Midnight census is considered to be the number of inpatient within a specific unit. I would personally say this isn’t the most favorable method of measuring intensity. Inverse of length of stay, also known as patient turnover, is another important measurable factor affecting the intensity of care. Given that this method can never really be stable, I would also say this method is unreliable in measuring intensity. Admission, discharge, and transfer, work intensity index (ADT Work intensity index) can be found by taking total admissions adding discharge, discharges adding transfers in 24 hours and then dividing this the sum of these three items by the midnight census. I personally think this is the best/ most accurate method of measuring unit intensity given that it provides insights into patient care as well as provides better calculations when considering nursing staff ratios.
Majority of my nursing experience has been in the emergency department. When reviewing the types of unit intensity used to measure the busyness of a unit, the admission, discharge, and transfer (ADT) work intensity index fits best. One of the reasons this is true for the emergency department, is because of patient influx at different times of the day. ADT allows the intensity of a unit be measured during specific times of the day to allow scheduling of additional nurses during peak times (Waxman, 2018). This is why there are mid-shifts available at peak times of 1100, 1300, and 1500. During the night, the census decreases and the mid-day nurses leave their shift during this decline. Also, with the high turnover rate of the emergency department, whether it be by admission, discharge or transfer, it is important to consider the midnight census of other units in order to reallocate useable staff to units with shorter lengths of stay, i.e. emergency departments (Waxman, 2018). This is especially helpful when there are admission patients boarding in the emergency department, but still have that influx of patients throughout the day seeking emergency care.
One of the concepts described in this lesson was unit intensity, which measures the “Business” of a unit. In the lesson, three measures of ADT intensity were given: midnight census, inverse length of stay (LOS), and the ADT work intensity index.
Given the type of unit you work in or have worked on, what do you believe is the best measure of unit intensity? Explain why.
While working on a renowned medical surgical transplant unit, I had the opportunity to function as a charge nurse. Part of the responsibilities of the charge nurse is to make continuous assessment of the unit flow and staffing resources with the anticipation that regardless of what occurs in admissions, discharges and transfers (ADT) during the day, that the hours per patient day meets the target for the unit by midnight. The charge nurse also evaluated all the skill mix and sources of staffing to make sure the ratio of nurse to nursing assistant to patient, and correct cost center is recorded and balanced with all units involved. The charge nurse in collaboration with the unit manager, central hospital nursing office worked hard to make sure the activities are within the parameters of the budgeted hours for the unit. There were many challenges especially when there were busy times where transfers and discharges needed to happen because many more patients waiting to be admitted to prevent diversion to other facilities which is considered loss of revenue.
Assignments were made based on nurse-to-patient ratios and not necessarily on acuities (how sick the patient is). As a result, the assignment may not capture some of the details of care the nurse provides, creating uneven workload, perceived rushed care, and feeling of guilt on the part of the nurse for perceived decrease in time spent with patient (Dark et al., 2020).
The most difficult situation for charge nurses is the fact that the unit could be very busy due to many admissions, discharges and transfers but fall short at midnight to maintain enough census to sustain allocated HPPD for the unit. This means a summon to the office to discuss strategies to prevent future occurrence of the shot fall.
Currently, this workload calculation is more of variable cost analysis factor and favors revenue goals. However, there is the need for nursing to document the amount of work involved in providing safe care for the patients so that the budget can be evaluated to accommodate the labor in the production process involving admissions, discharges, and transfers.
I worked for 16 years in an Emergency Department (ED). After completing the reading for the week, I believe that the admission, discharge, and transfer (ADT) Work Intensity Index would be the best measurement for staffing and is the most accurate measure of unit intensity (Bradley University, n.d.). Both midnight census and length of stay (LOS) did not account for nursing workload intensity, which becomes highly significant with critical patients and the inability to control the number of patients in ED. Departments like the ED that use the ADT Work Intensity Index have a considerable increase in calculated nurse staffing to patient mix compared to the inverse LOS and midnight census measurement (Waxman, 2018). Creating a positive working environment that is less stressful can be done in the ED if management looks at the unit workload on each shift, the ADT activity, and patient acuity. ED’s are a unique area to work in due to the influx of patients with a wide variety of acuity levels. Holding patients has become a significant problem in ED’s; unlike other units, the ED doors are always open, and there is no patient volume capacity, so having the correct staff-to-patient ratio with staffing protocols for extreme volume changes is beneficial to the department.
One of the concepts described in this lesson was unit intensity, which measures the “Business” of a unit. In the lesson, three measures of ADT intensity were given: midnight census, inverse length of stay (LOS), and the ADT work intensity index.
Given the type of unit you work in or have worked on, what do you believe is the best measure of unit intensity? Explain why.
Currently I work in a long-term care facility that uses midnight census as unit intensity. ADT does not appear to work for the best measure of unit intensity because the facility does not have the frequent turnover of patients.
I worked as a bedside nurse in an adult ICU setting in the beginning of the COVID-19 pandemic and remember the charge nurse receiving a call from the manager asking for the unit census. The information included in the unit census was how many of the patients were on ventilators, had central venous access lines, and foley catheters. I recall that this number and the acuity of patients determined how many nurses were scheduled for the following shift. It did not appear to account for admissions from the emergency unit or transfers from medical units and recalled feeling overwhelmed with the (unexpected) added workload during my shift.
Studies indicate the ADT work intensity index is the most accurate measure of unit intensity.
The analysis showed that midnight census and I/LOS alone did not account for the workload intensity. When ADT is considered, the workload of nurses increases beyond the patient care demands based only on the midnight census. (Waxman, p.73)
“Planning for the additional within-shift unit-level workload required for admitting, discharging and transferring patients, which is not accounted for by the patient census at midnight or the beginning of the shift, can be overwhelming for nurse managers. Previous research, which has primarily included data aggregated to the hospital level and has not involved unit-level analyses, provide little guidance to managers for staffing adjustments that account for fluctuations in unit-level workload occurring during a shift.” (Hughes, et al, 2015). One study describes and compares two methods of calculating nurse staffing requirements on a daily basis (midnight census and length of stay (LOS) adjustment to midnight census) with a measure using adjustments for patient admissions, discharges and transfers (ADT) that can be applied on each shift. (Hughes, et al, 2015)
“Research has indicated that when done correctly, the effective deployment of nursing staff improves the quality of their work and diminishes the consequences of work overload Conversely, ineffective deployment, specifically when there are insufficient numbers of RNs and high or heavy nursing workload, can lead to adverse patient safety events , increase in patient morbidity and mortality, and poor nurse outcomes including job burnout, dissatisfaction and nurses feeling that they are too busy to provide the level of care they believe necessary.” (Hughes, et al. 2015). I often wondered if the outcomes of the patients could have improved if the workload was better. Studies have shown increases in nurse-to-patient ratios and reduced nursing workloads have been found to be associated with positive patient quality and outcomes of care including decreased mortality, length of stay, complications and hospital costs. (Waxman, 2018).
By using the formula described in Waxman (2018), staffing can be adjusted to account for the increased busyness, during peak times. ADT work intensity can be used to increase nurse staffing requirements more than midnight census and I/LOS.
Hughes, R.G, et at. (2015). Comparison of Nurse Staffing Based on Changes in Unit-Level Workload Associated with Patient Churn. Journal of Nursing Management. 23(3): 390-400. https://doi-org.ezproxy.bradley.edu/10.1111/jonm.12147Links to an external site.
Waxman, K.T (2018). Financial and Business Management for the Doctor of Nursing Practice. Springer Publishing Company.
I work as a float pool nurse and float among all the units in the hospital. I think the best measure of unit intensity for most floors that I work on is the ADT work intensity index. The observation unit I often float to for example experience a high patient turn- over. There are many admits and discharges throughout the shift which impacts the unit workload. The midnight census does not account for the extra workload of admitting and discharging a patient, but the ADT work intensity index does. “…the midnight census does not fully describe the impact of the work on the unit, as it usually excludes the bedded outpatients, unit- based outpatient procedures, and outpatient observation hours…” (Waxman, 2018, p. 75). The ADT intensity index considers the busy periods of time on a unit. “These periods of work intensity may also be called “churning”” (Waxman, 2018, p. 75). The observation unit has constant churning and patient turnover, especially in the afternoon as more patients are being discharged. The ADT intensity measurement, as noted in our book, has proven to increase nurse staffing requirements because it accounts for the intensity, thus nurses tend to have greater job satisfaction. The observation unit will often have a resource nurse for the floor that helps with discharges and admissions. Adding an extra nurse during these churning times decreases the stress for the nurses on the floor. I think most nurses, especially those working through the COVID-19 pandemic would agree, staffing by the ADT work intensity index can bring better patient safety and nurse satisfaction.
While the ADT method may not be the best for outpatient use, I believe it is the very best way of analysis for inpatient use as it gives the most accurate estimate. The Admission, discharge and transfer (ADT) module is used in the HIS for the purposes of managing appointments, patient admission, daily control of hospital beds, planning surgery procedures, keeping up-to-date on patient discharges, and registering patient transfers within or outside the hospital (Farrahi et al., 2019). In addition to this, studies show that ADT work intensity index is the most accurate measure of unit intensity and its use resulted in an increase in calculated nurse staffing requirements. There is more detailed components to the formula for this unit of intensity making it a more significant value compared to the other unit of intensity measures.
I work on a pediatric oncology/hematology unit. Which is often very busy as the patients are either actively receiving treatment, managing side effects and complications of treatments, and/or post-op. For this type of unit, I believe the best measure of the unit intensity is the ADT work intensity index (Waxman, 2018). ADT work intensity index is seen as the most accurate measure of the activity on a unit including total admissions, transfers, discharges in 24 hours divided by the midnight census (Waxman, 2018). New admissions can occur at any time on our unit and since we are exclusively a pediatric hospital, we receive transfers from all over the region. Although most transfers do occur during the day vs night shift due to the logistics of transportation as well as discharges. The typical admission rate per shift can range from 4 to 7 patients. Although our management seems to use UOS to predict nurse staffing because we experience a lot of call-offs as the census changes more on the day shift than on the night shift. We rarely get asked to work on our days off or pick up extra shifts. I don’t believe the LOS would be helpful as our turnover rate doesn’t change as often as most units (Waxman, 2018). We often have patients stay anywhere from 14-30 days based on their chemotherapy schedules.
Given the type of unit you work in or have worked on, what do you believe is the best measure of unit intensity? Explain why.
I work on a locked adolescent psychiatric unit. We have varying days of business or churning. As with any unit, it depends on the types of patients that we have. I believe that the best measure of intensity really depends on midnight census and admission, discharge, and transfer (ADT). We only have one registered nurse (RN) and if we are lucky two behavioral health technicians (BHT) for nine patients. No matter what the acuity is for the unit, the staffing remains the same. If we have a sitter case where a patient requires constant observation, we will get another staff member to take that position. We must be flexible. A sitter is usually a BHT, but occasionally we will have an RN.
Rule of thumb is that we try to get all our admissions into our unit before midnight. The reason for this is because the hospital can bill for an entire day versus not being billed until with first twenty-four hours. Midnight census makes sense, but since our staffing does not change much with the admissions, I would have to say ADT is the best pick. Having worked as a supervisor and overseeing the staffing that we are budgeted for, we are budgeted for one RN’s and two BHT’s for nine patients. The problem is that we are in such a staffing shortage that we don’t always get that. If we have a sitter case, we try to eliminate the sitter as soon as it’s safe.
I believe that our psychiatric units are bundled together, and census is looked at as a whole. Based on my reading, it seems that the hospital administrators look at the midnight census because many times, I see that staff is being flexed early (allowed to leave) around that time. The staff will be moved around to cover where others were pulled from. This is not safe practice. We find that on the adolescent unit, we lose a BHT regardless of the ADT. To be safe, to prevent burnout, and high turnover rates, ADT would be a better way of assessing the needs for the unit (Suby, 2018).
References
Suby, C. M. (2018). Budgeting, Scheduling, and Daily Staffing for Acute Care Nursing Units. In Financial and Business Management for the Doctor of Nursing Practice (pp. 74-76). New York: Springer Publishing Company.
I am currently working in a pediatric transitional care facility. We take care of transitional and respite patients in a home like setting. Transitional care patients are patients that are coming out of the hospital and preparing to go home. They need additional time for family training to take care of a medically complex patient at home as well as organizing home nursing to continue care while at home. The goal is for transitional care patients to have a maximum length of stay of 120 days, but many patients stay for over a year due to social concerns within the family. Respite patients are patients that are at home most of the year, cared for by family and home nursing when needed. In order for the family to have a break, travel, or due to family illness, respite patients will stay for up to a week at a time. These respite patient stays are planned, and many times only one or two respite patient will stay at one time.
The model of this transitional care facility is to take care of patients that are medically stable enough to go home. Thus, if a patient gets sick and requires more medical treatment than families could be expected to give at home, the patient is directly admitted to the pediatric intermediate care unit of our affiliated children’s hospital. There is constant communication between our medical leadership (APN/FNP) and the children’s hospital physicians. Many times, we try to avoid sending a patient into the hospital, but there are times when hospitalization for a period of time is necessary. While a patient is hospitalized, we hold their bed until they are medically stable enough to return.
Due to the extended length of stay of transitional care patients, holding beds for patients that acutely need hospitalization, and respite patients that are planned to visit, the midnight census is the most accurate tool for calculating unit intensity. When compared with inpatient units such as the medical ICU where I previously worked for two hours, there is very little turnover in my current role. Thus, including admissions, discharges, and transfers in the work intensity index wouldn’t make a significant difference in the calculation of unit “business.” Additionally, length of stay doesn’t necessarily correlate with patient acuity for the patients I serve. Midnight census is a helpful way to calculate unit intensity in my role, especially when factoring in patient acuity. We take care of trached vented patients at my facility, and we have specific ratios for nurses to ventilators. Ideally, each nurse should be expected to take care of a maximum of two ventilated patients. Each nurse may then care for one additional patient that is not ventilated if needed. When calculating midnight census, we count the total number of patients including the number of ventilators. Since only one of our patients is not ventilated full time, we staff the unit so that we have one nurse for every two ventilators. If a patient gets admitted to the hospital or a respite patient cancels their visit, we adjust the number of nurses for the next shift accordingly.
I work on a medical-psych and medical overflow unit. We are also a secured medical unit. When we are not on diversion we do not get any direct admits to our unit. Now that we have a lot of overflow, there has been an increase in patient directly admitted from other hospitals or the ED. We only transfer patient when they require an upgrade or they are medically cleared to be transferred to our psych focused unit. Because of this I do not this the ADT work intensity index would be the best measure. I believe that the midnight census is the best measure of unit intensity. It is more direct and accurate to the type of unit that I work on.
Midnight census is defined as “the number of inpatients within a particular unit” (Bradley University, 2022).
Inverse length of stay, or patient turnover, can be written as 1/LOS and refers to when a patient is moved from one unit or floor to a different area in the hospital (Unruh & Fottler, 2006). This can lead to underestimated nursing workload and causes it to seem like less staffing may be needed (Unruh & Fottler, 2006).
Admission, discharge, and transfer (ADT) work intensity index can be found by taking total admissions, adding discharges and transfers, and dividing by the midnight census (Bradley University, 2022). Staffing should be adjusted depending on when ADT is highest during different times of the day.
I currently work on a PCU unit, and based on what I have seen, I think a midnight census approach is used. However, I believe that the ADT work intensity index would work best because it not only looks at how many people are on the unit currently, but it also looks at the patient being moved from and to the unit between us and different units. It also takes into consideration subsequent admission and possible discharges. We are constantly starting shifts, doing assessments, and passing meds only to be told we need to move the patient to another floor and get ready for an admission. It can be very labor-intensive. ADT seems like an all-inclusive way of looking at work intensity related to staffing.
One of the concepts described in this lesson was unit intensity, which measures the “Business” of a unit. In the lesson, three measures of ADT intensity were given: midnight census, inverse length of stay (LOS), and the ADT work intensity index.
Given the type of unit you work in or have worked on, what do you believe is the best measure of unit intensity? Explain why.
The unit that I work in is the Emergency Department. For this department I think the best measure of ADT intensity would be the ADT work intensity index. The work intensity index is considered the most accurate measure of business of a unit and often results in a higher nurse staff requirement. In the Emergency Room more staffing is never a bad thing. To find the ADT work intensity index you take the total admissions added to the total discharges, subtracted from that is the sum of the discharges and transfers. That number is then divided by the midnight census. The inverse length of stay would not be a good fit for this department due to the varying times different acuities can have, as well as taking into the account the doctors and nurse’s on staff for the day. The midnight census would not be a good fit for this unit either as that is normally the least busy time for ER’s, and not accurately reflect the business of the unit throughout the day.
I’ve recently had the opportunity to serve in a management position at an assisted living setting during the pandemic. The community offers independent living, skilled nursing, and assisted living for residents that want medical and nursing support. After reviewing the concepts in our text this week, the best measure of unit intensity for an assisted living facility is the ADT work intensity index.
According to our text, “The ADT activity should be measured by time of day to see when it is the highest and schedule requirements should be adjusted to accommodate this pattern of activity” (Waxman,77). At the beginning of the pandemic, staffing was an issue in many healthcare facilities and communities. Nursing management had to outsource labor from agencies for nursing care in order to meet the needs of the residents. In this case, the ADT index could help determine the deployment of staff according to level of activity per shift. More staff would be needed during daytime shift when the workload was heavier as opposed to the night shift when the activity was low.
Another reason why the ADT Work Intensity index would benefit this assisted living community would be because it helps assess the shift and maintain nurse to patient ratios. This is important because nursing staff can get burned out if the workload is too heavy and in turn causes increase turnovers. Nursing Management can use this information to staff accordingly and eliminate stress on the staff employees. When the ADT index is calculated correctly, hours are compared to the midnight census and staff is deployed accordingly.
One of the concepts described in this lesson was unit intensity, which measures the “Business” of a unit. In the lesson, three measures of ADT intensity were given: midnight census, inverse length of stay (LOS), and the ADT work intensity index. Given the type of unit you work in or have worked on, what do you believe is the best measure of unit intensity? Explain why.
Unit intensity is the measure of how busy a unit is, and three measurements to describe this concept are midnight census, length of stay (LOS) or inverse length of stay (ILOS), and admissions, discharge, & transfers (ADT). Midnight census is the number of inpatients within a particular unit; LOS is length of stay and ILOS is one day longer than length of stay; ADT is considered to be the most accurate measure of unit intensity and is resulted in an increase in nurse staffing requirements. ADT activity is measured by time of day to determine when acuity is the highest and staffing should be accommodated to equal this. To calculate ADT: Admissions + Discharges + Transfers in 24 hours/ midnight census (# patients in a unit).
An acuity system identifies the amount of nursing care needed for each patient on a unit based on the level of intensity, nursing care and tasks needed for each patient. The system allocates resources based on patients’ needs, not according to raw patient numbers. (Allina Health, 2016)
I work on the Oncology unit, and we have an available 36 bed unit. Our unit can staff up to 5 patients maximum per RN for day shift and 6 patients maximum for night shift. At minimum staffing level we need at least 7 day-shift RNs and 6NOC-shift RNs. When staffing is at these ratios, it’s termed emergency staffing. For each patient we score them on a numeric scale from one to four, one being the lowest acuity and four being the highest. The patient acuity tool displays the intensity of patient care as: 1-Stable Patient, 2-Moderate Risk Patient, 3-Complex Patient, and 4-High Risk Patient. To keep acuity level among staff, RNs are not given a higher acuity than 10-11. This is not true for CNAs though. Day shift CNAs can have up to 13 patients each and NOC shift CNAs can be given up to 16 patients each on a low-staffed night. Either way, these ratios are not safe for the staff nor the patients. Flaws with this scale though, are that each nurse is giving the patient acuity rating based on their opinion. Which means if a seasoned RN scores a team of 5 patients for example, a total acuity score of 11, the new-grad RN coming onto shift may have a different experience and feel overwhelmed. Secondly, I have experienced multiple shifts when a patient of mine is scored lower due to the change in their behavior and needs between NOC vs day shift. This then creates a higher risk of errors to be caused and danger to staff and patient safety. Third, rather than score patients’ acuity level at the end of each shift, I believe it would be more accurate for the CN to check in with each nurse several times during the shift to re-evaluate patient acuity level. I have seen patients decline through the day which makes them a higher level for the second half of my shift. Lastly, the hospital also likes to “save money” so they will staff based on patient acuity, but if patient acuity drops anytime during the shift, they will low-census staff, yet if patient acuity then increases due to new admits, new transfers, or fewer discharges than expected, the hospital now has to call staff in. So, in theory, the hospital spends more money because now they are paying the called-in staff double time termed “stacked.” This is an RNs hourly wage doubled plus $19 per hour.
It states in a 2018 American Nurse journal article that used the same patient acuity tool we use, “after reviewing the annual performance improvement data, we found no direct correlation between using the acuity tool and patient safety measurements (rate of falls, medication errors, and restraint use).” A few comments given by RNs surveyed were, “Patient assignments can lead to dissatisfaction among nursing staff, especially when they’re not consistent, objective, and quantifiable” and “dissatisfaction can create barriers to the adaptability and teamwork that are critical to good patient care.” In the article’s conclusion, it points out that, the patient acuity tool addresses the important issue of unbalanced nurse-patient assignments and helps nurses influence decision-making in their organizations. I agree that the use of this tool can be helpful to reduce staff overload and increase patient safety, if used effectively. Similarly, it’s stated, “However, by distributing high-acuity patients among nurses, this tool, used in conjunction with other current actions, can reduce the need for patient safety measures such as using sitters and frequent rounding. (Ingram & Powell, 2018)
Acuity Proposal. (2016). ALLINA HEALTH SYSTEM. TM – A TRADEMARK OF ALLINA HEALTH SYSTEM. Retrieved from https://www.allinahealth.org/-/media/allina-health/files/footer-pages/acuity-proposal-highlights-2016.pdf
Ingram, A., Powell, J. (April 11, 2018). Patient acuity tool on a medical-surgical unit. American Nurse, 13(4). Retrieved from https://www.myamericannurse.com/patient-acuity-medical-surgical-unit/
One of the concepts described in this lesson was unit intensity, which measures the “Business” of a unit. In the lesson, three measures of ADT intensity were given: midnight census, inverse length of stay (LOS), and the ADT work intensity index.
Given the type of unit you work in or have worked on, what do you believe is the best measure of unit intensity? Explain why.
At my Hospital I work on the Medical/Surgical Unit and the best measure of unity intensity we use would be the ADT work intensity index, which is total admissions+discharges+transfers in 24 hours/midnight census. We have patients that are being admitted through the ER/ED everyday and we have transfers from ICU/TELE/DOU every day. Discharges happen almost every day on my unit. With the high census and continuous flow of patients, I believe that this index would be the best to use for the most accurate measure of unity. We have to provide the safe and proper amount of staffing per the number of patients and unfortunately there is a lot of times that safe staffing isn’t obtainable. This index would help supply staffing for each unit and each day.