Remind physicians about those admissions criteria
Criteria should reflect sound clinical principles
Are the written admissions criteria for your ICU patients getting dumped into the back seat whenever someone pulls rank on your nurses? Many RNs bristle and answer yes when physicians order a patient admitted and the patient clearly doesn’t meet the official criteria.
Based on your staff’s assessment, that same patient could be monitored just as safely on a regular medical-surgical floor. Yet, primary care physicians and even specialists, are apt to sometimes disregard the standards and arbitrarily order the admission, many nurses complain.
It doesn’t happen all the time. But these orders seem to occur whenever the unit is experiencing a bed shortage and there’s nothing that nurses can do about it, says Pamela Hunt, RN, MSN, director of surgery at Marion (IN) General Hospital.
Hunt advises that nurse managers support their staff and the unit’s admission policy and persevere with physicians by sticking to the letter of the law. "Be courteous and professional, but use the published criteria as a backup when speaking with the provider," Hunt recommends.
APACHE can form basis for criteria
Many times, the physician’s decision is based on mere convenience and not medical necessity, Hunt says. Stick to the facts and resort to the criteria as the basis for your convictions, she urges, and don’t wait until there’s a bed crunch to speak up.
Of course, the assumption made in these cases is that the nursing assessment has accurately determined that admitting the patient to the unit would constitute an inappropriate admission. For this reason, the admissions criteria have to be authoritative and based on sound principles.
But what should a good set of criteria be based on? How strong are they when stating your nurse’s case with a provider?
Researchers have been asking the same question but for a different reason. They’ve been looking at better ways to evaluate ICU patients to predict mortality, length of stay, and resource utilization, especially with patients suffering multiple organ failure or following serious cardiac surgery.
The tool they have tested closely in research has been the Acute Physiology and Chronic Health Evaluation system, commonly known as APACHE. The tool was originally designed more than two decades ago at George Washington University in Washington, DC, to classify severity of diseases.
Now the company that developed subsequent generations APACHE II and III says the system can be dependably used to help develop intelligent admissions criteria. The system contains hundreds of thousands of pieces of medical data on acute and critical conditions broken down into specific characteristics.
Though not the only system available, it is one that has been used by researchers in critical care with consistency. For use in developing admissions criteria the tool can pinpoint specific issues such as diagnoses, outcomes, and mortality rates.
It can even help suggest length of stay and appropriate case management for transfer from the ICU for a range of critical cases, says Alicia Saia, a representative with APACHE Medical Systems, the McLean, VA, company that holds the copyright to APACHE II and III.
Tool has certain limitations
The tool has been used extensively to help determine outcomes, for example, in cardiac and other intensive surgical procedures. Although the APACHE will not tell you exactly whether a patient is appropriate for the ICU, it will provide severity-of-illness data that can be used by the medical staff in setting up minimal admission benchmarks.
For example, APACHE III offers a range of mean arterial blood pressure readings and assigns a numerical weight to each reading. Each weight reflects a level of severity that is based on how the patient’s blood pressure relates to 16 other physiologic indicators such as pulse rate and respiration.
The weights also reflect the presence of one or more of seven comorbid conditions, such as arrhythmia complicated by diabetes, that can influence a patient’s immune status and short-term mortality risk in the ICU.
The APACHE then assigns a series of scores to the weights. An increasing APACHE III score (0-299) is associated with a higher risk of hospital mortality. The result is called the Acute Physiology Score (APS). If your patient’s mean blood pressure reading falls within a certain range, the corresponding weights assigned by the tool will suggest a certain level of acuity.
The tool also can measure the type and amount of ICU care needed on a patient and assigns a one to four score based on the increasing level of complexity and effort for 80 diagnostic, monitoring, and therapeutic tasks commonly performed in an ICU blood gas monitoring and ventilator weaning.
In the past, these scores, known as the Therapeutic Intervention Scoring System (TISS), have been used to describe ICU services, evaluate nurse staffing needs, and measure cost and resource use in the unit.1
By using the APACHE scores as a guide, nurses and physicians can set up appropriate values in developing standard assessment criteria for their unit, says Saia. Much of the available data in performing these tasks can be obtained from a software program that APACHE Medical makes available to subscribers.
The database contains more than a half million pieces of patient information to enable clinicians to generate patient profiles based on age, sex, principal diagnosis and other complications. The profile can help complete the nursing assessment and determine whether a patient is right for an admission, Saia says.
"The tool is valuable as a collaborative criteria," says Kathleen Rafferty, RN, MS, cardiac ICU manager at St. Elizabeth’s Medical Center in Boston. Rafferty’s unit has incorporated certain APACHE III measures in developing its admissions criteria.
But Rafferty emphasizes that the tool should not form the central basis for nursing assessment. "It should be used with your nurses’ own experience and judgment," she says.
APACHE III is not foolproof. In one study involving outcomes of surgical patients, the tool underestimated actual mortality rates in patients. And it isn’t applicable for making predictions about individual patients, the study also noted.2
At Marion General, the nursing staff used a little creativity in developing their own admissions criteria. They concentrated their efforts on using the cache of rich patient data sets in the hospital’s records, Hunt says. Clinicians reviewed the clinical data for information about the ICU’s most common critical conditions and developed the findings into a best practice for each condition, Hunt recalls.
The unit keeps separate detailed criteria for a range of conditions, including shock, acute respiratory distress, and renal failure. Among the concerns listed in the criteria for hemorrhaging are: 1) active bleeding; 2) blood pressure of 90/60; and 3) urine output of less than 30 cc.
The point isn’t to keep a set of published criteria on hand, Hunt says. It’s to ensure that they are valid, reflect strong input by the medical staff, and are regularly used, she says.
"As acuity levels rise and beds start to go at a premium, strong admissions criteria that are signed and supported by the medical director will become increasingly important," Hunt concludes.
[Editor’s note: For further information about the APACHE II and III systems, contact: Alicia Saia, marketing and product manager, APACHE Medical Systems, 1650 Tysons Blvd., Suite 300, McLean, VA 22102-3915. Telephone: (703) 847-1400. Fax: (703) 847-1401. E-mail: [email protected].]
References
1. Becker RB, Zimmerman JE, Knaus WA, et al. The use of APACHE III to evaluate ICU length of stay, resource use, and mortality after coronary artery by-pass surgery. J Cardio Surg 1995; 36:1-10.
2. Barie PS, Hydo LJ, Fischer E. Utility of illness severity scoring for prediction of prolonged surgical critical care. J Trauma 1996; 40:513-518.
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