Patient Classification and Nurse Staffing System

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.

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

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

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.

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