Kelsey Jones, BSN, RN, MEDSURG-BC, is the Patient Acuity Nursing Tool (PANT) project coordinator for Sentara Health System in Virginia and North Carolina that encompasses 12 hospitals. The PANT tool is used to calculate the workload of the direct patient care team, based on the nursing interventions documented in the electronic health record (EHR).
The tool’s scores are validated by direct care nurses and support decisions about patient assignments and unit-level staffing grids. Jones was the lead nurse on the team that developed the tool, working alongside data scientists, IT developers and a nurse scientist. Jones spoke with AACN Clinical Practice Specialist Sarah Delgado about the tool and how other units can implement it.
Tell us a little about the Patient Acuity Nursing Tool (PANT) and what it does?
The PANT workload tool is an algorithm that the Sentara Health team has designed in the background of the electronic health record (EHR) that is calculating the amount of time it takes for the direct patient care team to provide safe, quality care. It does not dictate the composition of the nursing care team or which roles are performing the nursing tasks (e.g., registered nurse, licensed practical nurse, unlicensed assistive personnel). We identified an amount of time that is associated with different workload elements. We attached that time to a specific place in the electronic health record, so that as the nurse documents a flow sheet or a physician order, it will ping in the background to calculate a total workload score. It's calculated every two hours on the odd hour, 24 hours, seven days a week. It's a live, inpatient tool for our medical-surgical, surgical, intermediate or progressive care, and intensive care or critical care settings.
And this tool is used across all 12 hospitals; is that right?
Yes, it certainly is. We piloted it on a couple of our med-surg units at one hospital. When that pilot was successful, we branched out to then include all med-surg units. It has been an iterative process over the years, as we added to med-surg with intermediate care, oncology and critical care workload items over the last five years. Now the tool is used on more than 100 nursing units across the 12 hospitals.
Can you describe your process of developing PANT?
First, we met with our clinical team members for the specific level of care. So med-surg with med-surg nurses, intermediate with intermediate care nurses, critical care with critical care nurses. And with each of those stages we met with them and determined which workload elements we wanted to address. The med-surg build was a foundational build that included general nursing elements such as medication administration, Foley catheter care and head-to-toe assessments. Once we identified the workload element, we sat down with the team and asked the question, “How much time is it taking you to provide direct and indirect aspects of nursing care?” In other words, how long does it take you to prepare for the task by gathering supplies, perform and document the task?
Then we surveyed all of the nurses in our system for that level of care. So for med-surg, it was around 2,000 nurses that we surveyed and received valid surveys. We then met with clinical team members (the subject matter experts), to review the survey results and determine a final time associated with each workload element.
Something that's unique to our algorithm is the equation that translates time, in minutes, to a PANT workload score. The workload score is then linked to a place in the EHR. Part of this development process has also streamlined our documentation practices. Over the years, we have identified duplicative documentation or elements that could be improved upon to ease the documentation burden for our clinicians. Our IT team members then designed and built the EHR algorithm.
From there, we validated the algorithm in two main ways. First, once it went live, we sat down with our clinical team and asked, “Is this score reflective of the work that you are performing? Is it what you would expect to see?” There were times that the team said, “Yes, that feels right.” And then there were times they said, “No, that does not feel right.” And so we would dig into the scores and determine what's missing, or is something not triggering properly?
A really good example of this “what's missing” category is when we sat down with our intermediate-care-level build. We had this patient who had a complex workload. They were bedbound and required total assistance with feeding. We were capturing many different activities of daily living but identified a need to more precisely capture “assistance” as partial or total assistance with feeding. And so that was a really great example of how sitting down with clinical team members to validate our tool resulted in a more comprehensive score that was more reflective of the patient care being performed.
The second thing that we did was an extensive analysis of historical data. So, we would take the first month or the first quarter, and we would pull every PANT score to analyze the outliers. When you're looking at data, you want to see an even distribution of numbers in the bell curve. There will always be outliers, the scores that fall three standard deviations away from the median. We evaluated each of the outlier scores that were above three standard deviations (the very high scores). We looked at each contributing workload element to determine what element(s) were driving the scores very high. In doing this, we were able to identify algorithm updates.
Can you describe the situation you had in one ICU with outliers and the changes they drove?
Yes. As I mentioned earlier, this build has been iterative, starting with med-surg and adding additional workload elements including critical care. As we started to build critical care, we realized that there are so many layers for one, single workload element. A good example was pulmonary artery catheters. Some people might view pulmonary artery catheters as a “whole” task and hypothetically assign 60 minutes every shift. But it's not just a blanketed 60 minutes. There are multiple components: the insertion, maintenance and removal of the catheter. Each time, you perform and document hemodynamic monitoring interventions such as wedge pressure and waveforms. What I want to convey is that the more pointed we are about what, where and how often something is being documented, the more reflective the score is. If the patient’s acuity is changing and you are having to document interventions more often, you can see those changes in the score. That is the beauty of PANT!
I mentioned that we've crosswalked this against our staffing grids. Our Process Improvement Team manages staffing grid resource allocation for our hospital, and we have a great, collaborative relationship with that team. By including them in our development along the way, it has helped with their confidence in what our tool is and that the scores are reflective of nursing workload.
One example from the recent grid review cycle is a cardiac surgery intensive care unit; they have significantly higher-scoring patients. When we evaluated their data, the majority of the scores fall within three standard deviations (the bell curve I mentioned earlier), but their scores are significantly shifted toward the higher end. They also have more outlier scores; to be exact, 5% of their patient population on a monthly basis falls into this “very high score” category. So when we talk about the importance of acuity-based staffing or the need to have acuity and workload driving the resources allotted by our nursing grids, this is a perfect example. We were able to show the intensity of the work that is required to provide patient care and help justify the need to be bumped up into a different critical-care-level grid! That's just really great to have data driving these discussions and to be able to sit down with non-nursing team members and help them better understand what it means to provide nursing care.
Was there a change nurses needed to make in the documentation in order for PANT to function?
No. Documentation burden is real! PANT calculations occur in the background; we are simply asking that our clinical team members document what they've performed, so it's no additional work. I will say this tool has highlighted the need to document in real time as best we can. That continues to be a struggle.
I understand you've recently done some work with your system leadership for PANT.
So a few things. This idea started with two clinical nurses at Sentara Leigh Hospital who wanted to have a more objective way to drive their patient assignment process. We worked with our research team and determined that we needed to build something internally. Our leadership team had the foresight to incorporate it into our strategic plan. I believe that has been one of the most successful elements of this project. My recommendation to people who are trying to move any type of innovative solution forward is to get buy-in from your executive team to help break down the barriers and provide the resources for you to be successful.
The Nurse Executive Team has been involved since the project’s inception, and we provide updates to their team on a regular basis. This team provides the “big picture,” which guides the project’s overall goals. And the flip side of that is, PANT contribute to our greater system goals by incorporating leadership, providing frequent updates, and maintaining transparency (tool development, adoption, positive and negative feedback from staff, etc.).
Another meaningful takeaway that we’ve been focused on this past year is sustainability. We've incorporated information about PANT into our charge nurse and our preceptor nurse training materials as well as our nurse manager competency tool. We’ve created online learning modules and established site leads at each hospital division.
And the charge nurses look at the PANT score to make patient assignments?
They do, yes! So like I said, PANT updates every two hours, 24/7. Charge nurses use this to drive their patient assignment decisions in combination with their clinical decision-making. Room location, isolation, critical medications, all of that still factors into the decision. Now you have an objective tool (PANT) to ask, “Is this equitably distributed among our team?” “Does it make sense for me to have a slightly lower score for somebody who's freshly off orientation, etc.?” So you're able to balance the scales of patient care needs and staff needs.
Is there other advice you would give nurses who are looking to do something similar?
I think that anytime you are trying to improve your work environment, you have to go into it with the expectation that it's not an easy process. You're going to have to put in just as much work as you do with different types of nursing. That was a big shift personally when I changed from doing patient care to being in an office setting. It is a different mindset, but you have to remember that advocating for our nursing profession is worthy of the work … and it's good work! Also, nursing 101 is to know your resources, so find people who want to help, who are passionate. Last, don’t forget to involve the people who are impacted. It must matter to your clinical team, because if your clinical team doesn't feel it's important, it's not important. In order to be successful, you will need buy-in from both leadership and your clinical team members.
It sounds like it took a fair amount of persistence. You didn't develop this overnight; am I right?
It's been seven years in the making and it's really cool to be on this side of it! For many years, the project has only lived internally for the Sentara Health system and, now, we are sharing this on external platforms. We believe the Sentara PANT tool is a highly reliable, validated workload tool. It has been incredibly validating to talk to people across the country and come away from it realizing that, yes, we are on the right track. Yes, we have established a great process. Yes, there is always room for improvement, but it's a really great start! … Quantified nursing care reinforces the value of nursing care!
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