1. Maher, Maribeth


As temperatures rise in critically ill patients, so do nurses' workloads.


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An ICU nurse's workload can increase when patients are febrile, yet hospitals often don't consider that fact when staffing their units. For that reason, Kiekkas and colleagues studied the relationship between nursing workload and fever for nearly a year at a 14-bed, medical-surgical ICU at a university hospital in Greece. The study included patients whose ICU stays were at least 12 hours; of 361 patients, 188 (52%) had fever.


To gauge nursing workload, investigators used the Therapeutic Intervention Scoring System-28 (TISS-28), which assigns points to patient care activities. One TISS-28 point corresponds to 10.6 minutes of a nurse's shift; in a typical shift, a nurse is considered capable of delivering the care equivalent of 46.35 TISS-28 points. Nurses took patient temperatures at one-hour intervals around the clock, as was routine practice in this ICU.


Peak temperature was a significant predictor of mean daily TISS-28 scores, which were significantly higher in patients with fever than in those without. The presence of fever increased mean daily nursing workload by 9.7% overall and by 11.4% and 25.9%, respectively, when peak temperatures rose above 39.2[degrees]C (102.5[degrees]F) and 40.2[degrees]C (104.3[degrees]F).


So why don't administrators think about fever in terms of staffing? According to Linda Bell, a clinical practice specialist at the national office of the American Association of Critical-Care Nurses in Aliso Viejo, California, "When estimating nursing workload, we tend to look more at the technological indicators-mechanical assist devices, the number of drips, how frequently those drips need adjustment-rather than at the actual patient symptoms."


Working two days a month as a bedside staff nurse in a medical ICU, Bell knows firsthand that fever amplifies nursing time. Of the tasks required-obtaining blood cultures, implementing cooling measures, and administering antipyretics-she says, "if two of my patients have a fever, that's a huge increase in the workload." Still, even Bell has overlooked the staffing implications of fever. "If one patient has a fever," she acknowledges, "I'd tell the physician or pass it along to the nurse on the next shift, but I might neglect to tell my charge nurse." The findings of Kiekkas and colleagues serve as a reminder that clinical signs and symptoms "remain important predictors of nursing intensity."


Bell suggests that nurses ensure that administrators recognize fever's impact on nursing workload in a number of ways. Educators can use studies such as Kiekkas and colleagues' to raise awareness. Moreover, she adds, nurses "who take such findings and build them into their institution's system for extrapolating acuity data can affect decision making on a unit level."


Maribeth Mahe


Kiekkas P, et al. Am J Crit Care 2008;17(6): 522-31.