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Enfermería Global

On-line version ISSN 1695-6141

Enferm. glob. vol.17 n.52 Murcia Oct. 2018  Epub Oct 01, 2018

https://dx.doi.org/10.6018/eglobal.17.4.303011 

Originals

Dependency levels in hospitalized patients in surgical units of a university hospital

Francine Lima Gelbcke1  , Ana Paula de Souza2  , Bruna Cunha2  , José Luís Guedes dos Santos3 

1 Enfermera. Profesora Asociada del Departamento de Enfermería de la Universidad Federal de Santa Catarina. Florianópolis/SC, Brasil. francine.lima@ufsc.br.

2 Estudiante de Enfermería. Universidad Federal de Santa Catarina. Florianópolis/SC, Brasil.

3 Enfermero. Profesor Asociado del Departamento de Enfermería de la Universidad Federal de Santa Catarina. Florianópolis/SC, Brasil.

ABSTRACT:

Objective:

To identify the dependency levels of hospitalized patients in surgical clinical units.

Method:

It is a cross-sectional study. A total of 5,083 evaluations were performed through the User Dependency Evaluation Tool between May and October 2015, totaling 120 days of collection in two surgical hospitalization units of a university hospital in the southern region of Brazil. The User Dependency Evaluation Tool is a new Patient Classification System developed in Brazil to access the patients’ dependency levels and the demand of the nursing team.

Results:

It was evidenced that in 2,452 (48.2%) of the evaluations the patients required intermediate care, followed by 1,913 (37.6%) requiring minimal care, 652 (12.9%) requiring high dependency care and 59 (1.1%) requiring semi-intensive care. No patients were classified as requiring intensive care.

Conclusion

The results identified the degree of patient dependency in relation to nursing care, providing support to the management practice in nursing, especially for staff dimensioning in surgical units.

Key words: Nursing evaluation; Classification; Security management; Nursing human resources

INTRODUCTION

In the context of nursing management, staff dimensioning has gained increasing importance for the planning of care actions aimed at patient safety and quality of care in health institutions1 . In addition, it also aides cost management, better utilization of location and human resources, ensuring greater effectiveness and nursing team productivity2 .

The use of a Patient Classification System (PCS) is one of the main strategies for adequate staff quantification planning3 . The PCS identifies the nursing care demands of the patients, allowing the workload of the team and its quantitative-qualitative adjustment to be monitored , when necessary. Based on these data, nurses can also characterize the patients' care profile and readjust their allocation in the units4 . In Brazil, the importance of PCS implementation in professional practice was recognized by the Federal Nursing Council (COFEN) through Resolution 293/045 and updated by Resolution 527/166 , which establishes the minimum parameters for nursing staff dimensioning.

Among the PCSs used in Brazil, the tool called "Level of Dependency of Users" was elaborated in 2012 by the Laboratory for Research on Work, Ethics, Health and Nursing (Laboratório de Pesquisa sobre Trabalho, Ética, Saúde e Enfermagem - PRÁXIS) in the Federal University of Santa Catarina, Brazil7 . The instrument Level of Dependency of Users was adapted from Fugulin's instrument8 , resulting from the identification of the need to include other factors which interfere with nursing care, such as cutaneous mucosal integrity, education / communication, sleep and rest, emotional security, sensory organ perceptions, as well as caring for the family7.

In recent years, there has been a growing scientific production on care complexity and patient care demands in relation to nursing1)(2)(3)(4)(9)(10)(11 . However there are no studies in the literature regarding the demand of the nursing team based on the Level of Dependency of Users. In addition, the analysis of patient dependence level is a constant demand from health institutions, especially considering the particularities of each professional nursing practice context.

The surgical hospitalization units are the places where the necessary services are provided to people with health needs who require hospital admission. Therefore, they are relevant and determinant scenario of health care aimed at the population12. Specifically in relation to the hospital context of this study, the surgical units underwent recent changes in the patient care complexity profile. One of the units started attending patients who had bariatric surgery, neurological surgery for the correction of epilepsy and liver transplantation. The other unit started to receive patients from the medical clinic, as well as the patients from the surgical clinic.

Thus, it became necessary to classify patients according to the level of care complexity, both to assess the demand for nursing staff to perform the care and to identify other aspects of care demands that vary according to the seasonality and complexity of care that these patients require. Thus, this study questions: what is the level of dependence for patients hospitalized in the surgical clinic units of a university hospital?

Based on the presented panorama, the objective of the research was to identify the level of dependence of patients from clinical surgical units of a university hospital.

MATERIAL AND METHOD

This is a descriptive-exploratory study with a quantitative approach. The research area included two surgical hospitalization units in the University Hospital of the Federal University of Santa Catarina, Florianópolis, Brazil, which are identified as Unit A and Unit B. The units care for patients of both sexes, who are hospitalized for treatment through the Brazilian Unified Health System (SUS).

The Unit A has 30 beds and is characterized as a general surgery unit, which also serves medical specialties such as: liver transplantation, neurosurgery, thoracic surgery, head and neck, and maxillofacial, as a specialty of dentistry. The nursing team consists of 30 professionals, of whom include 8 nurses and 22 nursing technicians or nursing assistants. The Unit B also has 30 beds which provides care for patients in four specialties: vascular surgery, plastic surgery, urological surgery and proctological surgery. In addition, it cares for patients with clinical pathologies, mainly related to neoplasias, digestive, respiratory and neurological diseases. For these services, it counts on 31 nursing professionals, consisting of 8 nurses, 20 nursing technicians or nursing auxiliaries and 3 nursing assistants. Data collection was performed between May and October 2015, totaling 120 days of collection in each of the units. Thus, an intentional sample of 5083 evaluations was obtained. The collections were carried out by two nursing students, who had already developed practical activities in the surgical units, having been trained to do so and under the supervision of the extension project team titled: "Evaluation of the user dependence level: validation and improvement of a computerized instrument".

Data were obtained through consultations with the patient's chart and direct observation, i.e. from the evaluation of the patient's care needs. The evaluations were carried out daily from Monday to Friday, except public holidays, with all the patients of the unit and referred to the 24 hours of the previous day, except for those who, at the time of data collection, were in exams or surgical procedures or other out-of-unit procedures. It is emphasized that, according to the length of stay, the same patient was evaluated more than once in the period of data collection.

In the data collection, the evaluation instrument the Level of Dependency of Users7) was used, which is constituted of 16 evaluation indicators, including: mental state (neurological regulation), perception of sensory organs, oxygenation therapy, hormonal regulation, food, water intake, elimination/vomiting/drainage, vital signs/central venous pressure/mean arterial pressure, ambulation, mobility, body care, cutaneous and mucosal integrity, sleep and rest, emotional safety, and family, companion. Each score indicator has a score range from 1 (lowest score) to 5 (highest score). From this classification, a minimum score of 16 points and maximum of 80 can be obtained, and the patient is classified according to the following scores: minimal care (MC): 16 to 26 point, intermediate care (IC): 27 to 37 points, high-dependency care (HDC): 38 to 48 points, semi-intensive care (SIC): 49 to 59 points, intensive care (IC): up 59 points. The content validation of the instrument was carried out in 201513 .

The data collected was charted and recorded using the Microsoft Office Excel® program and analyzed by simple percentages. The results were presented in Tables with the absolute and relative frequency calculations.In addition to the data collection with the GDU, the reports and statistical bulletins related to the hospital movement were also consulted. These sources were used to identify the occupancy rate of the beds and the average length of stay of the patients in the two units where the study was developed.

From the data related to the classification of patients, the personnel was calculated from the two units. The formula recommended by the Federal Nursing Council in Brazil6) was used, in which the nursing hours are determined by means of the classification of patients, application of the technical safety index and weekly hours worked for the definition of the constant of Marinho. The constant of Marinho is a constant number defined by a scholar Brazilian and applied in the personnel sizing, by recommendation of the Federal Nursing Council.

The study was approved by the Ethics Committee, and registered on the National Information System on Ethics in Research: CAAE n° 39820314.0.0000.0110.

RESULTS

During the data collection period, the bed occupancy rate in the Unit A was 79.5% and the mean length of stay of the patients was 5.56 days, with the Unit B showing a bed occupancy rate of 74.9% and the mean patient stay of 6.23 days. In relation to the classification of dependence level, the predominance of patients in minimal care (n=1192; 49.4%) in Unit A and in intermediate care (n=1426; 53.4%) in Unit B was obtained. The complete classification of patient dependence level in the units is presented in Table 1 .

Table 1 Classification of patient dependence level. Florianópolis (SC), 2015. 

The majority of users throughout all months of data collection who were cared for at Unit B consisted of patients requiring intermediate care. In Unit A, where patients predominate in minimal care, it was observed that in July most of the patients required intermediate care (n=210; 56%) from the nursing team. Table 2 presents the classification of users over the months that covered the period of data collection in the units.

Table 2 Classification of users over the months that covered the period of data collection. Florianópolis (SC), 2015. 

*MC = Minimal care; IC = Intermediate care; HDC = High dependency care; e, SIC = Semi-intensive care

From the data on the degree of dependence of the patients, the quantity of personnel of the two hospitalization units was defined. The formula recommended by Federal Nursing Council in Brazil6 was calculated from the calculation of Total Nursing Hours (TNE) and Constant of Marinho (KM), as shown in Table 1:

Table 1 Formula for calculating staff dimensioning 

It should be noted that for the TSI definition, the absenteeism rate of around 20% and the 30-hour workweek were taken into account.

Based on the above formulation, a total of 30 workers (9 nurses and 21 nursing technicians) were identified for Unit A an a total of 40 workers (13 nurses and 27 nursing technicians) for Unit B were identified. The distribution of professionals considered the group of patients with the highest prevalence - minimum care in the Unit A and intermediate care in Unit B, as defined in Resolution 527/166 .

DISCUSSION

The patient classification systems allow to establish the relationship between the demand for patient care and the offer of care defined by the number of available workers aiming for quality patient care and safety. Brazilian studies on staff dimensioning have been carried out in recent years with varied focuses and objectives, mainly emphasizing the proposal of scale models14 , literature review15) and evaluation of several services using existing scales such as Fugulin, from Perroca, the Nursing Activities Score, the Therapeutic Intervention Scoring System (TISS - 28), among others3)(9)(15)(16 .

In this sense, the innovation of this study corresponds to the use of Level of Dependency of Users Tool, which is a validated instrument which extended the instrument proposed by Fugulin7 . Thus, this is the first study conducted in Brazil using Level of Dependency of Users Tool to evaluate hospitalized patient dependence levels in surgical clinics. The results showed a higher concentration of patients requiring intermediate care, followed by minimal care, high dependency care and semi-intensive care. This result is compatible with the characteristics of a university hospital, which receives and provides care to cases which range from simple to complex. Similarly, a study in surgical units using the Perroca instrument found a predominance of semi-intensive patients, followed by intermediate care, justifying these data as a function of the hospital's profile, which is characterized as highly complex9 .

In relation to the surgical units in which the data were collected, the Unit A had the highest patient turnover (52.2%) in relation to Unit B (43.7%). This can be explained by the fact that in the Unit A patients are submitted to procedures that require short periods of hospitalization, such as patients admitted for thyroidectomy or appendectomy. Regarding the degree of dependence, the predominance of patients requiring minimal care (49.4%) in Unit A and a small number of patients in semi-intensive care (0.2%) were obtained. In Unit B, there was a predominance (53.4%) of patients requiring intermediate care. In addition, patients in semi-intensive care accounted for 1.99% of admissions, higher than in SHU-I.

The predominance of patients in intermediate care is related to the profile of the patients treated in the Unit B who obtained higher scores on the Level of Dependency of Users Tool for mobility, locomotion, body care and mucosal integrity. In this unit, the patients are submitted to procedures that require long periods of hospitalization and thus require more care from the nursing team, as in the case of vascular surgeries and treatment of large burns. In addition, the SHU-II also serves medical clinic patients, mostly elderly, who have a longer period of hospitalization.

A study carried out in an inpatient unit of a teaching hospital outside of São Paulo city in Brazil showed that 43.9% of the patients were 60 years old or older17 . This portion of the population corresponded to 53% of the patients of a medical clinic unit in Brasília, Brazil18 . In comparison to young patients, the elderly are at increased risk of complications, such as falling out of beds, urinary tract infections associated with bladder catheterization, adverse outcomes associated with the use of restraint, and development of acute confusion. Therefore, the patient with these characteristics requires differentiated nursing care, as well as greater attention from the nursing team professionals19)(20 .

Reinforcing this line of thought, research carried out in a urological unit in a hospital in Spain pointed out that the level of dependence increases when patients are older21 . Another study developed in a medical clinic unit of a Swiss university hospital showed that as care complexity increases, more nursing time is needed to perform patient care. In addition, a greater number of nurses contributes to patient safety22 .

Patients in semi-intensive care are usually bedridden and require bathing in bed, continuous O2 use, enteral nutrition support, bladder catheter and drains, items that have a higher score on the classification instrument. It is expected that they represent a smaller number in surgical units, because after more complex surgical procedures patients go to the Intensive Care Unit, where they remain until their clinical and hemodynamic parameters are stabilized.

Regarding the degree of dependence, the predominance of patients requiring minimal care (49.4%) in Unit A and a small number of patients requiring semi-intensive care (0.2%) were obtained. In Unit B, the predominance of patients requiring intermediate care (53.4%) was found. In addition, patients requiring semi-intensive care accounted for 1.99% of admissions, higher than in the Unit A.

Another result that attracted attention was the number of patients requiring minimal care, referring to those awaiting surgery. These data corroborate the study findings using the Perroca instrument in surgical hospitalization units, in which the majority of patients were classified as requiring minimal care, and the level of complexity varied after performing the surgical procedure, later returning to minimal care23 .

Studies point out the need to establish the complexity profile of patient care in the unit so that the adequate number of workers can be estimated so that the team is not overworked1)(2 . The use of a systematized instrument helps to have a classification pattern in the daily follow-up of patients. In addition, classification tools allow us to identify changes in the complexity profile of hospitalized patients due to the seasonality of the pathologies or the increase in chronic diseases due to the aging process and changes in the population profile20)(24 .

Regarding the calculation of personnel, it is observed that the current number of Unit A workers, considering the occupation rate and the degree of complexity of the patients, is adequate. In the Unit B, there is an under-dimensioning of the team, which was defined mainly by the greater degree of complexity of the patients. The adequate number of nursing professionals is of extreme importance, as it guarantees the quality and safety of care.

Adequate nursing staff dimensioning is considered an incentive factor for excellent professional nursing performance. This issue should receive special attention on the part of managers, because the quality of customer service is directly linked to the employees` satisfaction, especially with regard to nursing staff, which work in direct contact with the patient in the hospital25 . Therefore, it is imperative that nursing managers and health organizations seek strategies to overcome the difficulties in allocating human, financial and technological resources for a service based on best practice.

The use of Level of Dependency of Users was adequate for the establishment of the assistance complexity profile, contributing to adequate staffing. Thus, the main contribution of this study is to provide scientific evidence for the planning of nursing care and nursing staff/personnel dimensioning for the investigated area. The differences in the level of patient dependence of the two surgical units were already expected, given the specificities of the patients treated in each of them. However, until the development of this research, such differences were based only on the perception of nursing professionals and managers.

One limitation of the research was that data regarding sociodemographic characteristics and the pathology and/or reason for hospitalization were not collected. Thus, it is recommended that future investigations include these variables in order to test associations with care categories. Further studies are also needed to investigate the relationship between the number of nursing care hours for each category of care regarding safety and quality.

CONCLUSIONS

The present study contributed to knowledge regarding to the level of patient dependence from surgical hospitalization units of a university hospital. It was found that in 2,452 (48.2%) of the evaluations the patients required intermediate care, followed by 1,913 (37.6%) minimal care, 652 (12.9%) high dependency care and 59 (1,1%) semi-intensive care. Patients with this degree of complexity were usually not admitted to intensive care units.

The Level of Dependency of Users Tool proved to be feasible as a means of evaluating and monitoring the care needs of the hospitalized patient. In addition, it is a tool that can help the process of staff dimensioning for nursing teams in inpatient units, considering the units’ particular area of care.

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Received: September 03, 2017; Accepted: October 18, 2017

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