Refinement of the Intensive Care Unit Complexity Assessment and Monitoring to Ensure Optimal Outcomes III Acuity Tool

Development and Implementation of a Pediatric Nursing Emergency Behavioral Health Assessment Tool

INTRODUCTION

The national pediatric mental and behavioral health crisis dramatically increased emergency department mental and behavioral health visits and changed emergency nursing practice. Acuity assessment determines patient severity level and supports appropriate resources and interventions. There are no established nursing tools that assess pediatric mental or behavioral health acuity in the emergency department setting. Our goal was to develop and implement the novel pediatric emergency nurse Emergency Behavioral Health Acuity Assessment Tool.

METHODS

This quality-improvement project used the plan, do, study, act model to design/refine the Emergency Behavioral Health Acuity Assessment Tool and a non-experimental descriptive design to assess outcomes. The setting was a 47-bed urban level 1 pediatric trauma center with more than 60,000 annual visits. The team designed the tool using published evidence, emergency nurse feedback, and expert opinion. The tool objectively captured patient acuity and suggested acuity-specific nursing interventions. Project outcomes included acuity, length-of-stay, restraint use, and patient/staff injuries. Analyses included descriptive statistics and correlations.

RESULTS

With over 3000 annual mental/behavioral-related visits, the emergency department had an average daily census of 23 mental and behavioral health patients. Implementation occurred in August 2021. The Emergency Behavioral Health Acuity Assessment Tool dashboard provided the number of patients, patient location, and acuity. Length-of-stay did not change; however, patient restraint use and patient/staff injuries declined. Number of restraints positively correlated with moderate acuity levels (r = 0.472, P = 0.036).

DISCUSSION

For emergency nurses, the Emergency Behavioral Health Acuity Assessment Tool provided an objective measure of patient acuity. Targeted interventions can improve the care of this population.

Cognitive mental workload of emergency nursing: A scoping review

AIM

Emergency nurses work in an environment of high cognitive mental workload. Excessive cognitive mental workload may result in patient harm and nurses' burnout. Therefore, it is necessary to understand nurses' subjective experience of cognitive workload. This scoping review aimed to curate literature about the subjective experience of cognitive mental workload reported by nurses and psychometric measures of the phenomenon.

DESIGN

The scoping review was conducted in accordance with JBI methodology and reported using PRISMA extension for scoping review checklist.

METHODS

A priori protocol was created with Peer Review of Electronic Search Strategies checklist and registered in the OSF registry. Databases including PubMed, CINAHL, ProQuest, Scopus, Science Direct, Web of Science and Google Scholar were searched. Published reports were reviewed against the eligibility criteria by performing Title and Abstract screening, followed by Full-text screening. The initial search yielded 1373 studies. Of these, 57 studies met the criteria for inclusion in this study.

RESULTS

The search revealed five general measures of cognitive mental workload and their variations. Only one customised measure specifically for medical-surgical nurses was found in the study. Identified measures were collated and categorised into a framework for conceptual clarity. NASA Task Load Index and its variations were the most popular subjective measure of cognitive mental workload in nursing. However, no measure or self-report scale customised for emergency nurses was identified.

PATIENT OR PUBLIC CONTRIBUTION

The findings of this scoping review can inform future research into the cognitive mental workload of nurses. The findings have implications for workplace health and safety for nurses and patients.

An examination of characteristics, social supports, caregiver resilience and hospital readmissions of children with medical complexity

BACKGROUND

Children with medical complexity (CMC) account for 1% of children in the United States. These children experience frequent hospital readmissions, high healthcare costs and poor health outcomes. A link between CMC caregiver social support, resilience and hospital readmissions has never been fully investigated. This study examines the feasibility of a prospective, descriptive, repeated measures research design to characterize CMC and their caregivers, social supports, caregiver resilience and hospital readmissions to inform a larger prospective investigation.

METHODS

Caregivers of CMC with unplanned hospitalizations completed surveys at the index hospitalization and 30 and 60 days after discharge. CMC caregiver and child characteristics, social supports and hospital readmissions were examined using an investigator-developed survey. Resilience was measured using the Resilience Scale-14© (7-Point Likert Scale, score range 14-98), and feasibility was measured by calculating enrolment, attrition, survey completion and item response. Analysis included descriptive statistics and qualitative data visualization.

RESULTS

Of caregivers who were approached for participation, 81.1% consented  and completed 76 surveys. Attrition was 31%. Item response rates were ≥ 90% for all but one item. A total of 62.1% of children had hospital readmissions within 90 days and 37.9% within 30 days. Additionally, 70% of caregivers had home care nursing, but the approved hours were only partially filled. More than 70% of caregiver resilience scores were moderate to high (score range 74-98) and were stable across repeated measures and hospital readmissions. Open-ended question responses revealed the following five categories: All-consuming, Family Reliance, Impact of Covid, Taking Action and Broken System.

CONCLUSIONS

Studying CMC caregiver social supports and resilience using repeated measures is feasible. CMC caregivers reported stressors including coordinating their child's substantial healthcare needs and managing partially filled home care nursing hours. Caregiver resilience remained stable over time, amidst frequent CMC hospital readmissions. Findings can inform future research priorities and power analyses for CMC caregiver resilience.