1 St udy ext ract ed from Mast er Thesis; 2 Nurse, Sc.M. in Nursing, e- m ail: sa.t elles@zipm ail.com .br; 3 Advisor, Nurse, Professor, University of São Paulo, College of Nursing, Brazil, e- m ail: [email protected]
Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae
STAFF COST I N DI RECT NURSI NG CARE AT AN I NTENSI VE CARE UNI T
1Sandr a Cr ist ina Ribeir o Telles2 Valér ia Cast ilho3
Telles SCR, Cast ilho V. St aff cost in dir ect nur sing car e at an int ensive car e unit . Rev Lat ino- am Enfer m agem 2007 set em br o- out ubr o; 15( 5) : 1005- 9.
This quant it at ive case st udy aim ed t o learn and analyze t he personnel cost in nursing direct care in t he int ensiv e car e unit . We opt ed t o use a t her apeut ic int er v ent ion scor e index , TI SS- 28, for t he analy sis of t he indirect gravit y of pat ient s and t he dim ension of t he nursing st aff working t im e. Evaluat ing t he cost by a gravit y score present ed t o be a logical and relat ively sim ple m et hod t o allocat e cost s per pat ient in t he int ensive care unit . I n t his explorat ory and descript ive st udy, t he average TI SS- 28 per pat ient was 31 point s, requiring a daily expendit ure of care hours of R$ 298.69. I t was evidenced in t his st udy t hat personnel cost s are variable since t here are pat ient s wit h different com plexit ies. Therefore is possible t o est im at e t he nursing st aff cost by assessing it s w or k load.
DESCRI PTORS: cost s and cost analy sis; int ensiv e car e; nur sing
COSTO DE LOS PROFESI ONALES EN LA ATENCI ÓN DI RECTA DE ENFERMERÍ A EN LA
UNI DAD DE CUI DADOS I NTENSI VOS
Con est e est udio de caso con apr ox im ación cuant it at iv a, pr et endem os conocer y analizar el cost o de los pr ofesionales en la at ención dir ect a de enfer m er ía en una unidad de cuidados int ensiv os. Opt am os por la ut ilización de un índice de int er v enciones t er apéut icas, TI SS- 28, par a análisis de la gr av edad indir ect a de los pacient es y dim ensionam ient o del t iem po de t r abaj o del equipo de enfer m er ía. Al indagar el cost o com o un ín dice de gr av edad ést e se m ost r ó u n m ét odo lógico y r elat iv am en t e sen cillo de pr esu pu est ar cost os por pacient e en la unidad de cuidados int ensiv os. En est e est udio, el TI SS- 28 pr om edio por pacient e fue de 31 punt os, lo que dem andó un cost o diario de R$ 298,69 de horas de at ención de enferm ería. En est e t rabaj o, se ident ificó que el cost o de los pr ofesionales es v ar iable, pues ex ist en pacient es con div er sas com plej idades y m uy difer ent es, siendo posible, por m edio de la ev aluación de la car ga de t r abaj o del equipo de enfer m er ía, est ablecer est im at iv as indiv iduales de su cost o.
DESCRI PTORES: cost os y análisis de cost o; cuidados int ensiv os; enfer m er ía
CUSTO DE PESSOAL NA ASSI STÊNCI A DI RETA DE ENFERMAGEM EM UNI DADE DE
TERAPI A I NTENSI VA
Pr et endeu- se com est e est udo de caso, com abor dagem quant it at iv a, conhecer e analisar o cust o de pessoal na assist ência diret a de enferm agem em unidade de t erapia int ensiva. Opt ou- se pela ut ilização de um índice de int ervenções t erapêut icas, TI SS- 28, para análise da gravidade indiret a dos pacient es e dim ensionam ent o do t em po de t r abalho da equipe de enfer m agem . Ev idenciou- se, nest e t r abalho, que o cust o com pessoal é v ar iáv el, pois h á pacien t es com com plex idades bem dif er en t es, sen do possív el, por m eio da av aliação da carga de t rabalho da equipe de enferm agem , est abelecer est im at ivas individuais de seu cust o. Nest e est udo o TI SS- 28 m édio por pacient e foi de 31 pont os, dem andando cust o diário de horas de assist ência de enferm agem de R$ 298,69. Apur ar o cust o por um índice de gr avidade m ost r ou- se m ét odo lógico e r elat ivam ent e sim ples de alocação de cust os por pacient e em unidade de t er apia int ensiv a.
I NTRODUCTI ON
C
onsidering t he int ensive care unit ( I CU) ast h e place in h ospit als w er e car e deliv er y t o sev er e
and high- r isk pat ient s is cent r alized, j oining hum an
resources, m at erial and equipm ent , it is fundam ent al
t o balance t he pat ient s’ needs wit h t he infrast ruct ure
f o r t h e i r ca r e . Mo r e a n d m o r e , t h e h i g h co st o f
m ain t ain in g a st r u ct u r e as com plex as t h e I CU h as
j ust ified st r ict cost cont r ol in t his ar ea, especially in
t er m s of st aff. One of t he m ain r esponsibles for I CU
hospit al cost s has been t he sophist icat ed t echnology
u sed f or diagn osis an d t r eat m en t . I n par allel, car e
deliv er y t o t hese pat ient s dem ands m any hour s, as
hospit alizat ion t im e and com plex it y ar e incr easing.
Specialized int ensiv e car e lit er at ur e show s a
g r ow i n g n u m b er of p u b l i cat i on s t h at u se sev er i t y
in dices t o m easu r e t h e w or k load an d n u r sin g car e
needs, due t o t heir easy applicat ion and int erpret at ion
in charact er izing pat ient . Mor eov er, t he dy nam ics of
t he unit , t he efficacy of t he t reat m ent and it s cost can
be m onit or ed and analy zed, leading t o an adequat e
a l l o c a t i o n o f t h e a v a i l a b l e h u m a n a n d m a t e r i a l
r esou r ces.
Research carried out at 36 I CUs from t welve
count r ies in t he Eur opean com m unit y det ect ed t hat
t h ese ar e r esp on sib le f or t h e ad m ission of 5 % of
pat ient s but consum e 20% of t he hospit al budget( 1).
Th ese st u dies also h igh ligh t t h at 9 0 % of I CU st af f
consist s of t he nursing t eam .
A st udy on t he cost of nur sing car e in I CUs
fr om Aust r alia and New Zealand, using a sam ple of
1 3 9 p at i en t s, v er i f i ed t h at t h e n u r si n g t eam w as
r esp on sib le f or b et w een 3 0 an d 4 0 % of t ot al car e
cost s( 2).
The m ost used cost verificat ion m et hodology
in h ealt h or gan izat ion s is a pr ocess in w h ich cost s
relat ed t o service product ion are grouped t o t he unit s
t hat produce end services, which is called absorpt ion
c o s t i n g( 3 ). H o w e v e r, o n e c r i t i q u e a g a i n s t t h i s
m et hodology is t hat , alt hough it pr ov ides k now ledge
abou t t h e f ix ed cost s of labor, it ign or es v ar iat ion s
due t o pat ient com plex it y.
I n g en er al, st at ist ical d at a r elat ed t o b ed
occu pat ion r efer t o t h e I CU occu pat ion per cen t age.
I n t his t ype of analysis, however, t he daily variabilit y
in care com plexit y and in care delivery cost s for t hese
p a t i e n t s ca n n o t b e p e r ce i v e d , a s d i f f e r e n t ca r e
com plexit y levels can repr esent t he sam e occupat ion
r at e.
The hy pot hesis t hat nur sing car e is dir ect ly
pr opor t ion al t o t h eir cost w as con f ir m ed in st u dies
t hrough t he Therapeut ic I nt ervent ion Scoring Syst em ,
TI SS- 28( 4- 6). They have dem onst rat ed t hat t he use of
t h i s i n d e x t o m e a su r e d i r e ct n u r si n g ca r e h o u r s
revealed t o be a logical and relat ively sim ple m et hod
of cost allocat ion per pat ient at I CUs.
Wh at t h e iden t if icat ion of pat ien t s’ dif f er en t
lev els of sev er it y an d, h en ce, of n u r sin g car e n eeds
is con cer n ed, t h e Th er apeu t ic I n t er v en t ion Scor in g
Sy st e m ( TI SS) w a s d e v e l o p e d a s a sy st e m t h a t
classif ies t h e p at ien t ’s in d ir ect sev er it y, b ased on
t h e p r i n c i p l e t h a t t h e a m o u n t o f t h e r a p e u t i c
in t er v en t ion s p at ien t s ar e su b m it t ed t o is r elat ed
t o t h e sev er it y of t h e clin ical p ict u r e, t h at is, t h e
m or e sev er e t h e pat ien t ’s con dit ion , t h e h igh er t h e
n u m b e r o f t h e r a p e u t i c i n t e r v e n t i o n s n e e d e d f o r
t r eat m en t an d , con seq u en t ly, t h e lon g er t h e t im e
n u r sin g sp en d s t o d eliv er t h is car e. Th e TI SS w as
o r i g i n a l l y i d e a l i z e d i n 1 9 7 4 a n d c o n s i s t s o f 5 7
t h er ap eu t i c i n t er v en t i o n s i n t o t al( 7 ). I n 1 9 8 3 , t h e
i n d e x w a s r e c o n s i d e r e d a n d u p d a t e d t o 7 6
t h er ap eu t i c i n t er v en t i o n i t em s( 8 ). Th e TI SS- 2 8 , a
si m p l i f i ed v er si o n o f t h e a b o v e, w a s i d ea l i zed i n
1 9 9 6( 4 ). Th e f i n a l s c o r e o f t h e TI S S - 2 8 , w h i c h
r an g es f r om a m in im u m of zer o t o a m ax im u m of
7 6 p o i n t s, p e r m i t s n o t o n l y t o e st i m a t e p a t i e n t
i n t er v en t i o n s, b u t a l so t o d i m en si o n t h e n u r si n g
w o r k l o ad .
Asse ssi n g p a t i e n t s, t h r o u g h i n d i ce s t h a t
obj ect ively m easure t he severit y of clinical condit ions,
t he int ervent ions used, as well as nursing care needs,
has becom e com pulsory in t he current int ensive care
cont ext , in view of t he cost t his ent ails for t he healt h
sy st em .
Consider ing t he lack of lit er at ur e about t his
t hem e, t his st udy aim ed t o ex plor e and descr ibe t he
u se o f a n I CU ca r e co m p l e x i t y l e v e l a sse ssm e n t
m et h od , w h ich p er m it s m easu r in g t h e w or k load of
t h e n u r s i n g t e a m a n d i t s i m p a c t o n c a r e c o s t
v ar iat ion s.
OBJECTI VES
- To i d e n t i f y t h e m e a n d a i l y n u r s i n g c a r e t i m e
d ed i ca t e d t o p a t i en t s, a cco r d i n g t o t h e p a t i e n t s’
com plex it y lev el, using t he TI SS- 28 index .
- To calculat e t he m ean daily cost of dir ect nur sing
METHOD
This ex plor at or y and descr ipt iv e case st udy
adopt s a quant it at ive approach. I t was carried out at
t he adult int ensive care unit of t he Universit y Hospit al
at t he Universit y of São Paulo, Brazil.
The Univ er sit y Hospit al is a secondar y - lev el
gener al t eaching hospit al. I t offer s 247 act iv e beds,
dist r ibut ed am ong t he four basic specialt ies: m edical
clinic, pediat r ics, sur ger y and or t hopedics, obst et r ics
and gy necology. The I CU, w it h 14 beds, is dest ined
f o r ca r e d e l i v e r y t o cl i n i ca l a n d g e n e r a l su r g e r y
p at ien t s, ad m it t in g an av er ag e of 4 5 p at ien t s p er
m on t h .
Th e st u d y p op u lat ion in clu d ed all p at ien t s
consecut iv ely adm it t ed at t he I CU as fr om Febr uar y
1st 2003, as well as pat ient s hospit alized on t hat day,
t ot alin g 1 2 0 pat ien t s. As in clu sion cr it er ia, pat ien t s
aged fift een or older were considered, wit h a m inim um
I CU st ay of 24 hours, as required for t he applicat ion
of t he TI SS( 4).
Dat a w er e collect ion bet w een Febr uar y and
April 2003, t ot aling 89 days. During t his period, every
day, t he researcher analyzed t he TI SS- 28 index, which
t he inst it ut ion had already been applying t o int ensive
car e pat ient s, classify ing t he com plex it y lev el of t he
pat ient s hospit alized during t he m ont hs under analysis.
Th i r t y - t h r e e p a t i e n t s w e r e n o t i n cl u d e d i n d a i l y
m easu r em en t s b ecau se t h ey d id n ot com p let e 2 4
hour s of hospit alizat ion.
A m at hem at ical ex pr ession w as pr oposed t o
est im at e t h e v ar iab le cost s of lab or con su m ed p er
day ( cost of daily dem an d) in fu n ct ion of t h e daily
TI SS- 2 8 , i n cl u d i n g t h o se p a t i e n t s w h o w e r e n o t
co n si d er ed i n d ai l y cal cu l at i o n s, as sh o w n i n t h e
for m u la below .
r ep r esen t t h e w or k t im e n eed ed f or each TI SS- 2 8
poin t per eigh t - h ou r w or k sh if t . Nex t , t h e r esu lt is
m ult iplied by t hree, as one day consist s of t hree eight
-hour shift s. Finally, t his is div ided by 60 m inut es in
or d er t o r each t h e n u m b er of n u r sin g car e h ou r s
needed for each pat ient . I n shor t , t he m ult iplicat ion
fact or is 0.53, where 10.6 x 3 : 60 = 0.53.
To find the m ean cost per hour of the nursing
team , the salary of the categories included in the nursing
t e a m w e r e su r v e y e d a t t h e Un i v e r si t y Ho sp i t a l ’ s
Personnel Departm ent. To the gross salary, 60% of taxes
and charges were added. The m ont hly hour load was
180 hours, which t he inst it ut ion adopt ed as t he basis
for it s calculat ions. Hence, t he cost of a m ean st aff
m em ber per hour was R$18.18, which corresponds t o
the sum of the whole team ’s salary and charges, divided
by the sum of the num ber of hours.
As m ent ioned, due t o t he st andar dizat ion of
t he TI SS- 28 index, pat ient s hospit alized for less t han
24 hour s w er e not m easur ed. How ev er, t o calculat e
cost s, t h ese pat ien t s’ com plex it y w as m easu r ed by
t he m ean m ont hly TI SS at t he unit . This explains t he
n eed t o in clu d e t h e K f act or in t h e m at h em at ical
ex p r ession ab ov e.
Th e r esear ch p r oj ect w as ap p r ov ed b y t h e
t e a c h i n g a n d r e s e a r c h c o m m i s s i o n a n d b y t h e
r esear ch et hics com m it t ee at t he st udy inst it ut ion.
RESULTS
I n t h e p e r i o d o f 8 9 d a y s , w i t h 7 2 2
m easur em ent s in t ot al, t he m ean TI SS- 28 scor e per
pat ient was 31 point s.
The m ean age of t he pat ient s classified wit hin
t he st udy period was 61 years, ranging from fift een t o
90 years, wit h a prevalence ( 52% ) of fem ale pat ient s.
Pat ient s w it h baseline chr onic disease pr edom inat ed
( 79% ) . I n t er m s of or igin, m ost pat ient s cam e fr om
t he em er gency car e unit , follow ed by pat ient s fr om
t he sur gical cent er. Clinical causes pr edom inat ed as
t he reason for hospit alizat ion in 55% of pat ient s. As t o
t he pat ient s’ dest iny aft er t hey left t he unit , it was found
t hat 59 % went t o t he sem i- int ensive unit .
Th e m ean TI SS- 2 8 scor e of 3 1 p oin t s p er
pat ient dem anded 16.43 care hours at a variable daily
cost of R$ 298.69, using t he proposed form ula.
I n t h is st u dy, t h e TI SS- 2 8 of less com plex
p at ien t w as 1 0 p oin t s, ag ain st 5 8 p oin t s f or m or e
com plex pat ien t s.
k
s
T
s
T
D Md D
C
/0
.
53
u
u
0
.
53
u
u
u
Wh er e:
CD/ d - Daily cost of nur sing t eam accor ding t o daily
dem and assessed by t he TI SS- 28.
0.53 - Fact or needed t o convert t he TI SS- 28 int o hours
( 10.6x 3: 60)
TD - Daily TI SS- 28.
S - Salary of t he whole t eam per hour.
0.53 - Fact or needed t o convert t he TI SS- 28 int o hours.
TM - average m ont hly TI SS- 28 at t he unit
K - num ber of pat ient s not considered in TD calculat ion
To conv er t t he TI SS- 28 index int o hour s, it
The m ean daily TI SS- 28 score was 251, which
cor r esponds t o t he sum of t he TI SS- 28 scor es of all pat ient s hospit alized on t hat day. The m ean num ber of pat ien t s per day w as 8 . 1 6 , dem an din g 1 3 3 car e hours at a cost of R$ 2,531.13.
Th e m o st co m p l e x d a y d u r i n g t h e st u d y present ed a TI SS- 28 score of 353 point s, dem anding 187 care hours at a cost of R$ 3,399.39.
Th e l e a st co m p l e x d a y d u r i n g t h e st u d y
present ed a TI SS- 28 score of 147 point s, dem anding 78 care hours at a cost of R$ 1,415.61.
Figure 1 represents the cost of the nursing team according t o t he daily dem and assessed by t he TI
SS-28 ( CD/ d) , including m inim um , m ean and m axim um .
At I CUs, calculat ing t he cost of pat ient car e
by t he fixed or st andard cost s has disadvant ages. I n
r e s e a r c h c a r r i e d o u t i n Ge r m a n y i n 1 9 9 9( 1 0 ),
disadvant ages were shown from a budget perspect ive,
as st andard charges do not give a good view on t he
d y n a m i c s o f c o s t s p e r p a t i e n t g r o u p , p e r
hospit alizat ion st age, per day of t he week et c. Despit e
t he high level of fixed cost s per day at an I CUA, t here
ar e con sider able v ar iat ion s in cost s per day, w h ich
depend on t he sever it y of t he disease.
St aff cost s have been syst em at ically ver ified
by dividing t he t ot al cost of hum an resources by t he
num ber of pat ient s, r eaching a fix ed cost . This is a
s i m p l e r v a l u e t o r e a c h a v a l u e t o b e u s e d f o r
est im at in g t h e cost of p r oced u r es or d aily p at ien t
hospit alizat ion fees. However, t he use of t he TI SS- 28
i n d e x sh o w e d t h a t ca r e co st s a r e n o t f i x e d , b u t
v ar iable, as pat ient s’ com plex it ies ar e v er y differ ent .
By assessi n g t h e w o r k l o ad o f t h e n u r si n g t eam ,
indiv idual est im at es can be m ade.
Th e m et h odological possibilit y of u sin g t h e
index as dem onst rat ed in t his st udy applies t o t he use
of a new cost dim ensioning m et hod, besides ser v ing
as a support for t echnical and adm inist rat ive decisions.
Ho w e v er, f u r t h e r r e se a r ch i s n e e d e d f o r a m o r e
t horough assessm ent of it s applicat ion wit h t his goal.
The nur sing t im e dedicat ed t o per sonal car e
d eliv er y t o each p at ien t v ar ies f r om case t o case,
especially in I CU pat ient s( 11). Wit h a view t o allocat ing
the costs of nursing services directly to the patients who
actually used them , it is im portant to apply a m ethodology
that classifies each patient either according to the severity
of his/ her disease or based on t he num ber of nursing
hours predicted for his/ her care.
The nursing service cost m ethodology m ust be
based on t he pr em ise t hat pat ient s ar e pat ient s ar e
individuals with different nursing care needs, which vary
from day to day, which is why prices m ust vary as well.
Severity classification indices can be useful to differentiate
bet ween different care levels. Analyzing t he t ype and
the quantity of resources needed for patient care delivery
according t o t he severit y level has been a widely used
m echanism at I CUs, m aking it possible to determ ine the
greater or lesser need for nursing care(12).
CONCLUSI ON
Th e m ean daily n u r sin g car e t im e fou n d at
t he I CU of t he Univ er sit y Hospit al under st udy w as 1300
1800 2300 2800 3300 3800
1 5 9 1317212529333741 454953576165697377 81 85 89
Observation day
TISS Max. = 353
TISS Mean = 251
TISS Min. = 147
C
o
st
(R
$)
Figure 1 - Dist ribut ion of nursing care cost according
t o t he variat ion in t he daily TI SS- 28 and it s m inim um ,
m ean and m ax im um values. São Paulo, SP, 2003
DI SCUSSI ON
The m ean TI SS- 28 scor e of 31 point s found
in t his st udy is high in com parison wit h ot hers, which
v a r i e d f r o m 2 0 t o 2 6 p o i n t s ( 4 , 9 ) . I n a s t u d y
developed at I CUs in São Paulo Cit y in t he year 2000,
t he m ean score found w as 20 point s ( 4) . I n anot her
r esear ch , d ev el o p ed i n t h e Eu r o p ean Co m m u n i t y,
in clu d in g 1 3 , 0 0 0 p at ien t s f r om t w elv e cou n t r ies, a
score of 26 point s was found( 9).
As show n in t he r esult s, t he assessm ent of
t h e n u r si n g t e a m co st t h r o u g h t h e m e t h o d o l o g y
adopt ed in t his st udy pr esent ed gr eat v ar iat ions, as
dem onst rat ed in ot her st udies( 4- 6). The m axim um cost
w a s R$ 3 , 4 3 8 . 0 7 ; m e a n c o s t R$ 2 , 5 3 1 . 1 3 a n d
m inim um cost R$ 1,415.61.
The possibilit y of using a severit y index t hat
m e a su r e s i n d i v i d u a l co m p l e x i t y a n d , i n p a r a l l e l ,
assessed t he daily cost and it s variat ions, can be an
133 hours, corresponding t o 251 point s on t he TI
SS-28, for an av erage of 8.16 pat ient s/ day.
Th e m ean daily cost of dir ect n u r sin g car e
for 1 3 3 hour s, apply ing t he pr oposed m at hem at ical
ex pr ession, w as R$ 2,531.13.
The analysis of t he 89 days of TI SS- 28 scores
t o m easu r e t h e t eam ’s w o r k l o ad ev i d en ced g r eat
v ar iat ion. This dem onst r at es m or e clear ly how t hese
hours are consum ed and m akes it possible t o est im at e
car e cost s of nur sing st aff m or e accurat ely.
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