Patient Acuity Ratios

At Vanderbilt University Medical Center in Nashville, Leann Grimes, RN, has seen the ups and downs, all the while managing a steady hand in occasionally chaotic situations.

In her role as charge nurse, Grimes has been in the eye of the storm since beginning her Vanderbilt career in 1995.

These days, the whirling tempest around her is capably handled by more accurate nurse staffing. Knowing the right number is all based on acuity, a familiar term in today’s nursing world that regulates staffing according to need, and not raw patient numbers.

More than 2 ½ years ago, although Vanderbilt Medical Center provided excellent patient care, staffing was at times less than ideal. Nurses endured a blistering pace that started from the moment they came on the floor and lasted until the minute they left. Turnover and staff satisfaction became issues.

Grimes responded by recording several months of data that demonstrated how acuity had changed within the unit.

“I knew we needed more nurses, but I didn’t know how to go about [fixing] it,” Grimes said of her efforts in 2009. “How do you change the budget? How do you tell your manager, CEO, and your financial advisors that you need more staff?”

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Thanks to a program called the Frontline Nursing Leadership Workshop, Grimes knew what to look for, and she had the confidence to share what she found.

The workshop is an outside program that takes 50 people twice a year. The 2-year commitment involves meeting four to five times as a large group in an all-day session.

“We are a Magnet hospital and part of the charter is transformational leadership,” Grimes said. “My acuity project was part of that. Management listened to me and took into account what I had to say.”

Ultimately, she had a 4-hour meeting with a financial advisor for the medical center and covered Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) staffing guidelines and how they application to Vanderbilt’s specific situation.

Within the framework of those guidelines, Grimes detailed 9 months of previous patient status records.

“I recorded how many patients would qualify for a high and low risk postpartum, antepartum, GYN, etc.,” she said. “The data showed we needed a nurse or two more, depending on acuity.

“On the low acuity days, we staffed appropriately. If there were not a lot of sick patients, we did not have an issue,” she continued. But when you all of a sudden have 15 antepartum patients, that’s a 3:1 ratio; that’s five nurses for just those 15 patients, and we were staffing with 6 to 7 for the entire unit of 32. At that point, you see the imbalance.”

AWHONN states that high-risk postpartum patients should be staffed at a ratio of 3:1. Low-risk post-partum patients should be 6:1, and antepartum 3:1. When available, Vanderbilt staffs gynecology, oncology, and off-service patients at a 4:1 ratio.

Grimes transformed the charge nurse staffing sheet to reflect patient acuity. She recalculated the ratios and created a staffing model to reflect fluctuating acuity on the unit.

As a result of her efforts, she received a Future of Nursing Leadership Award in 2008, one of just three given in the U.S.

Census numbers have since then gone up considerably at Vanderbilt, with projected deliveries in 2012 at about 4,200 (up from 2,500 in 2008).

“We have recently changed the [cesarean-section patient/nurse ratio from 4:1 to no more than three in one nurse’s assignment,” noted Grimes.

These days, each shift usually has seven to eight nurses, up from six or seven in 2008.

“We calculate the amount of patients and the nurses we need every 4 hours,” says Grimes. “Our unit holds 32 patients, and staffing depends on what we have and what is coming – the level of acuity. We assess acuity of the unit every 4 hrs continuously and make adjustments as needed.”

Six charge nurses have permanent positions on the unit, three on days and three on nights, which means relatively few people must learn the acuity grid.

Effective Transformation

Consistency is extremely important for the acuity model to be effective.

Each individual must have leadership skills and be a role model who is willing to mentor staff, especially at a teaching institution like Vanderbilt.

Meanwhile, a Maternal Specialty Care Unit has recently been added to the Women’s Patient Care Unit. The unit adds four triage beds and 6 additional beds to place patients who are high risk and may be used for additional labor beds. This addition has helped decrease the number of triage patients occupying a labor bed.

“We’re almost 1,500 deliveries more now than 2 years ago, so that makes a big difference,” Grimes noted. “Our patients are more satisfied now. The community surveys show nurses are happier, and happier nurses make happier patients.”

Instead of nurses leaving for better working conditions at new institutions, nurses at Vanderbilt tend to move because they have advanced to higher-level jobs or received promotions.

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“We don’t have nurse practitioners on our unit that are working one-on-one with patients. If you’ve got your master’s degree, and you’re a nurse practitioner, you have to go where that need is; and we don’t have that need here,” Grimes explained.

“You may lose two or three nurses a semester because they went back to school,” she continued, noting Vanderbilt offers nurses tuition reimbursement. “You don’t want turnover, but you support turnover like that.”

Grimes is convinced that low turnover often hinges on a sense of fulfillment that goes hand in hand with a feeling that real progress has been accomplished at the end of a shift.

“You don’t want nurses who work tirelessly throughout their shift to leave and feel like they have left something undone,” notes Grimes. “You want the nurse to feel like she’s had the time she needs with the patients, and the patients deserve that. The acuity grid definitely helps with that. Retaining nurses is the most important thing right now.

“They say it’s anywhere from $40,000 to $60,000 to hire and orient a new nurse. Turnover will kill your budget. You want to keep what you have for the sake of the budget, staff satisfaction, and patient care above all,” she continued.

“You want to try to avoid only having new nurses on your unit. You want to retain experienced staff because they help educate and serve as resources to your new staff,” Grimes conluded. “When you find a good place, you don’t want to leave.”

Greg Thompson is a frequent contrbutor to ADVANCE.

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