Determinants of increased nursing workload in the COVID-era: A retrospective analysis of prospectively collected data

Workload assessment using the nursing activities score in intensive care units: Nationwide prospective observational study in France

BACKGROUND

Within French intensive care units (ICUs), patients are treated with two levels of care (intensive or intermediate) with different nurse-to-patient ratios legally defined.

OBJECTIVES

We aimed to compare the nursing workload associated with these two levels of care.

RESEARCH METHODOLOGY

A nationwide prospective observational study was conducted in France between April and July 2023. Each ICU was allowed to choose its own two-week period of data collection during which the Nursing Activities Score was collected by nurses at patients' bedside, during each shift. The Nursing Activities Score ranges from 20 to 177% and a 100% score represents a nurse per shift. The number of patients per nurse was collected and the Nursing Activities Score per nurse was assessed.

RESULTS

One hundred and five ICUs participated. Overall, 21,665 measurements of Nursing Activities Score per patient and 9,885 Nursing Activities Score per nurse were collected. ICUs were composed by 2083 beds distributed into 1520 (73 %) intensive care beds and 563 (27 %) intermediate care beds. Among the participating units, 93 (89 %) of the teams worked in 2 shifts. Median [p25-p75] Nursing Activities Score per adult patient was 61 % [49-80] for intensive care patients and 47 % [38-61] for intermediate care patients (p < 0.001). Median Nursing Activities Score per nurse for adult population was 127 % [92-167], 143 % [92-198], and 164 % [126-213] for nurses only providing intensive care, only intermediate care or both levels of care, respectively (p < 0.001). A Nursing Activities Score per nurse value >100 % was observed in 71.4 %.

CONCLUSIONS

Nurses' workload was high in the ICU, especially when providing intermediate or mixed levels of care.

IMPLICATIONS FOR PRACTICE

In order to reduce nurses' workload, a review of the nurse-to-patient ratios is expected. Physically separating the two levels of care may be a valuable option.

Association between nursing workload and staff size with the occurrence of adverse events and deaths of patients with COVID-19: A retrospective cohort study

BACKGROUND

The safety of patients in the intensive care unit (ICU) is significantly impacted by inadequate staffing of nursing professionals to meet the demand for care of critically ill patients. COVID-19 patients increased nurses' workload, particularly in high-intensity care settings like the ICU.

AIM

To evaluate the association of workload and number of patients per nursing professional with the occurrence of adverse events and death in critically ill patients with COVID-19 in the ICU.

STUDY DESIGN

This is a retrospective cohort study. This study analysed patients with COVID-19, aged 12 years or older, admitted between 1 April 2020 and 31 May 2021 in the ICU of a hospital in Brazil. Nursing workload was measured by the Nursing Activities Score (NAS). The independent variables were the ratio of the NAS score per nursing professional (NNR) and the ratio of the number of patients per nursing professional (PNR). Dependent variables included adverse events (pressure injuries and health care-associated infections-HAIs) and death in the ICU.

RESULTS

Of the 386 included patients, 59.59% were male and the median age was 60.5 years. The median NAS, NNR and PNR values were 72.81%, 128% and 1.64, respectively. The frequency of pressure injuries (31.09%) exceeded that of HAIs (16.06%), and 218 patients (56.48%) died. The NNR was associated with HAIs (OR 1.006; CI95% 1.001-1.012; p = .012), pressure injury (OR 1.005; CI95% 1.000-1.010; p = .033) and death (OR 1.010; CI95% 1.005-1.015; p < .001) in the ICU. There was no association between PNR values and the study's dependent variables.

CONCLUSION

A high workload per nursing professional was associated with the occurrence of adverse events and deaths of patients with COVID-19 in the ICU, while the nursing staff sizing was not.

RELEVANCE TO CLINICAL PRACTICE

The results reinforce the importance of evaluating the workload of nursing professionals to establish safety measures for the care of patients with infectious diseases.

Reliability and validity of the Turkish form of intensive care nursing activities score

BACKGROUND

The purpose of this study was to examine the reliability and validity of the Turkish version of the Nursing Activities Score.

METHODS

To validate the Turkish version of the Nursing Activities Score, a sample comprising 30 adult intensive care patients and 30 nurses was employed. After a pilot study, the internal consistency, Cronbach's alpha coefficient, was found to be p = 0.718. Following the significant internal consistency obtained in the pilot study, the correlation between Nursing Activities Score internal consistency and Critical Nursing Situation Index scores was examined in 150 adult intensive care patients and 150 nurses.

RESULTS

The assessment of inter-rater reliability showed a high level of agreement (99%) and an average Kappa index of 0.598 (p < 0.001). Concurrent validity was demonstrated through a statistically significant correlation between Nursing Activities Score and the Critical Nursing Situation Index (r = 0.71, p < 0.001) and multivariate regression analysis (R2 = 83%, p < 0.001). The validity is supported by the statistically significant relationship between Nursing Activities Score and Critical Nursing Situation Index.

CONCLUSION

These results demonstrate that Nursing Activities Score is a valid and reliable tool for measuring nursing workload in Turkish intensive care units.

TRIAL REGISTRATION

Samsun University Samsun Training and Research Hospital, following ethics committee approval (Samsun University clinical research ethics committee (KAEK) 202312/2) and Clinical Trials (NCT04928040) registration.

Impact of a 'Catheter Bundle' on Infection Rates and Economic Costs in the Intensive Care Unit: A Retrospective Cohort Study

INTRODUCTION

Catheter-related infections (CBRSIs) are a widespread problem that increase morbidity and mortality in intensive care unit (ICU) patients and management costs.

OBJECTIVE

The main aim of this study was to assess the prevalence of CBRSIs in an intensive care unit following international literature guidelines for managing vascular lines in critically ill patients. These guidelines include changing vascular lines every 7 days, using needle-free devices and port protectors, standardising closed infusion lines, employing chlorhexidine-impregnated dressings, and utilising sutureless devices for catheter securement.

MATERIALS AND METHODS

This single-centre retrospective observational study was conducted in a general Italian ICU. This study included all eligible patients aged > 1 year who were admitted between January 2018 and December 2022.

RESULTS

During the study period, 1240 patients were enrolled, of whom 9 were diagnosed with a CRBSI. The infection rate per 1000 catheters/day was as follows: femorally inserted central catheter, 1.04; centrally inserted central catheter, 0.77; pulmonary arterial catheter 0.71, arterial catheter, 0.1; and peripherally inserted central catheter and continuous veno-venous haemodialysis dialysis catheters equal to 0. No difference in CRBSI was observed between the years included in the study (p = 0.874). The multivariate analysis showed an association between the diagnosis of CBRSI and Nursing Activities Score (per single point increase β = 0.04-95%CI: -0.01-0.09, p = 0.048), reason for ICU admission-trauma (β = 0.77-95%CI: -0.03-1.49, p = 0.039), and use of therapeutic hypothermia (β = 2.06, 95%CI: 0.51-3.20, p < 0.001). Implementing the study protocol revealed a cost of EUR 130.00/patient, equivalent to a daily cost of EUR 15.20 per patient.

CONCLUSIONS

This study highlights the importance of implementing a catheter care bundle to minimise the risk of CRBSI and the associated costs in the ICU setting. A policy change for infusion set replacement every 7 days has helped to maintain the CRBSI rate below the recommended rate, resulting in significant cost reduction and reduced production of ICU waste.

Weak Correlation Between Perceived and Measured Intensive Care Unit Nursing Workload: An Observational Study

BACKGROUND

Efficient management of nursing workload in the intensive care unit (ICU) is essential for patient safety, care quality, and nurse well-being. Current ICU-specific workload assessment scores lack comprehensive coverage of nursing activities and perceived workload.

PURPOSE

The purpose of this study was to assess the correlation between ICU nurses' perceived workload and the Nine Equivalents of Nursing Manpower Use Score (NEMS).

METHODS

In a 45-bed adult ICU at a tertiary academic hospital, nurses' perceived shift workload (measured with an 11-point Likert scale) was correlated with the NEMS, calculated manually and electronically.

RESULTS

The study included 1734 observations. The perceived workload was recorded for 77.6% of observations. A weak positive correlation was found between perceived and objectively measured workload.

CONCLUSION

Findings indicate a need to consider the multifaceted nature of nursing activities and individual workload perceptions in the ICU.

Effects of closed loop ventilation on ventilator settings, patient outcomes and ICU staff workloads - a systematic review

BACKGROUND

Lung protective ventilation is considered standard of care in the intensive care unit. However, modifying the ventilator settings can be challenging and is time consuming. Closed loop modes of ventilation are increasingly attractive for use in critically ill patients. With closed loop ventilation, settings that are typically managed by the ICU professionals are under control of the ventilator's algorithms.

OBJECTIVES

To describe the effectiveness, safety, efficacy and workload with currently available closed loop ventilation modes.

DESIGN

Systematic review of randomised clinical trials.

DATA SOURCES

A comprehensive systematic search in PubMed, Embase and the Cochrane Central register of Controlled Trials search was performed in January 2023.

ELIGIBILITY CRITERIA

Randomised clinical trials that compared closed loop ventilation with conventional ventilation modes and reported on effectiveness, safety, efficacy or workload.

RESULTS

The search identified 51 studies that met the inclusion criteria. Closed loop ventilation, when compared with conventional ventilation, demonstrates enhanced management of crucial ventilator variables and parameters essential for lung protection across diverse patient cohorts. Adverse events were seldom reported. Several studies indicate potential improvements in patient outcomes with closed loop ventilation; however, it is worth noting that these studies might have been underpowered to conclusively demonstrate such benefits. Closed loop ventilation resulted in a reduction of various aspects associated with the workload of ICU professionals but there have been no studies that studied workload in sufficient detail.

CONCLUSIONS

Closed loop ventilation modes are at least as effective in choosing correct ventilator settings as ventilation performed by ICU professionals and have the potential to reduce the workload related to ventilation. Nevertheless, there is a lack of sufficient research to comprehensively assess the overall impact of these modes on patient outcomes, and on the workload of ICU staff.