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Circular 87-01


DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service
Health Resources and Services Administration
Indian Health Service
Rockville, Maryland 20857

INDIAN HEALTH SERVICE CIRCULAR NO. 87-01


Effective Date:  February 18, 1987

PATIENT CLASSIFICATION AND NURSE STAFFING SYSTEM

  1. PURPOSE:  The purpose of this Circular is to set forth the policy regarding identification and classification of patients into care levels and quantification of these levels as a measure of nursing effort required.

  2. BACKGROUND:  One of the most critical and continuing concerns facing administration of health care delivery systems is the management and effective application of a realistic nurse staffing system based on patient acuity level.  Joint Commission of Hospitals (JCH), Health Care Financing Administration, state licensing agencies and the American Nurse's Association set standards for nursing care based on principles inherent in this patient classification and nurse staffing system.  The nursing personnel needed in a nursing unit can be properly determined only by an effective system that evaluates and assesses the needs of patients concurrently with the individual capabilities of the nursing staff assigned to the unit.  By the same token it is imperative that records and reports of both staffing patterns and patient acuities be consistently maintained, regularly reviewed and revised when appropriate.  The patient classification system supplies the tools necessary to provide and justify adequate nursing staff to meet the standards for quality and appropriateness of nursing care.

  3. POLICY:  The Indian Health Service (IHS) Patient Classification system will be implemented as described in this policy at all IHS hospitals and PL 93-638 tribally operated hospitals to standardize patient classification within IHS.  The classification system will be used to measure productivity of nursing staff, to compare nursing resources with patient care needs within and between facilities, to provide equitable staffing and allocation of resources.

  4. DESCRIPTION:

    1. Level of Care With Definitions:

      In order to be consistent with the inpatient census, Form HRSA 165-2, the classification of patients will be at four levels, according to nursing care needs and will be a basis for determining personnel requirements.  The four levels will be minimal, partial, full, and complex.

      The following is a breakdown of the four levels with definitions.

      Level I -  Minimal Nursing Care

      A patient whose nursing care needs are almost entirely met by routine ward activities.  A patient requiring minimal nursing care whose condition is characterized by:

      1. Mild symptoms, usually considered in the later stages of convalescence.

      2. Little or no deviation from normal (acceptable) behavior pattern.

      3. No restriction of activity.

      4. Simple treatments and few medications.

      5. Follow-up instructions and supervised practice in self-care measures in preparation for discharge.

      6. Discharge.

      Patient requires nursing supervision and encouragement to provide own personal care.  Has learned to manage own personal hygiene even though may have maintenance intravenous therapy, catheter, other type of tubes or dressing.  May be independent in wheelchair.

      Level II -  Partial Nursing Care

      A patient requiring a moderate amount of nursing care whose condition is characterized by:

      1. Subacute symptoms, usually either in early stages of convalescence or chronically ill, but not completely dependent on others for activities of daily living.

      2. Intermittent or occasional deviation from normal (acceptable) behavior pattern.

      3. Limited or periodic restriction of activities.

      4. Periodic treatment, observation, and/or instruction.

      Level III -  Full Nursing Care

      A patient who has most of his activities initiated, performed and/or supervised by nursing personnel or who is confined to bed for the major portion of the twenty-four hour period.  A patient requiring considerable direct care whose condition is characterized by:

      1. Acute symptoms that may be subsiding or impending, or symptoms of a chronic condition that makes the patient almost completely dependent on nursing personnel for activities of daily living; usually seriously ill.

      2. Significant deviation from normal (acceptable) behavior pattern.

      3. A need for general control of activities.

      4. Frequent treatment, observation and/or instructions.

      Level IV -  Complex Nursing Care

      A patient whose nursing care becomes so intricate or time-consuming as to require the equivalent of a special duty nursing service.  A patient requiring intensive nursing care whose condition is characterized by:

      1. A need for life-saving measures promptly and constantly.

      2. Extreme symptoms; usually termed acutely or critically ill.

      3. Pronounced deviation from (acceptable) behavior pattern.

      4. A need for rigid restriction of activities.

      5. A need for continuous treatment, observation, monitoring and/or instructions.

    2. Definitions of levels of Care for Intensive Care Patients:

      Level I -  Minimal Nursing Care

      Patients who are ready to transfer to wards.

      Level II -  Partial Nursing Care

      Patients who need a short period of intense care or require constant observation and monitoring to maintain stability.  Examples are surgical recovery, MI patients, etc.

      Level III -  Full Nursing Care

      Patients who require frequent lab studies, blood transfusions, arterial blood gases, and other special procedures.  Example are GI Bleeders, hepatic comas, MI’s arrhythmias, etc.

      Level IV -  Complex I.C.U. Care

      Patients require special assistance such as ventilator, or special equipment such as a PA line for pulmonary artery pressures, and intra-arterial lines for direct BP measurements. Also, requires special IV drip medications which should not be administered without the proper monitoring of the responses.  Also, if patient in above category requires isolation.

  5. TIME REQUIRED:

    The time required for each level of care includes both the direct care (the time actually spent caring for the patient) and the indirect care (the time spent on other activities specific to the patient).

    The hours per level are:

    1. General Medical/Surgical/Pediatric/Obstetric Patients:

      Level I Minimal 2.0 hours per 24 hours
      Level II Partial 4.0 hours per 24 hours
      Level III Full 6.0 hours per 24 hours
      Level IV Complex 10.0 hours per 24 hours

    2. Intensive Care Patients:

      Level I Minimal 6.0 hours per 24 hours
      Level II Partial 12.0 hours per 24 hours
      Level III Full 18.0 hours per 24 hours
      Level IV Complex 24.0 hours per 24 hours

  6. STAFFING:

    1. Formula for Day to Day and Shift to Shift Calculation:

      The sum of the standard times for each level of care multiplied by the number of patients in the level equals the required hours of patient care.  Dividing this value by 7.0 (number of hours staff actually work each shift) results in the number of staff required to work per 24 hours.

      Total hours of care needed = number of employees per twenty-four hours 7 (hours per employee)

      Employee Mix:

      Professional (RN) 70% of total staff
      Non-professional (LPN, NA) 30% of total staff

      Distribution Per Shift:

      Night shift   25% of total staff
      Evening shift   32% of total staff
      Day shift   43% of total staff

      Example:

      Level of Care No. of Patients Hours of Care Per 24 Hours Total Hours Needed
      Level I 2 X 2 = 4
      Level II 8 X 4 = 32
      Level III 10 X 6 = 60
      Level IV 2 X 10 = 20
      Totals 22 22 = 116

      Applying the Formula: 22 = 16.5 or 17 employees per 24

      Employee Mix: Professional employees 70% x 17 = 11.9 or 12
      Non-professional employees 30% x 17 = 5.1 or 5
      Total 17

      Shift Distribution: Professional D 43% x 12 = 5.2 = 5
      E 32% x 12 = 3.8 = 4
      N 25% x 12 = 3 = 3
      Non-professional D 43% x 5 = 2.1 = 2
      E 32% x 5 = 1.6 = 2
      N 25% x 5 = 1.2 = 1
      Total 17

      See Table I to determine number of total nursing staff needed for 24 hour period and per shift.

    2. Formula for Budgeted Position Calculation:

      Average care hours needed per patient day times the average daily patient census times days of the year; divided by the days of the year, minus the administrative necessities, times the daily duty hours per employee equals the hours of nursing care divided by the hours of care delivered by each employee per year equals the number of employees to be budgeted for the unit.

      Ave. Care hours Ave. Daily
      Per Pt. Day x Pt. Census x Days Per Year = Hours of Nursing Care Per Year = No. of Employees
      Days Per Year - Admin. Necessities x Daily Duty Hrs. Per Employee = Hours of Care Del. by Each Employee per year to be Budgeted for unit cost

      Interpretation of Formula:

      Average care hours per patient day: Yearly average of all care hours needed per day.
      Average daily patient census: ADPL for unit.
      Days of the Year: 365
      Daily hours/employee: 8 minus 1 for fatigue = 7 hours.

      Administrative Necessities:

      Regular days of duty = 104
      Holidays = 10
      Vacation days = 15
      Sick leave = 12
      Other absences = 3
      Continuing Education = 3
      147 days/year

      Example:

      Using 5.27 care hours as an average and 22 as the unit ADPL:

      5.27 x 22 x 365 = 42313 = 27.7 or 28 employees
      365 - 147 x 7 = 1526

  7. IMPLEMENTATION:

    1. Form I:  Computation of Levels of Patient Care

      An RN should classify the patient on admit and daily using this form.  If a patient's condition changes, the patient should be reclassified.

      Directions for patient classification are on the form.

      Be sure the classification is recorded on the patient kardex for ease in counting the number of patients for each level at the end of the shift.

    2. Form II:  Staff Hours Available Daily Report

      The form is to be completed for each unit by the off going supervisor before shift report.

      All nursing staff on a unit for the next 8 hours should be listed.  Use 7 hours for Hours Scheduled Column which allows for meals and breaks.  Follow through columns as form indicates.

      If an employee is scheduled and not on the unit, indicate this in the appropriate column with the reason code.

      Figure totals and transfer the "Hours Needed" from Form III Column D.  This will show the comparison of hours available for care on the on-coming shift and hours needed for care as determined at the end of the previous shift.

      The comparison may be used to show need for additional staff or justify pulling staff to another unit.

    3. Form III:  Nursing Patient Classification Shift Acuity Worksheet

      Each unit should complete Box B, Box Ea, and Box Fa at the end of each shift and submit to the Nursing Office.  (This consists of a total count of patients in each level and can be obtained from the patient kardex).

      Box B is to be obtained from the Kardex at the end of each shift.  It will reflect the total number of patients in each class at this time.

      For ICU add a total of 4 points for telemetry (out of Unit); not for each patient on telemetry.  Also add 5 points for the recovery of a patient.

      Add 1 for each non-stress test.  The off-going supervisor will compute the number of care hours needed for that unit before shift report.  A form is needed for each unit.

    4. Form IV:  Nursing Patient Classification Daily Acuity Report Summary of All Shifts

      To be completed by Supervisor at the end of 24 hours. Use Form III to complete.

      Transfer numbers from Form III Box B "Nights" to box B of Form IV under Nights.  Also fill in the number of admits and discharges.  The same thing is done with Form III for Days and Evenings; transferring to appropriate columns.

      The figures are calculated as directed on the form.

      The last section is for the 24 hour average.  Total class I patients from Day, Evening, and Night and divide by 3.  Repeat for each level of care.  For the admits, discharges, telemetry, recovery, and non-stress tests follow the same procedure.

      Calculations are to be made as directed by the form.

      ADPL = Census/Days in Month

      % Occupancy Rate = Census/(# of beds x 100)

    5. Form V:  Patient Classification Monthly Worksheet.

      Needs to be completed by the same individual routinely.

      Complete according to the directions that are on the form.  To be filed in Nursing Office.

    6. Form VI:  Productivity Form

      Also needs to be completed by the same individual routinely.

      Complete according to the directions that are on the form. To be filed in the Nursing office.

    /Everett R. Rhoades, M.D./
    Everett R. Rhoades, M.D.
    Assistant Surgeon General
    Director, Indian Health Service

    Attachment

    (For a copies of these forms please contact your Area Directives and Delegations Control Officer)

    Form I - Computation of Level of Patient Care
    Form II - Staff Hours Available Daily Report
    Form III - Patient Classification Shift Acuity Worksheet
    Form IV - Patient Classification Daily Acuity Report Summary of All Shifts
    Form V - Patient Classification Monthly Worksheet
    Form VI - Productivity Form
    Form VII - Nursing Staffing Table Per 24 Hours by Shift


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