Development And Evaluation Of An Appraisal Form To Assess Care Complexity Of Stroke Patients

Objectives:(1) To develop an appraisal form to assess care complexity of stroke patients and to calculate the weight of each complexity indicators.(2) To assess complexity of care for stroke patients and to explore association with nursing performance indicators. Methods:(1) A mixed methods design utilised qualitative and quantitative approaches was used. We performed a semi-structured in-depth interview to develop basic elements of patients care complexity. Expert panel and project analysis were used to screen indicators.Construct validity and reliability testing(n = 50) of the instrument was completed, weight of each complexity indicators were caculated based on the analytic hierarchy process.(2)A prospective cohort study design based upon a convenience sample consisting of 241 stroke patients was recruited to describe complexity of care in two departments of internal neurology of a large public hospital. Dates about nursing performance indicators(length of stay, nursing hours per patient day and nursing costs per patient day) were also collected.We used t test, one-way analysis of variance or Mann-whitney U test, Kruskal-Wallis H test to compare the differences of complexity score between patients with different stroke subtype, gender, patterns of admission to hospital, time intrval from onset to admission and past history of stroke, the differences of complexity of care and nursing performance among two departments.The spearman rank correlation was adopted to describe the association between complexity of care and nursing performance indicators. Results:(1)The appraisal form included 4 dimensions and 9 complexity indicators, its content validity index was 0.956, factor analysisi of the instrument resulted in 3 factors that could explain 69.741% of the total varilances, the cronbach's alpha was 0.724.(2)The weights of 4 dimensions rank from high to low were: severity of illness(0.3835)?care dependency(0.2710)?general condition(0.1890)?psychological features(0.1565). In the 9 complexity indicartors, activities of daily living received the highest weight(0.2170), anxeity indicated the lowest weight with 0.0434.(3)The specific calculation of complexity score was, in which, S is the complexity score, iW is the weight of each indicator, iS is the score of each indicator, n is the number of indicators.the distribution of the scores was range from 0 to 4, Dates on 241 stroke patients were collected, the average score was 1.3126, lowest score was0.4107, highest score was 3.1336. patients were classified into A, B, C, D four types based on k-means clustering analysis, complexity scores of category A: 0.4107 ~ 0.9916, category B : 1.0013 ~ 1.4613,category C:1.4850 ~2.0658,category D:2.1434~3.1336. The number of patients in each category was as follows: 84(34.85%) of A, 82(34.02%) of B, 46(19.09%) of C, 29(12.03%) of D.(4)There were significant differences complexity score between patients with different stroke subtype, gender, patterns of admission to hospital and time intrval from onset to admission(P<0.05).(5)Nursing performance indicators such as length of stay(r=0.506, P<0.001), nursing hours per patient day(r=0.621, P<0.001) and nursing costs per patient day(r=0.512, P<0.001) were significantly associated with complexity of care. Conclusions:(1)The appraisal form is a valid and reliable measure that offers a comprehensive assessment of care complexity in stroke patients.(2) There were significant differences in complexity score between patients with different stroke subtype, gender, patterns of admission to hospital and time intrval from onset to admission,Nurses should pay more attention to those who get higher complexity scores,such as CE?SUE?LAA patients, female patients, patiens with emergency admission to hospital and time intrval from onset to admission?24 hours.(3)Care complexity of patients could be used as one indicator of nursing performance evaluation system and make the evaluation result more credible.It is possible to compare nursing performance btween different hospitals or departments using care complexiy as the tool for risk adjustment.