Clinical Patient Acuity
Measurement in Healthcare and
Oncology Critical Care
Brenda K. Shelton M.S., R.N., CCRN, AOCN
Clinical Nurse Specialist
The Sidney Kimmel Comprehensive Cancer
Center at Johns Hopkins
Baltimore, MD
sheltbr@jhmi.edu
sheltbr@jhmi.edu
4/9/11
Objectives
• Evaluate acuity and prognostic scoring tools that
have been researched for use in critically ill patients
with cancer.
• Identify challenges in implementation of acuity
measurement instruments for oncology units.
• Identify common clinical practice concerns of SIG
meeting attendees.
• Develop an education needs agenda for the SIG and
2011-2012 ONS conference attendees.
Measurement of Acuity: The Problem
• No uniform method of
measurement has been
established.
• Acuity measures have not
been translated to nursing
intensity.
• Acuity is anticipatory,
current, and potential.
• Measurement takes “time”,
and there are no incentives.
Types of Acuity Measurement
Nursing Intensity
• Focus on tasks which may
vary according to setting,
institutional geography,
workflow processes.
• Time oriented does not
always reflect individual
variation.
• Does not usually effectively
factor psychosocial and
family dimensions.
Patient Intensity
• Focus on severity of illness
for the patient.
• Does not always
differentiate needs met by
professionals versus
unlicensed personnel.
• Many tools do not account
for individual patient
variations.
Why does this remain a burning issue?
There is consensus
that we WANT
acuity tools to assist
in making
assignments and
determining nursing
staffing.
What WE want from
acuity measurement tools
is NOT what they claim to
be able to do?
Acuity Measurement in Oncology: State
of the literature
• Pubmed and CINAHL search 1980-20111
– Two existing published oncology inpatient instruments.
– Critical illness prediction models includes cancer patients and
validation with separate studies in cancer patients.
• Acuity/ intensity nursing tools are available from forprofit companies.
• “Oncology units” or specialty units dedicated to
oncology (e.g. BMT) were NOT evaluated in the samples
used to design California nursing staffing ratios.
– Oncology Specialty units are noted as comparable examples to
“step-down” areas.
Oncology Acuity Models
• Arenth (1985)
– Dated
– Small application for validation
• Vanderbilt (2007)
– More recent
– Small application for validation
– Unable to access for details
Arenth Model of Oncology Patient Acuity
(1985)
• Oncology Specific.
• Incorporated common oncology
and critical illnesses.
• Not current for today’s
technology and inpatient
population.
• Does not differentiate high
needs due to infection risk or
self-care deficit from
intermediate care (high
dependency).
Critical Care Acuity Models
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APACHE/ SAPS
ICCM
TISS
MPM
LOD
SOFA
MODS
Interqual McKesson
APACHE (Acute Physiology and Chronic
Health Evaluation)
• Versions I, II, III from original research with large
volume of patients from a variety of settings.
• Shortened version called SAPS-II (Simplified Acute
Physiology Score).
• Used for prognostication in critically ill.
• Not accurate for individual patient assessment.
• Time consuming to perform.
• Most helpful when done repetitively.
Intensive Care Mortality Model (ICMM)
• Based upon APACHE instrument.
• Cancer-specific variables incorporated.
• Found to be predictive for mortality in most
circumstances.
– Not predictive in sepsis.
– Most sensitive when done 72 hours after onset critical
illness.
• Shows important aggregate information.
– Status of cancer is most predictive of survival.
– Neutropenia does not predict for mortality.
Therapeutic Index Scoring System (TISS28 or TISS-76)
• Technology based rather than patient based.
• At risk for bias based upon care that is chosen to be
implemented.
– Underpredicts critical illness in patients with cancer
• Time-consuming to perform.
Mortality Prediction Model
(MPM-II, MPM-III)
• Limited testing in patients with cancer.
• Did not perform well with heterogenous populations.
Mortality Prediction Models for Sepsis
• Logistic Organ
Failure (LOD)
• Sequential
Organ Failure
Score (SOFA)*
• Multiple Organ
Dysfunction
Score (MODS)
• Identifies extremes of excellent
and moribund prognosis.
• Must be used sequentially for best
performance- cancer patients
often experience highest severity
of illness 24-72 hours after onset
critical illness.
• Only SOFA performed well with
patients having hematologic
malignancy.
Interqual McKesson (v2009)
• Several different versions and criteria.
– Cardiac, surgical, medical
– Intermediate (IMC) or critical care
• No single instrument developed from criteria.
• Not clear that selection of criteria is evidence-based.
• No oncology specific variables and unclear how to
incorporate oncologic acuity.
• Not studied to predict patient outcomes.
• Used for determination of unit admission.
• Used to predict and plan staffing ratios.
Interqual McKesson- Sample IMC Criteria
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Anti-infectives > 1 drug, initial two days
Bicarbonate and pH < 7.25
IV medication and titration q 3-4 hours
K < 2.5, < 3.0 with PVCs, > 6.0
KCl admin > 10 mEq/hr or > 120 mEq/L
O2 > or = 40% (5L/min) for < or = 48 hrs
Blood products > 2 products/24 hr (pooled products = 1)
Clinical RN interventions more than q 4 hrs (e.g. assessment, complex skin care, CBI)
Neuro assessments > 5 times/ 24 hr, initial 2 days
Bleeding with any: chest pain, dyspnea, systolic BP < 30 mm from baseline, HR > 100,
> 50 mL blood
GVHD grades 2,3 (grade 4 classed as ICU)
Wound care of at least 30 min > 2 X/24 hr
Sepsis with any 2: T > 100.4 F or < 35.0 C, HR > 100/min, RR > 24/min, WBC > 12,000 or
< 4000
Just when you think you’d like to bail
out, someone else will be thinking….
“my what a great learning opportunity”