Applying the Simple 4 Step Approach in Practice

To demonstrate how the simple four step approach works in practice work through the following example, you will need to download the Welsh Levels of Care from the resources section:

  • Alice is 30, she has been admitted to a medical ward from the Emergency Department with severe joint pain.
  • Alice is currently unable to mobilise from her bed and is experiencing 10/10 pain in all of her joints.
  • Alice has been seen by a consultant rheumatologist and has been diagnosed with reactive arthritis following an infection.
  • Alice is dehydrated, she has been cannulated in her leg and commenced on an intravenous infusion of saline.
  • Alice has been commenced on oral flucloxacillin, prednisolone, omeprazole, Adcal D3, naproxen, and tramadol.
  • Because of the pain in her joints, Alice requires assistance of two with personal care and using the bedpan, and assistance of one with eating and drinking and taking her medications.
  • Alice's observations are: BP 90/70, HR 93, RR 14, Temp 37.0oC, Sats 99% on room air, her NEWS is 4.

Step 1: Use lay descriptors and professional judgement to determine the patient's level of acuity.

  • Alice's care needs are being met within the normal routines of the medical ward.
  • Alice has a clearly defined problem, but there may be a small number of additional factors that affect how treatment is provided, including Alice's pain and her NEWS.
  • The care is fully planned out, but because of Alice's current NEWS there is a need for regular observation to look out for any variations or changes in Alice's condition.
  • Alice meets Level 2: Care Pathway.


Step 2: Use clinical descriptors to support professional judgement.

  • Alice is in a stable condition but is dependant on nursing care to meet most or all of her activities of daily living.
  • Alice meets Level 3 - Complex Care.


Step 3: Use nursing themes descriptors as guidance to determine the patient's level of need. Remember a patient can be at different levels of care in each of the nursing themes.

Assessment and observation:
  • NEWS score trigger point reached and requiring escalation.
  • Patient stable but requires monitoring and regular interventions.
  • Alice meets Level 2 - Care Pathway.
Respiration:
  • No respiration needs.
  • Alice meets Level 1 - Routine Care.
Personal care, nutrition and hydration:
  • Mobility or repositioning difficulties requiring the assistance of two people.
  • Requires assistance with most or all activities of daily living.
  • Alice meets level 3 - Complex Care.
Cognition and communication:
  • Alice is compliant and has full capacity.
  • Alice meets Level 1 - Routine Care.
Medication:
  • Alice requires assistance of one to take medications, lasting less than 30 minutes.
  • Alice meets Level 2 - Care Pathway.


Step 4: Aggregate information for steps 1, 2 and 3, then make a professional judgement on the level of care best describing the patient.

Alice has a range of acuity scores. Using the lay descriptors her care appears to be Level 2 - Care Pathway, as Alice has a defined problem, her care is fully planned out and her care needs are being met within the normal routines of the ward. However, looking at the clinical descriptors, Alice is in a stable condition but is dependant on nursing care to meet most or all of her activities of daily living, which escalates her acuity to Level 3 - Complex Care. Looking at the nursing themes descriptors to determine Alice's level of need, Alice has two level 1 scores, two level 2 scores, and one level 3 score. It is possible for a patient to have needs in different levels of care in the nursing themes. The nurse completing Alice's acuity score needs to make a professional judgement as to the level of care that best describes Alice. As Alice requires assistance of two with personal hygiene and toileting needs, and assistance of one with nutrition and hydration and taking medications, it would be reasonable to assess Alice's acuity as Level 3 - Complex Care to reflect the intensity of the nursing care Alice is receiving.