Understanding the Patient Care Unit Activity Index

This program identifies the “churn” that can lead to staff and physician burnout and unintended events.

Last month  (March 14-20) was this year’s Institute for Healthcare Improvement’s (IHI’s) Patient Safety Awareness Week. It is an annual event in which the IHI intends to “encourage everyone to learn more about healthcare safety” and “inspire action to improve the safety of the healthcare system – for patients and the workforce.” 

In my role as a hospital-based physician advisor, I am primarily tasked with managing progression of care. I obsessively track metrics like length of stay, excess days (the difference between discharged patients’ geometric mean length of stay and actual length of stay), case mix index, discharges before noon, emergency department holds without completed admission orders, emergency department holds with completed orders, admissions by hour, admissions by provider, admission by diagnosis, discharges by hour, discharges by provider, discharges by unit, patients with a length of stay greater than six days, and patients with a length of stay greater than 10 days – just to name a few!

I utilize a business intelligence tool that pushes utilization management dashboards to an email account on my phone every four hours so that I am updated throughout the day (and night). And then I round throughout the hospital, encouraging physicians, case managers, social workers, and nurses to focus their efforts on improving these metrics while I help remove any administrative barriers to discharge and applaud their success. 

So, where does patient safety come in? And how do I ensure that the work I do does not inadvertently contribute to medical errors and preventable harm? 

One countermeasure to utilization management performance improvement is the Patient Care Unit Activity Index. This Index measures the workload of the patient care unit. While metrics like the average daily census or the census at midnight indicate the static number of occupied beds on the patient care unit, the Patient Care Unit Activity Index identifies the “churn” that can lead to staff and physician burnout and unintended events. Admissions, discharges, and transfers in and out of the patient care unit lead to an increased workload.

Dividing the sum of these activities by the total number of treated patients on the patient care unit each day to determine the Patient Care Unit Activity Index reveals a more accurate picture of the challenging and often chaotic environment in which patient care is delivered. 

While healthcare reimbursement, admission, and discharge practice patterns have changed drastically over the last two decades, decreases in hospital length of stay leads to increased patient turnover. And while much of the low-acuity medical care provided to patients now occurs in an outpatient setting, the acuity of hospitalized patients continues to rise. These changes may lead to an increase in the Patient Care Unit Activity Index, and increase the variability in healthcare delivery processes that negatively impact patient safety.

While the Patient Care Unit Activity Index has been described in nursing literature in the context of nurse-to-patient ratios, the index may be applied to other members of the interdisciplinary care team, as well as case managers, social workers, and physicians. Providing safe, efficient, cost-effective care requires a commitment to develop the appropriate processes and staff resources. A collaborative, interdisciplinary approach, combining unit-based nurses with a team of geographically varied case managers, social workers, pharmacists, physical therapists, respiratory therapists, and physicians provides the necessary framework.

When the interdisciplinary team rounds together daily with dedicated touchpoints and coordinated, scripted communication, including direct provider-to-provider sign-out, it is less likely that patients will suffer harm. Furthermore, a collaborative, interdisciplinary approach provides a forum for discussing adherence to standardized order sets and evidenced-based clinical pathways, when appropriate, which are essential components of safe, high-quality patient care.

So, while I remain focused on patient flow, I can feel comfortable that patient safety is never compromised.