Supervisors info:
Μαργαρίτα Γιαννακοπούλου, Καθηγήτρια, Νοσηλευτική, ΕΚΠΑ
Γεώργιος Φιλντίσης, Καθηγητής, Νοσηλευτική, ΕΚΠΑ
Θεόδωρος Κατσούλας, Επίκουρος Καθηγητής, Νοσηλευτική, ΕΚΠΑ
Summary:
Introduction-Background: Nursing workload scales consist valuable tools for the assessment of provided care’s quality, including the nurse staffing. However, the incidence of nursing adverse outcomes has not been investigated.
Aim: The implementation of Nursing Activities Score (NAS) in an adult ICU and the evaluation of nurse-to-patient ratio and nursing adverse outcomes.
Methods: A prospective cohort study was performed in two general adult ICUs of Athens during October - December 2017. Data were collected via: a) NAS and TISS-28 for nursing workload measurement, b) Simplified Acute Physiology Score III (SAPS III), Charlson Comorbidity Index (CCI), Sequential Organ Failure Assessment (SOFA), Glasgow Coma Scale (GCS) for assessing patient’s clinical severity, comorbidities and organ failure and c) demographic-clinical data collection sheets, a nursing adverse outcomes sheet and also a nursing structure sheet. TISS-28 was used as a gold standard. Four hundred seventy six (476) daily NAS and TISS-28 reports were obtained from a sample of 45 patients (1 readmission), during 60 continuous days. Ιnter-rater reliability (Cohen's Kappa, ICC: Intraclass Correlation Coefficient), descriptive statistics, parametric and non-parametric correlation analyses were carried out using SPSS 24.0 ( p≤0.05).
Results: Patients’ demographic and clinical data were: gender (male 53,3%), mean age (66,07±16.68 years), mean length of ICU stay (34.98 ± 45.68 days) (median=15.5 days). The mean score of NAS (±SD) was 65.90(±7.19). The incidence density of catheter-related bloodstream infection (CRBSI), ventilator-associated pneumonia (VAP), catheterassociated urinary tract infection (CAUTI), unplanned extubation, unplanned removal of the feeding tube and pressure ulcers was 10.846/1000 days , 25.641/1000 days, 14.706/1000 days, 0/1000 days, 26.253/1000 days and 65,126/1000 days, respectively. The optimal nurse/patient ratios were estimated as 1:1.52(1:1.40-1:1.65) for NAS and 1:1.36(11.20-1:1,56) for TISS-28.The ICC for inter-rater reliability was 0.945 for NAS (p<0.001) and the estimated kappa value was 0.948 for NAS (p<0.001). NAS and TISS-28 measurements were significantly correlated (rho=0.546, p<0.001).Τhe AUC (95% confidence interval-CI) for SAPS III score was 0.907(0.820-0.994) (p<0.001). The cut-off point, sensitivity and specificity of SAPS 3 score were 59, 95.2% and 73.9%, respectively. The severity scales’ scores of admission were correlated with the mean NAS score per patient (p ≤0.038). Moreover, SOFA score of hospitalization was correlated significantly with both nursing workload scales scores (rho= 0.262 for NAS and rho=0.531 for TISS-28, p<0.001).The mean NAS per patient was significantly correlated also with the patient’s outcome, with patients who died having higher nursing workload (p=0.004). Specifically, patients with mean NAS of more than 65.00 had 4.688 times greater probability to die during their hospitalization in the ICU (OR 4.688, 95% CI 1.306 – 16.821, p-value=0.018). Total NAS per day was also significantly correlated with the number of pressure ulcers per day (rho= 0,355, p= 0,005).
Conclusions: These results support the validity, reliability and usefulness of NAS scale for use in Greek general ICUs in order to estimate the optimal nurse to patient ratios. During the study the ICUs were understaffed, while the incidence of nursing sensitive outcomes was increased. NAS score seems to be predictor of patient’s outcome in the ICU.
Keywords:
General adult ICU, Nursing workload, Νursing Activities Score, Therapeutic Intervention Scoring System, Nursing structure, Nursing sensitive outcomes-Adverse outcomes