PREDICTORS OF NURSING WORKLOAD IN ELDERLY PATIENTS ADMITTED TO INTENSIVE CARE UNITS

Disponible en castellano/Disponível em língua portuguesa SciELO Brasil www.scielo.br/rlae 1 RN, Hospital Nove de Julho, First Aid Post, Brazil, e-mail: cleber73@gmail.com; 2 MS in Nursing, RN, Hospital Sírio Libanês, Brazil, e-mail: leilaneag@yahoo.com.br; 3 RN, Doctoral Student, e-mail: mariacel@usp.br, karileao@usp.br; 4 RN, Associated Professor, e-mail:kgpadilh@usp.br. University of Sao Paulo, School of Nursing Brazil PREDICTORS OF NURSING WORKLOAD IN ELDERLY PATIENTS ADMITTED TO INTENSIVE CARE UNITS


INDICADORES DE LA DEMANDA DE TRABAJO DE ENFERMERÍA PARA ATENDER ANCIANOS INTERNADOS EN UNA UNIDAD DE TERAPIA INTENSIVA
La edad de los pacientes es un factor polémico en las internaciones en UTI(s).El objetivo del estudio fue comparar la gravedad y la demanda de trabajo que tiene enfermería para atender ancianos, agrupados en diferentes intervalos de edad, en la UTI, e identificar los indicadores de la alta carga de trabajo de enfermería en esa población.Se realizó un estudio transversal en tres UTI(s) de hospitales del municipio de San Pablo, con una muestra de 71 ancianos admitidos entre octubre y noviembre de 2004.Para la prospección y recolección de los datos se utilizó Nursing Activities Score (NAS) y el Simplified Acute Physiology Score II (SAPS II).No se encontraron diferencias en la demanda de trabajo de enfermería entre ancianos, agrupados en diferentes intervalos de edad; y, los factores asociados a la alta carga de trabajo fueron la gravedad, la edad y el tipo de internación.La edad como un factor aislado no debe constituirse en un factor discriminante para la admisión de ancianos en las UTIs.

INTRODUCTION
Ageing of the world population is occurring in a large scale in the last decades.This phenomenon occurs not only in developed countries but also in developing, and its results in society are sizeable, especially regarding health (1) .Because of this process, the number of chronic diseases characterized by organic instable disorders has increased among older people, which results in increase demand for beds in Intensive Care Units (ICU) to meet the needs of these patients (2)   .
ICUs are costly, requiring the use of high technology, appropriate room and highly trained team.
Studies show that the single largest contributor to an ICU cost is nursing services.Therefore, one strategy to lower cost of care is scheduling nurse staff adequately.Staff schedules should be driven by patient needs of care in order to ensure a rational use of the ICU resources (3) .To that end, it is important to be aware .

Within this context, admission of elderly patients
in ICUs is a controversial issue, and age is considered as a refusal criterion for these patients in some centers (5-6)   .In the literature, there is no consensus on the issue of investing resources in elderly patients admitted to a hospital, especially when they demand ICU hospitalization.Mortality of these patients is high, especially when associated with the use of invasive mechanical ventilation, reaching up to 92% among elderly people over 75 years old (7)   .

PATIENTS AND METHODS
Data were collected in October and November NAS supplies data for staff quantification and also helps calculating budget for nursing service of hospitals (8) .
SAPS II is an instrument to measure severity obtained from the assessment of clinical and laboratory features and of the existence of chronic comorbidities.
The final score, applied to a math formula, enables to calculate the mortality risk at ICU (9) .
After the Project was approved by the Ethical Committee of the hospital fields of study, prospective follow-up of patients were performed, considering a minimum period of admission to ICU of 24 h and a maximum of 30 days, when data collection was stopped. For

Sociodemographic and clinical characteristics
Elderly patients were equally distributed according to gender, with a 75.8 (SD=9.9)mean age.
Regarding clinical characteristics, the oldest (≥80) stayed in hospital for a significantly longer time than those with 60-69 years of age (p=0.006), and also presented a greater mortality risk (p=0.026).
Although elderly patients with ages from 70-79 presented greater risk than those from 60-69, this difference was not statistically significant (Table 1).
When elderly patients from the different age groups were compared, no statistically significant difference was seen regarding severity (SAPS II), although there were significant differences in death risk (Table 1).1).
When the three groups of elderly patients were compared, we saw that there was no statistically significant differences in the total score of the nursing work demand among elderly in different age groups (p=0.84) and also when compared with the distribution of elderly in high and low demand (p=0.36).

Factors associated with high nursing work demand
To identify predictors of high nursing workload, all sociodemographic and clinical variables were assessed using univariate logistic regression.Only severity, age and type of admission presented an independent effect in determining high nursing work demand.Patients with ages ranging from 70-79 presented greater chance of high nursing workload than those from 60-69, especially when they were patients admitted for surgical reasons and that were high severe.OR (Odds Ratio) of the age was adjusted according to severity and type of admission (Table 2).regarding male predominance (53.5%) (8) , high age average (10) , coming from Emergency Room (ER) (10) , with cardiac, respiratory and gastrointestinal changes (11) , admitted to ICU for clinical treatment (10) .
These data confirm that with the ageing of the population, health problems increase with the need for interventions demanding ICU stay.Also, admission in ER allows us to infer that old patients, with chronic diseases, were referred to ER with severe instability requiring intensive care.
The high SAPS II found in the sample (38.4) confirms the information presented above, and they are compatible with some national studies (9) , however, they are higher when compared with other national and international investigations (12)   .Additionally, it was observed a long average of stay (13.9 ± 14.2 days), different from findings of studies with average between 3 and 6 days (11)   , demonstrating the need for intensive care for a longer period of time for this specific population.
Regarding characterization of the nursing work demand required by the elderly patients, a high average of the total score of NAS was observed (72.9%), with a minimum of 54% and maximum of 110%, superior to several national studies (8) , including a study that compared workload among elderly and non-elderly (10) , whose average of NAS varied from 65.5% to 69.9%.
Although patients from the present study were in an advanced age, severe and demanding a high workload, mortality rate was low (17.2%), in agreement with foreign studies (10,13)   , with the majority of patients (68.8%) being transferred to admission unit after ICU discharge.With these findings we may assume that patients received quality medical and nursing care, thus justifying the low mortality rate found.
From a quantitative standpoint of nursing personnel, considering the high work demand of elderly (about 73%), the 1:2 professional relationship nurse/patients recommended by the Regulation of the Ministry of Health (14) , would be enough for the care of patients in this population, according to work shift, which would demand one professional per shift for their care.

DISCUSSION
Results referring to demographic and clinical characteristics of the total of patients in this study are similar to most research performed at ICU interesting to see by the use of NAS that there was no difference in the application of therapy resources between elderly and non-elderly patients, demonstrating that, once admitted to ICU, regardless of the age, patients received all kinds of investment available for their treatment.
Results of this investigation point out for the need to increase the discussion on the referral of elderly to ICU because of the high financial, physical and emotional cost of care in this Unit.Obviously, it is not about discouraging referral of elderly to ICU, but deepening the discussion on the issue aiming at balanced and sensible decisions on how much investment should be given to treatment, without lowering human beings.However, other studies must be performed to explore the issue, because of the small number of research assessing the nursing workload of elderly staying at ICU (s).

CONCLUSIONS
The results of the study in this sample of patients allowed us to conclude that nursing work demand of elderly patients of age groups 60-69, 70-79 and ≥ 80, at ICU, was high, respectively, 72.43%, 74.25%, and 71.93%.Patients undergoing surgical treatment demanded greater nursing workload (p=0.036), and elderly patients aged 80 or over presented higher mortality risk (p=0.034).There was no difference between the groups regarding severity (p=0.070) and nursing workload (p=0.842).Factors associated with high nursing work demand at ICU were age, severity, and type of admission in the Unit.Results indicate the need for a greater number of studies on the issue, so that the age does not become a discriminative factor for care of elderly patients at ICU.
2004.The inclusion criteria were older than 60 years of age, minimal ICU stay of 24 hours and maximum 30 days.Elderly patients were divided into three subgroups, according to their age: A (60-69), B (70-79) and group C (≥80).For data collection, the study instruments included an instruments for identification of demographic and clinical characteristics, the Nursing Activities Score (NAS) to assess nursing work demand, and the Simplified Acute Physiology Score (SAPS II) to assess patient severity and mortality risk.NAS is an instrument that scores needs for care required by patients in 24 hours, as of the quantification of interventions performed in this period of time.It consists of 23 items divided into seven intervention categories.Each item receives a score whose final grade shows the percentage of time spent by nurses in direct care of patients; it may range from 0 to 100 % or over.
data collection of NAS, in the first admission day, the interventions performed from admission at ICU until 8 o'clock the next day were computed, regardless of completing 24 hours.Regarding patients leaving the unit, interventions computed were those from 8 o'clock and the time of discharge or death.NAS was applied by nursing aids of the respective ICUs, using information from the patient medical records and daily patient worksheet.SAPS II was collected only on the first day of stay, also with data from medical records, from the time of ICU admission until 8 o'clock in the morning of the following day, regardless of completing 24 hours.In the logistic regression models, nursing workload assessed by Nursing Activities Score (NAS), was considered as a dependent variable, and it was changed into a binary variable: high (1) and low load (0).Transformation considered the median from the Predictors of nursing workload...

Table 1 -
Distribution of patients according to demographic and clinical characteristcs.São Paulo, 2004 * Kidney dysfunctions, related with gynecological, and hepatic dysfunction and exogenous intoxication, SD=standard deviation, a = Chi-square (χ 2 ), b =ANOVA with post-hoc analysis with Bonferoni test, c = difference between means is significant, d = difference between the means is not significant (p> 0.05).