Multiresistant infections in ICU patients mean far more work for nurses
By Robert Roos,
icanNEWS staff
icanNEWS –- To care properly for an intensive care unit (ICU) patient who has a nosocomial infection involving multidrug-resistant bacteria may take more than 4 hours of extra nursing time per day compared with other ICU patients, according to a study reported in Infection Control and Hospital Epidemiology.
Investigators at Calmette University Hospital in Lille, France, did a detailed functional analysis of nursing tasks involved in caring for patients colonized or infected with multiresistant bacteria (MRB) and found that the excess time required was much greater than was suggested by established scoring systems used to measure nursing workloads.
"The functional analysis showed that the amount of time needed each day to carry out MRB-driven tasks was 245 minutes per patient," states the report by Fabienne Saulnier, MD, and colleagues. "Most of this time was spent on isolation precautions and antiseptic baths."
The retrospective study was an analysis of the care provided for all patients admitted to the hospital's 10-bed medical ICU in an 8-month period in 1995 and 1996. Patients were sorted into two groups depending on the presence or absence of MRB nosocomial infections (NIs). Centers for Disease Control and Prevention criteria were used to define NIs. The investigators examined length of stay and used three methods to assess nursing workloads: Omega score, the Projet de Recherche en Nursing (PRN) score, and the functional analysis.
The Omega score is a therapeutic activity scale consisting of 45 items (activities and procedures) that are assigned a score between 1 and 10. The PRN, designed specifically for assessing nursing workloads, sorts all nursing activities into eight categories and gives each activity a point value based on the time it takes.
For the functional analysis, the authors used a quality assurance method called Analysis of Failure Modes, their Effects, and their Criticality. Seventy-eight procedures were analyzed by estimating the time required for each specific step or task involved. Four of these procedures were identified as being directly related to MRB NIs: isolation precautions, bathing the patient with antiseptic solution, bedpan management, and microbiologic screening.
During the 8-month study period, 177 patients were admitted to the ICU, of whom 37 were colonized or infected with MRB. Length of stay and mean Omega and PRN scores for the entire stay were significantly greater for the MRB-positive patients than for MRB-negative patients: length of stay, 23+20.6 days vs 12+15.3 days (P<.001); Omega score, 164+103.4 vs 123+93.7 points (P<.001); PRN score, 3,606+3,187 vs 1,854+2,356 points (P<.001). The mean daily PRN score was also significantly higher in the MRB-positive group: 160+25 vs 146+34 points (P<.028).
The functional analysis showed that the four MRB-driven tasks took a mean of 245 minutes per patient-day, including 230 minutes for isolation precautions and 15 minutes for bathing with antiseptic solution. Bedpan management did not require extra time because automatic washing equipment was used, and weekly microbiologic screening was done on all patients, so there was no difference in time requirement. In contrast with the functional analysis, the PRN system indicated that the four tasks took only 85 minutes per patient-day.
The authors comment that the Omega system focuses on technical procedures and omits routine infection control practices and basic nursing activities. The PRN system, they add, counts these activities but still underestimates the volume of work involved in caring for ICU patients with resistant infections when current recommendations are followed.
The investigators say their findings should be useful in matching staffing levels to workloads. "Understaffing can create a vicious circle," they write. "If the nurses do not have enough time to do their work properly, lapses in infection control procedures may occur, increasing the rate of NIs in the unit, and thereby further increasing the nurse work load."
Saulnier FF, Hubert H, Onimus TM, et al. Assessing excess work load generated by multiresistant nosocomial bacteria in intensive care. Infect Control Hosp Epidemiol 2001;22(5):273-8
First published (July 5, 2001) on icanPREVENT.com. Copyright 2001, ican INC.
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