Inpatient nursing at Madigan Army Medical Center is breaking new ground in how they manage both patients' care and nurse staffing with the help of specialized software.

As one of the first military treatment facilities to use Clairvia, a workload management tool in the electronic health record MHS GENESIS, Madigan's Inpatient Services now tracks how individual patients' health statuses are trending to see if they should receive additional interventions or be rounded on more often. In addition, since patients' acuity levels are easier to view and track, nursing assignments can now be refined to both ensure each nurse has the appropriate workload and continues to safely build their skills.

"We're changing the way we make patient assignments," said Mark Sanders, the nurse methods analyst with Inpatient Services. "We're also able to identify challenging assignments to help prepare folks that are deployable to get them operating at the highest level of licensure."

He explained that Clairvia's analytics allow nursing management to make safe yet challenging patient assignments that let nurses hone their expertise under appropriate supervision, ensuring they build their skillsets and are better prepared for downrange deployments. Other goals with finding new ways to use this cutting edge software are to increase patient safety, increase patients' and staff's satisfaction, and lower the number of patients readmitted, Sanders said.


Changing staffing model

Traditionally in the nursing field, patients are assigned to nurses on a ratio basis, which vary according to the type of unit, such as an intensive care unit or a medical/surgical floor.

"The ratio-based staffing was an accepted methodology for determining productivity in the nursing career field, but the rub that goes with that is that just like all patients aren't created equal, all nurses aren't created equal, and as a nurse's experience grows, they can be challenged with patients who require more and more care or are sicker on the continuum of illness … or you can be given patients who are less sick and you can take care of more (of them)," said Sanders.

A landmark mid-1990s study from the University of Iowa and the NANDA Foundation (an international nursing diagnoses organization) though found that nursing interventions and outcomes should be measured and used to establish nursing workloads. Before Clairvia, nurses at Madigan used a workload management tool that relied largely on manual entry, and on their perception at the end of their shifts of their patients' acuity levels.

Now, Clairvia automatically calculates in real time the actual amount of work and nursing hours per individual patients based on their interventions and outcomes as shown in MHS GENESIS, drawing from nursing documentation, lab values, physician orders and consults, and equipment used at bedside, tracking over 50,000 data points to tabulate the patients' acuity. The use of technology captures 10 -- 15 percent more workload than the previous tool because it's more accurate, Sanders said.

When calculating nursing hours per patient day, Clairvia also automatically takes into account the extra time spent with patients with multiple medical conditions, or with an unusual test result such as an extremely high blood pressure reading -- all from documentation.

"The things that get lost that Clairvia recognizes are the fact that I probably repositioned you, I probably took it on your other arm, I probably walked out and checked the medication administration record to see if I gave you the proper medication at the right dose and at the right time, I probably asked you questions -- all of those other things that would go along with an elevated blood pressure are all nursing time, and that's a part of the intervention," said Sanders.

In fact, Clairvia assigns each patient an acuity score to let nurses and management more easily decipher and follow how ill each patient is. The system tracks patient outcomes in 12 -- 16 different areas (such as cardiac status, respiratory status and skin integrity) based on the type of patient demographics (i.e. age and gender), and then uses algorithms to create acuity scores of 0 -- 12. Combined with demand configuration unique to each department, Clairvia calculates the amount of nursing hours each patient needs per day.

"You can see how the ratio starts to go away because you're basing it on acuity and intensity," said Sanders.

Clairvia can look at not only the intensity of each patient's care, but also the intensity on each floor on a percentage basis. For example, a floor may be running at 104 percent productivity but if further broken down, it might show that licensed practical nurses are maxed out but registered nurses and certified nursing assistants may have time to care for additional patients.

"We look for free hands instead of free rooms," said Sanders.


Enhancing patient monitoring

The ability to follow patients' ever-changing acuity levels also allows nursing management to better follow trends in patients' care status and to staff for patient needs.

"There are certain things I can do that I never could do before, and one of those is to see the trending. I can tell if a patient is getting sicker because I can see every assessment that was done on them and when you do a nurse to nurse handoff on the floor, you'll get history as a part of your report, but I have objective history that I can see now and I can see trending that might not get passed on," said Sanders.

He explained that even away from the nursing floor he can help closely follow a patient and be another set of eyes to see if the patient's respiratory status is slowly declining, for example. He can then call the charge nurse to encourage them to take an extra look at a patient and discuss their status and next care interventions.

"We now have this in our collective consciousness," said Sanders.

Clairvia assists with forecasting staffing needs too.

"Now that we're getting more and more data into the system, I can forecast 36 hours ahead, and if I can forecast 36 hours ahead, I will no longer need to float nursing staff after the shift started. I can maybe get ahead of the game and start layering my staffing where the demand is because I can not only see it, I now after getting two years' worth of data in, I can start to forecast it."

As the largest inpatient MTF using MHS GENESIS, Sanders offered some advice for future MTFs as they transition to MHS GENESIS and Clairvia.

"If I had to pass on something to my peers, it would be you're going to have better data on patient acuity and intensity, and you'll have a culture shift when you move from ratio-based staffing to acuity-based staffing," he said.

This change is the right answer for patient care and nursing workload management, he said.

"It's where we needed to be and it's where intuitively nurses have always been."