Using Patient Acuity to Inform Care Placement
By Richard Watson, MD
Ensuring that patients are placed in the right facility at the correct level of care is critical for healthcare efficiency. While hospitals often use patient acuity measurements—an assessment of the intensity of care needed by a patient—to better leverage their nursing resources and ensure more equitable assignments, they also commonly use patient acuity to match resources of all types to the current demand.
Accurately and consistently assessing patient acuity is important not only for workload balancing, but also for placing patients in the correct level of care. In many instances, low-acuity patients receive treatment in high-acuity hospitals, even though they would be better placed in another facility. Utilization review research has shown that many acute hospital bed days do not meet the criteria for an acute level of care, and a significant portion of medical emergency admissions remain in the hospital for non-acute care.
Identifying patients who are appropriate candidates for transfer to an alternate level of care can be challenging without a standardized process. Once these patients are identified, logistical process and scheduling delays—including waiting for clinical reviews, specialist consultations, procedure results, and discharge—can impede patient flow. Hospitals can also be reluctant to transfer patients, as they do not want to incur a financial loss. Our focus should be on getting patients to the best hospital for their condition, so we can open those high-acuity beds for patients who actually need them.
Given these systemic limitations, ensuring that patients are in the appropriate hospital for their condition can be challenging. The patient’s acuity functions as the most crucial information when making a point-of-care decision: Should this patient’s needs be met here, or at another facility? Having a standardized process regarding when, why, and how patients should be transferred to another facility can help hospitals make timely decisions to transfer both low- and high-acuity patients. When hospitals establish best practices for particular conditions, circumstances, and constraints, they are better positioned to keep the patients they can treat.
Use objective acuity tools to mitigate risk and empower staff
Some health systems already rely on patient acuity systems, which typically use evidence-based criteria, clinical characteristics, and workload indicators to provide an objective acuity score. These tools help balance nursing assignments by equitably distributing the workload, thereby improving nurse satisfaction and reducing patient safety concerns. Without adequate resources at hand, patient outcomes can suffer.
A study published in the International Journal of Studies in Nursing examined common challenges created by volume-based census staffing models, which do not account for patient acuity. Nurses who are caring for high-acuity patients may not have the time to recognize changes in a patient’s condition, which can lead to rapid deterioration and a resuscitation event. The authors found that failure to rescue is associated with inadequate staffing, lack of competency addressing the problem, and no tools to measure acuity.
While the authors noted that nursing is moving toward acuity-based staffing models, they also stated that “nurses are not guaranteed adequate staffing based on acuity” regardless of the data an acuity tool provides. To implement acuity-based staffing successfully, facilities need support from administrators, adequate reimbursement, and staffing availability.
When patients’ clinical severity and nurse workload indicators are misaligned, both patients and nurses take on more risk. By providing more structure and objectivity in our approach to patient acuity, we can better balance patient needs with a facility’s capabilities. When we empower our nurses with the right data and digital tools, we are more likely to be successful in the long run. This means that we must invest in our nurses, take stock of what they can do, and position them to maximize their success.
Tap into available data to improve patient placement decisions
Healthcare leaders must do everything possible to provide patients with safe, quality care while supporting the clinicians delivering that treatment. According to the book Measuring Capacity to Care Using Nursing Data, healthcare executives should stop considering patient acuity systems as simply a resource management tool, and begin to recognize the gold mine of nursing data they provide.
The book’s authors argued that efficient healthcare management requires better use of informatics to collect, share, and utilize operational and process data. By taking the time to study how patients move into and out of the health system, executives can gain critical insights into how their facility makes placement decisions and how they can improve its processes and performance.
For example, analyzing patient admission trends can provide insights into how patient acuity is affecting throughput, patient transfer decisions, and overall capacity. One hospital was able to successfully reduce its emergency department (ED) turnaround time by 11% simply by reconfiguring its triage process based on patient acuity. After examining its patient distribution based on Emergency Severity Index triage scores, Palomar Medical Center realized it was seeing 28% more high-acuity patients than the typical ED. The center reduced ED wait times by creating a separate triage room for high-acuity patients, where a dedicated physician/nurse team can conduct more extensive evaluations more rapidly.
Partner with other facilities to right-size care within a regional ecosystem
In addition to equipping nurses with technology and useful data, there is also merit in creating clinical arrangements between provider organizations to transfer lower-acuity patients as needed. If an organization isn’t the right place for the patient, it’s incumbent upon that organization to find the facility that is.
A case study recently published in the New England Journal of Medicine underscored the value of transferring lower-acuity patients from an academic medical center to a community hospital in an effort to better right-size care. The study detailed a clinical partnership between the University of California, San Francisco (UCSF) and St. Mary’s Medical Center to transfer lower-acuity patients to “reduce ED congestion and boarding time, improve inpatient capacity at UCSF, and match patient acuity with site of care.”
Through the arrangement, which continued despite the COVID-19 pandemic, UCSF created thousands of patient-bed days, while St. Mary’s increased both its patient volume and bed utilization. If those two organizations were able to benefit significantly from such a simple partnership, countless others across the country could likely replicate this mutual reliance.
Acuity-based staffing is central to ensuring quality patient outcomes, a stable nursing workforce, and financial viability, according to Frost & Sullivan. Allocating resources based on patient need introduces an opportunity for more collaboration between hospital CNOs and CFOs, as they must bridge the clinical considerations and cost management concerns. Acuity-based staffing allows patients to receive treatment at the most appropriate site of care, which improves patient outcomes and provides staff with the appropriate clinical support.
Acuity-based staffing also provides an opportunity for hospitals and health systems to curb a significant cost driver. By placing patients in the right hospital care setting for their medical needs, hospitals can achieve more cost-effective, flexible staffing while impacting key performance indicators tied to reimbursement, such as hospital days and adverse outcomes.
We already have some of the resources required to reorient ourselves. By tapping into existing nursing data, our frontline workers can more proactively make decisions based on a patient’s acuity, such as the decision to transfer a patient to another care setting. When we make our data actionable, we can achieve results that benefit not only our facility, but the healthcare system at large.
Dr. Richard Watson is the co-founder of Motient, a pioneer in patient movement solutions.