WO1994007210A1

WO1994007210A1 - A method for classifying a client

Info

Publication number: WO1994007210A1
Application number: PCT/DK1993/000306
Authority: WO
Inventors: Tove Buch; Flemming Mikkelsen; Grethe Wejlgaard; Mogens TANGØ; Peter JØRGENSEN
Original assignee: Structura Edb- Og Virksomhedskonsulenter A/S
Priority date: 1992-09-23
Filing date: 1993-09-23
Publication date: 1994-03-31
Also published as: AU4815493A; DK118092D0

Abstract

A method for classifying a client, such as a patient in a hospital or under district nursing care or district psychiatry nursing care or a client at a social institution, with respect to the needs for treatment and/or health care and/or social care. The classification is performed based on needs reported by professional staff and needs expressed by the client himself, thereby conforming to the WHO definition of quality in health care. An embodiment is a method for classification patients with respect to their need for nursing care. The method evaluates a number of selected parameters which correlate well with the condition of the client/patient and classify the client/patient according to his needs for care. The method is applicable in all social and health care institutions, and the direct involvement of the client/patient makes it applicable in a variety of environments.

Description

A METHOD FOR CLASSIFYING A CLIENT

The present invention relates to a novel method of classify¬ ing a client with respect to the needs for treatment and/or health care and/or social care.

Health and social institutions are known to be some of the most cost-incurring institutions in a modern society. Paral¬ lel to scientific advances within the medical field, the strain on health and social institutions have increased significantly during the last decades as more diseases have become targets for efficient medical and surgical treatment and as the average lifetime has increased with a resulting increase in the strain on the social and health institutions. In order to control the expenses in such institutions, it is necessary to provide precise estimates concerning the alloca- tion of resources within the institution in order to maximize the utilization of the resources at hand and to make it possible to utilize the quality of the institution in treat¬ ment and/or health care and/or social care as a function of the need of the client.

One way of obtaining an optimization of the use of resources within the health and social institutions is to predict with a high degree of accuracy the amount of resources an individ¬ ual client will be consuming during his contact with the institution.

With this intention, systems for client classification have previously been developed which are based on the activities that have taken place in connection with the patient or client.

However, these previous systems do not take into account the quality of the care actually given to the clients and the need for care. The invention relates to a novel method for classifying a client with respect to the needs for treatment and/or health care and/or social care, which method is client-orientated and complies with the WHO definition of "quality" in connec- tion with patients which is:

Patient satisfaction, maximum security (technological as well as in treatment and nursing) , entirety (during hospital stay as well as between the primary and secondary health service) , a high level of standards and quality and finally effective utilization of the resources.

The method of the invention for classifying a client with respect to the needs for treatment and/or health care and/or social care, comprises incorporating

1) the client's attendant-reported needs for treatment and/or health care and/or social care, established by evaluating parameters of importance for resource consump¬ tion per time unit assuring a defined level of standard of treatment and/or health care and/or social care,

and

2) the client's self-reported needs for treatment and/or health care and/or social care, established by requesting the client of his needs,

in the classification so as to establish a classification result based on parameters related to both the attendant- reported needs for treatment and/or health care and/or social care and the self-reported needs for treatment and/or health care and/or social care.

The classification may be performed in one operation incor¬ porating both the attendant-reported needs and the client's self-reported needs (for definition of these terms, see below) , or the classification may be performed by first classifying on the basis of attendant-reported need and then reclassifying based on the client's self-reported need in order to have a starting classification for an initial period and then to reclassify when the client's self-reported needs have been obtained.

In this embodiment, the method of the invention for classify¬ ing a client with respect to the needs for treatment and/or health care and/or social care comprises classifying the client's attendant-reported needs for treatment and/or health care and/or social care, by evaluating parameters of importance for resource consump¬ tion per time unit assuring a defined level of standard of treatment and/or health care and/or social care,

requesting the client of his needs, and thereby iden- tifying the client's self-reported needs for treatment and/or health care and/or social care,

reclassifying the client based on parameters where dif¬ ferences between the attendant-reported needs for treat¬ ment and/or health care and/or social care and the self- reported needs for treatment and/or health care and/or social care have occurred, and

establishing a classification result.

Thus, in this embodiment, the client will be classified on the basis of a predefined standard and the expected level of treatment and care, but the classification is modified on the basis of information given by the client to the attendant who is performing the classification.

Contrary to prior classification methods, the method of the invention is client-orientated and takes into account the client as a whole, and not only parts of information about the client. In the present context a "predefined standard" is intended to indicate a description of a level of quality which is gen¬ erally accepted within the institution/department where the standard is used. Typically, standards for examination, care, therapy and rehabilitation are defined within the medical sector. The level of quality may be described as a general principle, as a standard for specific actions and/or as a goal to be reached.

The description of a standard may thus be structured accord- ing to the following principle:

The structure is the description of the organisation, i.e. the general scope,

the process is the description of the actions, and

The resul t is the goal to reach.

However, it is not a necessity that a standard is structured as described above.

In the present context the term "client" means a person applying for treatment and/or health care and/or social care such as a patient in a hospital or in the primary health care sector, or a client in a social institution.

"Needs for treatment and/or health and/or social care" denotes the need of treatment and/or care a client has in a specific situation, which treatment and/or care will help the client to either a better condition, the condition being physical, psychological or social, or to prevent that his condition deteriorates. The needs may be divided into the attendant-reported needs and the self-reported needs, whereby both predefined standards for the care as well as the client's own opinion will be considered. In the present context the term "attendant-reported needs for treatment and/or health and/or social care" means the needs for treatment and/or health care and/or social care as repor¬ ted by a person (the "attendant") who is professionally related to the client, which person evaluates the needs based on a knowledge of the predefined standards in the field. Such a person could be a nurse, a physician or a social advisor. The needs reported are those that would give the best and most ideal treatment and/or care. It is not the idea of the present invention only to report needs that have been ful¬ filled but to report all necessary needs.

The term "self-reported needs for treatment and/or health care and/or social care" in the present context is intended to denote the needs for treatment and/or health care and/or social care as reported by the client himself. However, the wording "reported" is not necessarily to be understood in the strict sense that the client explicitly expresses his or her own needs. Thus, "reported" may also indicate that by com¬ municating with the client, the attendant has got an impres- sion of what the client likes and dislikes and what he would like different from the predefined standard, even though the client has not expressed it directly. Further, in some cases the client may be unable to express himself, e.g. when the client is a patient who is unconscious or in a coma, and in such situations close relatives may supply the necessary information concerning needs which could modify the classifi¬ cation. Moreover, even in cases where clients are able to express themselves it may be useful to imply the information from a close relative, such as is the case when the client is a child or a patient in psychiatric care, and this embodi¬ ment, whether implemented through a reporting attendant or implemented by the person in question expressing himself or herself, is included under the above definition "client's self-reported needs".

The consumption of resources may be divided into: elements of time consumption, and/or elements of resource consumption.

In the preferred embodiment there is 1 to 2 consumption elements either from both types or just from one of them.

These elements may be such as time consumption which is dependent on the duration of an admittance to health or social institution. For instance, the time consumption of doctors' rounds in a hospital is closely related to the duration of the admittance. Alternatively, a time consumption element may be one which is independent of the duration of the admittance, e.g. the duration of post-operational care in a hospital which is not related to the duration of the oper¬ ation.

It will be understood that the time consumption can be esti- mated/measured by the combined use of classical activity registrations and the method according to the invention which takes the needs of the patient into account. The classical activity registrations are useful when well-defined activ¬ ities are considered (such as duration of surgery) , whereas the method according to the invention is the tool of choice when considering activities which involve e.g. fulfilment of the patient's needs for information, education etc.

With respect to resource consumption elements, these may also be divided into at least 2 groups, such as groups dependent and independent on the duration of an admittance to the health or social institution, respectively. An example of resource consumption dependent on the duration is the con¬ sumption of bed linen or the meals in a hospital, whereas an example of resource consumption independent of the duration is the cost of a hip prothesis.

The resource consumption may be calculated as a function of a predefined standard, e.g. that the resource consumption is the time used in predefined standard routines and/or the costs related to a predefined routine. In order to estimate the resource consumption an expert opinion is provided which is the result of the combination of theoretical knowledge and practical experience. The estimated resource consumption is then expressed as average resource consumption per time unit.

For the purpose of classification, the treatment, health care or social care may be divided into subgroups such as nursing care, medical and surgical care, examinations, social advis¬ ing and pedagogic advising. This means that the client is classified either by taking each subgroup at a time or with respect to one of the subgroups only; the clients may be in contact with a different number of groups performing the classification.

The parameters evaluated are chosen carefully so as to be the characteristic parameters which most accurately assess the consumption of resources in connection with the handling of the client. The parameters are chosen within each subgroup and in some instances even within parts of a subgroup.

The numbers of parameters evaluated in the specific clas- sification situation may vary from 2-50, such as 3-40, pre¬ ferably 5-30. The variation appears when the treatment, health care or social care is divided into subgroups wherein the number of parameters not necessarily is equal. Further¬ more, the number of parameters in a specific subgroup may also vary depending on the purpose of the classification, confer Fig. la and lb where it can be seen that the medical classification requires only 6 parameters whereas the nursing classification requires 10 parameters.

In a preferred embodiment 5-15 parameters are evaluated, and in accordance with the above, about 6-10 parameters will often be the number of parameters evaluated in practice.

Different ways of measuring the parameters are possible: One way is to designate a score to each possible response to a parameter, whereby the amount of scores for each parameter corresponds to the possible amount of ways to respond to a parameter. The amount of scores per parameter can then be either a fixed amount for each parameter within a subgroup or different amounts of scores for different parameters.

The score can for instance be a number from an ordinal scale, but it can also be a weighted score, which has the implica¬ tion that some responses to a parameter weighs, more than just the next number corresponding to the next response in the line of responses to a parameter. This is typically the case when a response to a parameter results in a consumption of resources which is out of proportion with other possible responses to the same parameter.

According to the invention the score could be a number between 1-50, preferably between 1-40, when the score is a number from an ordinal scale.

In a preferred embodiment of the invention the score is between 1-30, such as 1-20.

In a most preferred embodiment the score is between 1-10, such as 1-5, most preferably 1-3.

When the time consumption is to be determined on the basis of such a scoring system the optimum is to determine a linear interrelationship between the scores representing the evalu¬ ated parameters and the time consumption so as to express the time consumption as a continuous function of the scores; thereby a very precise estimate of the time consumption in connection with a given client is obtained. For this purpose one can employ a multivariate regression analysis on data sets consisting of the observed time consumption and the scores representing the evaluated parameters. In such a situation the scoring results themselves will constitute the classification result. However, a multivariate regression analysis demands that a large statistical material is available in order to determine the coefficients for each type of score representing an evaluated parameter. Therefore, a practical solution is to use the scoring of the client in order to classify him in one of a small number (e.g. 4) of classification groups, estab¬ lishing the time consumption corresponding to each group and thereby predicting the time consumption.

Thus, when using the method of the invention to predict the time consumption in a specific health or social institution, a prediction based on classification in groups will be pre¬ ferred when one initializes the use of the classification method, whereas the prediction based on a linear inter- relationship between scores and time consumption will be preferred when an amount of data is available to ensure an acceptable determination of coefficients in the multivariate regression analysis.

With respect to surgical and medical care which are subgroups of treatment/health care, the parameters evaluated are such as preliminary diagnosis, additionally complicating diag¬ noses, and general condition of the client. By the term "preliminary diagnosis" is in the present context understood the diagnosis assigned to the client at the time of classi- fication. It will be appreciated that the diagnosis may change when the client has been examined more thoroughly. "Additionally complicating diagnoses" are diagnoses of dis¬ eases from which the client suffers independent of the dis¬ ease that led him to the hospital, but which nevertheless may complicate the examination for and/or the treatment of the disease that caused the client's hospitalization. Such addi¬ tional complicating diagnoses could be chronical dis¬ eases/conditions like diabetes mellitus, hypertension, con¬ gestive heart failure, chronical bronchitis, osteoporosis etc. or they could be conditions which have an impact on the choice and efficiency of therapy, such as allergies. The term "general condition of the client" as defined herein denotes the general functional level of the client. This parameter is evaluated by taking into consideration general conditions, such as age, obesity, mobility, vision, hearing, psychological state etc., but it is clearly distinguished from the above-mentioned complicating diagnoses in that they have no direct impact on the choice and prognosis of therapy.

"Reclassifying the client based on the parameters where differences between the attendant-reported needs and the self-reported needs have occurred" means that the response to the parameter that the attendant has given is modified by the information given by the client. Thus, for the parameters where differences occur between the attendant-reported and the self-reported needs of a patient, the classification may be changed. However, it is also possible that one or more of such differences in reported needs neutralize each other, with the result that the classification is left seemingly unchanged.

The frequency of classification of a specific client depends on the purpose of the classification. At hospitals it could be useful to classify the client every day, or even more frequent if the condition of the client changes frequently or continuously, as is often the case in intensive-care units. At social institutions the classification could appropriately take place each time the client is in contact with the atten¬ dant.

A very efficient practical utilization of the method of the invention comprises starting with a "model classification" based upon information received about the client before the client enters the system in question, in which case the parameters on which the classification is based can be combi¬ nation of model parameters (e.g. parameters based on experi¬ ences from previous clients) believed to conform most closely with the actual parameters for the client in question, com- bined with actual parameters where available, such as the client's age, level of self-dependency, presumed level of disease, etc. Already on this basis, the incorporation of the client in the system, e.g. time of hospitalization and run¬ ning the course, can be planned and pre-analyzed. At the time when the client is actually incorporated in the system, e.g. hospitalized, the classification is individualized, either first based upon attendant-reported needs and later addi¬ tionally based on client's self-reported needs, or based on both attendant-reported needs and client's self-reported needs. In many cases, there will be a constant adjustment of the classification at intervals between e.g. from 8 hours to several days, based upon fresh attendant-reported and/or client's self-reported needs.

The result of the classification may be used for several purposes. One such purpose is the allocation of resources to the institutions performing the treatment and/or health and/or social care. In such a case the allocated resources could be money or products for use in the institution. Espec¬ ially, the classification results could be used in allocating man resources to the institutions. The classification method is extremely sensitive when used in assessing the require¬ ments for manpower in order to fulfil the needs for treatment and/or health care and/or social care.

Another use of the classification result is in statistics , when evaluating national as well as regional treatment and/or health care and/or social care. In such a situation it is advantageous if the classification results are compared with the actual fulfilled needs.

The results from the classification is conveniently processed in a computer in order to store the results for later use, but also in order to make calculations based on the clas¬ sification results.

A great advantage of the present method is its general appli¬ cability. Because of the unique client-oriented approach of the present invention it may be employed worldwide as the parameters and the corresponding results may be established locally. When the classification is modified by incorporating the self-reported needs, all types of cultural and national characteristics can be taken care of.

In a very important embodiment of the invention, the treat¬ ment and/ or health care is nursing care.

The term "nursing care" as used herein is defined as the care instituted and maintained in order to fulfil the client's needs with respect to, i . a . dependency (personal hygiene, medication, mobility, nutrition etc.), surveillance of the state of illness as determined by monitoring parameters such as the level of consciousness, temperature, blood pressure, diuresis, cardiac rhythm, concentrations of blood gasses etc, psychological contact, information and education, rehabilita¬ tion to life after discharge etc.

The nursing care may be carried out at various institutions such as a hospital, which in the present context means both normal hospitals as well as hospices, nursing homes, resting homes and children's homes. However, the nursing care may also take place in the primary health care sector, i.e. the nursing care that takes place outside hospitals, such as district nursing care and district psychiatry nursing care. Furthermore, nursing care which takes place in a general practice or at a school are also meant to be included in the present invention.

The parameters and the way of measuring the responses to the parameters, e.g. scoring, is as described above.

The nursing care may be carried out at various hospital departments, such as an intensive care unit, a medical de¬ partment or a surgical department, a radiotherapy department or a children's department or hospital. The variability of the method with respect to the places where the care is carried out is due to the fact that for each place where the method is desired to be used, it is possible to determine the characteristics that indicate the resource consumption most accurately.

With respect to an intensive care unit the following parame¬ ters are considered to be characteristic-

frequency of observation of clinical parameters,

CNS-status, - respiration, cardio-vascular function, information/teaching of a client, renal function, infusions/medication, - need for help to personal hygiene and mobilization, other treatment and care, examination and coordination,

and with respect to the various parameters the following variables are considered when the attendant-reported needs are reported:

clinical parameters are such as blood pressure, pulse and temperature,

CNS-status is evaluated by observing the pupils, the risk of convulsions, the mental state of the client,

- respiration is evaluated by observing the need for as¬ sisted respiration, inhalation of drugs, PEEP (positive end-expiratory pressure therapy) and CPAP (continuous positive airway pressure therapy) ,

cardio-vascular function is evaluated with respect to the need for medication and for a pacemaker, renal function is evaluated by evaluating the need for dialysis and for measurement of diuresis,

infusions/medications are evaluated with respect to amounts and frequency,

- other treatment and care are such as control of aorta pump, Swan Ganz catheter, treatment of heart insuffi¬ ciency, intubation, shift of bandages, arterial and venous entrances and fistulas, and gastric tubes,

examination relates to amounts and frequency of blood samples, and the coordination relates to coordination of persons from several professions.

In a most preferred embodiment the parameters are those shown on the form in Fig. la.

It will be understood that the above-mentioned utilization of multivariate regression analysis in the establishing of a correlation between individual scores and consumption of resources is a task which demands the use of computer pro¬ cessing. Further, the computing of the resource consumption based on the individual scores, also will be greatly facili- tated by the use of computerized methods.

Thus an important aspect of the invention is a method as which employs a method as defined above, wherein several classes of attendants are involved in reporting the needs of the client, including the client's self-reported needs, each class of attendants delivering its individual reporting, the scores of the parameters from each class of attendants are weighted, and the weighted scores are used as arguments in a linear equation expressing of the resource consumption for the client. Normally such a method will be used, wherein the number of variables of the linear equation equals the number of classes of attendants. If the equation is based on more classes of attendants than those delivering the input scores, and thus comprises more variables, the remaining variables are expressed as a standardized constant in the equation.

It will thus understood that the coefficients of the linear equation have been determined by multivariate regression analysis of the consumption of resources as a function of identically weighted scores. This will normally have been done as a statistical work prior to the use of the above- indicated method.

As mentioned herein a similar method can be used wherein several classes of attendants are involved in reporting the needs of the client, including the client's self-reported needs, each class of attendants delivering its individual reporting, the scores of the parameters from each class of attendant needs are weighted, and the sum of the weighted scores from each class of attendants is weighted according to a predetermined resource consumption of the class, the clas¬ sification being the index of an interval in a table of intervals in which interval the sum of the thus weighted scores is located.

Such a method will normally be used in the early phase of the utilization of the method of the invention as insufficient amounts of statistical material will available.

LEGENDS TO FIGURES

Figure la and lb Record forms for the scoring of cardiological patients. 1 to 3 points are given for each of 10 parameters of nursing care, 0 to 4 points are given for each of 6 parameters of medical care. The parameters in the form have been chosen on the basis of expert opinions.

Figure 2 The figure shows the correlation between the present method (NCR) and TISS. The line of regression: Y = 33.7 + 0.5x; r = 0.60, SD = ± 8.6; p < 0.05.

Figure 3 Classification of the client according to the parameters of the form shown in Fig. la (NCR) and TISS scores. The esti¬ mated time for each client category according to the present method per 8 hour shift is also shown.

Figure 4 The difference between the measured nursing time ( ) during one month (day shift) compared with the available nursing time taken into account the Staff Member's level of education and authority ( ) and without taken this into account ( ). The measured mean nursing time was 59.8 hours and the available mean nursing time was 49.6 hours and 44.9 hours, respectively. Thus, the difference between measured and available nursing time proved to be 10.2 hours and 14.9 hours respectively. ( ) : measured time ( ) : 1:1:1

( ) : 1:0.75:0.5

SI: Available nursing time evaluated as "too high". : Available nursing time evaluated as "too low" .

Figure 5 The validity of the estimated nursing time (average) . 20 observational studies. The differences are caused by the number of patients and the short study period.

Figure 6

Interrater test. 3 nurses' record score of the same patient (14 totally) . Correlation 90.5%. Kappa 0.9.

Figure 7

The number of registrations (day/evening/night) for category II (A) , III (B) and IV (C) during a one year period. Figure 8

Schematic drawing of the heart of the hospital administration system PARRIS. First a patient is "typed" (in this figure the type is: "Patient with angina pectoris"). Based on a previous expert evaluation of the consumption by such a patient of resources and the available data concerning the patient, a model plan for the patient is created. Such a model plan comprises one or more sub plans. Finally, when the patient is hospitalized and data are available, the model plan is con- verted to a patient plan, which is continuously updated. Both the model plan and the patient plan are updated by use of the methods of the invention.

EXAMPLES

EXAMPLE 1 Examples of the standards used in nursing care

Ethi cal :

Autonomy should be the ethical principle in treatment and caring.

Ethical and satisfaction : The client's opinion concerning the level of treatment should be noticeable in treatment and nursing.

The clients and their relatives should be informed optimally concerning risks, possibilities and the expected quality of life.

Ethical and securi ty:

If the communication is not possible because of the actual client's condition, the staff members has to treat and nurse the client and legally and ethically investigate the client's opinion concerning the level of treatment and nursing.

Security: The client, unconscious, anxious or in danger must never be left alone.

The client "at risk" must never be left alone to the techni¬ cal alarms.

Nursing:

Nursing must be arranged taken into account the client's re¬ sources (self-care) .

The client treated by mechanical ventilation should be turned over each second hour.

The client treated by mechanical ventilation should be man¬ ually ventilated and suctioned every second hour.

Nursing and security:

The day-and-night rhythm should be respected in treatment and nursing related to the individual client's condition.

Nursing, security and entirety:

The nursing model is "the same, small number of staff members (nurses and physicians) to the same few clients related to severity of illness and the staff members education and authority" .

Primary health care in its original version is not possible because of a lot of circumstances.

Entirety and satisfaction :

The standards should be ordered hierarchically related to the individual client's condition.

EXAMPLE 2

Classification of clients ' individual needs for nursing care in an intensive care uni t Method:

All clients were scored with respect to the ten parameters shown in Fig. la.

Each parameter was assigned from one to three points using an ordinal scale, depending upon the estimated duration of the procedures.

The variables describe the clients' level of illness, signs or nursing diagnoses, and the nurses' task concerning the level and frequency of observation and monitoring, investiga- tion, treatment and caring and the level of information and instructions.

Each client was scored at the end of a nursing shift, i.e. every 8 hours; less than one minute was used to score a client.

Only one score is possible for each parameter meaning that in a situation where two or more scores would seem more conveni¬ ent in the classification of a particular client the highest relevant score is chosen.

An example of the classification of one client is described below:

Parameters Score

Measurement of parameters 2

CNS 1 - Respiration 2 Cardiovascular 2

Information, teaching 1

Renal function 1

Infusions, medical treatment 2 - Hygiene, mobilization 1

Other treatment/care 2

Examinations, coordination 2 Total score 16

After the scoring of the client by the nurse, the client who had been artificially ventilated, but was trying to reduce the need for respirator treatment, expressed that he felt comfortable by knowing that he could always call for help when necessary and told the nurse that he did not need con¬ stant watch.

Taking a client away from a respirator is well-known to be a stressful situation for the client who very often gets very anxious and the standard routine of the intensive care unit is to observe the client constantly in order to make the client feel safe.

Thus, the score for respiration could be reduced from 2 to 1, which means that the total score for the client in the par¬ ticular situation is reduced from 16 to 15, because of the modification based on the clients' self-reported needs for care.

Resul ts and conclusion

Based on the total score each of the clients are shifted into one of four nursing care categories.

Using the correlation between the present method and TISS (vide example 3) the categories are defined as follows:

Category I, are the clients to be prophylactically surveyed, e.g. the clients after uncomplicated surgical procedures in recovery rooms. The need for nursing requirements rapidly decreases. Score 3-9.

In this study client-category I was not taken into account as the recovery room was placed in another department. Category II constitutes the stable clients in need of inten¬ sive care monitoring and intensive nursing care - the client "at risk". Score 10-15.

Category III constitutes the stable clients in need of inten- sive nursing care - the client's condition is stabilized due to a specific treatment. Score 16-23.

Finally, category IV constitute the unstable clients in need of maximal intensive care therapy and specific intensive nursing care - the client's condition is getting worse in spite of maximal therapeutic efforts. Score 24-30.

Using the classification every 8 hours it is possible to elucidating the client's responses to therapy and the nursing care more rapidly than classification methods used for 24 hours periods. Thereby it is possible to manage the nursing resources admitted per shift more precisely.

The result of the self-reported needs will not always lead to a reduction of the total score of the client: the self-repor¬ ted needs may also lead to an increase of the score, or even in cases where more parameters have been amended the changes may equalize each other.

EXAMPLE 3

Comparing the nursing care method with TISS

Method:

The method described in example 2 is used and compared to a classification method (TISS) described in Cullen, David J. et al, Critical Care Medicine, March-April, 1974: Therapeutic intervention scoring system: a method for quanti tative com¬ parison of patient care.

The total score, the sum of ten parameters shown in example 2 from a single shift, classifies the clients into one of four categories. The levels of the four categories are found by correlating the present method to the Therapeutic Intervention Scoring System (TISS) . The correlation between the present method and TISS was found to be significant; r = 0.66, p < 0,05. The result is shown in Fig. 2 and 3.

The Therapeutic Intervention Scoring System quantitates the sort and the number of treatment. It comprises 82 parameters divided in 17 indicators collecting the past 24-hours of therapy. TISS measures the amount of time and effort used in treating critically ill clients.

The main difference between TISS and the present method was related to recording procedures and to the contents of the estimated time.

Studies using the present method and TISS have demonstrated that one nurse can take care of the physical needs of a client equivalent to 40 TISS points. For comparison 40 TISS points corresponds to 18 scores according to the form shown in Fig. la. However, in the present system 18 scores repre¬ sent the work of 1.5 nurse, because the method takes into account the needs for and the resources to the psychological care.

EXAMPLE 4 JnteroJbservational studies

The aim of the study was to evaluate the estimated nursing time and the interrater reliability.

20 observational studies were carried out.

The correlation between the estimated nursing time and the observational studies was found to be significant, Fig. 5 and Fig. 6. The differences can be explained by the number of observa¬ tional studies and the short period of investigation.

In the interrater reliability study 42 scores were recorded representing 14 clients. Three nurses familiar to the scoring system and the ICU recorded the clients.

In classifying the clients there were 100 % correlation bet¬ ween two of the nurses and 90,5 % with the third nurse. Kappa is 0.9 where 1.0 is the perfect, cf. figure 3.

Scoring the single indicator the correlation was 89.8 % (range 83.3 to 100).

EXAMPLE 5

The use of the method of the invention in PARRIS

PARRIS (PAtient Related Resource management & Information System) is a system for resource administration in hospital units, for patient as well as personal and departmental administration, including productivity, efficiency and qual¬ ity evaluations. A central part of PARRIS is the classifica¬ tion of patients according to the present invention.

The method according to the invention is used multidisciplinary in PARRIS, i.e. all categories of staff at a hospital which are in contact with the patients are involved in the use and utilization of the system.

PARRIS is based on the idea of using classical registrations of activity in the care as well as the registration of the patient's need for care by the method according to the inven¬ tion in order to accurately predict the resources to be spent in connection with a given patient. The classical activity registrations are typically performed when the activity is well-defined (such as surgery) whereas the classification method according to the invention is the method of choice when the activity is hard to define with respect to usage of time; examples of this are activities wherein personal infor¬ mation or guidance is a substantial part and wherein a regis¬ tration of the time spent on the activity therefore will underestimate the actual time spent.

Methodologically, the patients are categorized, based on their diagnoses, their clinical condition, and the specified level of examination, treatment and nursing care (the nursing diagnoses) , into pre-determined patient types with a uniform course of care.

Each patient type corresponds with a model plan, as shown in Fig. 8, describing the expected resources needed. This esti¬ mate in turn is based on both the method according to the invention and the estimated time for specified activities. The model plan is used in planning the time and course of the hospitalization.

The patient plan is the modified model plan for the actual patient taking into account the actual condition of the patient and describing in detail the course of treatment and nursing care. The shift between model plans and patient plans usually takes place when the patient is received at the hospital and more information becomes available. Both the model plan and the patient plan are constructed of sub plans specifying minor parts of the total course and the level of involvement for selected resources.

The sub plan states the patient's estimated need for resources in hours, number, costs, activities such as moni¬ toring, level of observation, examination, treatment, level of quality standards and type of resources such as bed, room, physician, surgeon, nurse and physiotherapist.

Each patient's hospital stay is based on a defined level of standards for quality in nursing, treatment as well as in examination. The patient plan can be modified when the method according to the invention gives the result that resources have to be increased or decreased in conjunction with the care of the patient. This means that resources will be distributed in a manner which ensures a maximum utilization of the available resources.

In the PARRIS computer system, the PCR method is implemented as 7 edp programmes:

Programme A is used for a registered department and resour¬ ce type, for example Department B Physician, Department NK Nurses, to define each element in a PCR scheme.

Programme B is used for a registered department and resour¬ ce type to define the calculation method, para¬ meters and the whole PCR scheme. In the pro¬ gramme, the user can choose one of two calcula¬ tion methods:

C The categorized method

L The linear functional calculation

If the user chooses the linear functional me¬ thod, the constraint used in the linear func¬ tion must also be registered.

In the programme, the user then defines each line in the PCR scheme and one of two parame¬ ters for this line:

1. If the categorized method is used, a so- called sum-score parameter which can be 1, 2 or 3, is registered.

If the linear functional method is used, the coefficient to the parameter related to the actual line in the linear function is registered.

Programme C is only used if the categorized method is cho¬ sen in programme B. The programme is used for a registered department and resource type to define, for each sum-score parameter used in programme B, the relation between intervals for obtained scores and a PCR sum category.

Programme D is only used if the categorized method is cho¬ sen in programme B. The programme is used for a registered department and resource type to define all possible combinations of PCR sum categories and PCR categories.

Programme E is only used if the categorized method is cho¬ sen in programme B. The programme is used for a registered department and resource type to define the average resource consumption per shift for each PCR category.

Programme F is only used if the linear function method is chosen in programme B. The programme is used for a registered department and resource type to define a PCR category for intervals of aver¬ age resource consumption per shift.

Programme G is used to register the predicted scores or the realized scores for each line in the relevant PCR scheme for shift in a department for a chosen resource type. The programme validates the registration and calculates the resource consumption and PCR category.

EXAMPLE 6

Practical examples of the utilization of PARRIS The PARRIS method (and thereby the method of the invention) was implemented in Rigshospitalet, Copenhagen in Denmark, in an intensive care unit receiving post-operative patients with pancreas transplantations.

The patient's need for observation, nursing care and treat¬ ment was described in the standard describing the total surgical and post-surgical course. This description was employed in order to assign scores to the patient in each shift in the first 3 days after surgery. In order to predict the necessary resources the total a priori scores for a patient with no complications and a patient with maximum complications were calculated and these scores were used to classify the patient. It came out that independent of the post-surgery course the patients would be categorized in the following classes in the first three days:

Shift 1-4: class 4; shift 5-7: class 3; and shift 8-10: class 2.

Class 4 elicited a sum of 16 hours of nursing per shift, class 3 elicited 12 hours per shift and class 2 elicited 6 hours per shift.

If all went according to schedule, the patient should be transferred from the ICU after three days.

The ICU received the resources predicted to be necessary according to the method described above. Thereafter, the courses of each of the first 5 patients were evaluated in order to assess whether the received resources correlated with the actual needs.

The patients were registered in each shift and the nurse in charge evaluated in collaboration with the patient's nurse the actual course and the assigned resources. There was good correlation between activities, registrations and nursing resources.

In a similar scenario a prediction of the expected costs in the transplantation unit (excluding the ICU post-operative course) in connection with lung transplantations. The calcu¬ lations (scoring, classification and conversion to nursing resources) were performed by 3 expert nurses with experience in intensive care and treatment of patients with sever pul¬ monary disease. The course of hospitalization was described as the average: investigation: 3 weeks; post-operative course: 6 weeks; and control: 2 weeks a year.

On the basis of these data it was calculated that such an average patient would elicit a need for 684.4 nursing hours.

5 patients entered in the period 1 January - 31 August 1992 in the validation of the calculated nursing hours.

The actual consumption of hours in each shift was recorded. The time of hospitalization was on the average 78 days (rang¬ ing between 54 and 112) . The expected consumption was 77 days. The conclusion was that the 5 patients consumed a total of 682.2 hours (ranging from 294 to 1092) which should be compared to the predicted 684.4 hours.

Claims

1. A method for classifying a client with respect to the needs for treatment and/or health care and/or social care, comprising incorporating

and

2. A method according to claim 1, comprising:

- classifying the client's attendant-reported needs for treatment and/or health care and/or social care, by evaluating parameters of importance for resource consump¬ tion per time unit assuring a defined level of standard of treatment and/or health care and/or social care,

- requesting the client of his needs, and thereby iden¬ tifying the client's self-reported needs for treatment and/or health care and/or social care,

reclassifying the client based on parameters where dif¬ ferences between the attendant-reported needs for treat- ment and/or health care and/or social care and the self- reported needs for treatment and/or health care and/or social care have occurred, and

establishing a classification result.

3. A method according to claim 1 or 2 wherein the resource consumption is divided into time consumption elements and/or resource consumption elements, such as 1 to 2 elements for each.

4. A method according to claim any of the preceding claims, wherein the resource consumption is calculated as a function of a defined standard for treatment and/or health care and/or social care.

5. A method according to any of the preceding claims, wherein the treatment and/or health care and/or social care is divided into subgroups such as nursing care, medical and surgical care, examinations, social advising and pedagogic advising.

6. A method according to any of the preceding claims, wherein 2-50 parameters are evaluated for a subgroup of treatment and/or health care and/or social care, such as 3-40 parame¬ ters, preferably 5-30 parameters, more preferably 5-15 para¬ meters and most preferably 10 parameters.

7. A method according to any of the preceding claims wherein the treatment and/or health care is surgical treatment or medical treatment and the parameters evaluated are selected from the group consisting of preliminary diagnosis, addi¬ tionally complicating diagnosis and general condition of the client.

8. A method for classifying a client with respect to the needs for nursing care, comprising incorporating 1) the client's attendant-reported needs for nursing care, established by evaluating parameters of importance for resource consumption per time unit assuring a defined level of standard of nursing care,

and

2) the client's self-reported needs for nursing care, established by requesting the client of his needs,

in the classification so as to establish a classification result based on parameters related to both the attendant- reported needs for nursing care and the self-reported needs for nursing care.

9. A method according to claim 8, comprising:

classifying the client's attendant-reported needs for nursing care, by evaluating parameters of importance for resource consumption per time unit assuring a defined level of standard of nursing care,

requesting the client of his needs, and thereby iden¬ tifying the client's self-reported needs for nursing care,

- reclassifying the client based on parameters where dif¬ ferences between the attendant-reported needs for nursing care and the self-reported needs for nursing care have occurred, and

establishing a classification result.

10. A method according to claim 8 or 9, wherein the nursing care is carried out in a hospital department such as an intensive unit, a medical department or a surgical depart¬ ment, a radiotherapy department or a children's department or hospital.

11. A method according to claim 8 or 9, wherein the nursing care is in the primary health care sector such as district nursing care and district psychiatry nursing care.

12. A method according to claim 8 or 9, wherein the nursing care is carried out in an intensive care unit and the parame¬ ters evaluated are selected from the group of frequency of observation of clinical parameters, CNS-status, respiration, cardio-vascular function, information/teaching of a client, renal function, infusions/medication, need for help to per¬ sonal hygiene and mobilization, other treatment and care, examination and coordination.

13. A method according to claim 12 wherein the clinical parameters are selected from blood pressure, pulse and tem- perature.

14. A method according to claim 12 wherein the CNS-status is evaluated by observing the pupils, the risk of convulsions, the mental state of the client.

15. A method according to claim 12 wherein respiration is evaluated observing the need for assisted respiration, inha¬ lation of drugs, PEEP and CPAP.

16. A method according to claim 12 wherein the cardio-vascu¬ lar function is evaluated with respect to a need for medica¬ tion and for pacemaker.

17. A method according to claim 12 wherein the renal function is evaluated by the need for dialysis and for measurement of diuresis.

18. A method according to claim 12 wherein the infusions/- medications are evaluated with respect to amounts and fre- quency.

19. A method according to claim 12 wherein the other treat¬ ment and care are control of aorta pump, Swan Ganz catheter, treatment of heart attack, intubation, shift of bandages, arterial and venous entrances and fistulas, and gastric tubes.

20. A method according to claim 12 wherein the examination relates to amounts and frequency of blood samples, and the coordination relates to coordination of persons from several professions.

21. A method according to claim 12 wherein the parameters evaluated are the parameters of the form shown in Fig. la.

22. A method according to any of claims 8-21, wherein 2-50 parameters are evaluated, such as 3-40 parameters, preferably 5-30 parameters, more preferably 5-15 parameters, such as 6- 10 parameters.

23. A method according to any of the preceding claims wherein each parameter is given a score.

24. A method according to claim 23, wherein the score is a number between 1-50, such as a number between 1-40, preferab- ly a number between 1-30, more preferably a number between 1- 20, even more preferably a number between 1-10, still more preferably a number between 1-5, and most preferably a number between 1-3.

25. A method according to claim 23 or 24, wherein several classes of attendants are involved in reporting the needs of the client, including the client's self-reported needs, each class of attendants delivering its individual reporting, the scores of the parameters from each class of attendants are weighted, and the weighted scores are used as arguments in a linear equation expressing of the resource consumption for the client.

26. A method according to claim 25, wherein the number of variables of the linear equation equals the number of classes of attendants.

27. A method according to claim 25 or 26, wherein the coeffi- cients of the linear equation have been determined by multivariate regression analysis of the consumption of resources as a function of identically weighted scores.

28. A method according to claim 23 or 24, wherein several classes of attendants are involved in reporting the needs of the client, including the client's self-reported needs, each class of attendants delivering its individual reporting, the scores of the parameters from each class of attendant needs are weighted, and the sum of the weighted scores from each class of attendants is weighted according to a predetermined resource consumption of the class, the classification being the index of an interval in a table of intervals in which interval the sum of the thus weighted scores is located.