Nurses and providers typically assess patient acuity and volume at the beginning of their shift, whether formally or informally. Managers use patient acuity to balance nursing assignments, and nursing staff uses it to determine which patient care action should be prioritized next. Taking a standardized approach to acuity assessments not only provides more objectivity, but also gives hospitals the data they need to make a variety of tactical and strategic decisions, from daily unit staffing to future space, specialty services, and bed capacity.
In addition to providing clinicians with a standardized perspective of their patient populations, acuity assessments also enhance patient safety. The number of handoffs between inpatient care providers and units is a proven risk factor for negative clinical outcomes, and a uniform language of assessment can help manage that risk.
In one study published in the Journal of Hospital Medicine, clinicians used a 7-point patient acuity rating (PAR) to assess the likelihood of a patient experiencing cardiac arrest or ICU transfer within the next 24 hours. The researchers found that a simple scoring system reliably quantified the clinicians’ judgment, accurately conveying which patients were at risk during handoffs. Additional research validates this data, indicating that patients whose condition triggered an unplanned transfer or rapid response team activation are more likely to have higher PAR scores upon initial assessment than more stable patients.
Despite the importance of standardized language in clinical communication, there are several challenges of terminology, utility, and implementation at scale. Regulatory bodies have long realized the value of standardized acuity, and continue to drive progress in areas such as long-term care facilities. More than a decade ago, CMS established the Continuity Assessment Record and Evaluation (CARE) set to measure the health and functional status of Medicare beneficiaries at the time of discharge and/or admission in post-acute care settings.
In other areas, the use of standardized language to objectively measure and communicate a patient’s clinical needs is not widespread. In the segment of interfacility transport, many well-recognized issues—including process inefficiencies, inconsistent assignment of care level during transport, and the difficulty of justifying transport mode and patient destination selection—can be directly traced to this overall lack of standardization.
Using Acuity Scoring in Interfacility Medical Transport
The decision to transfer a patient to another facility reflects a myriad of considerations. Unlike much of medicine, the decision is traditionally made without the benefit of a large body of evidence. In the emergency department, a patient’s care is driven by the experience of physicians, nurses, and ancillary staff, who rely on their accumulated clinical wisdom in selecting the next step in a patient’s care. Yet when a patient is handed off to a transport team for transfer, there is often a communication gap regarding how the patient’s current condition, their care needs during transport and upon arrival, and the risk of those needs changing.
Although patient handoffs are central to the field of medical transport, there are no national standards for patient severity of illness or the clinician accreditation needed for that severity. According to the Association of Critical Care Transport, a national patient advocacy association, this lack of standardization presents patient safety risks that are often invisible to referring and receiving clinicians, as well as to patients and their families.
Transport staff delivering a patient to the hospital or another care setting initially seek to understand two variables: exactly how sick the patient is, and how urgently they need the care at their destination. A standardized communication framework that centers on patient acuity and uses objective language turns this universal assessment into a repeatable, organized process that can be applied to every patient across the board.
Communicating Acuity for Interfacility Transfers
The patient’s acuity functions as the most pivotal information at a fundamental point-of-care decision point: do we have the resources to give this patient what they need, or will they require greater resources available at another facility? An acuity score allows sending and receiving hospitals to prioritize patient movement based on the time-sensitive acuity of those patients. Receiving centers can also survey incoming patients to assist in their internal bed management.
When clinicians have the common language of acuity at their disposal, the patient’s score functions as shorthand, immediately conveying the difference between patients. This utility is essential, as a score can quickly communicate the core gestalt of “how sick is this patient?” without the listener having to parse the details in that moment. The receiving manager or intake center does not need to hear the clinical components that describe a patient’s status (which are detailed in the patient report) if they know the patient’s acuity score is extremely high. Clinicians who are well-versed in the acuity scale will immediately understand what the score represents and can act accordingly.
Acuity scores can also be used to help clinicians guide bed placement decisions. As an example, a telemetry bed request for a patient with a high acuity score can trigger a pre-arrival screening to clarify if a patient with high care needs should be placed on an intermediate unit. Appropriate initial placement of a transferred patient can save valuable clinical time.
An easily understood, numerical summary that accurately reflects patients’ status is beneficial not only during the episode of care but also retrospectively. The same scoring system that helps to send hospitals with transfer decisions can also be used for outcomes-based research; by comparing the outcomes for patients who were transferred versus those who stayed in-house, hospitals can adjust their transfer pathways and plan more effectively for similar scenarios in the future.
The Value of Simplicity: Understanding the Utility of Acuity Scores
Of course, highly subjective scoring methodologies are of limited use. To reduce this risk and minimize scoring variation across clinicians, some facilities implement paralyzingly complicated clinical scoring via a detailed algorithm, multiple categories, or clinical data minutiae. While the scores these systems generate may well be accurate, they’re not particularly useful.
Clinical scoring should not require a great deal of input from staff, nor should it require specialized patient information which is not widely shared. Scoring tools should also not be arduous to implement. By using just a few clinically relevant status indicators, a well-built acuity tool can deliver a true reflection of the patient’s condition that can be quickly, clearly communicated. Keeping acuity categories inclusively broad can help hospitals make more accurate decisions as rapidly as possible.
Although we live in the information age, the default setting of patient transfer information remains a phone call. Physicians may call a transfer center, dutifully stating their name, hospital, and the patient’s name, date of birth, and diagnosis before stating the transfer request. In some cases, they may call the receiving physician directly to discuss the possibility of a transfer. In either instance, a simple acuity score communicates the reason for the call much more succinctly: a patient is in need. If this important first step in the patient transfer process can be done more accurately and efficiently, improvements in patient outcomes will likely follow.
Navigating Reimbursement: Using Acuity to Justify Appropriate Care
Our inevitable journey toward value-based care underscores the importance of sound justification for all patient intervention and treatment, as it will be required for reimbursement. The field of medical transport is no exception. Standardizing the language of patient severity—and hence the care required during transport—not only assists in clinical transfer decisions, but also facilitates the reimbursement process, benefitting transport agencies and patients.
Acuity data helps health plans and other non-clinical users understand why a patient was transferred from one facility to another, why the receiving facility was chosen, and why a particular transport method was required given the specific clinical scenario. This justification is especially important during COVID-19, as the widespread bed shortage has made previously anomalous scenarios much more common. The same low-acuity patient who might have taken a 40-mile ride in an ambulance to the local hospital in 2019 may now be transported via air to a regional care center in another state.
Integrating an acuity scoring methodology with a patient management system for monitoring admissions, discharges, and transfers can also offer a streamlined approach to analyzing financial flow. Health systems can access the patient’s initial acuity score and reveal the documented attempts to find an available bed without having to reconstruct the entire chain of events from disparate sources. Unexpected transport expenses are much more likely to be reimbursed when the patient’s clinical condition clearly justified the course of action—and this information is documented in the medical record. This benefits not only the patient but also the transport service, which may require documentation to help explain the choice of transport unit or destination as the most appropriate for that situation.
While every patient’s clinical circumstances are unique, standardizing the process and language of acuity measurement would go a long way toward improving our current approach to medical emergencies, interfacility transfers, and patient transport in general. When resources are scarce and there is no organized approach to how and when we utilize those resources, workload escalates. Using a simple, fast acuity scoring system can help health systems align provider expectations, conserve limited resources, and deliver patients to the best possible care setting for their needs.
About Dr. Martin Sellberg
Dr. Martin Sellberg has spent more than 30 years in emergency medicine, holding director positions at level 1 trauma centers, regional EDs, and emergency medical services. He is the co-founder of Motient, a patient movement technology company that supports safe, efficient interfacility patient transfers.
