A Unit-Specific Patient Intensity Tool

We thank Riman and Kahn for their much needed contribution to the research into the challenges facing nurse staffing and patient outcomes. We agree that understanding how nurse-patient assignments are created will allow development of tools and methods to improve assignments for nurses and patients.1 We developed an evidence-based practice project to further understand the impact of assignments on patients.In our unit, no criteria were available to guide charge nurses in decision-making for nurse-patient assignments. Reports by nurses of the intensity or business of assignments affecting patient care led to conversations about finding creative solutions.2,3 We decided to use a patient intensity tool (PIT), and we measured the impact of this tool on health care–associated pressure injuries (HAPIs) and central line [catheter]–associated bloodstream infections (CLABSIs).The PIT served as a guideline for charge nurses when they made assignments. We grouped patients into categories of intensity on the basis of patient care needs, including ventilator support, vasoactive drip management, cardiac mechanical support devices, and isolation precautions. These categories were color coded, and patients in certain color categories were discouraged from being paired with other colors (eg, red patients should not be paired with orange but could be paired with green). We tracked rates of CLABSIs and HAPIs, and we used 1:1 and 1:2 ratios.1The PIT was revised by the shared governance council, charge nurses, and manager. Charge nurses received education about the tool and were instructed to color code unit assignments with highlighters based on the associated intensity on the tool. The color-coded assignments were used to determine appropriate nurse-patient assignments, potentially changing patient pairings from previous shifts, and during charge report to center conversations on assignments that were more intense. This practice change was intended to focus rounds and CLABSI and HAPI initiatives on high-intensity assignments. Following education on the tool, feedback was requested from charge nurses, and the tool was updated. Data were evaluated for 3 months following the practice change. Pre- and postsurveys were sent to charge nurses to assess knowledge and perceptions of the PIT.Following the implementation of the PIT, there was a reduction in HAPIs and CLABSIs. The preimplementation data included 3 CLABSIs and 9 HAPIs. Following the intervention, there were 2 CLABSIs and 1 HAPI. Of the charge nurses surveyed, 100% felt confident in their ability to create equitable assignments. Ninety percent of charge nurses felt they gained increased knowledge about the relationship of hospital-acquired complications to the intensity of nurse-patient assignments, and 100% of the charge nurses reported wanting to use the tool during charge report to discuss assignments, focus on quality care, and allocate resources. As with many evidence-based practice projects, continuing to use the PIT in our unit proved to be difficult, and it is currently not being used. Conversations around nursing assignments are ongoing, and we hope a version of the PIT may be used again in the future. The tool continues to be a collaborative, working document in the ECMO (extracorporeal membrane oxygenation) intensive care unit since the unit's development in 2022.More research is needed to understand the relationships between nurse-patient assignments and patient outcomes and to better assess how charge nurses create pairings.1 Evidence-based tools can positively impact charge nurses' confidence in leading a unit with challenging and busy assignments and influence patient outcomes for the better.4