Publication/Presentation Date

7-25-2014

Abstract

Abstract

The Lehigh Valley Health Network (LVHN) Observation Unit, located at the Cedar Crest Campus, is claimed to be understaffed, currently operating with approximately one nurse responsible for six patients. A time study, with the objective of recommending an appropriate patient-nurse ratio for the LVHN Observation Unit confirmed the validity of this claim.

Background

The LVHN Observation Unit (OU) is an extension of the LVHN Emergency Department (ED) and Hospital Medicine Service. This OU is where patients are sent after ED admission if they are not sick enough to require an inpatient admission, but still require medical attention before they can be discharged [1]. These patients rarely have life threatening symptoms, but are more likely to struggle with pain or discomfort [1][2]. However, after some observation, about 12% of LVHN OU patients require inpatient admission for further treatment [2]. The OU has thus proven to be an effective tool in reducing unnecessary inpatient admissions at LVHN [2].

However, for an OU to be considered as such, patients may not stay on the unit for more than 48 hours, and documented nurse or doctor treatment is required every hour [3]. Most of these patients are present in the OU for 6-24 hours, with an average length of stay of 23.6 hours [2][3]. In other Med/Surg units, patients tend to have a length of stay closer to four days [2]. It is believed that the OU patients require more work from nurses because the nurses have 48 hours to complete work that nurses in other units have 96 hours to spread out. Also, nurses in the OU claim that they chart patients twice as much as Med/Surg nurses do [2]. For these reasons, the OU staff believes that they should be responsible for fewer patients per nurse than other Med/Surg unit nurses are. However, OU nurses are currently responsible for 6-8 patients, while Med/Surg unit nurses are responsible for 5-6 patients [2]. In the opinion of the OU staff, 4-5 patients per nurse is an appropriate patient-nurse ratio for the OU [2].

Methodology

This time study was designed so that direct observation of nurses on two different medical units at the LVHN Cedar Crest Campus could be translated into meaningful time-based data. Twelve hours of observation were conducted on both the Observation Unit (5C) and a comparable Medical-Surgery Unit (7BP).

A set of typical tasks (Chart 1) and procedures was created in order to differentiate between medical value added to a patient and other occupational tasks required of the nurses.

Care Process

Non-Care Process

Other Process

Patient Care (PC)

Paper Work (PW-X)

Start (S)

Check Rates (CR)

Computer Work (CW-X)

End (E)

Supply (SU)

Nurse Consult (NC-X)

Idle (I)

Paper Work (PW)

Doctor Consult (DC-X)

Trade Off w/ Coworker (TO)

Computer Work (CW)

Family Consult (FC-X)

Medicine Delivery (CM)

Employee Consult (EC-X)

Emergency Response (BR)

Use Phone (UP-X)

Use Phone (UP)

Nurse Consult (NC)

Doctor Consult (DC)

Family Consult (FC)

Chart 1: Nurse tasks and procedures, differentiated as either a care, non-care, or other process. The process identifier/code in parenthesis was used for simplicity when observing many processes in continuous flow.

Medical value added to a patient can be defined as any operation that directly treats, concerns, or relates to one specific patient. For example, an instance of computer work adding medical value to a patient could be updating medical charts for a patient. An example of computer work that doesn’t add value to a patient (non-care process) could be responding to an email.

Along with the process identifier, the start and end time of each process, and the room number of the patient involved were recorded. The observed nurses were chosen simply through assignment by the present Charge Nurse of the unit. These observations were performed on 6 nurses in the 5C unit and 4 nurses in the 7BP unit, totaling 24 observed hours and 692 observed processes on 57 patients. Elapsed time data was collected in minutes, and was retrieved from calculating the difference between the start time and the end time of each task.

All of the collected data was stored in a Microsoft Excel workbook. The data was then manipulated in many ways in order to run two-sample t-tests through Minitab, a statistical analysis software. This two-sample t-test was chosen because it highlighted the differences between the 7BP and 5C data sets.

Results

In the 10 different observation periods on the 5C and 7BP, the 5C operated on average at a 6:1 patient-nurse ratio, comparing to the 7BP at a 5.25:1 patient-nurse ratio. In addition, 20 different t-tests were conducted, providing metrics such as mean, standard deviation, sample size, and p-values of the two data sets. These tests were designed to compare the amount of work that one nurse in each unit is responsible for. The results are as follows:

Comparison

Stat

5C

7BP

Difference/p-value

1) Time spent between tasks

SS

402

214

No

Mean

0.24876

0.24299

STDV

0.84323

1.137

0.948

2) Percent of observation period spent on one patient in patient care

SS

36

21

Yes

Mean

11.325%

15.539%

STDV

7.343%

7.034%

0.038

3) Duration of time spent per patient care interaction

SS

81

41

Yes

Mean

2.7058

6.3659

STDV

2.3331

4.927

0

4) Duration of time spent per computer work interaction

SS

154

101

Yes

Mean

1.1805

1.83

STDV

1.1111

1.8651

0.002

5) Duration of time spent per idle period

SS

34

16

No

Mean

2.5098

3.1771

STDV

2.154

2.8031

0.408

6) Duration of time spent per nurse consult interaction

SS

36

36

Yes

Mean

1.4444

2.8333

STDV

1.2916

1.9011

0.001

7) Percent of observation period spent on computer work

SS

6

4

No

Mean

24.613%

25.642%

STDV

6.860%

6.625%

0.82

8) Percent of observation period spent on Patient Care

SS

6

4

No

Mean

29.427%

36.012%

STDV

11.208%

16.401%

0.522

9) Percent of observation period spent on consult

SS

6

4

No

Mean

11.170%

18.438%

STDV

5.603%

8.414%

0.204

10) Percent of observation period spent on Supplies

SS

6

4

Yes

Mean

7.578%

2.608%

STDV

3.407%

2.107%

0.025

11) Percent of observation period spent on paper work

SS

6

4

Yes

Mean

2.473%

0.713%

STDV

1.141%

0.744%

0.021

12) Percent of observation period spent on phone

SS

6

4

No

Mean

7.108%

2.280%

STDV

8.182%

2.615%

0.227

13) Amount of medicine checks per patient

SS

36

21

No

Mean

0.05556

0.04762

STDV

0.23231

0.21822

0.898

14) Amount of computer work instances per patient

SS

36

21

No

Mean

4.27780

4.80950

STDV

3.37730

2.71330

0.518

15) Amount of consults per patient

SS

36

21

Yes

Mean

0.50000

1.33333

STDV

0.77460

1.15470

0.006

16) Amount of patient care instances per patient

SS

36

21

No

Mean

2.22222

2.05000

STDV

1.86870

1.60510

0.719

17) Amount of paper work instances per patient

SS

36

21

Yes

Mean

0.47222

0.14286

STDV

0.77408

0.35857

0.034

18) Amount of supply retrieval instances per patient

SS

36

21

No

Mean

0.66667

0.42857

STDV

0.98561

0.74642

0.308

19) Amount of phone calls per patient

SS

36

21

No

Mean

0.22222

0.04762

STDV

0.48469

0.21822

0.068

20) Amount of beep responses per patient

SS

36

21

No

Mean

0.11111

0.19048

STDV

0.52251

0.40237

0.524

Table of results of 20 t-tests. SS=Sample Size. STDV= Standard Deviation. The difference column signifies whether or not the tests showed a conclusive statistical difference between the 5C and the 7BP in the given metric. Note: Numbered comparisons correspond to numbered list in conclusion section.

Assessment

The following can be summarized in regards to the work done by nurses in the 5C and 7BP units from evaluating Chart 2:

  1. Both units spend approximately the same amount of idle time in between processes.
  2. Nurses in the 7BP unit spend a higher percentage of shift time on direct patient care of any given patient than do nurses in the 5C unit.
  3. Individual periods of direct patient care in the 7BP unit take more time to conduct than they do in the 5C unit.
  4. Individual periods of computer work in the 7BP unit take more time to conduct than they do in the 5C unit.
  5. Individual idle periods in the 7BP unit are lengthier than they are in the 5C unit.
  6. Individual periods of nurse consultation in the 7BP unit take more time to conduct than they do in the 5C unit.
  7. Both units spend approximately the same percentage of shift time on computer work.
  8. Nurses in the 7BP unit spend a higher percentage of shift time on direct patient care than do nurses in the 5C unit.
  9. Nurses in the 7BP unit spend a higher percentage of shift time consulting either a doctor, nurse, patient’s family member, or other employee than do nurses in the 5C unit.
  10. Nurses in the 5C unit spend a higher percentage of shift time gathering supplies for a patient than do nurses in the 7BP unit.
  11. Nurses in the 5C unit spend a higher percentage of shift time completing patient paper work than do nurses in the 7BP unit.
  12. Nurses in the 5C unit spend a higher percentage of shift time on their work cell phone than do nurses in the 7BP unit.
  13. Nurses in both units delivered or checked any given patient’s medicine approximately as frequently as each other. This process in itself was performed rarely in both units.
  14. Nurses in both units completed any given patient’s computer work approximately as frequently as each other.
  15. Nurses in the 7BP unit consulted either a doctor, nurse, patient’s family member, or other employee in regards to any given patient more frequently than did nurses in the 5C unit.
  16. Nurses in both units conducted direct patient care on any given patient approximately as frequently as each other.
  17. Nurses in the 5C unit completed any given patient’s paper work more frequently than did nurses in the 7BP unit. This process in itself was performed rarely in both units.
  18. Nurses in the 5C unit retrieved supplies for any given patient more frequently than did nurses in the 7BP unit.
  19. Nurses in the 5C unit completed more phone calls for any given patient more frequently than did nurses in the 7BP unit.
  20. Nurses in the 7BP unit responded to patient emergencies more frequently than did nurses in the 5C unit. However, this was out of the nurses’ control as they cannot determine when a patient decides to request for immediate medical attention.

These summaries reveal an encompassing conclusion about the nurses’ comparative workload in the two units. The units share a similar workload, although the work was completed in different fashions. The 5C unit’s nurses conduct many short tasks more frequently, while the 7BP unit’s nurses conduct longer, less frequent tasks. This is supported by the evidence that each floor was observed for 12 hours, but 437 processes were observed in the 5C unit, while only 250 processes were observed in the latter. However, the average process in the 5C unit only lasted 1.65 minutes while the average process in the 7BP unit lasted 2.88 minutes. Also, both floors spent similar percentages of their day idle, which suggests that both floors have similar workloads. For these reasons, it can be concluded that the patient-nurse ratios in the two units should be equivalent. It is recommended that the 5C OU operate at a 5:1 patient-nurse ratio.

There were a few limitations of this time study. Firstly, twelve hours of observation time on each floor is not enough time to make conclusive decisions on how the 5C unit should be staffed. Secondly, the timing of the processes was only accounted for in minutes, depriving the study of possible levels of precision that could have been reached if accounted for in seconds. It is recommended that this study be expanded for longer periods of observation, as well as conducted using a more precise unit of measurement.

References

[1] Martinez, E., Reilly, B., Evans, A., & Roberts, R. (2001). The observation unit: a new interface between inpatient and outpatient care. The American Journal of Medicine, 110(4). http://dx.doi.org/10.1016/S0002-9343(00)00710-5

[2] Teets, C. (2014, June 26). [Personal interview by M. Kashkoush]. [3] Aston, G. (2012, February 1). Observation units: A tightrope act. Retrieved July 15, 2014, from Hospital and Health Networks website: http://www.hhnmag.com/display/ HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Magazine/2012/Feb/ 0212HHN_FEA_clinical

Comments

Mentor: Shelly Schleicher

Department(s)

Research Scholars, Research Scholars - Posters

Document Type

Poster

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