Risk of acute deterioration and care complexity individual factors associated with health outcomes in hospitalised patients with COVID-19: a multicentre cohort study.

BACKGROUND: Evidence about the impact of systematic nursing surveillance on risk of acute deterioration of patients with COVID-19 and the effects of care complexity factors on inpatient outcomes is scarce. The aim of this study was to determine the association between acute deterioration risk, care complexity factors and unfavourable outcomes in hospitalised patients with COVID-19. METHODS: A multicentre cohort study was conducted from 1 to 31 March 2020 at seven hospitals in Catalonia. All adult patients with COVID-19 admitted to hospitals and with a complete minimum data set were recruited retrospectively. Patients were classified based on the presence or absence of a composite unfavourable outcome (in-hospital mortality and adverse events). The main measures included risk of acute deterioration (as measured using the VIDA early warning system) and care complexity factors. All data were obtained blinded from electronic health records. Multivariate logistic analysis was performed to identify the VIDA score and complexity factors associated with unfavourable outcomes. RESULTS: Out of a total of 1176 patients with COVID-19, 506 (43%) experienced an unfavourable outcome during hospitalisation. The frequency of unfavourable outcomes rose with increasing risk of acute deterioration as measured by the VIDA score. Risk factors independently associated with unfavourable outcomes were chronic underlying disease (OR: 1.90, 95% CI 1.32 to 2.72; p<0.001), mental status impairment (OR: 2.31, 95% CI 1.45 to 23.66; p<0.001), length of hospital stay (OR: 1.16, 95% CI 1.11 to 1.21; p<0.001) and high risk of acute deterioration (OR: 4.32, 95% CI 2.83 to 6.60; p<0.001). High-tech hospital admission was a protective factor against unfavourable outcomes (OR: 0.57, 95% CI 0.36 to 0.89; p=0.01). CONCLUSION: The systematic nursing surveillance of the status and evolution of COVID-19 inpatients, including the careful monitoring of acute deterioration risk and care complexity factors, may help reduce deleterious health outcomes in COVID-19 inpatients.

Care complexity individual factors associated with adverse events and in-hospital mortality.

INTRODUCTION: Measuring the impact of care complexity on health outcomes, based on psychosocial, biological and environmental circumstances, is important in order to detect predictors of early deterioration of inpatients. We aimed to identify care complexity individual factors associated with selected adverse events and in-hospital mortality. METHODS: A multicenter, case-control study was carried out at eight public hospitals in Catalonia, Spain, from January 1, 2016 to December 31, 2017. All adult patients admitted to a ward or a step-down unit were evaluated. Patients were divided into the following groups based on the presence or absence of three adverse events (pressure ulcers, falls or aspiration pneumonia) and in-hospital mortality. The 28 care complexity individual factors were classified in five domains (developmental, mental-cognitive, psycho-emotional, sociocultural and comorbidity/complications). Adverse events and complexity factors were retrospectively reviewed by consulting patients' electronic health records. Multivariate logistic analysis was performed to identify factors associated with an adverse event and in-hospital mortality. RESULTS: A total of 183,677 adult admissions were studied. Of these, 3,973 (2.2%) patients experienced an adverse event during hospitalization (1,673 [0.9%] pressure ulcers; 1,217 [0.7%] falls and 1,236 [0.7%] aspiration pneumonia). In-hospital mortality was recorded in 3,996 patients (2.2%). After adjustment for potential confounders, the risk factors independently associated with both adverse events and in-hospital mortality were: mental status impairments, impaired adaptation, lack of caregiver support, old age, major chronic disease, hemodynamic instability, communication disorders, urinary or fecal incontinence, vascular fragility, extreme weight, uncontrolled pain, male sex, length of stay and admission to a medical ward. High-tech hospital admission was associated with an increased risk of adverse events and a reduced risk of in-hospital mortality. The area under the ROC curve for both outcomes was > 0.75 (95% IC: 0.78-0.83). CONCLUSIONS: Several care complexity individual factors were associated with adverse events and in-hospital mortality. Prior identification of complexity factors may have an important effect on the early detection of acute deterioration and on the prevention of poor outcomes.

Acuity, nurse staffing and workforce, missed care and patient outcomes: A cluster-unit-level descriptive comparison.

AIM: To compare the patient acuity, nurse staffing and workforce, missed nursing care and patient outcomes among hospital unit-clusters. BACKGROUND: Relationships among acuity, nurse staffing and workforce, missed nursing care and patient outcomes are not completely understood. METHOD: Descriptive design with data from four unit-clusters: medical, surgical, combined and step-down units. Descriptive statistics were used to compare acuity, nurse staffing coverage, education and expertise, missed nursing care and selected nurse-sensitive outcomes. RESULTS: Patient acuity in general (medical, surgical and combined) floors is similar to step-down units, with an average of 5.6 required RN hours per patient day. In general wards, available RN hours per patient day reach only 50% of required RN hours to meet patient needs. Workforce measures are comparable among unit-clusters, and average missed nursing care is 21%. Patient outcomes vary among unit-clusters. CONCLUSION: Patient acuity is similar among unit-clusters, while nurse staffing coverage is halved in general wards. While RN education, expertise and missed care are comparable among unit-clusters, mortality, skin injuries and risk of family compassion fatigue rates are higher in general wards. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers play a pivotal role in hustling policymakers to address structural understaffing in general wards, to maximize patient safety outcomes.

Predicting patient acuity according to their main problem.

AIM: To assess the ability of the patient main problem to predict acuity in adults admitted to hospital wards and step-down units. BACKGROUND: Acuity refers to the categorization of patients based on their required nursing intensity. The relationship between acuity and nurses' clinical judgment on the patient problems, including their prioritization, is an underexplored issue. METHOD: Cross-sectional, multi-centre study in a sample of 200,000 adults. Multivariate analysis of main problems potentially associated with acuity levels higher than acute was performed. Distribution of patients and outcome differences among acuity clusters were evaluated. RESULTS: The main problems identified are strongly associated with patient acuity. The model exhibits remarkable ability to predict acuity (AUC, 0.814; 95% CI, 0.81-0.816). Most patients (64.8%) match higher than acute categories. Significant differences in terms of mortality, hospital readmission and other outcomes are observed (p < .005). CONCLUSION: The patient main problem predicts acuity. Most inpatients require more intensive than acute nursing care and their outcomes are adversely affected. IMPLICATIONS FOR NURSING MANAGEMENT: Prospective measurement of acuity, considering nurses' clinical judgments on the patient main problem, is feasible and may contribute to support nurse management workforce planning and staffing decision-making, and to optimize patients, nurses and organizational outcomes.

Care Complexity Individual Factors Associated With Hospital Readmission: A Retrospective Cohort Study.

PURPOSE: To determine the frequency of care complexity individual factors documented in the nursing assessment and to identify the risk factors associated with hospital readmission within 30 days of hospital discharge. DESIGN: Observational analysis of a retrospective cohort at a 700-bed university hospital in Barcelona, Spain. A total of 16,925 adult patient admissions to a ward or intermediate care units were evaluated from January to December 2016. Most patients were admitted due to cardiocirculatory and respiratory disorders (29.3%), musculoskeletal and nervous system disorders (21.8%), digestive and hepatobiliary conditions (17.9%), and kidney or urinary disorders (11.2%). METHODS: Readmission was defined as rehospitalization for any reason within 30 days of discharge. Patients who required hospital readmission were compared with those who did not. The individual factors of care complexity included five domains (developmental, mental-cognitive, psycho-emotional, sociocultural, and comorbidity or complications) and were reviewed using the electronic nursing assessment records. Multivariate logistic analysis was performed to determine factors associated with readmission. FINDINGS: A total of 1,052 patients (6.4%) were readmitted within 30 days of hospital discharge. Care complexity individual factors from the comorbidity or complications domain were found to be the most frequently e-charted (88.3%). Care complexity individual factors from developmental (33.2%), psycho-emotional (13.2%), mental-cognitive (7.2%), and sociocultural (0.7%) domains were less frequently documented. Independent factors associated with hospital readmission were old age (≥75 years), duration of first hospitalization, admission to a nonsurgical ward, major chronic disease, hemodynamic instability, immunosuppression, and relative weight of diagnosis-related group. CONCLUSIONS: A substantial number of patients required readmission within 30 days after discharge. The most frequent care complexity individual factors recorded in the nursing assessment at index admission were related to comorbidity or complications, developmental, and psycho-emotional domains. Strategies related to transition of care that include clinical characteristics and comorbidity or complications factors should be a priority at hospital discharge and after leaving hospital, but other factors related to developmental and psycho-emotional domains could have an important effect on the use of healthcare resources. CLINICAL RELEVANCE: Nurses should identify patients with comorbidity or complications, developmental, and psycho-emotional complexity factors during the index admission in order to be able to implement an effective discharge process of care.

Una terminología interfase como eje de unos cuidados seguros. Nivel de conocimiento y de comprensión de intervenciones enfermeras ATIC(R) / Interface terminology as an axis for safe care: on line questionnaire about knowledge and understanding of ATIC(R) nursing interventions

Introducción. Los lenguajes enfermeros deben contribuir a obtener datos precisos y fiables que faciliten una comunicación eficaz y garanticen unos cuidados seguros. Las terminologías de interfase, como ATIC(R), surgen para complementar las terminologías de referencia y orientan su desarrollo hacia su uso en la práctica clínica. Además, contribuyen a proporcionar información en relación con los conceptos que representan los cuidados con suficiente especificidad clínica que conlleva a un mejor entendimiento entre los miembros del equipo asistencial. Objetivo. Evaluar el nivel de conocimiento y comprensión de las enfermeras acerca de las intervenciones de vigilancia y control de la terminología ATIC(R). Material y métodos. Estudio descriptivo, observacional, transversal y multicéntrico, mediante un cuestionario electrónico validado. Los datos recogidos se analizaron utilizando estadística descriptiva e inferencial. Resultados. Un 85 % de las enfermeras evalúan favorablemente su nivel de conocimientos sobre las intervenciones de vigilancia y control de la terminología ATIC(R). El 51.8 % refiere un nivel de conocimiento superior y el 32.8 % adecuado. Se identificaron diferencias significativas respecto el nivel de conocimientos y el tiempo de uso de ATIC(R), el lugar de trabajo o la asistencia a sesiones clínicas de cuidados (SCS). La evaluación de la comprensión indica que más del 95 % de las participantes tienen una comprensión elevada (75.8 %) o moderada (20.1 %). Además, se identificaron diferencias significativas en relación con la utilización de ATIC(R) durante más de 1 año y la asistencia a SCC. Conclusiones. Las enfermeras que utilizan la terminología ATIC(R) en los registros electrónicos de salud tienen un elevado nivel de conocimiento y comprensión de las intervenciones de vigilancia y control. Las enfermeras entienden los conceptos de forma clara y precisa, lo que contribuye a establecer la fiabilidad del eje de intervención de esta terminología en términos de usabilidad y aumenta la seguridad del proceso de prestación de cuidados (AU)

Introduction. Nursing languages should contribute to obtain ccurate and reliable data to ease effective communication and ensure patients’ safety. Interface terminologies like ATIC(R), arise to complement reference terminologies and are intended to guide their use in clinical settings. Moreover, these terminologies provide information regarding healthcare concepts with sufficient clinical specificity, leading to a better understanding among healthcare team members. Objective. To evaluate nurses’ level of knowledge and understanding in clinical settings surveillance and control interventions of ATIC terminology(R). Materials and methods. A descriptive, observational, cross-sectional, multicenter study was performed administering a validated electronic questionnaire. Collected data was analyzed using descriptive and inferential statistics. Results. 85 % of nurses favorably assessed their knowledge level about surveillance and control interventions of ATIC terminology (R). Higher levels were achieved by 51.8 % and 32.8 % scored as adequate level. Significant differences were found in knowledge level and length of use of terminology, as well as workplace and attendance to clinical care sessions (CCS). The evaluation of understanding indicates that over 95 % of participants have high (75.8 %) or moderate (20.1 %) understanding levels. Furthermore, we found significant differences in relation to the level of understanding and length of time using ATIC(R) (more than 1 year) together with attendance to CCS. Conclusions. Nurses that use the ATIC Terminology© in electronic health records have a high knowledge and understanding level of surveillance and control interventions. Nurses understand the concepts clearly and accurately, what might be considered as an indirect measurement for reliability of the ATIC intervention axis in terms of usability, enhances at the same time safety in the provision process of care (AU)