Working towards dependency scoring in critical care

InlmsiucCarcNut~ing(1991) 7,214-218 0 Longman GroupUK Ltd 1991

Working towards dependency scoring in critical care W. P. Large, M. Nattrass and M. Simpson

of the main disadvantages of dependency scoring in the intensive care unit, is that popular scoring systems such as the Intensive Care Register (ICR) fail to take into account many of the most important factors that contribute to patient dependency. Factors such as counselling of patients and their families, setting up for certain procedures and dealing with an agitated patient, for example, all contribute to the overall dependency of the patients; and ultimately influence the level of nursing support required. It is with these thoughts in mind that a system of dependency scoring has been developed for the intensive care unit (ICU). The system outlined here is designed to be used in conjunction with the ICR, thus One

providing maintaining

a more accurate and realistic measure of dependency; a vital link to a well established system.

INTRODUCTION Scoring patient dependency in critical care has always been a difficult process. Due to the unpredictability of admission time and severity, prospective dependency scoring is almost impossible. This means that it is difficult to forecast staffing levels and patient allocations in advance. However, a retrospective method of dependency scoring enables the nurse manager to show whether the staffing levels over a period of time have been adequate for the number of patients and severity of their conditions over the same period.

Wayne P. Large RGN, Charge Nurse, ITU, Glenfield, General Hospital, Leicester, Michael Nattrass RGN DPSN, Charge Nurse, ITU, Glenfield General Hospital, Leicester Mike Simpson RGN, Intensive Care Manager, BUPA Hospital, Leicester. (Requests for offprints to WL) Manusoript 214

accepted

7 August

1991

while

still

The dependency scoring system described here has been adapted so that it can be used in conjuction with the recommendations of the Intensive Care Society (1983). This Society set up a working party to look into the requirements of ICUs and went into detail about how patient dependency should be scored. The same system has been used in the production of the Intensive Care Patient Register published by CMA Medical Data Ltd, which has been widely used within the UK for many years. This register has enabled nurses working within an ICU to describe the type of patients that are being treated using this information to indicate the staffing levels required to care for a group of patients. Another value of this wellestablished system is that it can provide trends which are useful when compiling statistics. The problem with this, and many other dependency scoring systems, is that they are unable to take into account the many aspects of care that render critically ill people dependent.

INTENSIVE

The more commonsense criteria such as whether a patient is artificially ventilated are an obvious inclusion when calculating dependency. Using this as an example, the system used in the ICR simply categorises all ventilated patients within the same category. The problem with this practice is that it is based on the assumption that all ventilated patients require roughly the same nursing support. Indirect criteria such as setting up equipment and procedure trolleys, counselling, filling in investigation forms and spending time on the telephone are all essential to total patient management and they are generally ignored in the present system. These activities are often seen to be within the remit of nurses, but are rarely seen as relevant when formulating the dependency of patients. Also not considered are activities associated with caring for a patient who has just been admitted, transferred or has just died. These patients may all come into the same category in the register as a ventilated patient who is stable and requires observation. Clearly this is unsatisfactory when it is obvious that a patient who has died or is undergoing admission may need two nurses for a particular period of time. It is with these issues in mind that a more comprehensive dependency scoring system has been developed that will achieve several objectives. Firstly, the scoring system should take into account, quite specifically, the clinical therapy and treatment that a patient receives. Secondly, the indirect care and preparation needed to deliver total patient care should be assessed. Lastly, some link should be provided between the actual numerical dependency score and the implications that this has for the level of nursing needed; in terms of the number of nurses required on a particular shift. To keep within the guidelines set down by the Intensive Care Society, the system has also been linked to the Dependency Weighted Occupancy (DWO). Crude bed occupancy as it stands will indicate the number of beds occupied over a period of time, but it can be argued that it is of little use when using these figures to determine staffing levels. This is because it takes no account of the severity of illness and the actual required level of nursing that is needed to care for the

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patients in these beds. The dependency weighted occupancy is a way of taking these problems into account. It is calculated by working out the dependency score and dividing it by the number of open beds. The Figure shows the actual dependency scoring sheet that is being used at present. It is important to note that this system has been modified several times and is constantly being revised with the aim of ‘fine tuning’ the result in order to be both realistic and accurate. The form is designed to be completed by the nurse at the bedside; after which the results are input into a general computerised database and spreadsheet. for collective statistical analysis.

DEPENDENCY FOR THE ICU Scoring

SCORING SYSTEM

treatment

and therapy

Possibly the most important and usually the most obvious factor in calculating dependency in critical care is the level of respiratory support that is required by the patient. Looking at the Figure, the various modes of ventilatory support are listed together with an appropriate score. It is important at this point to realise that the scores used on this form are completely discretionary; in isolation they mean nothing. Collectively, however, they can be converted into a more meaningful percentage for further use. It can be seen, then that full ventilatory support is given the highest score, while the patient needing oxygen via a face mask or nasal cannulae scores relatively lower. Some of the intermediate modes of support may need a little clarification due to the abbreviations used for the form. The nasal ventilator we use is a Monnal ventilator trigger which delivers positive pressure via a nasal face mask. This form of ventilation is suitable for domiciliary ventilation but takes a great deal of time and patience on the part of the nurse to enable the patient to accept it. Treatment is also provided here for patients who require negative pressure ventilation using a tank ventilator or ‘iron lung’ as it is commonly known; this scores 30 on the scoring form. The

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INTENSIVE

CARE NURSING

BED NUMBER :

DATE

NAME:

VENTILATION CMV/SIMV/WEANING NASAL VENT4 TANK VENT. CPAP CBH/MASK ~50%02 CBH/MASK 35-50% 02 CBH/MASK (35% 02 NASAL CANNULA MINITRACH/TRACI-IY RENAL CATHETERISED CAVHD

E

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N

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40

35

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35

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25

25

25

20

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20

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15

5

5

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5

5

5

5

5

5

20

20

20

:

CARDIOVASCULAR ECG/PRESS MONITOR INOTROPES CRYSTALOID/COLLOID NEUROLOGICAL UNCONSC/PARALYSED CONFUSED/DISORIENT DROWSY/SEDATED NUTRITIONAL TPN ENTERAL FEED OBESITY 8okg

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5

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5

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10

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5

FREQUENCY SUCTIONING BLOOD GASES IVS GIVEN IV1CHANGES BEDPAN/URINALS LINENCHANGE ORAL/EYECARE

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4-5

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4-5

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4-5

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3

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3

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3

2

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TURNS

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DRESSINGS

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TIME (MIN) PROCEDURES

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If procedure

time is more than 20 min, add 1 point for every additional 5 min up to a maximum of 90 min (18 pts). Score ALL procedures such as admissions, discharges, transfers, theatre, physio assistance, pacing, intubation, CAVHD setup, meal preparation, washes, counselling and anything else which takes up time.

Fig. 1 ITU Nursing Dependency

Assessment

lSSC-1991

3

2

SHIFT

Early

::

i

Name

j(

Late

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2 Night

IKTEh’SIVE

term CBH refers to a Cape Blower Humidifier which delivers humidified oxygen at different flow rates and concentrations. It is essential that the nurse scores for only one of the ventilatory modes. In practice, however, the patient may be swapping-from one form of ventilation to another. The patient may be weaned and extubated, only to be reintubated shortly after. In these situations the nurse should use her discretion and score either the most important mode for her patient or the mode that is administered the most during the period covered by the form. Also incorporated on the dependency form are the various important factors that contribute to a higher dependency. The patient may have a tracheostomy for example, or be fed intravenously. Each of these takes times to care for, and renders the patient more dependant upon the nurse. It is also worthy of note that a patient receiving continuous Arterio-Venous HaemoDialysis (CAVHD) requires relatively more nursing time to ensure adequate results, hence the comparatively high additional score.

Scoring

the conscious

state

Other infusions small weighting

Contributing

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17

are also scored to give a further to the overall dependency.

factors

The nurse completing this form is required t.o circle the appropriate scores relating to a list of activities that clearly contribute to the dependency of the patient. This practice is repeated down the list of activities adding to the total score for each shift. If, however, none of the values apply, for example the patient required no suction at all then the nurse would simply not score for that activity. This accommodates patients who require minimal care thus giving a lower dependency score. Other important information is incorporated into the system, such as the weight of the patient. This rs obviously important as obese patients will take more nurses to lift them safely. This section not only allows for the more obvious activities such as blood gas analysis and the number of intravenous injections to be accounted for, but also takes into account activities such as washing the patient and changing the bed linen. These procedures often take up a lot of nursing time and frequently need Iseveral nurses to perform.

Another important factor to consider when formulating a dependency score and one which is often neglected, is the degree of consciousness Procedure scoring and neurological state of the patient. A patient who is agitated and confused will need a good The last scoring item on the form is for the total deal more attention than one who is fully sedated amount of procedure time that the patient has and paralysed during artificial ventilation. On required. Procedure time is defined in this the other hand, a patient who is lightly sedated context as any activity that takes up nursing time and is able to sleep is obviously less dependant in and that will ultimately contribute to patient terms of consciouness; this is not to say that they dependency. Take, for example, counselling of do not require continuous observation for the patient and relatives. The amount of reasons of safety. A patient being weaned from counselling a family needs varies from patnent to artificial ventilation is also given an additional patient depending upon several aspects such as score due to the extra care needed while ’ the seriousness of the patient’s condition and the changing from one mode of ventilation to relatives’ ability to accept the patient’s situation. another. The level of inotropic support that the Some nurses using this system of scoring are patient requires is an important factor, so this is making a point of noting the time taken to counsel patients and their relatives. It is then included in the scoring system, not only to allow quite easy to add these times together and score for care of the infusions themselves but also for appropriately in the appropriate section (of‘the the cardiovascular instability that is usually form. To arrive at a total procedure Scot-e the present in patients requiring inotropic support.

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INTENSIVE

CARE NURSING

nurse simply adds together all the relevant procedure times and scores appropriately up to a maximum of 18 points. It is important to note that the nurse may also add times for procedures not listed, as long as the maximum scoring limit is observed.

THE FINAL SCORE To obtain a final score the nurse adds all the separate scores together and enters this into the total score box for that particular shift. To make this arbitrary number more meaningful the score is converted into a percentage. From this it is possible to say that a patient may be 75% dependent. The final link between the percentage score and the number of nurses needed is made by a computerised spreadsheet programmed to compare actual levels of staff to that recommended by the scoring system. The spreadsheet is able to display in a graphical format trends of staffing and dependency and from this it is possible to calculate how effectively staff are being used. on a particular day.

THE FUTURE Coronary care patients are to be included in the future so that other factors can be considered. Inclusions such as a linear pain scale and perhaps an arrhythmia scoring system. may be appropriate in the future. Patients who are in pain or having arrhythmias are obviously more

dependent than those who are completely stable and pain free. During the development of this system it has been found that patient dependency scoring is not easy. Furthermore, to be done adequately, it cannot be calculated by using only a few criteria, but needs a far more comprehensive approach that takes into account all aspects of the total management of critically ill patients. A system such as this needs to evolve over a period of time, taking into consideration local as well as universal factors. After this period of ‘evolution’ the system should accurately reflect not only the dependency of each patient but what level of nursing is needed for a particular group of patients; a very important source of information that is bound to become more so in the future.

CONCLUSION It needs to be emphasised that while the present system of dependency scoring offers many advantages for nurses, it is clear that it also has some important limitations. It is hoped that the system described here will be used in conjunction with the ICR to provide a more accurate and realistic measure of dependency than at present. It is also hoped that this system will reduce the limitations of the ICR while still maintaining a very important link with a reliable and popular system.

References The Intensive Care Society (1983) Standard For Intensive Care. London, Biomedica Ltd