Acuity Tool Research Articles

IURead: a new computer-based reading test.

To develop a computer-based single sentence reading test especially designed for clinical research enabling multiple repeat trials without reusing the same sentences. We initially developed 422 sentences, with an average of 60 characters and 12 words. Presentation controls were improved by employing computer-based testing and the oral reading was recorded by visual inspection of digital audio recordings. Variability in reading speed of normally sighted adults between sentences, between charts, between subjects, between formats, and between display devices was quantified. The impact of display size and pixel resolution on test geometry was assessed, and the impact of reduced retinal image quality and retinal illuminance were compared for reading and standard letter acuities. Eleven visually normal subjects (age: 18-60years) participated in this study. Stopwatch timing of sentences reliably underestimated reading times by about 0.3s, and exhibited coefficients of repeatability 17 times larger than those estimated from visual inspection of digital recordings. A slight relaxing of the lexical content constraints had no effect on reading speed; neither did sentence format (single vs three lines) or display size or distance. Within subject standard deviations of reading speed for different sentences were small (between 6% and 9% of the mean speed) requiring only small samples sizes to achieve typical statistical reliability and power when comparing conditions within individual subjects. The greater variability associated with stopwatch timing necessitates larger sample sizes. As defocus and light level were varied, reading acuity and standard letter acuity were highly correlated (r(2) =0.99), and reading acuity was slightly better. A computer-based IURead reading test provides a useful reading speed and reading acuity tool for clinical research involving multiple conditions and repeat testing of individual subjects. Ready to use IURead files for use with a computer, tablet or cell phone can be downloaded from our lab website (https://www.opt.indiana.edu/Bradley/Downloads.aspx).

Using an Acuity Tool to Maintain Productivity While Adhering to AWHONN's Perinatal Nurse Staffing Guidelines

Poster Presentation Purpose for the Program The art of scheduling perinatal nursing staff in a small community hospital is challenging in a specialty where census and acuity are highly unpredictable. This challenge on a women and children's (WMCH) unit is particularly complex because of five specialties: labor and delivery, postpartum/newborn, pediatrics, Level‐II nursery, and cesarean birth operating room. The hospital was facing decreasing revenue, increased cost because of health care reform, fluctuations in volume, and uncompensated costs. The hospital took this opportunity to reevaluate productivity and used a health care analytics company to adopt a new productivity benchmark for all departments. Proposed Change The hospital's operations excellence process utilized the Lean and Six Sigma methods to improve performance, which required that frontline staff of all levels creatively develop solutions. The WMCH department used the Lean and Six Sigma methods to determine a plan to meet this goal while maintaining quality care and patient satisfaction. Previously the staffing assignments were done every shift based on charge nurse predictions not on evidence. This method was unreliable and generated frustration when there were discrepancies. To staff for patient census, varying acuity levels, and maintain staffing ratios recommended by AWHONN, the department incorporated an acuity tool into the daily nursing assignment sheet. Implementation, Outcomes, and Evaluation The sheet yielded a productivity standard that clearly demonstrated whether each nurse assignment was appropriate and the unit was staffed safely every 2 hours. Charge nurses were able to make staffing decisions based on real‐time data. Department leaders could look at retrospective long‐range acuity and productivity data that allowed them to analyze trends and make departmental decisions. The staffing decisions were based on the acuity tool were clearly and objectively displayed to staff nurses, which allowed the nurses to feel confident with their assignments because of the alignment with AWHONN guidelines. After 6 months of utilizing the acuity tool, the department reduced the hours worked per equivalent patient days from 23 hours to 18.7 hours. This reduction was projected to save $800,000 a year, although it actually resulted in hospital savings of $1,300,000. Implications for Nursing Practice These metrics demonstrate the benefits of an acuity tool in a daily nursing assignment sheet for safe patient care, improved nursing satisfaction, increased productivity, and financial savings.

Obstetric triage: a systematic review of the past fifteen years: 1998-2013.

Triage concepts have shifted the focus of obstetric care to include obstetric triage units. The purpose of this systematic review is to examine the literature on use of triage concepts in obstetrics during a 15-year time frame. A systematic review was completed of the obstetric triage literature from 1998 to 2013 using the electronic online databases from PubMed, CINHAL, Ovid, and Cochrane Library Reviews within the English language. Reference lists of articles were reviewed to identify other pertinent publications. Both peer-reviewed and non-peer-reviewed documents were used. articles specifically related to obstetric triage or obstetric emergency practices in the hospital setting. Exclusion criteria included: manuscripts that focused on general, nonobstetric emergency and triage units, telephone triage, out-of-hospital practices, other clinical conditions, and references outside the time frame of 1998-2013. Key categories were identified: legal issues and impact of Emergency Medical Treatment and Active Labor Act (EMTALA); liability pitfalls; risk stratification (acuity tools); clinical decision aids; utilization, patient flow, and patient satisfaction; impact on interprofessional education and advanced nursing practice; and management of selected clinical conditions. Components of a best practice model for obstetric triage are introduced. Seven key triage categories from the literature were identified and best practices were developed for obstetric triage units from this systematic review. Both can be used to guide future practice and research within obstetric triage.

Methodological challenges of validating a clinical decision-making tool in the practice environment.

Validating a measurement tool intended for use in the practice environment poses challenges that may not be present when validating a tool intended solely for research purposes. The aim of this article is to describe the methodological challenges of validating a clinical decision-making tool, the Oncology Acuity Tool, which nurses use to make nurse assignment and staffing decisions prospectively each shift. Data were derived from a larger validation study, during which several methodological challenges arose. Revisions to the tool, including conducting iterative feedback cycles with end users, were necessary before the validation study was initiated. The "true" value of patient acuity is unknown, and thus, two approaches to inter-rater reliability assessment were used. Discordant perspectives existed between experts and end users. Balancing psychometric rigor with clinical relevance may be achieved through establishing research-practice partnerships, seeking active and continuous feedback with end users, and weighing traditional statistical rules of thumb with practical considerations.

Developing a Reliable and Valid Scale to Measure Psychosocial Acuity

This tool is a unique comprehensive scale and methodology to measure the psychosocial acuity of patients and families across a health care continuum. Coupled with other measures, psychosocial acuity can tell a complete and compelling story of social work contributions and aid in resource alignment. Accurately conveying the full scope of social work value to anyone, especially health system leadership, requires that the psychosocial acuity of the patient and family be measured and factored into the equation, along with productivity, time spent, and services provided. The development and utilization of the Psychosocial Acuity Tool is the focus of this publication.

Implementing an Obstetric Triage Acuity Tool in a High-Volume Obstetric Unit

INTRODUCTION: Our objective was to evaluate an obstetric triage acuity tool that we developed and implemented in January 2013. METHODS: A four-level triage acuity tool, Level 1 (most acute) to Level 4 (least acute), was developed to prioritize patients presenting for urgent care to the obstetric triage unit. Acuity scores, assigned by a triage nurse, dictated acceptable wait times for a medical screening examination (Level 1, 5 minutes; Level 2, 15 minutes; Level 3, 30 minutes; Level 4, 60 minutes). This was a prospective cohort study of all 2,228 urgent triage visits from March 1 to May 31, 2013. The validity of obstetric triage acuity tool was evaluated by comparing hospital admission rates across acuity levels to determine whether admission rates increased with increasing acuity level. Wait times from acuity score to medical screening examination and to final disposition were calculated and assessed by acuity level. RESULTS: Admission rates increased significantly across acuity levels from least acute to most acute; admission rates at Level 4, 3, 2, and 1 were respectively, 16%, 40%, 54%, and 84%, respectively (Table 1; P<.001). Goals for acceptable wait time for a medical screening examination were met for 89% of Level 1, 84% of Level 2, 91% of Level 3, and 94% of Level 4 visits.CONCLUSIONS: Increasing hospital admission rates across acuity levels supports the validity of obstetric triage acuity tool. Since implementing the obstetric triage acuity tool, most patients presenting for urgent care were seen for a medical screening examination within clinically acceptable wait times.

Appropriate Staffing for a Healthy Work Environment

Appropriate Staffing for a Healthy Work Environment

The Oncology Acuity Tool: A Reliable, Valid Method for Measuring Patient Acuity for Nurse Assignment Decisions

Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments. Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events. Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls. The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.

The Development of an Obstetric Triage Acuity Tool

The purpose of this article is to describe the journey a multicampus hospital system took to improve the obstetric triage process. A review of literature revealed no current comprehensive obstetric acuity tool, and thus our team developed a tool with a patient flow process, revised and updated triage nurse competencies, and then educated the nurses about the new tool and process. Data were collected to assess the functionality of the new process in assigning acuity upon patient arrival, conveying appropriate acuities based on patient complaints, and initiating the medical screening examination, all within prescribed time intervals. Initially data indicated that processes were still not optimal, and re-education was provided for all triage nurses. This improved all data points. The result of this QI project is that our patients are now seen based on their acuity within designated time frames.

Developing a real-time assessment of staffing needs in delivery suites

The workload in delivery suites can not easily be managed as women arrive in labour and give birth at any time in the day or night, and emergencies can arise at any time. Matching this dynamic work pattern with the necessary numbers and skills of midwives to meet agreed care standards is difficult. The Birthrate Plus Acuity tool has been designed to give midwives a prospective and predictive measure of client needs and the staff needed to meet those needs, and to assist the development of care policies in clinical governance. First developed with services in Wales, the Acuity system has now been used in a variety of maternity services. This is the third article in the series.

Creating A Valid And Reliable BMT Inpatient Acuity Tool That Reflects Current BMT Nursing Practice And Workload

Blood and marrow transplant (BMT) is a complex treatment modality. Managers are challenged to determine appropriate staffing to ensure safe, effective and efficient BMT nursing care. Tools to assess patient acuity can assist managers to meet this staffing challenge. An effective acuity tool reflects the complex and unique aspects of patient care and of the location where it will be used. Since 1993, the BMT unit of our NCI-designated Cancer Center has used the Bone Marrow Transplant Acuity Tool of Lovett and McMillan.

How to keep score of acuity and dependency

This article describes how the introduction of an acuity and dependency tool at University Hospitals Coventry and Warwickshire NHS Trust has provided nurses with a structure for gathering evidence about patient care levels, and discusses how this information is shared throughout the trust to improve patient outcomes and safety.

Reliability and Validity of the Emergency Severity Index for Pediatric Triage

The Emergency Severity Index (ESI) triage algorithm is a five-level triage acuity tool used by emergency department (ED) triage nurses to rate patients from Level 1 (most acute) to Level 5 (least acute). ESI has established reliability and validity in an all-age population, but has not been well studied for pediatric triage. This study assessed the reliability and validity of the ESI for pediatric triage at five sites. Interrater reliability was measured with weighted kappa for 40 written pediatric case scenarios and 100 actual patient triages at each of five research sites (independently rated by both a triage nurse and a research nurse). Validity was evaluated with a sample of 200 patients per site. The ESI ratings were compared with outcomes, including hospital admission, resource consumption, and ED length of stay. Interrater reliability was 0.77 (95% confidence interval [CI] = 0.76 to 0.78) for the scenarios (n = 155 nurses) and 0.57 (95% CI = 0.52 to 0.62) for actual patients (n = 498 patients). Inconsistencies in triage were noted for the most acute and least acute patients, as well as those less than 1 year of age and those with medical (rather than trauma) chief complaints. For the validity cohort (n = 1,173 patients), outcomes differed by ESI level, including hospital admission, which went from 83% for Level 1 patients to 0% for Level 5 (chi-square, p < 0.0001). Nurses from dedicated pediatric EDs were 31% less likely to undertriage patients than nurses in general EDs (odds ratio [OR] = 0.31, 95% CI = 0.14 to 0.67). Reliability of the ESI for pediatric triage is moderate. The ESI provides a valid stratification of pediatric patients into five distinct groups. We found several areas in which nurses have difficulty triaging pediatric patients consistently. The study results are being used to develop pediatric-specific ESI educational materials to strengthen reliability and validity for pediatric triage.

Implementing an Automated Acuity Tool for Scoring Case Management Cases and Caseloads at Blue Cross Blue Shield of Massachusetts

Blue Cross Blue Shield of Massachusetts (BCBSMA) required a statistically validated tool to understand the acuity of its case management (CM) populations. The BCBSMA management sought reliable methods to quantify the weights of case managers' caseloads, allow associates and managers to have conversations about workloads based on objective measurable data, and analyze the data to ensure that the correct populations are being targeted for CM. The tools, techniques, and strategies described in the Acuity and eQuity Workflow Solutions are suitable for all healthcare practice settings. Acuity scoring metrics are designed especially for CM settings such as independent stand-alone companies, inpatient and outpatient practices, and multistrata health plans and hospital consortia. The customized BluCuity assessment tool, tested in the interrater reliability (IRR) study arm of the project, was validated to a high degree of concordance in BluCuity scoring among CM raters with an overall agreement of 82% (20 novel raters, 20 cases, 190 rater pairs, 3,800 pairwise case reviews; p = .03). The BluCuity tool and workflow strategies were implemented into the BCBSMA information technology (IT) system for oncology and other CM teams in 2008. Report data demonstrated the acuities of case managers' cases, the relative case and caseload weights among a team of case managers, and the differences in cases and caseloads across CM product offerings. Acuity-based tools such as BluCuity to access the severity, intensity, and complexity of CM cases operationalize quality assessments into quantifiable data. Acuity score reports can join other accounting and operational reports to determine appropriate caseloads, case assignments, and staffing. To assess consistency of judgment among case managers, CM organizations can implement a formal IRR testing methodology to evaluate the level of clinical assessment reliability and establish training protocols. The automated IT acuity assessment system and data outputs can be used to assess the overall weight of a caseload based on diagnosis code groupings such as oncology, pediatric, transplants, and stroke, and illustrate the intensity of services required by CM clients at different times or in different programs. Organizations that sell CM services can use the ability to score the acuity of CM cases to scale and justify the pricing of their services.

The Development of a BMT-Specific Acuity Tool for the Outpatient Treatment Center

The Development of a BMT-Specific Acuity Tool for the Outpatient Treatment Center

Designing an Acuity Tool for an Ambulatory Oncology Setting

Staffing needs in an ambulatory oncology infusion setting can be challenging. The workload of nurses and time required to provide patient care are increasing. With the addition of new targeted therapies and complicated treatment regimens, increased patient acuity should be considered when determining daily staffing. This article describes the development of an acuity tool based on the complexity of patient treatments. The first part of the process focused on development of the tool and data collection during a two-month period to assess the complexity of patient treatments. The second part used the tool to determine daily staffing for infusion rooms. The tool provides a better representation of acuity in infusion rooms by connecting the complexity of patient treatments with staffing on a daily basis. In addition, the tool is easily adaptable to changing oncology treatment regimens because it provides a basis for assessing treatment complexity in the infusion room.

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.

Acuity and Case Management

This is the third 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. Concepts were presented that related the practice of CM to the use of evidence-based practice (EBP), knowledge, and methods and the development of instruments that measure and score pivotal CM actions. 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. Part II further explained dosage and 2 acuity instruments, the Acuity Tool and AccuDiff. Part III presents linkage to EBP and practical applications. The information contained in the 3-part series applies to all CM practice settings and contains ideas and recommendations useful to CM generalists, specialists, supervisors, and business and outcomes managers. The Acuity Tools Project was developed from frontline CM practice in one large, national telephonic CM company. 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, b 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 b-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). 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 were used for internal quality improvement and outcomes monitoring. To show value, case managers need to access the evidence base for practice, use tools to capture quantities of intervention intensity, and precisely specify 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, and thus provide data and evidence that contributes to the accumulating body of definitive proof regarding the exceptional worth of CM. Proving business and professional worth in CM through EBP is a clarion call that case managers must heed and an innovation that all case managers can practice.

Acuity and Case Management

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. 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. 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). 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. 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.

Acuity and Case Management

This article presents acuity and dosage as two concepts that describe how the business case for case management (CM) can be made. Dosage and acuity concepts are explained as client need-severity, CM intervention-intensity, and CM activity-dose by amount, duration, extent, and timing. Concepts are related to the practice of CM using evidence-based knowledge and methods to develop instruments that measure and score pivotal CM actions. The purpose of this series of three articles is to introduce the two concepts of dosage and acuity, discuss their importance for making the business case for CM and for translation into evidence-based practice, and present a powerful example of how they can be used in everyday CM. The articles feature a specific exemplar, the CM Acuity Tools project, and explain how the melding of the acuity and dosage innovations will improve the capture of CM outcomes. Part I focuses on the CM Acuity Tool(c) instrument. The article's information applies to all CM practice settings, and contains ideas and recommendations useful to CM generalists, specialists, supervisors, and outcomes managers. The Acuity Tools Project was developed from frontline CM practice in one large, national telephonic CM company. For dosage, the Huber-Hall Dosage Model and its testing are described and explained. The intersection of dosage and acuity is analyzed. For the Acuity Tools Project, a structured literature search and needs assessment launched the development of the suite of acuity tools. The resulting 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 several junctures along the development pathway, including after initial tool draft and both before and after beta-tests (n = 5) and pilot tests (n = 28). 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 to August 2000). Positive results generated approval from the expert review panel to apply the suite of acuity tools beyond (1) the initial draft phase, (2) the test population phase, and then (3) at a national CM organization level. This article defines and discusses acuity and dosage as two practical conceptual tools that successfully unite clinical quality and business practices and measure and analyze CM activities. The CM Acuity Tool(c) is a master conceptual framework in three dimensions that synthesizes key components of CM practice, organized into indicators, drivers, and subdrivers. To show value, case managers need to access the evidence base for practice, use tools to capture quantities of intervention-intensity, and specify the activities that produce better outcomes.