of workload and its maximum admissible values. Energy expenditure is commonly used as an index of work severity (or occupational work load). It is determined to assess the systemic load associated with performing various activities during occupational work, sports, rehabilitation treatment, etc. Human energy expenditure can be measured via direct or indirect calorimetric or tabular methods. The existing methods are encumbered with various disadvantages and the search for new, possibly simple but reliable methods, continues. MATERIAL AND METHODS: Based on the literature data, results of our own research, as well as the laws of heat exchange and fluid flow, a new model of temperature control system has been developed, which comprises some elements of the human circulatory system. This model has made it possible to develop our own, simple method for the assessment of energy expenditure, in Watts (W), and energy expenditure per human body area (or energy expenditure density), in Watts per square meter (W/m2). The new method involves measurements of inner body temperature, body mass and height to assess energy expenditure. RESULTS: The results of energy expenditure assessments: obtained using our new method do not differ significantly from those obtained in the same subjects with the indirect calorimetric method. CONCLUSIONS: Our new method may be considered as an alternative for existing methods of energy expenditure assessment.

Enterprise bargaining: a case study in the de-intensification of nursing work in Australia.

This paper explores labour negotiations between nurses and government in the public health sector in Australia between 1996 and 2005. During this period, industrial negotiations between nurses and government in the public health sector moved from centralized wage determinations to agreements made at the level of the enterprise through the Workplace Relations Act 1996. Simultaneously, public sector nurses reported increased work intensification, a result of new public management strategies. This led to the Australian Nursing Federation negotiating enterprise agreements that included the introduction of highly specified workload algorithms in an attempt to de-intensify nurses' labour. The irony of this strategy is that these calculations and tools operate as both a human resource mechanism for maximizing productivity as well as an industrial relations tool for reducing work intensification.

The influence of sick leave frequency determinants on homogeneous groups in two socio-economically comparable, but socio-culturally different regions in The Netherlands.

OBJECTIVES: The aim of this study was to explore the influence of sick leave frequency determinants on in terms of age and profession homogeneous groups in two socio-economically comparable, but socio-culturally different regions in The Netherlands, i.e., Utrecht (mean frequency 1.10 spells) and South Limburg (mean frequency 1.92 spells). In addition, to get an idea of the study's topical interest, a literature review on sick leave frequency determinants covering the past few decades was performed. MATERIAL AND METHODS: 184 participants in the Utrecht and South Limburg regions were interviewed on work, individual and health characteristics. Sick leave frequency data were obtained from a social fund. For the literature review (inter)national scientific journals, academic theses and Medline were consulted. RESULTS: A comparison of sick leave frequency in the two regions showed that, in South Limburg, the determinants called 'opinion on social-medical support during sick leave', 'type of appointment' and 'annual number of visits (family doctor)' were associated with sick leave frequency whereas this was not the case in Utrecht. The literature review presented a highly consistent picture of determinants of sick leave frequency over the last few decades. CONCLUSIONS: In the two regions studied, different determinants appeared to be associated with sick leave frequency. This phenomenon is attributed to the different socio-cultural characters of the regions. As per region different determinants appeared to be associated with sick leave frequency, nationwide interventions to reduce sick leave frequency should take into account the potential influence of regional differences in determinants that predict sick leave frequency. Sick leave frequency determinants have not changed in the past few decades. Although the study was performed in the nineties, its results are still relevant.

Acuity systems dialogue and patient classification system essentials.

Obtaining resources for quality patient care is a major responsibility of nurse leaders and requires accurate information in the political world of budgeting. Patient classification systems (PCS) assist nurse managers in controlling cost and improving patient care while appropriately using financial resources. This paper communicates acuity systems development, background, flaws, and components while discussing a few tools currently available. It also disseminates the development of a new acuity tool, the Patient Classification System. The PCS tool, developed in a small rural hospital, uses 5 broad concepts: (1) medications, (2) complicated procedures, (3) education, (4) psychosocial issues, and (5) complicated intravenous medications. These concepts embrace a 4-tiered scale that differentiates significant patient characteristics and assists in staffing measures for equality in patient staffing and improving quality of care and performance. Data obtained through use of the PCS can be used by nurse leaders to effectively and objectively lobby for appropriate patient care resources. Two questionnaires distributed to registered nurses on a medical-surgical unit evaluated the nurses' opinion of the 5 concepts and the importance for establishing patient acuity for in-patient care. Interrater reliability among nurses was 87% with the author's acuity tool.

Benchmarking in nursing care by the RAFAELA patient classification system - a possibility for nurse managers.

AIM: The aim of the study was to explore the possibilities of benchmarking with the RAFAELA system. In this study, comparisons are made between: (1) costs for one nursing care intensity point; (2) the nursing care intensity per nurse; (3) the relationship between nursing care intensity per nurse and (4) the optimal nursing care intensity. BACKGROUND: During the period from 1994 to 2000 a new system for patient classification, the RAFAELA system, was developed in Finland. METHODS: 86 wards from 14 different hospitals in Finland took part in the study. RESULTS: The costs for one nursing care intensity point on the adults' wards were on average 7.80euro. The average workload was 25.2 nursing care intensity points per nurse. The optimal nursing care intensity was exceeded during 49.5% of the days and under during 20% of the days. CONCLUSIONS: The study shows that benchmarking with the RAFAELA system provides many opportunities for the nurse managers' resource allocation and their personnel administration.

Acuity and case management: a healthy dose of outcomes, part II.

PURPOSE: This is the second of a 3-part series presenting 2 effective applications-acuity and dosage-that describe how the business case for case management (CM) can be made. In Part I, dosage and acuity concepts were explained as client need-severity, CM intervention-intensity, and CM activity-dose prescribed by amount, frequency, duration, and breadth of activities. Part I also featured a specific exemplar, the CM Acuity Tool, and described how to use acuity to identify and score the complexity of a CM case. Appropriate dosage prescription of CM activity was discussed. Part II further explains dosage and presents two acuity instruments, the Acuity Tool and AccuDiff. Details are provided that show how these applications produce opportunities for better communication about CM cases and for more accurate measurement of the right content that genuinely reflects the essentials of CM practice. PRIMARY PRACTICE SETTING(S): The information contained in the 3-part series applies to all CM practice settings and contains ideas and recommendations useful to CM generalists, specialists, and supervisors, plus business and outcomes managers. The Acuity Tools Project was developed from frontline CM practice in one large, national telephonic CM company. METHODOLOGY AND SAMPLE: Dosage: A literature search failed to find research into dosage of a behavioral intervention. The Huber-Hall model was developed and tested in a longitudinal study of CM models in substance abuse treatment and reported in the literature. Acuity: A structured literature search and needs assessment launched the development of the suite of acuity tools. A gap analysis identified that an instrument to assign and measure case acuity specific to CM activities was needed. Clinical experts, quality specialists, and business analysts (n = 7) monitored the development and testing of the tools, acuity concepts, scores, differentials, and their operating principles and evaluated the validity of the Acuity Tools' content related to CM activities. During the pilot phase of development, interrater reliability testing of draft and final tools for evaluator concordance, beta (beta) testing for content accuracy and appropriateness, and representative sample size testing were done. Expert panel reviews occurred at multiple junctures along the development pathway, including the 5 critical points after initial tool draft and both before and after beta-test (n = 5) and pilot-test (n = 28) evaluations. The pilot testing body (n = 33) consisted of a team of case managers (n = 28) along with quality analysts (n = 2), supervisory personnel (n = 2), and the lead product analyst (the developer). Product evaluation included monitoring weekly reports of open cases for the 28 case managers for 3 months (June-August 2000). RESULTS: The Acuity Tools suite was used to calculate individual case acuity, overall caseload acuity profiles, case length, and acuity differentials. Normal distributions and outliers were analyzed and the results used for internal quality improvement and outcomes monitoring. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: To show value, case managers need to access the evidence base for practice, use tools to capture quantities of intervention intensity, and specify precisely the activities that produce better outcomes. Acuity and dosage can help case managers explore and fully describe their own practice in ways that can be measured. This data-driven evidence contributes to the accumulating body of definitive proof regarding the exceptional worth of CM. Proving business and professional worth in CM though evidence-based practice is a clarion call that case managers must heed and an innovation that all case managers can practice.

Nursing workload in intensive care units: a study using the Therapeutic Intervention Scoring System-28 (TISS-28).

UNLABELLED: The Therapeutic Intervention Scoring System-28 (TISS-28) is an instrument that has been used to measure severity of illness and nursing workload in intensive care units (ICUs). OBJECTIVES: To characterize the severity of illness and nursing workload using the TISS-28 in 11 ICUs of a university hospital in the city of São Paulo, Brazil. METHODS: In a prospective study, data were collected from 271 patients admitted to the ICUs in December 2000 and the patients were followed up for 1 week. RESULTS AND CONCLUSIONS: Most of the patients were males (60.0%) and their mean age was 51(+20.6) years. Surgical treatment (66.8%) and admissions from the operating room were predominant. The mortality rate was 25.0% and the average length of stay was 7.7 (+10.4) days. The mean TISS-28 score was 23 (range: 14-32 points). The lowest mean score was observed for patients from the Burn ICU and the highest mean score was obtained for patients from the Liver Transplant ICU. A change in TISS-28 scores was observed in the same ICU over the 7-day study period. Units differed in terms of severity of illness and nursing workload. Patients who died received a higher TISS-28 score than patients who survived (p=0.00). As the nursing staff are the largest economic investment in an ICU, so measuring nursing workload in different ICUs from different centres can contribute to the estimation of nursing staff required according to the specific demands of the units.

[Patient classification systems. Nursing workload from the perspective of applied research (part I)]. / Patientenklassifikationssysteme. Leistungsdaten im Blickfeld angewandter Forschung (Teil 1).

This article describes in two parts the basic principles of categorising nursing data into Patient Classification Systems (PCS) and related findings of nursing research. PCS are used to group patients into classes by using some specified criteria or indicators, e.g. needs of a patient, functional status or different nursing activities. They are often applied to constitute staff requirements. Since the large number of available classification systems differs in terms of development procedures and use of resulting data, it was rarely possible to compare different PCS with each other until now. Therefore a typology of PCS was developed, which is presented in the first part of this article. While assigning current PCS to adequate classes of the typology, the development and complexity of different PCS can be evaluated and discussed. Thus using the typology allows to identify advantages and limitations of individual classification systems. Conclusions can be drawn about requirements for further PCS development.

The Community Client Need Classification System - a dependency system for community nurses.

AIM: The aim of this paper was to discuss the predictive validity and reliability of the Community Client Need Classification System (CCNCS), the results of using this tool and public health nurses' satisfaction with the system. BACKGROUND: Public health nurses provide the majority of community nursing services in Ireland. The traditional method of measuring workload in the community is based on recording the number of visits. The revised Easley-Storfjell instrument for Caseload/Workload Analysis was modified for the Irish context and permission from the authors was sought to use it in this study and was thus named the CCNCS. METHODS: A convenience sample of 29 public health nurses used the CCNCS to classify 1352 clients for 2 weeks. RESULTS: The elderly and child health groups accounted for the majority of the nurses' direct and indirect time. Predictive validity analysis demonstrated a positive relationship between needs level and nursing time. Nurses reported that the CCNCS was useful in predicting the needs of new and existing clients. CONCLUSIONS: This classification system, albeit in the first draft of its revised form, was perceived by the chosen sample of public health nurses as useful in measuring their workload. Further research is required to ascertain the reliability of the modified classification system with a larger sample size.

Assessment of nursing management and utilization of nursing resources with the RAFAELA patient classification system--case study from the general wards of one central hospital.

BACKGROUND: RAFAELA is a new Finnish PCS, which is used in several University Hospitals and Central Hospitals and has aroused considerable interest in hospitals in Europe. AIMS AND OBJECTIVES: The aim of the research is firstly to assess the feasibility of the RAFAELA Patient Classification System (PCS) in nursing staff management and, secondly, whether it can be seen as the transferring of nursing resources between wards according to the information received from nursing care intensity classification. METHODS: The material was received from the Central Hospital's 12 general wards between 2000 and 2001. The RAFAELA PCS consists of three different measures: a system measuring patient care intensity, a system recording daily nursing resources, and a system measuring the optimal nursing care intensity/nurse situation. The data were analysed in proportion to the labour costs of nursing work and, from that, we calculated the employer's loss (a situation below the optimal level) and savings (a situation above the optimal level) per ward as both costs and the number of nurses. RESULTS: In 2000 the wards had on average 77 days below the optimal level and 106 days above it. In 2001 the wards had on average 71 days below the optimal level and 129 above it. Converting all these days to monetary and personnel resources the employer lost 307,745 or 9.84 nurses and saved 369,080 or 11.80 nurses in total in 2000. In 2001 the employer lost in total 242,143 or 7.58 nurses and saved 457,615 or 14.32 nurses. During the time period of the research nursing resources seemed not have been transferred between wards. CONCLUSIONS: RAFAELA PCS is applicable to the allocation of nursing resources but its possibilities have not been entirely used in the researched hospital. The management of nursing work should actively use the information received in nursing care intensity classification and plan and implement the transferring of nursing resources in order to ensure the quality of patient care. RELEVANCE TO CLINICAL PRACTICE: Information on which units resources should be allocated to is needed in the planning of staff resources of the whole hospital. More resources do not solve the managerial problem of the right allocation of resources. If resources are placed wrongly, the problems of daily staff management and cost control continue.

Care needs of residents in community-based long-term care facilities in Taiwan.

AIM: The purpose of this study is to gain an understanding both of the characteristics of residents who receive the services of nursing assistants and the service intensity (service tasks, service time and cost) of nursing assistants as a means of developing a patient classification based upon resource consumption. BACKGROUND: Most people in Taiwan send their disabled older family members to community-based long-term care facilities instead of nursing homes because they are much cheaper, and because they are generally closer to their homes, making visits more convenient. Nursing assistants make up the largest group of personnel in long-term care facilities. To determine resource use, both the service time and the actual activities performed for a resident by nursing assistants need to be assessed and this will help to develop a patient classification system to predict resource use and patient outcomes. METHODS: A descriptive survey method was used to identify the tasks performed by nursing assistants in community-based long-term care facilities in Taiwan. Nursing assistants were recruited from 10 long-term care facilities in the Shihlin and Peitou Districts of Taipei City. Thirty-four nursing assistants and 112 residents participated in this study. RESULTS: Findings showed that each nursing assistant spent 5.05 hours per day doing direct service care, which is much higher than the 2.08 hours for nursing assistants in the United States. Among service tasks provided by nursing assistants, personal care consumed 35.1% of their time. Non-complex treatments were second (33.3%). Skilled nursing and medical services were third (31.6%). The service intensity required of nursing assistants was strongly related to the residents' activities of daily living and their needs. CONCLUSION: Complex nursing procedures are normally provided by Registered Nurses in nursing homes and consumed almost as much of the nursing assistants' time as did personal care activities in this study. RELEVANCE TO CLINICAL PRACTICE: It is suggested that a training program for nursing assistants, especially for foreigners in community-based long-term care facilities, should be mandated to assure the quality of service.