Around five years ago the nursing staff of Nenagh Hospital became increasingly concerned about the amount of time they were spending on documentation, which included the Barthel score, falls risk assessment, a manual handling score and the Waterlow bedsore score. 

Completion of these, along with the recently added National Early Warning Score (NEWS), takes more than 30 minutes. The nurses were concerned that the paperwork added considerably to their work with little obvious benefit to patients. In the UK, nurses spend approximately 20% of their time on documentation¹ and in the US every hour of patient care requires 30-60 minutes of paperwork.²

Collection of data is expensive, time consuming and detracts from patient care. Documentation is seldom shared between clinical staff and, even though it may contain important information, it is not used to prospectively drive or assist patient management. Moreover, important pieces of information that are essential to make wise decisions on patient management are often difficult to find. This includes:

• The presenting complaint and precise need for hospital admission 
• A summary of comorbid conditions and their severity prior to the current illness
• The patient’s mental status and functional capacity 
• An estimate of illness severity and the immediate risk of death
• The patient’s life expectancy and their wishes for resuscitation and/or end-of-life care.

Without this information it is difficult to know what to do given the expertise, facilities and resources available, and each individual patient’s unique clinical needs. Furthermore, the quality of treatment cannot be properly audited unless all of this data is known.

There is growing evidence that nurse understaffing and overwork result in negative patient outcomes.³ Nursing care accounts for more than a quarter of hospital costs⁴, and quantifying nursing workload is difficult. Several methods for measuring nursing workload have been suggested.^5-7 However, none have found universal acceptability for routine use as they all require additional resources to implement. Moreover, workload measures developed by supervisors and senior management may not reflect the views of those doing the work at the coal face. 

In consultation with her colleagues, Ann Hickey, CNM2 for Nenagh Hospital’s elderly care unit, started to develop a workload score based on the documentation routinely collected in the hospital. After several attempts, a simple colour coded score was devised. 

Ann, her CNM2 colleague Margaret Gleeson and I, encouraged by Colette Cowan, group director of nursing and midwifery, developed the Rapid Electronic Assessment Documentation System (READS), a computer program that manipulates routinely collected information to quantify the severity of illness and the nursing workload required for each individual patient. 

READS combines these with estimates of in-hospital mortality and life expectancy to provide a one page summary of the reason for hospital admission, the patient’s functional status and prognosis as well as a measure of nursing workload. The program uses this data to generate patient specific suggestions to guide immediate management. This document is automatically generated, and can be immediately shared with everyone who is looking after the patient. 

Currently the READS prototype is a ’stand alone’ program written in Visual Basic that runs on any PC and stores information as a simple database. The program has six data entry screens including: demographics and co-morbidity; presenting complaint(s); mental status; functional status; bedsore risk; and vital signs. After it is entered, the data is re-structured into a print-out in a situation, background, assessment, recommendation (SBAR) format.⁸

In a pilot study READS reduced the time spent recording routine data from 30 to 6.5 minutes, and recorded nursing workload without creating additional work.⁹

READS is being further developed at Mid Western Regional Hospital, Nenagh by Annette Ridley and Margaret Gleeson. It is being beta-tested by Edel Mannion and her colleagues at Galway University Hospital, by Dr Mike Watts at University Hospital Limerick, and by Dr Declan Byrne at Tralee Hospital. 

References

1. UK Best Practice Nursing Database - personal communication courtesy of Dr Keith Hurst
2. American Hospital Association and PricewaterhouseCoopers.Patients or Paperwork? The Regulatory Burden Facing America.s Hospitals, May 1, 2001
3. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. (2002) Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 346(22):1715–22.
4. Wilson L, Prescott PA, Aleksandrowicz L. 1988 Nursing: A major hospital cost component. Health Services Research; 22(6): 774-796
5. Italian multicenter group of Research (GIRTI) (1991). Time Oriented Score System (TOSS): a method for direct and quantitative assessment of nursing workload for ICU patients. Intensive Care Med. 17(6): 340-5
6. Keene A.R., Cullen D.J. (1983) Therapeutic intervention scoring system: update. Crit Care Med 11(1): 1-3
7. Miranda DR, Nap R, deRijk A, Schaufeli W, Iapichino G. and the TISS Working Group. (2003) Nursing Activities Score. Crit. Care Med. 31(2): 374-82
8. Velji K, Baker R, Fancott C et al. (2008) Effectiveness of an adapted SBAR communication tool for a rehabilitation setting. Healthcare Quarterly 11(Suppl): 72-79
9. Hickey A, Gleeson M, Kellett J. (2012) READS: the Rapid Electronic Assessment Documentation System. British Journal of Nursing, 21(22): 1333-8