Nursing Activities Score, Nurse Patient Ratios, and ICU Mortality: Its More Complicated Than That.
Nursing Activities Score, Nurse Patient Ratios, and ICU Mortality: Its More Complicated Than That.
复制标题
护理活动评分、护士患者比率和 ICU 死亡率：比这更复杂。
作者：
E. Scruth
126 www.ccmjournal.org January 2020•卷48•编号1护理诊断、结果和干预措施都是患者复杂性的衡量标准。ICU的护理需求需要通过循证、可靠和有效的系统来精确测量。该系统应量化护士的工作量，包括所有方面，包括非护理任务和可能发生在危重病人身上的事件。目前有几种分类系统用于量化临床表现和探索工作量对护士敏感结果的影响。得分系统并不平等。其中包括治疗干预评分系统（TISS-28），这是原始TISS的简化版本，由28个项目组成，并在22个荷兰ICU进行了验证，2000年由Lefering等人（1,2）在德国的一个大型外科ICU进行了进一步验证。九等量护理人力使用评分（NEMS）通过描述治疗干预措施的九个项目来衡量工作量表现。该指数从1到56分加权，每天回顾性评估一次(3)。NEMS的开发是为了比较不同单位的护理工作量，而不是最初设计用于单个单位的基础上。护理活动评分（NAS）衡量患者层面的护理工作量，考虑治疗和护理活动的平均时间消耗，包括卫生、动员、行政活动、对患者和家属的心理支持以及患者护理(4)。NAS由23个条目组成，每个条目的总得分为1% ~ 177%(4)。所有这些计分系统都是按每班或每天回顾性计算的。与TISS-28和NEMS相比，NAS在评估护理活动方面更具体，并已在15个国家的99个ICU中得到验证，解释了81%针对患者的护理时间（4,5）。在本期的《重症监护医学》中，Margadant等人(6)报告了护理工作量与住院死亡率之间的关系，对比了重症监护室的病人护士比例和住院死亡率。采用NAS量表对护理工作量进行量化。这项大型研究是在15个荷兰icu中进行的，为期2年。作者使用回顾性设计和逻辑回归模型对队列进行分析。数据提取自荷兰国家重症监护评估（NICE）质量注册表，该注册表允许计算每班每位患者的NAS所需的所有数据项(7)。作者评估了平均或第1天每名护士的比率，以及每名护士每名患者的NAS比率与院内死亡率的关系。对2016年1月1日至2018年1月1日收治的所有ICU患者进行结局评估。作者观察到，每名护士的NAS比大于41，无论是平均每名护士的NAS比还是ICU入院第1天的每名护士的NAS比，都与更高的住院死亡率相关（优势比[OR]， 1.19和1.17）。每名护士的平均NAS比大于61，以及第一天和住院死亡率的每名护士的NAS比都是显著的（OR， 1.29和1.26）。病人/护士比率与住院死亡率无关。这些数据应该在更大的背景下谨慎解读。第一个警告是Margadant等人(6)的研究使用了NICEa质量注册表的数据。登记处的数据是回顾性收集的；因此，在分析中，缺失的数据很难解释。NICE的护理工作量模块是可选的，其中icu每班登记全职等效护士的数量和计算每班每位患者的NAS所需的所有项目。尽管护理工作量模块90%的数据是从电子病历（EMR）中提取出来的，但一些医院要求护士在轮班结束时手动将数据注册到EMR中的特定表单中。作者没有说明研究中包括的15家医院中是否有任何一家要求ICU护士手动输入数据。其次，该研究是回顾性进行的，允许关联而不是因果关系。第三，由于研究的设计，缺失的数据无法解释。NAS没有考虑到一些与患者临床状况无关的因素。这些是难以衡量和量化的，迄今为止，没有包括在任何患者分类评分系统中。护理人员的资格和能力，年资在0090-3493
126 www.ccmjournal.org January 2020 • Volume 48 • Number 1 Nursing diagnoses, outcomes, and interventions are all measures of patient complexity. Nursing care requirements in the ICU need to be accurately measured with systems that are evidence-based, reliable, and valid. The systems should quantify workloads of nurses that include all aspects including nonnursing tasks and events that could potentially occur in critically ill patients. There are currently several classification systems used to quantify clinical performance and to explore the effects of workloads on nurse-sensitive outcomes. The scoring systems are not created equally. These include the Therapeutic Intervention Scoring System (TISS-28)—a simplified version of the original TISS, consisting of 28 items and validated at 22 Dutch ICUs with further validation conducted in 2000 by Lefering et al (1, 2) in a single large surgical ICU in Germany. The Nine Equivalents of Nursing Manpower Use Score (NEMS) measures workload performance by describing therapeutic interventions in terms of nine items. The index is weighted from 1 to 56 points assessed retrospectively once a day (3). The NEMS was developed to compare nursing workloads across different units and not originally designed to be used on an individual unit basis. The Nursing Activities Score (NAS) measures nursing workload at the patient level considering the average time consumption for therapeutic and nursing activities including hygiene, mobilization, administrative activities, psychologic support for patient and family in addition to patient care (4). NAS consists of 23 items with subitems with summed scores 1% to 177% (4). All these scoring systems are calculated retrospectively on a per shift or per day basis. Compared to the TISS-28 and NEMS the NAS is more specific in assessing nursing activities and has been validated in 99 ICU’s in 15 countries explaining 81% of nursing time directed toward patients (4, 5). In this issue of Critical Care Medicine, Margadant et al (6) report the association of nursing workload on in hospital mortality, compared to patient nurse ratios and in hospital mortality in ICUs. Nursing workload was quantified with the NAS instrument. The large study was conducted in 15 Dutch ICUs over a period of 2 years. The authors analyzed the cohorts using a retrospective design and logistic regression models. Data were abstracted from the Dutch National Intensive Care Evaluation (NICE) quality registry which allowed for all data items needed to calculate the NAS per patient per shift (7). The authors evaluated the association of mean or day 1 patient per nurse ratio, and NAS per patient per nurse ratio with in hospital mortality. All ICU patients admitted from January 1, 2016, to January 1, 2018, were evaluated for outcomes. The authors observed NAS per nurse ratio of greater than 41 for both mean NAS per nurse ratio as well as NAS per nurse ratio on day 1 of ICU admission were associated with a higher in hospital mortality (odds ratio [OR], 1.19 and 1.17). A NAS per nurse ratio of greater than 61 for both mean NAS per nurse ratio as well as NAS per nurse ratio on day 1 and in hospital mortality were significant (OR, 1.29 and 1.26). Patients per nurse ratio was not associated with in hospital mortality. The data should be interpreted with caution and in a larger context. The first caution is that the study by Margadant et al (6) used data from NICEa quality registry. The data in the registry is collected retrospectively; therefore, missing data are difficult to account for in analyses. The nursing workload module in NICE is optional, in which, ICUs register each shift the number of full-time equivalent nurses and all items needed to calculate the NAS per patient per shift. Although 90% of the data for nursing workload module is abstracted from the electronic medical record (EMR) some of the hospitals require the nurse to manually register the data into a specific form in the EMR at the end of their shift. The authors did not state if any of the 15 hospitals included in the study required the ICU nurse to manually input data. Second, the study was conducted retrospectively allowing for associations not causalities. Third, due to the design of the study missing data could not be accounted for. There are several factors the NAS does not account for that are not related to the patient’s clinical condition. These are difficult to measure and quantify and to date, are not included in any of the patient classification scoring systems. Qualifications and competence of the nursing staff, years of experience in the 0090-3493