Nurse staffing and inpatient hospital mortality

Nurses' assessments of the work environment, organisational culture and work arrangements: a cross-sectional study of Estonian hospitals in 1999, 2009 and 2021

BACKGROUND

Nurses play a vital role in patient care, and their perceptions of their work environment are crucial for healthcare quality. A supportive and well-resourced work environment enhances the quality of care and increases employee commitment. The physical environment directly influences nurses' well-being and efficiency, while a culture that fosters collaboration and communication is essential for improving patient outcomes and ensuring high-quality care. This study aimed to analyse nurses' assessments of the work environment, organisational culture and work organisation over three decades (1999, 2009 and 2021) to understand their connection to changes in nursing activities over time. Data were collected via a structured questionnaire.

METHODS

A cross-sectional survey methodology was adopted. Descriptive statistical analysis, correlation analysis and logistic regression analysis were conducted via IBM SPSS. These analyses sought to track temporal changes, explore relationships between workforce resources and nursing activities, and investigate the determinants of the perceived nurse-to-patient ratio.

RESULTS

In the work environment domain, the perceived quality of the physical work environment remained stable, although the nurse-to-patient ratio increased insufficiently. Changes in organisational culture yielded improvements in communication and the psychosocial work environment but reductions in the quality of collaboration. With respect to work organisation, a greater standardisation of nursing work emerged over time. The logistic regression analysis indicated that nurses working in regional hospitals and departments with more beds more frequently considered the nurse-to-patient ratio to be insufficient.

CONCLUSIONS

The nurses' views showed that despite the increased health care workforce, the nurse-to-patient ratio was often seen as insufficient. Although the quality of the physical environment either remained stable or improved, organisational culture shifts indicated less group work and greater multiprofessional cooperation. This study underscores the necessity of a comprehensive approach for evaluating the nurse-to-patient ratio, integrating both quantitative and qualitative measures to effectively gauge and improve the nursing work environment.

CLINICAL TRIAL NUMBER

Not applicable.

Cost-effectiveness of eliminating hospital understaffing by nursing staff: a retrospective longitudinal study and economic evaluation

BACKGROUND

Understaffing by nursing staff in hospitals is linked to patients coming to harm and dying unnecessarily. There is a vicious cycle whereby poor work conditions, including understaffing, can lead to nursing vacancies, which in turn leads to further understaffing. Is hospital investment in nursing staff, to eliminate understaffing on wards, cost-effective?

METHODS

This longitudinal observational study analysed data on 185 adult acute units in four hospital Trusts in England over a 5-year period. We modelled the association between a patient's exposure to ward nurse understaffing (days where staffing was below the ward mean) over the first 5 days of stay and risk of death, risk of readmission and length of stay, using survival analysis and linear mixed models. We estimated the incremental cost-effectiveness of eliminating understaffing by registered nurses (RN) and nursing support (NS) staff, estimating net costs per quality-adjusted life year (QALY). We took a hospital cost perspective.

FINDINGS

Exposure to RN understaffing is associated with increased hazard of death (adjusted HR (aHR) 1.079, 95% CI 1.070 to 1.089), increased chance of readmission (aHR 1.010, 95% CI 1.005 to 1.016) and increased length of stay (ratio 1.687, 95% CI 1.666 to 1.707), while exposure to NS understaffing is associated with smaller increases in hazard of death (aHR 1.072, 95% CI 1.062 to 1.081) and length of stay (ratio 1.608, 95% CI 1.589 to 1.627) but reduced readmissions (aHR 0.994, 95% CI 0.988 to 0.999). Eliminating both RN and NS understaffing is estimated to cost £2778 per QALY (staff costs only), £2685 (including benefits of reduced staff sickness and readmissions) or save £4728 (including benefits of reduced lengths of stay). Using agency staff to eliminate understaffing is less cost-effective and would save fewer lives than using permanent members of staff. Targeting specific patient groups with improved staffing would save fewer lives and, in the scenarios tested, cost more per QALY than eliminating all understaffing.

INTERPRETATION

Rectifying understaffing on inpatient wards is crucial to reduce length of stay, readmissions and deaths. According to the National Institute for Health and Care Excellence £10 000 per QALY threshold, it is cost-effective to eliminate understaffing by nursing staff. This research points towards investing in RNs over NS staff and permanent over temporary workers. Targeting particular patient groups would benefit fewer patients and is less cost-effective.

Workload assessment using the nursing activities score in intensive care units: Nationwide prospective observational study in France

BACKGROUND

Within French intensive care units (ICUs), patients are treated with two levels of care (intensive or intermediate) with different nurse-to-patient ratios legally defined.

OBJECTIVES

We aimed to compare the nursing workload associated with these two levels of care.

RESEARCH METHODOLOGY

A nationwide prospective observational study was conducted in France between April and July 2023. Each ICU was allowed to choose its own two-week period of data collection during which the Nursing Activities Score was collected by nurses at patients' bedside, during each shift. The Nursing Activities Score ranges from 20 to 177% and a 100% score represents a nurse per shift. The number of patients per nurse was collected and the Nursing Activities Score per nurse was assessed.

RESULTS

One hundred and five ICUs participated. Overall, 21,665 measurements of Nursing Activities Score per patient and 9,885 Nursing Activities Score per nurse were collected. ICUs were composed by 2083 beds distributed into 1520 (73 %) intensive care beds and 563 (27 %) intermediate care beds. Among the participating units, 93 (89 %) of the teams worked in 2 shifts. Median [p25-p75] Nursing Activities Score per adult patient was 61 % [49-80] for intensive care patients and 47 % [38-61] for intermediate care patients (p < 0.001). Median Nursing Activities Score per nurse for adult population was 127 % [92-167], 143 % [92-198], and 164 % [126-213] for nurses only providing intensive care, only intermediate care or both levels of care, respectively (p < 0.001). A Nursing Activities Score per nurse value >100 % was observed in 71.4 %.

CONCLUSIONS

Nurses' workload was high in the ICU, especially when providing intermediate or mixed levels of care.

IMPLICATIONS FOR PRACTICE

In order to reduce nurses' workload, a review of the nurse-to-patient ratios is expected. Physically separating the two levels of care may be a valuable option.

Facilitators of and Barriers to the Therapeutic Nurse-Patient Relationship: Perceptions From Psychiatric Mental Health Nurses

BACKGROUND

The therapeutic relationship serves as a cornerstone in psychiatric mental health nursing practice, providing a basis for implementing various interventions.

AIMS

This study aimed to explore the perspectives of psychiatric mental health nurses regarding factors that facilitate and impede the therapeutic nurse-patient relationship.

METHODS

A descriptive study was conducted among psychiatric mental health nurses employed at two community psychiatric hospitals in the northeast area of the United States. A list of facilitators and barriers was developed based on an extensive literature review and subsequently validated by three experts in the field of psychiatric mental health nursing. Participants rated these factors on a 10-point scale.

RESULTS

The study included 74 registered nurses from two psychiatric hospitals, yielding a 24% response rate. The highest-ranked facilitator was awareness that the relationship enables collaborative goal setting with patients. The most significant barrier was insufficient time due to administrative tasks.

CONCLUSIONS

This study highlights the importance of understanding facilitators and barriers in the therapeutic nurse-patient relationship. Replicating the study nationally on a larger scale among psychiatric mental health nurses is recommended.

Association Between Nurse Staffing Coverage and Patient Outcomes in a Context of Prepandemic Structural Understaffing: A Patient-Unit-Level Analysis

Objective: To evaluate the association between nurse staffing coverage and patient outcomes in a context of structural understaffing. Design: This is a population-based, cross-sectional, multicenter study, including patient and staffing data from eight public hospitals from Catalonia, Spain. Participants: A total of 183,085 adult in-patients admitted to hospital wards and step-down units during 2016 and 2017. Outcomes: In-hospital mortality, 30-day hospital readmission, and three cluster nurse-sensitive adverse events: healthcare-acquired infections, failure to maintain, and avoidable critical complications. The study factor is safe nursing staffing equivalent to nurse staffing coverage > 90%. Results: Average patient acuity was equivalent to 4.5 required nursing hours per patient day. The mean available nursing hours per patient day was 2.6. The average nurse staffing coverage reached 65.5%. Overall, 1.9% of patients died during hospitalization, 5% were readmitted within 30 days, and 15.9% experienced one or more adverse events. Statistically significant differences were identified for all patient outcomes when comparing patients safely covered (nurse staffing coverage > 90%) and under-covered (nurse staffing coverage < 90%). Increasing nurse staffing coverage to a safe level (> 90%) is associated with a reduction of the risk of death (RR: 0.41, 95% CI: 0.37-0.45), a decrease in the risk of hospital readmission (RR: 0.93, 95% CI: 0.89-0.97), and a reduction of nurse-sensitive adverse events (RR: 0.67, 95% CI: 0.66-0.69). Conclusion: Safe nurse staffing coverage acts as a protective factor for detrimental patient outcomes, significantly reducing the risk of in-hospital mortality, 30-day hospital readmission, healthcare-associated infections, failure to maintain, and avoidable critical complications. Further policy efforts are needed to guarantee a safe registered nurse staffing coverage.

A national survey of Intensive Care Medicine Services in Portugal: where we are and the road ahead

OBJECTIVE

The goal of this study was to assess the Portuguese Intensive Care Referral Network, namely the mission and organization of the Portuguese National Health Service Intensive Care Medicine Services and patient flows between them.

METHODS

The study was based on the responses to a semi-structured questionnaire by the directors of the forty-one Intensive Care Medicine Services, characterizing four domains: a) number, type, and management of beds; b) human resources and their consumption; c) outreach, including activities in the resuscitation room, intra-hospital emergency team and follow-up clinics; and d) referral network.

RESULTS

The number of active Intensive Care Medicine Services beds in Portugal markedly increased in the last 12 years, but the beds/habitant ratio is still below the Organization for Economic Cooperation and Development average. The activation of all installed beds would likely allow for the reduction of the hospital care gap perceived by many of the Intensive Care Medicine Services directors. There is significant geographic heterogeneity in the beds/habitant ratio and in the performance of outreach activities. The number of intensivists is rapidly growing, but nursing staff should be augmented, especially rehabilitation nurses. The referral network is globally complied, but the secondary transport of critical patients needs improvement and an electronic information system, which can be constantly updated, is seen as a relevant decision aid.

CONCLUSION

Although intensive care medicine has significantly strengthened in the last 12 years, both in number of beds and in role and mission, there is still relevant heterogeneity in the beds/habitant ratio and in the performance of outreach activities among different Intensive Care Medicine Services.

Machine Learning in Optimising Nursing Care Delivery Models: An Empirical Analysis of Hospital Wards

OBJECTIVE

This study aims to assess the performance of machine learning (ML) techniques in optimising nurse staffing and evaluating the appropriateness of nursing care delivery models in hospital wards. The primary outcome measures include the adequacy of nurse staffing and the appropriateness of the nursing care delivery system.

BACKGROUND

Historical and current healthcare challenges, such as nurse shortages and increasing patient acuity, necessitate innovative approaches to nursing care delivery. For instance, the COVID-19 pandemic highlighted the need for flexible and scalable staffing models to manage surges in patient volume and acuity.

MATERIALS AND METHODS

A descriptive study was conducted in 39 inpatient wards across a university hospital and three state hospitals, involving 117 ward-level observations. Data were collected using the Rush Medicus Patient Classification Scale and analysed using k-Nearest Neighbour, Support Vector Machine, Random Forest, and Logistic Regression algorithms. Effectiveness was measured by the accuracy of machine learning predictions regarding nurse staffing adequacy, while suitability was determined by the congruence between observed nursing care models and patient needs.

REPORTING METHOD

STROBE checklist.

RESULTS

The Random Forest algorithm demonstrated the highest accuracy in predicting both nurse staffing adequacy and the appropriateness of nursing care delivery systems. The study found that 68.4% of wards had sufficient nurse staffing and 26.5% of wards used appropriate care delivery models, with functional nursing and total patient care models being the most commonly used.

DISCUSSION

The study highlights functional nursing and total patient care models, emphasising the need to consider nurse qualifications and patient needs in selecting care systems. Machine learning, particularly the Random Forest algorithm, proved effective in aligning staffing with patient requirements.

CONCLUSION

Machine learning, particularly the Random Forest algorithm, proves effective in optimising nursing care delivery models, suggesting significant potential for enhancing patient care and nurse satisfaction.

IMPLICATIONS

The research underscores machine learning's role in improving nursing care delivery, aligning nurse staffing with patient needs, and advancing healthcare outcomes.

IMPACT

The findings advocate for integrating machine learning in the planning of nursing care delivery models. This study sets a precedent for using data-driven approaches to improve nurse staffing and care delivery, potentially enhancing global clinical outcomes and operational efficiencies. The global clinical community can learn from this study the value of employing machine learning techniques to make informed, evidence-based decisions in healthcare management.

PATIENT OR PUBLIC CONTRIBUTION

While the study lacked direct patient involvement, its goal was to enhance patient care and healthcare efficiency. Future research will aim to incorporate patient and public insights more directly.

Planned Changes to Nurse Leadership, Staffing and Skill-Mix: Impact on the Working Environment, Job Satisfaction and Intention to Leave

INTRODUCTION

Job satisfaction and intention to leave have been consistently linked to the working environment. However, there are few studies of interventions for improving the environment or staff outcomes.

AIM

To determine the impact of implementing a framework for safe nurse staffing on the environment and staff outcomes. This involved an assessment of required nursing hours per patient day, supernumerary nurse in charge and minimum 80:20 skill-mix, with intentional changes in staffing if required.

DESIGN

A pre-post observational design.

METHODS

This was a prospective observational study in six medical and/or surgical wards across three acute hospitals in Ireland. The outcomes were measured pre- and post-implementation, and included the environment, using the Practice Environment Scale of the Nursing Work Index; and job satisfaction and intention to leave using a dichotomised 4-point scale.

OUTCOMES

Changes in staffing levels, adjustments to skill-mix and the supervisory role of the ward leader were seen following the implementation. A multilevel model found significant increases over time on three of the five Nursing Work Index subscales: Staffing and Resource Adequacy, Collegial Nurse-Physician Relations, and Nurse Participation in Hospital Affairs. Job satisfaction increased and intention to leave decreased, although the differences were not statistically significant. Increased job satisfaction was significantly associated with Staffing and Resource Adequacy, Collegial Nurse Physician Relations and Nurse Manager, Leadership and Support. A decreased odds of intention to leave was associated with increased job satisfaction.

CONCLUSION

There were significant improvements in the environment following the implementation of the Framework. Three of the practice environment subscales were significantly associated with job satisfaction, while job satisfaction is a predictor of intention to stay. This study indicates that intentional changes to staffing can result in improvements to working environments which may in turn have an impact on job satisfaction and furthermore, on intention to stay.

IMPACT

This study investigated intentional changes to nurse staffing in medical and surgical wards, examining the impact pre- and post-implementation. This study underlined that when staffing is based on a systematic approach, based on a Framework for Safe Nurse Staffing, a subsequent improvement can be seen in staff's perceptions of the work environment, along with improvements in staff outcomes. This research will impact on staff working in acute settings as a means of determining staffing and improving outcomes using a Framework for Safe Nurse Staffing.

REPORTING METHOD

STROBE checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Impact of High Care Unit Management on In-Hospital Mortality in Patients with ST-Elevation Myocardial Infarction

The impact of HCU management on the short-term prognosis of STEMI patients undergoing primary percutaneous coronary intervention (PCI) remains unclear.We retrospectively assessed 694 STEMI patients who underwent primary PCI at 8 regional general hospitals in Iwate Prefecture from 2014-2018. The patients were categorized based on the hospital to which they were admitted with or without HCUs (353 versus 341 patients, from 3 versus 5 hospitals, respectively). There was no significant between-group difference for overall in-hospital mortality (7% versus 10%, P = 0.174). However, in the Killip Class II or higher, in-hospital mortality was significantly lower among patients admitted to the HCU (20% versus 44%, P < 0.001). After propensity score matching, we found that overall in-hospital mortality was significantly lower in patients admitted to HCUs (2% versus 8%, P = 0.008). Furthermore, mortality rates for patients requiring mechanical ventilation or circulatory support were significantly lower for patients admitted to HCUs, with mortality rates of 30% versus 50% (P = 0.037).Our findings suggest that in hospitals without CCUs, systemic management through HCUs may significantly improve the survival prognosis of STEMI patients with Killip classification of II or higher.

Heterogeneity of Intermediate Care Organization Within a Single Healthcare System

Intermediate care (IC) is prevalent nationwide, but little is known about how to best organize this level of care. Using a 99-item cross-sectional survey assessing four domains (hospital and physical IC features, provider and nurse staffing, monitoring, and interventions/services), we describe the organizational heterogeneity of IC within a five-hospital healthcare system. Surveys were completed by nurse managers from 12 (86%) of 14 IC settings. Six IC settings (50%) were embedded within acute care wards, four (33%) were stand-alone units, and two (17%) were embedded within an ICU. All had a nurse-to-patient ratio of 1:3, provided continuous cardiac telemetry, continuous pulse oximetry, high-flow nasal oxygen, and bedside intermittent hemodialysis. Most (> 50%) permitted arterial lines, frequent nursing assessments (every 2 hr), and noninvasive ventilation or mechanical ventilation via a tracheostomy. Vasopressors were less often permitted (< 25% of settings). Models of IC vary greatly within a single healthcare system.

Negative spillover due to constraints on care delivery: a potential source of bias in pragmatic clinical trials

BACKGROUND

Pragmatic clinical trials evaluate the effectiveness of health interventions in real-world settings. Negative spillover can arise in a pragmatic trial if the study intervention affects how scarce resources are allocated across patients in the intervention and comparison groups.

MAIN BODY

Negative spillover can lead to overestimation of treatment effect and harm to patients assigned to usual care in trials of diverse health interventions. While this type of spillover has been addressed in trials of social welfare and public health interventions, there is little recognition of this source of bias in the medical literature. In this commentary, I examine what causes negative spillover and how it may have led clinical trial investigators to overestimate the effect of patient navigation, AI-based physiological alarms, and elective induction of labor. Trials discussed here are a convenience sample and not the result of a systematic review. I also suggest ways to detect negative spillover and design trials that avoid this potential source of bias.

CONCLUSION

As new clinical practices and technologies that affect care delivery are considered for widespread adoption, well-designed trials are needed to provide valid evidence on their risks and benefits. Understanding all sources of bias that could affect these trials, including negative spillover, is a critical part of this effort. Future guidance on clinical trial design should consider addressing this form of spillover, just as current guidance often discusses bias due to lack of blinding, differential attrition, or contamination.

Relationship between Time of Day of Medical Emergency Team Activations and Outcomes of Hospitalized Pediatric Patients

This study was conducted to investigate whether outcomes of medical emergency team (MET) activations differ by time of day of hospitalized pediatric patients. This is a retrospective cohort study conduct at a tertiary pediatric hospital. Data were extracted from the charts of 846 patients (with one or more MET activations) over a 5-year period. Also can remove hospital names and affiliated institution from the body of the text as readers can find this information in the author list. Patients included children <18 years, admitted to a pediatric ward, who experienced a MET activation between January 1, 2016 and December 31, 2020. We excluded patients reviewed by the MET during a routine follow-up, planned pediatric intensive care unit (PICU) admissions from the ward, and MET activation in out-patient settings, post-anesthesia care unit, and neonatal intensive care unit. There was no intervention. A total of 1,230 MET encounters were included as part of the final analysis. Daytime (08:00-15:59) MET activation was associated with increased PICU admission (25.3%, p  = 0.04). There was some evidence of a higher proportion of critical deterioration events (CDEs) during daytime MET activation; however, this did not reach statistical significance (24%, p  = 0.09). The highest MET dosage occurred during the evening hours, 16:00 to 23:59 (15/1,000 admissions), and it was lowest overnight, 00:00 to 07:59 (8.8/1,000 admissions, p  < 0.001). This period of lowest MET dosage immediately preceded the highest likelihood of PICU admission (08:00, 37.5%) and CDE (09:00, 30.2%). Following the period of lowest MET activity overnight, MET activations during early daytime hours were associated with the highest likelihood of unplanned PICU admission and CDEs. This work identifies potential high-risk periods for undetected critical deterioration and targets for future quality improvement.

Effects of rural hospital closures on nurse staffing levels and health care utilization at nearby hospitals

Our study examines the causal effect of rural hospital closures on nearby hospitals' nurse staffing levels and health care utilization. We use data from the 2014-2019 American Hospital Association Survey on nurse staffing level outcomes including licensed practical or vocational nurses (LPNs), registered nurses (RNs), and advanced practice nurses (APNs); and health care utilization outcomes, including inpatient and outpatient surgical operations and emergency department (ED) visits. Using propensity score matching and difference-in-differences (DID) methods, we find that rural hospital closures lead to an average increase of 37.3% in the number of nurses in nearby rural hospitals during the 4 years following the closure. This increase is found across all categories of nurses, including LPNs, RNs, and APNs. We also find a substantial increase in the provision of inpatient and outpatient surgical operations but there is no change in ED visits. We do not find any effects for nearby urban hospitals. Our study suggests that a large proportion of the nursing workforce relocates to nearby hospitals after a rural hospital closure, which mitigates the negative consequences of such closures and allows these nearby hospitals to provide a larger volume of highly profitable services.

Nurse and doctor turnover and patient outcomes in NHS acute trusts in England: retrospective longitudinal study

OBJECTIVE

To investigate the association between monthly turnover rates of hospital nurses and senior doctors and patient health outcomes (mortality and unplanned hospital readmissions).

DESIGN

Retrospective longitudinal study.

SETTING

All 148 NHS acute trusts in England (1 April 2010 to 30 March 2019), excluding specialist and community NHS hospital trusts.

PARTICIPANTS

Yearly records on 236 000 nurses, 41 800 senior doctors (specialist, associate specialist and specialty doctors, and consultants), and 8.1 million patients admitted to hospital.

MAIN OUTCOME MEASURES

The panel data regression analysis used nine years of monthly observations from administrative datasets at healthcare worker and patient levels. Associations using linear and unconditional quantile regressions were estimated, including controls for seasonality and NHS hospital trust. Four hospital quality indicators (risk adjusted by patient age, sex, and Charlson index comorbidities) were used and measured at a monthly frequency on a percentage scale: mortality risk within 30 days from all cause, emergency, or elective admission to hospital, and risk of unplanned emergency readmission within 30 days from discharge after elective hospital treatment.

RESULTS

A 1 standard deviation (SD) increase in turnover rate for nurses was associated with 0.035 (95% confidence interval 0.024 to 0.045) and 0.052 (0.037 to 0.067) percentage point increases in risks of all cause and emergency admission mortality, respectively, at 30 days. The corresponding values for senior doctors were 0.014 (0.005 to 0.024) and 0.019 (0.006 to 0.033) percentage point increases. Higher nurse turnover rate was associated with higher mortality risk at 30 days in surgical (P<0.01) and general medicine (P<0.01) specialties, as well as mortality for patients admitted to hospital with infectious and parasitic diseases (international classification of diseases, 10th revision; P<0.05) and injury, poisoning, and consequences of external causes (P<0.01). Higher turnover rates for senior doctors were associated with higher mortality risk at 30 days for patients admitted to hospital with infectious and parasitic diseases (P<0.05), mental and behavioural disorders (P<0.05), and diseases of the respiratory system (P<0.05). Turnover rates for hospital nurses and senior doctors were not statistically significantly associated with risk adjusted hospital mortality and unplanned emergency readmissions for elective patients.

CONCLUSIONS

Lower turnover rates for nurses and senior doctors at hospital level were associated with better health outcomes for patients with emergency hospital admissions.

STUDY REGISTRATION

Integrated Research Application System project ID 271302.

Interprofessional teams with and without nurse practitioners and the level of adherence to best practice guidelines in cardiac surgery: A retrospective study

AIM

To examine the level of adherence to best-practice guidelines of interprofessional teams with acute care nurse practitioners (ACNPs) compared to interprofessional teams without ACNPs.

DESIGN

A retrospective observational study was conducted in 2023.

METHOD

A retrospective cohort was created including 280 patients who underwent a coronary artery bypass graft and/or a valve repair and hospitalised in a cardiac surgery unit of a university affiliated hospital in Québec (Canada) between 1 January 2019 to 31 January 2020. The level of adherence to best-practice guidelines was measured from a composite score in percentage. The composite score was created from a newly developed tool including 99 items across six categories (patient information, pharmacotherapy, laboratory tests, post-operative assessment, patient and interprofessional teams' characteristics). Multivariate linear and logistic regression models were computed to examine the effect of interprofessional teams with ACNPs on the level of adherence to best-practice guidelines.

RESULTS

Most of the patients of the cohort were male and underwent a coronary artery bypass graft procedure. Patients under the care of interprofessional teams with ACNP were 1.72 times more likely to reach a level of adherence higher than 80% compared to interprofessional teams without ACNPs and were 2.29 times more likely to be within the highest quartile of the scores for the level of adherence to best-practice guidelines of the cohort.

IMPACT

This study provides empirical data supporting the benefits of ACNP practice for patients, interprofessional teams and healthcare organisations.

RELEVANCE FOR PRACTICE

Our findings identify the important contributions of interprofessional teams that include ACNPs using a validated instrument, as well as their contribution to the delivery of high quality patient care.

REPORTING METHOD

This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

How Many Is Too Many? Using Cognitive Load Theory to Determine the Maximum Safe Number of Inpatient Consultations for Trainees

PURPOSE

Cognitive load, specifically extraneous load (EL) reflective of distractions, may provide evidence of a lack of focus, potentially making additional work unsafe. The assessment of trainees performing inpatient consultations provides a helpful model for examining this question. The goal of this study was to provide useful information to clinical and educational leaders to optimize inpatient consultation services and rotations and mitigate potential patient safety risk.

METHOD

In 2019, using the Consult Cognitive Load instrument, the authors obtained EL data from inpatient consultations performed by internal medicine fellows and psychiatry residents across 5 University of California hospitals. In 2023, the authors constructed a Wright map to compare the participants' EL data with the number of prior initial consultations performed during the shift.

RESULTS

Of 326 trainees contacted, 139 (43%) completed the EL survey items. The Wright map shows that trainees were estimated to agree that interruptions were already distracting at the first consultation of the shift. After 4 consultations, trainees were estimated to strongly agree that interruptions were distracting, and to agree that emotions, extraneous information, and technology were distracting.

CONCLUSIONS

The authors propose a quantitative, empirically driven, mean safety limit of 4 new inpatient consultations per shift for trainees to avoid cognitive overload, thereby potentially supporting patient safety. Clinical and educational leaders can adjust this limit to fit the unique needs of their practice setting. A similar approach using cognitive load and item response theory could be used to conduct patient safety research in other domains.

Do hospitals attaining a public recognition for treating nurses fairly deliver better-quality health care? Evidence from cross-sectional analysis of California hospitals

AIM

This study explored whether hospitals that allocate greater resources to their nursing staff provide better healthcare services than those that invest less in their nursing personnel.

DESIGN

Cross-sectional logistic and tobit analyses.

METHODS

We examined a sample of 314 California hospitals in 2017. We obtained a hospital's public recognition for treating nurses fairly between 2015 and 2017 from Nurse.org, the largest online community of nurses. We derived a hospital's healthcare quality in 2018 from the 2019-2020 Best Hospitals rankings released by U.S. News, a well-known media company publishing independent healthcare assessments periodically.

RESULTS

Our results showed that a nurse-friendly workplace was a crucial determinant of its overall healthcare quality.

CONCLUSION AND IMPLICATIONS

Healthcare administrators keen to enhance the quality of healthcare services should consider creating nurse-friendly workplaces. Furthermore, their evaluation of nurses' contributions to overall healthcare quality should not solely depend on the nurse-assessed quality of care, but rather comprise not only broad aspects of patient outcomes in primary care but also patient experiences, care-related factors and expert opinions.

PATIENT OR PUBLIC CONTRIBUTION

Our study helped address the overwhelmed healthcare system, whose long-running shortage of nurses has been exacerbated by the COVID-19 pandemic. Our work suggested that a hospital's investment in a nurse-friendly workplace can enhance its acquisition, retention and devotion of the nursing staff. This, in turn, can have profound impacts on its overall healthcare quality.

WHAT ALREADY IS KNOWN

Existing empirical evidence on the relation between nurse-friendly workplace and healthcare quality is limited and inconclusive.

WHAT THIS PAPER ADDS

We documented evidence that the quality of healthcare services provided by hospitals varies with their treatment of nursing staff.

IMPLICATIONS FOR PRACTICE/POLICY

Our results provided insights into key policies that have the potential to improve healthcare quality.

The Clinical Nurse Specialist: Maximizing Return on Investment

The United States health care system is facing an unprecedented nursing shortage, increasing complexity of care, and fewer experienced nurse mentors. These factors contribute to a cycle of burnout, turnover, decreased quality and safety, and a worsening financial bottom line. Improving these contributing factors depends on our ability to mitigate the structural causes of burnout and turnover. The clinical nurse specialist role is essential to improving the work environment, advancing evidence-based nursing practice, reducing turnover, and stabilizing the bottom line.

Association of Shift-Level Organizational Factors with Nosocomial Infection in the Neonatal Intensive Care Unit

Objective

To evaluate the association between shift-level organizational data (unit occupancy, nursing overtime ratios [OTRs], and nursing provision ratios [NPRs]) with nosocomial infection (NI) among infants born very preterm in the neonatal intensive care unit (NICU).

Study design

This was a multicenter, retrospective cohort study, including 1921 infants 230/7-326/7 weeks of gestation admitted to 3 tertiary-level NICUs in Quebec between 2014 and 2018. Patient characteristics and outcomes (NIs) were obtained from the Canadian Neonatal Network database and linked to administrative data. For each shift, unit occupancy (occupied/total beds), OTR (nursing overtime hours/total nursing hours), and NPR (number of actual/number of recommended nurses) were calculated. Mixed-effect logistic regression models were used to calculate aOR for the association of organizational factors (mean over 3 days) with the risk of NI on the following day for each infant.

Results

Rate of NI was 11.5% (220/1921). Overall, median occupancy was 88.7% [IQR 81.0-94.6], OTR 4.4% [IQR 1.5-7.6], and NPR 101.1% [IQR 85.5-125.1]. A greater 3-day mean OTR was associated with greater odds of NI (aOR 1.08, 95% CI 1.02-1.15), a greater 3-day mean NPR was associated lower odds of NI (aOR 0.96, 95% CI 0.95-0.98), and occupancy was not associated with NI (aOR, 0.99, 95% CI 0.96-1.02). These findings were consistent across multiple sensitivity analyses.

Conclusions

Nursing overtime and nursing provision are associated with the adjusted odds of NI among infants born very preterm in the NICU. Further interventional research is needed to infer causality.

Business cycles and healthcare employment

Is healthcare employment recession-proof? We examine the long-standing hypothesis that healthcare employment is stable across the business cycle. We explicitly distinguish between negative aggregate demand and supply shocks in studying how healthcare employment responds to recessions, and show that this response depends largely on the type of the exogenous shock triggering the recession. First, aggregate healthcare employment responds procyclically during demand-induced recessions but remains stable during supply-induced recessions. Second, healthcare utilization drops significantly during demand-induced recessions, explaining the decline in healthcare employment during these periods. Finally, there is significant heterogeneity in the employment responses of the healthcare sub-sectors. While healthcare employment in most sub-sectors responds procyclically during recessions caused by both negative demand and supply shocks, it responds countercyclically in nursing-dominant sectors. Importantly, by isolating the recessionary impact of negative aggregate demand shocks from supply shocks on healthcare employment, we provide new empirical evidence that healthcare employment, in general, is not recession-proof.

Impact of off-hours admissions in STEMI-related cardiogenic shock managed with microaxial flow pump - insights from J-PVAD

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (STEMI-CS) is associated with high mortality rates. Patients admitted during off-hours, specifically on weekends and at night, show higher mortality rates, which is called the "off-hours effect". The off-hours effect in patients with STEMI-CS treated with mechanical circulatory support, especially Impella, has not been fully evaluated.

AIMS

We aimed to investigate whether off-hours admissions were associated with higher mortality rates in this population.

METHODS

We used large-scale Japanese registry data for consecutive patients treated with Impella between February 2020 and December 2021 and compared on- and off-hours admissions. On- and off-hours were defined as the time between 8:00 and 19:59 on weekdays and the remaining time, respectively. The Cox proportional hazards model was used to calculate the adjusted hazard ratios (aHRs) for 30-day mortality.

RESULTS

Of the 1,207 STEMI patients, 566 (46.9%) patients (mean age: 69 years; 107 females) with STEMI-CS treated with Impella were included. Of these, 300 (53.0%) were admitted during on-hours. During the follow-up period (median 22 days [interquartile range 13-38 days]), 112 (42.1%) and 91 (30.3%) deaths were observed among patients admitted during off- and on-hours, respectively. Off-hours admissions were independently associated with a higher risk of 30-day mortality than on-hours admissions (aHR 1.60, 95% confidence interval: 1.07-2.39; p=0.02).

CONCLUSIONS

Our findings indicated the persistence of the "off-hours effect" in STEMI-CS patients treated with Impella. Healthcare professionals should continue to address the disparities in cardiovascular care by improving the timely provision of evidence-based treatments and enhancing off-hours medical services.

Describing a programme of implementation-effectiveness research on the organization and implementation of frontline nursing care delivery into diverse heath systems

AIMS

The longitudinal programme of research described in this paper seeks to generate knowledge about factors influencing the implementation of a system-level intervention, the clinical nurse leader care model, involving nurses as leaders at the frontlines of care and the outcomes achievable with successful implementation. The research programme has the following aims, (a) to clarify clinical nurse leader practice, (b) develop and empirically validate a translational model of frontline care delivery that includes clinical nurse leader practice and (c) delineate the patterns of and critical outcomes of successful implementation of the clinical nurse leader care model.

DESIGN

This programme of research follows a knowledge-building trajectory involving multiple study designs in both qualitative (grounded theory, case study) and quantitative (descriptive, correlational and quasi-experimental) traditions.

METHODS

Multiple mixed methods within a system-based participatory framework were used to conduct this programme of implementation-effectiveness research.

RESULTS

Findings are demonstrating how the clinical nurse leader care model, as a complex system-level intervention, can be implemented in diverse healthcare contexts to make a difference to patient care quality and safety. Findings also contribute to implementation science, helping to better understand the dynamic interdependencies between implementation, the interventions implemented and the contexts in which they are implemented.

CONCLUSION

Findings translate into sets of evidence-informed implementation 'recipes' that health systems can match to their specific contexts and needs. This allows health systems to take on strategies that both maximize resource impact within their existing structures and support achieving intended outcomes.

IMPLICATION

This programme of research is producing actionable implementation and outcome evidence about ways to organize nursing knowledge and practice into care models that can be successfully adopted within real-world healthcare settings to achieve safer and higher quality patient care.

Information Management in Hospital Unit Daily Operations: A Descriptive Study With Nurses and Physicians

Operations management of a hospital unit is a shared activity involving nursing and medical professionals, characterized by suddenly changing situations, constant interruptions, and ad hoc decision-making. Previous studies have explored the informational needs affecting decision-making, but only limited information has been collected regarding factors affecting information management related to the daily operations of hospital units. The aim of this study was to describe the experiences of nursing and medical professionals of information management in the daily operations of hospital units. This qualitative study consists of interviews following the critical incidence technique. Twenty-six nurses and eight physicians working in operational leadership roles in hospital units were interviewed, and the data were subjected to thematic analysis. The data analysis showed that strengths of current systems were organizational operational procedures, general instruments supporting information management, and a digital operations dashboard, whereas opportunities for improvement included the information architecture, quality of information, and technology use. The study findings highlight that despite several decades of efforts to provide solutions to support information management in hospital daily operations, further measures need to be taken in developing and implementing information systems with user-centered strategies and systematic approaches to better support healthcare professionals.

Hospital Nurse Staffing Legislation: Mixed Approaches In Some States, While Others Have No Requirements

Legislative agendas aimed at regulating nurse staffing in US hospitals have intensified after acute workforce disruptions triggered by COVID-19. Emerging evidence consistently demonstrates the benefits of higher nurse staffing levels, although uncertainty remains regarding whether and which legislative approaches can achieve this outcome. The purpose of this study was to provide a comprehensive updated review of hospital nurse staffing requirements across all fifty states. As of January 2024, seven states had laws pertaining to staffing ratios for at least one hospital unit, including California and Oregon, which had ratios pertaining to multiple units. Eight states required nurse staffing committees, of which six specified a percentage of committee members who must be registered nurses. Eleven states required nurse staffing plans. Five states had pending legislation, and one state, Idaho, had passed legislation banning minimum nurse staffing requirements. The variety of state regulations provides an opportunity for comparative evaluations of efficacy and feasibility to inform new legislation on the horizon.

Timing of Complete Revascularization Stratified by Index Presentation During On- and Off-Hours

Recent trials suggested immediate complete revascularization (ICR) as a safe alternative to staged complete revascularization (SCR), but the impact of the respective percutaneous coronary intervention strategies between on- versus off-hours is unclear. On-hours was defined as an index revascularization performed between 8:00 a.m. and 6:00 p.m., Monday to Friday, or else the procedure was defined as performed during off-hours. The primary end point consisted of a composite of all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, and cerebrovascular events at 1-year follow-up. We used Cox regression models to relate randomized treatment with study end points. We evaluated multiplicative and additive interactions between on- versus off-hours and randomized treatment. The BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndromes and Multivessel Disease) trial enrolled 1,097 and 428 patients during on- and off-hours, respectively. Patients randomized during off-hours were more likely to present with ST-segment elevation myocardial infarction (66.4% vs 29.5%, p <0.001). The composite primary outcome occurred in 8.4% and 10.1% of patients randomized to ICR and SCR, respectively, during on-hours (hazard ratio 0.80, 95% confidence interval 0.54 to 1.19). During off-hours, the primary composite outcome occurred in 5.4% and 7.7% in ICR and SCR (0.69, 95% confidence interval 0.32 to 1.46) with no evidence of a differential effect (interaction pmultiplicative = 0.70, padditive = 0.56). No differential effect was found between treatment allocation and on- versus off-hours in any of the secondary outcomes. In conclusion, no differential treatment effect was found when comparing ICR versus SCR in patients presenting with acute coronary syndrome and multivessel disease during on- or off-hours.

Evaluating associations between patient-to-nurse ratios and mortality, process of care events and vital sign documentation on paediatric wards: a secondary analysis of data from the EPOCH cluster-randomised trial

OBJECTIVE

To describe the associations between patient-to-nurse staffing ratios and rates of mortality, process of care events and vital sign documentation.

DESIGN

Secondary analysis of data from the evaluating processes of care and outcomes of children in hospital (EPOCH) cluster-randomised trial.

SETTING

22 hospitals caring for children in Canada, Europe and New Zealand.

PARTICIPANTS

Eligible hospitalised patients were aged>37 weeks and <18 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause hospital mortality. Secondary outcomes included five events reflecting the process of care, collected for all EPOCH patients; the frequency of documentation for each of eight vital signs on a random sample of patients; four measures describing nursing perceptions of care.

RESULTS

A total of 217 714 patient admissions accounting for 849 798 patient days over the course of the study were analysed. The overall mortality rate was 1.65/1000 patient discharges. The median (IQR) number of patients cared for by an individual nurse was 3.0 (2.8-3.6). Univariate Bayesian models estimating the rate ratio (RR) for the patient-to-nurse ratio and the probability that the RR was less than one found that a higher patient-to-nurse ratio was associated with fewer clinical deterioration events (RR=0.88, 95% credible interval (CrI) 0.77-1.03; P (RR<1)=95%) and late intensive care unit admissions (RR=0.76, 95% CrI 0.53-1.06; P (RR<1)=95%). In adjusted models, a higher patient-to-nurse ratio was associated with lower hospital mortality (OR=0.77, 95% CrI=0.57-1.00; P (OR<1)=98%). Nurses from hospitals with a higher patient-to-nurse ratio had lower ratings for their ability to influence care and reduced documentation of most individual vital signs and of the complete set of vital signs.

CONCLUSIONS

The data from this study challenge the assumption that lower patient-to-nurse ratios will improve the safety of paediatric care in contexts where ratios are low. The mechanism of these effects warrants further evaluation including factors, such as nursing skill mix, experience, education, work environment and physician staffing ratios.

TRIAL REGISTRATION NUMBER

EPOCH clinical trial registered on clinical trial.gov NCT01260831; post-results.

Children's Hospital Resource Utilization During the 2022 Viral Respiratory Surge

OBJECTIVES

Multiple viral respiratory epidemics occurred concurrently in 2022 but their true extent is unclear. To aid future surge planning efforts, we compared epidemiology and resource utilization with prepandemic viral respiratory seasons in 38 US children's hospitals.

METHODS

We performed a serial cross-sectional study from October 2017 to March 2023. We counted daily emergency department (ED), inpatient, and ICU volumes; daily surgeries; viral tests performed; the proportion of ED visits resulting in revisit within 3 days; and proportion of hospitalizations with a 30-day readmission. We evaluated seasonal resource utilization peaks using hierarchical Poisson models.

RESULTS

Peak volumes in the 2022 season were 4% lower (95% confidence interval [CI] -6 to -2) in the ED, not significantly different in the inpatient unit (-1%, 95% CI -4 to 2), and 8% lower in the ICU (95% CI -14 to -3) compared with each hospital's previous peak season. However, for 18 of 38 hospitals, their highest ED and inpatient volumes occurred in 2022. The 2022 season was longer in duration than previous seasons (P < .02). Peak daily surgeries decreased by 15% (95% CI -20 to -9) in 2022 compared with previous peaks. Viral tests increased 75% (95% CI 69-82) in 2022 from previous peaks. Revisits and readmissions were lowest in 2022.

CONCLUSIONS

Peak ED, inpatient, and ICU volumes were not significantly different in the 2022 viral respiratory season compared with earlier seasons, but half of hospitals reached their highest volumes. Research on how surges impact boarding, transfer refusals, and patient outcomes is needed as regionalization reduces pediatric capacity.

Outcomes of Weekday Versus Weekend Admissions for Heart Block Requiring De Novo Intracardiac Device Implantation

Even with comparable healthcare structure and staffing, patients presenting on weekends often face poorer outcomes, including longer wait times in the emergency department, extended hospital stays, and delays in major procedures. This discrepancy prompts questions about whether life-saving cardiac procedures, such as permanent pacemaker (PPM) implantation for atrioventricular block, also experience similar delays and differences in outcomes. We researched over 200,000 patients from the National Inpatient Sample (NIS) database to help study whether patients admitted on the weekend truly had worse outcomes than patients admitted on the weekday. Using the International Classification of Diseases, Tenth Revision (ICD-10) using STATA software (StataCorp LLC, College Station, TX), we found that 79.6% of patients were admitted on weekdays. Among these weekday admissions, 56.2% were males, with an average age of 75.8 years. Weekend admissions included 54.4% male patients, with an average age of 76.4 years. Key variables influencing outcomes were renal failure history, non-ST elevation myocardial infarction, diabetes mellitus, and percutaneous coronary intervention. Of the total patients, 1,315 died during hospitalization, with no significant difference in mortality between weekday and weekend admissions. However, weekend admissions had a higher rate of cardiac arrest, a greater likelihood of delayed pacer implantation, and longer hospital stays. Weekend admissions were linked to delays in PPM placement, longer hospital stays, and higher hospitalization costs. Mortality rates did not increase for patients admitted on weekends. Further research is needed to explore this issue in greater depth and to identify the specific factors contributing to the discrepancy between weekend and weekday admissions, which resulted in worse outcomes for weekend patients.

The Role of Intermediate Care in Supporting Critically Ill Patients and Critical Care Infrastructure

Intermediate care (IC) is used for patients who do not require the human and technological support of the intensive care unit (ICU) yet require more care and monitoring than can be provided on general wards. Though prevalent in many countries, there is marked variability in models of organization and staffing, as well as monitoring and interventions provided. In this article, the authors will discuss the historical background of IC, review the impact of IC on ICU and IC patient outcomes, and highlight where future studies can shed light on how to optimize IC organization and outcomes.

A Qualitative Study of Systems-Level Factors That Affect Rural Obstetric Nurses' Work During Clinical Emergencies

BACKGROUND

Maternal morbidity and mortality is rising in the United States. Previous studies focus on patient attributes, and most of the national data are based on research performed at urban tertiary care centers. Although it is well understood that nurses affect patient outcomes, there is scant evidence to understand the nurse work system, and no studies have specifically studied rural nurses. The authors sought to understand the systems-level factors affecting rural obstetric nurses when their patients experience clinical deterioration.

METHODS

The research team used a qualitative descriptive approach, including a modified critical incident technique, in interviews with bedside nurses (n = 7) and physicians (n = 4) to understand what happens when patients experience clinical deterioration. Physicians were included to better understand the systems in which nurses work. Clinicians were interviewed at three rural hospitals in New England, with a mean births per year of 190.

FINDINGS

Six systems-level factors/themes were identified: (1) shortages of resources; (2) need for teamwork; (3) physicians' multiple conflicting and simultaneous responsibilities, such as seeing patients in the office while women labor on the hospital floor; (4) need for all team members to be at the top of their game; (5) process issues during high-acuity patient transfer, including difficulty finding available beds at tertiary care centers; and (6) insufficient policies that take low-resource contexts into account, such as requiring two registered nurses to remove emergency medications from the medication cabinet.

CONCLUSION

Rural nurses need policies and protocols that are written with their hospital context in mind. Hospitals may need outside support for content expertise, but policies should be co-created with clinicians with rural practice experience.

Forecast accuracy of demand for registered nurses and its determinants in South Korea

BACKGROUND

Despite the significance of demand forecasting accuracy for the registered nurse (RN) workforce, few studies have evaluated past forecasts.

PURPOSE

This paper examined the ex post accuracy of past forecasting studies focusing on RN demand and explored its determinants on the accuracy of demand forecasts.

METHODS

Data were collected by systematically reviewing national reports or articles on RN demand forecasts. The mean absolute percentage error (MAPE) was measured for forecasting error by comparing the forecast with the actual demand (employed RNs). Nonparametric tests, the Mann‒Whitney test, and the Kruskal‒Wallis test were used to analyze the differences in the MAPE according to the variables, which are methodological and researcher factors.

RESULTS

A total of 105 forecast horizons and 196 forecasts were analyzed. The average MAPE of the total forecast horizon was 34.8%. Among the methodological factors, the most common determinant affecting forecast accuracy was the RN productivity assumption. The longer the length of the forecast horizon was, the greater the MAPE was. The longer the length of the data period was, the greater the MAPE was. Moreover, there was no significant difference among the researchers' factors.

CONCLUSIONS

To improve demand forecast accuracy, future studies need to accurately measure RN workload and productivity in a manner consistent with the real world.

The potential of patient-based nurse staffing - a queuing theory application in the neonatal intensive care setting

Faced by a severe shortage of nurses and increasing demand for care, hospitals need to optimally determine their staffing levels. Ideally, nurses should be staffed to those shifts where they generate the highest positive value for the quality of healthcare. This paper develops an approach that identifies the incremental benefit of staffing an additional nurse depending on the patient mix. Based on the reasoning that timely fulfillment of care demand is essential for the healthcare process and its quality in the critical care setting, we propose to measure the incremental benefit of staffing an additional nurse through reductions in time until care arrives (TUCA). We determine TUCA by relying on queuing theory and parametrize the model with real data collected through an observational study. The study indicates that using the TUCA concept and applying queuing theory at the care event level has the potential to improve quality of care for a given nurse capacity by efficiently trading situations of high versus low workload.

Patient Safety Indicators During the Initial COVID-19 Pandemic Surge in the United States

OBJECTIVE

The COVID-19 pandemic presented a challenge to inpatient safety. It is unknown whether there were spillover effects due to COVID-19 into non-COVID-19 care and safety. We sought to evaluate the changes in inpatient Agency for Healthcare Research and Quality patient safety indicators (PSIs) in the United States before and during the first surge of the pandemic among patients admitted without COVID-19.

METHODS

We analyzed trends in PSIs from January 2019 to June 2020 in patients without COVID-19 using data from IBM MarketScan Commercial Database. We included members of employer-sponsored or Medicare supplemental health plans with inpatient, non-COVID-19 admissions. The primary outcomes were risk-adjusted composite and individual PSIs.

RESULTS

We analyzed 1,869,430 patients admitted without COVID-19. Among patients without COVID-19, the composite PSI score was not significantly different when comparing the first surge (Q2 2020) to the prepandemic period (e.g., Q2 2020 score of 2.46 [95% confidence interval {CI}, 2.34-2.58] versus Q1 2020 score of 2.37 [95% CI, 2.27-2.46]; P = 0.22). Individual PSIs for these patients during Q2 2020 were also not significantly different, except in-hospital fall with hip fracture (e.g., Q2 2020 was 3.42 [95% CI, 3.34-3.49] versus Q4 2019 was 2.45 [95% CI, 2.40-2.50]; P = 0.01).

CONCLUSIONS

The first surge of COVID-19 was not associated with worse inpatient safety for patients without COVID-19, highlighting the ability of the healthcare system to respond to the initial surge of the pandemic.

When Agency Fails: An Analysis of the Association Between Hospital Agency Staffing and Quality Outcomes

Introduction

Staffing is critical to hospital quality, but recent years have seen hospitals grappling with severe shortages, forcing them to rely on contract or agency staff for urgent patient care needs. This shift in staffing mix has raised questions about its impact on quality. Consequently, this study investigated whether the increased use of agency staff has affected healthcare quality in hospitals. Given the limited recent research on this topic, practitioners remain uncertain about the effectiveness of their staffing strategies and their potential impact on quality.

Methods

Drawing from agency theory, data were obtained from Definitive Healthcare which consolidates information from numerous public access databases pertaining to hospitals such as the American Hospital Association Annual Survey (hospital profile) and the Hospital Value-Based Purchasing Program (quality data). We conducted a cross-sectional study using a multivariable linear regression model (2021-2022) with appropriate organizational and market- level control variables. Quality was measured across eight variables while the independent variable of interest was agency labor cost ratio operationalized as the percentage of net patient revenue consumed by agency labor expense.

Results

Our results suggested that the employment of agency staff was significantly and negatively associated with six of eight quality measures tested, including the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) star rating, Hospital Compare rating, the hospital Total Performance Score (TPS), and three of the four sub-domains that comprise the TPS: clinical domain score, person and community engagement domain score, and the efficiency and cost reduction score.

Discussion

Our results indicated that the increased use of agency labor may have a significant negative influence on quality outcomes at the hospital level. Our findings support the premise that interventions that promote full-time staffing may be more supportive of the quality of care delivered as well as patients' perceptions of care.

Nurses' intention to leave, nurse workload and in-hospital patient mortality in Italy: A descriptive and regression study

Higher nurse-to-patient ratios are associated with poor patient care and adverse nurse outcomes, including emotional exhaustion and intention to leave. We examined the effect of nurses' intention to leave and nurse-patient workload on in-hospital patient mortality in Italy. A multicentered descriptive and regression study using clinical data of patients aged 50 years or older with a hospital stay of at least two days admitted to surgical wards linked with nurse variables including workload and education levels, work environment, job satisfaction, intention to leave, nurses' perception of quality and safety of care, and emotional exhaustion. The final dataset included 15 hospitals, 1046 nurses, and 37,494 patients. A 10 % increase in intention to leave and an increase of one unit in nurse-patient workload increased likelihood of inpatient hospital mortality by 14 % (odds ratio 1.14; 1.02-1.27 95 % CI) and 3.4 % (odds ratio 1.03; 1.00-1.06 95 % CI), respectively. No other studies have reported a significant association between intention to leave and patient mortality. To improve patient outcomes, the healthcare system in Italy needs to implement policies on safe human resources policy stewardship, leadership, and governance to ensure nurse wellbeing, higher levels of safety, and quality nursing care.

The role of nursing care continuity report in predicting length of hospital stay in older people: A retrospective cohort study

BACKGROUND

The Nursing Care Continuity Report (NCCR) is a tool for evaluating the quality of nursing care during hospital admission.

AIM

To explore the role of the NCCR in predicting longer length of stay (LOS) in older adults (≥65 years) admitted to a tertiary hospital and determine possible clinical differences at discharge between patients who had a short LOS (≤7 days) and a prolonged LOS (>7 days).

RESEARCH DESIGN AND SETTING

A retrospective cohort study was conducted including all patients with a completed NCCR admitted to the hospital between 2015 and 2019. Sociodemographic data, risk of pressure injuries, level of dependence, presence and intensity of pain, and presence and type of pressure injury were the variables registered in the NCCR.

RESULTS

A total of 41,354 patients were included in this study, with a mean age of 78 years, of whom 47% were female. At admission, 21% of patients were at potential risk of developing pressure ulcers. Age, admission to the internal or respiratory medicine unit, and having at least medium risk of developing pressure ulcers were the predictors of prolonged LOS using a random sample of 950 patients. At discharge, patients with prolonged LOS presented higher risk of pressure ulcers and a higher level of dependency and were more likely to present hospital-acquired pressure ulcers.

CONCLUSIONS

Older adults from the internal or respiratory medicine unit who exhibited higher risk of pressure ulcers were related to a prolonged LOS, a higher level of dependency, and hospital-acquired ulcers at hospital discharge.

RELEVANCE TO CLINICAL PRACTICE

Identifying clinical data that have a greater relationship with LOS could be a useful tool for nursing management and for the implementation of strategies to prevent adverse events during hospitalisation.

NO PATIENT OR PUBLIC CONTRIBUTION

No direct patient contact was made during the data collection.

Effect of Admission Day and Time on Patient Outcome: An Observational Study in Intensive Care Units of a Tertiary Care Hospital in India

Background

The current study aimed to assess any association between intensive care unit (ICU) and hospital outcomes with ICU admission timings of critically ill patients.

Methods

Retrospective observational single-center study involving all adult admissions. Each patient admission was categorized in "after-hours" (08:00 p.m.-07:59 a.m.), or "normal-hours" (08:00 a.m.-07:59 p.m.), "Weekday" (Monday-Saturday), or "Weekend" (Sunday), "Same day" (admission directly to ICU) or "other day admission" (admission to ICU after a hospital stay of ≥24 hours). Intensive care unit and hospital mortality, length of stay (LOS), and ICU readmission were assessed for any association with different admission timings.

Results

Among 3,029 patients, 54.2% (1,668) were male, with mean age 66.49 (SD ± 15.69) years, mean acute physiology and chronic health evaluation-IV (APACHE-IV) score 55.5 (SD ± 26.3). Around 86.1% of admission occurred during weekdays, 13.9% on weekends, 57.4% normal-hours, 42.6% after-hours, 66.3% same day and 33.7% other day admission. Intensive care unit and hospital mortality were 10.8 and 14.2% respectively. Neither ICU nor hospital mortality were significantly different among patients admitted normal vs after-hours (p = 0.32, 0.23), and weekdays vs weekends (p = 0.09, 0.93), nor was ICU LOS (p = 0.21, 0.74). Intensive care unit and hospital mortality (p = 0.001), DORB (p = 0.001), hospital LOS (p = 0.001), and readmission to ICU (p = 0.001) were significantly higher in the other day admission group compared to same-day admission. In a multivariate regression analysis age, APACHE IV score along with other day admission to ICU did have a significant effect on both ICU and hospital mortality.

Conclusion

Intensive care unit and hospital mortality and LOS did not differ significantly with hours or days of ICU admission though they were significantly higher in other day admission groups.

How to cite this article

Bhattacharyya M, Todi SK. Effect of Admission Day and Time on Patient Outcome: An Observational Study in Intensive Care Units of a Tertiary Care Hospital in India. Indian J Crit Care Med 2024;28(5):436-441.

Protecting Patients And Society In An Era Of Private Equity Provider Ownership: Challenges And Opportunities For Policy

Private equity (PE) acquisitions in health care delivery nearly tripled from 2010 to 2020. Despite concerns around clinical and economic implications, policy responses have remained limited. We discuss the US policy landscape around PE ownership, using policies in the European Union for comparison. We present four domains in which policy can be strengthened. First, to improve oversight of acquisitions, policy makers should lower reporting thresholds, review sequential acquisitions that together affect market power, automate reviews with potential denials based on market concentration effects, consider new regulatory mechanisms such as attorney general veto, and increase funding for this work. Second, policy makers should increase the longer-run transparency of PE ownership, including the health care prices garnered by acquired entities. Third, policy makers should protect patients and providers by establishing minimum staffing ratios, spending floors for direct patient care, and limits on layoffs and the sale of real estate after acquisition (forms of "asset stripping"). Finally, policy makers should mitigate risky financial behavior by limiting the amount or proportion of debt used to finance PE acquisitions in health care.

TAILR (Nursing-Sensitive Events and Their Association With Individual Nurse Staffing Levels) Project: Protocol for an International Longitudinal Multicenter Study

BACKGROUND

Nursing-sensitive events (NSEs) are common, accounting for up to 77% of adverse events in hospitalized patients (eg, fall-related harm, pressure ulcers, and health care-associated infections). NSEs lead to adverse patient outcomes and impose an economic burden on hospitals due to increased medical costs through a prolonged hospital stay and additional medical procedures. To reduce NSEs and ensure high-quality nursing care, appropriate nurse staffing levels are needed. Although the link between nurse staffing and NSEs has been described in many studies, appropriate nurse staffing levels are lacking. Existing studies describe constant staffing exposure at the unit or hospital level without assessing patient-level exposure to nurse staffing during the hospital stay. Few studies have assessed nurse staffing and patient outcomes using a single-center longitudinal design, with limited generalizability. There is a need for multicenter longitudinal studies with improved potential for generalizing the association between individual nurse staffing levels and NSEs.

OBJECTIVE

This study aimed (1) to determine the prevalence, preventability, type, and severity of NSEs; (2) to describe individual patient-level nurse staffing exposure across hospitals; (3) to assess the effect of nurse staffing on NSEs in patients; and (4) to identify thresholds of safe nurse staffing levels and test them against NSEs in hospitalized patients.

METHODS

This international multicenter study uses a longitudinal and observational research design; it involves 4 countries (Switzerland, Sweden, Germany, and Iran), with participation from 14 hospitals and 61 medical, surgery, and mixed units. The 16-week observation period will collect NSEs using systematic retrospective record reviews. A total of 3680 patient admissions will be reviewed, with 60 randomly selected admissions per unit. To be included, patients must have been hospitalized for at least 48 hours. Nurse staffing data (ie, the number of nurses and their education level) will be collected daily for each shift to assess the association between NSEs and individual nurse staffing levels. Additionally, hospital data (ie, type, teaching status, and ownership) and unit data (ie, service line and number of beds) will be collected.

RESULTS

As of January 2024, the verification process for the plausibility and comprehensibility of patients' and nurse staffing data is underway across all 4 countries. Data analyses are planned to be completed by spring 2024, with the first results expected to be published in late 2024.

CONCLUSIONS

This study will provide comprehensive information on NSEs, including their prevalence, preventability, type, and severity, across countries. Moreover, it seeks to enhance understanding of NSE mechanisms and the potential impact of nurse staffing on these events. We will evaluate within- and between-hospital variability to identify productive strategies to ensure safe nurse staffing levels, thereby reducing NSEs in hospitalized patients. The TAILR (Nursing-Sensitive Events and Their Association With Individual Nurse Staffing Levels) study will focus on the optimization of scarce staffing resources.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56262.

Nurse/midwife-to-patient ratios: A scoping review

BACKGROUND

A significant body of work has linked high nurse or midwife workload to negative patient outcomes. Anecdotal reports suggest that mandated ratio models enhance patient care and improve nurse job satisfaction. However, there is limited focused research.

OBJECTIVE

To identify key outcomes, implementation processes, and research needs regarding nurse/midwife-to-patient ratios in the Australian healthcare context.

DESIGN

Scoping review.

METHODS

Data sources were CINAHL, Open Dissertations, Medline, and Scopus. 289 articles screened, and 53 full text documents independently assessed against criteria by two reviewers and conflicts resolved by a third reviewer, using Covidence™. Three studies were included in this review.

RESULTS

Studies focused on nurse (job satisfaction, burnout), patient (mortality, readmission, length of stay) and system (costs) outcomes with limited information on implementation processes and no midwifery research.

CONCLUSIONS

Ratios provide benefits for patients, nurses, and hospitals although there is limited research in Australia. Implementation was poorly reported..

Clinical deterioration as a nurse sensitive indicator in the out-of-hospital context: A scoping review

AIMS

To explore and summarise the literature on the concept of 'clinical deterioration' as a nurse-sensitive indicator of quality of care in the out-of-hospital context.

DESIGN

The scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review and the JBI best practice guidelines for scoping reviews.

METHODS

Studies focusing on clinical deterioration, errors of omission, nurse sensitive indicators and the quality of nursing and midwifery care for all categories of registered, enrolled, or licensed practice nurses and midwives in the out-of-hospital context were included regardless of methodology. Text and opinion papers were also considered. Study protocols were excluded.

DATA SOURCES

Data bases were searched from inception to June 2022 and included CINAHL, PsychINFO, MEDLINE, The Allied and Complementary Medicine Database, EmCare, Maternity and Infant Care Database, Australian Indigenous HealthInfoNet, Informit Health and Society Database, JSTOR, Nursing and Allied Health Database, RURAL, Cochrane Library and Joanna Briggs Institute.

RESULTS

Thirty-four studies were included. Workloads, education and training opportunities, access to technology, home visits, clinical assessments and use of screening tools or guidelines impacted the ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting.

CONCLUSIONS

Little is known about the work of nurses or midwives in out-of-hospital settings and their recognition, reaction to and relay of information about patient deterioration. The complex and subtle nature of non-acute deterioration creates challenges in defining and subsequently evaluating the role and impact of nurses in these settings.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Further research is needed to clarify outcome measures and nurse contribution to the care of the deteriorating patient in the out-of-hospital setting to reduce the rate of avoidable hospitalisation and articulate the contribution of nurses and midwives to patient care.

IMPACT

What Problem Did the Study Address? Factors that impact a nurse's ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting are not examined to date. What Were the Main Findings? A range of factors were identified that impacted a nurse's ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting including workloads, education and training opportunities, access to technology, home visits, clinical assessments, use of screening tools or guidelines, and avoidable hospitalisation. Where and on whom will the research have an impact? Nurses and nursing management will benefit from understanding the factors that act as barriers and facilitators for effective recognition of, and responding to, a deteriorating patient in the out-of-hospital setting. This in turn will impact patient survival and satisfaction.

REPORTING METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review guidelines guided this review. The PRISMA-Scr Checklist (Tricco et al., 2018) is included as (supplementary file 1).Data sharing is not applicable to this article as no new data were created or analysed in this study."

NO PATIENT OR PUBLIC CONTRIBUTION

Not required as the Scoping Review used publicly available information.

Treatable mortality and health care related factors across European countries

Introduction

Despite the improvements in European health systems, a large number of premature deaths are attributable to treatable mortality. Men make up the majority of these deaths, with a significant gap existing between women and men's treatable mortality rate in the EU.

Aim

This study aims to identify the healthcare-related factors, including health expenditures, human and physical resources, and hospital services use associated with treatable mortality in women and men across European countries during the period 2011-2019.

Methods

We use Eurostat data for 28 EU countries in the period 2011-2019. We estimate a panel data linear regression with country fixed effects and quantile linear regression for men and women.

Results

The results found (i) differences in drivers for male and female treatable mortality, but common drivers hold the same direction for both sexes; (ii) favorable drivers are GDP per capita, health expenditures, number of physicians per capita, and (only for men) the average length of a hospital stay, (iii) unfavorable drivers are nurses and beds per capita, although nurses are not significant for explaining female mortality.

Conclusion

Policy recommendations may arise that involve an improvement in hospital bed management and the design of more specific policies aimed at healthcare professionals.

Association of nurse understaffing and limited nursing work experience with in-hospital mortality among patients: A longitudinal register-based study

BACKGROUND

Although nurse understaffing and limited nursing work experience may affect hospital patients' risk of mortality, relatively little longitudinal patient-level evidence on these associations is available. Hospital administrative data could provide important information about the level of staffing, nurses' work experience and patient mortality over time.

OBJECTIVE

To examine whether daily exposure to nurse understaffing and limited nursing work experience is associated with patient mortality, using patient-level data with different exposure time windows and accounting for several patient-related characteristics.

METHODS

This longitudinal register-based study combined administrative data on patients (clinical database Auria) and employees (Titania® shift-scheduling) from one hospital district in Finland in 2013-2019, covering a total of 254,446 hospital stays in 40 units. We quantified nurse understaffing as the number of days with low nursing hours in relation to target hours (<90 % of the annual unit median), and limited work experience as the number of days with a low proportion of nurses with >3 years of in-hospital experience, and those aged over 25 (<90 % of the annual unit median). We used two survival model designs to analyze the associations between nurse understaffing and limited nursing work experience and the in-hospital mortality of the patients: we considered these exposures during the first days in hospital and as a cumulative proportion of days with suboptimal staffing during the first 30 days.

RESULTS

In total, 1.5 % (N = 3937) of the hospital stays ended in death. A 20 % increase in the proportion of days with nurse understaffing was associated with an increased, 1.05-fold mortality risk at the patient level (95 % confidence interval, 1.01-1.10). The cumulative proportion of days with limited nursing work experience, or the combination of nurse understaffing and limited work experience were not associated with increased risk of death among all patients. However, both indicators of limited nursing work experience were associated with an increased mortality risk among patients with comorbidities (HR 1.05, 95 % CI 1.02-1.08 and HR 1.05, 95 % CI 1.00-1.10, respectively).

CONCLUSIONS

Nurse understaffing was associated with a slight, but a potentially critical increase in patient in-hospital mortality. Limited nursing work experience was associated with increased in-hospital mortality in a subgroup of patients with comorbidities. Increased use of administrative data on planned and realized working hours could be a routine tool for reducing avoidable in-hospital mortality.

Association between regional critical care capacity and the incidence of invasive mechanical ventilation for coronavirus disease 2019: a population-based cohort study

BACKGROUND

Coronavirus disease 2019 (COVID-19) has exposed critical care supply shortages worldwide. This study aimed to investigate the association between regional critical care capacity and the incidence of invasive mechanical ventilation following novel COVID-19 during the pandemic in Japan, a country with a limited intensive care unit (ICU) bed capacity of a median of 5.1 ICU beds per 100,000 individuals.

METHODS

This population-based cohort study used data from the CRoss Icu Searchable Information System database and publicly available databases provided by the Japanese government and Japanese Society of Intensive Care Medicine. We identified patients recently diagnosed with COVID-19, those who received invasive mechanical ventilation, and those who received extracorporeal membrane oxygenation (ECMO) between February 2020 and March 2023. We analyzed the association between regional critical care capacity (ICU beds, high-dependency care unit (HDU) beds, resource-rich ICU beds, and intensivists) and the incidence of invasive mechanical ventilation, ECMO, and risk-adjusted mortality across 47 Japanese prefectures.

RESULTS

Among the approximately 127 million individuals residing in Japan, 33,189,809 were recently diagnosed with COVID-19, with 12,203 and 1,426 COVID-19 patients on invasive mechanical ventilation and ECMO, respectively, during the study period. Prefecture-level linear regression analysis revealed that the addition of ICU beds, resource-rich ICU beds, and intensivists per 100,000 individuals increased the incidence of IMV by 5.37 (95% confidence interval, 1.99-8.76), 7.27 (1.61-12.9), and 13.12 (3.48-22.76), respectively. However, the number of HDU beds per 100,000 individuals was not statistically significantly associated with the incidence of invasive mechanical ventilation. None of the four indicators of regional critical care capacity was statistically significantly associated with the incidence of ECMO and risk-adjusted mortality.

CONCLUSIONS

The results of prefecture-level analyses demonstrate that increased numbers of ICU beds, resource-rich ICU beds, and intensivists are associated with the incidence of invasive mechanical ventilation among patients recently diagnosed with COVID-19 during the pandemic. These findings have important implications for healthcare policymakers, aiding in efficiently allocating critical care resources during crises, particularly in regions with limited ICU bed capacities. Registry and the registration no. of the study/trial The approval date of the registry was August 20, 2020, and the registration no. of the study was lUMIN000041450.

Utility of salivary cortisol profile as a predictive biomarker in nurses' turnover risk: a preliminary study

BACKGROUND

Predicting nurse turnover risk is crucial due to the global nursing shortage; however, existing predictors, such as fatigue and burnout, lack objectivity. Salivary cortisol is a non-invasive marker of stress and fatigue, but its utility in predicting nurse turnover risk is unknown. We examined whether salivary cortisol profiles across three different day shifts in a month are predictors of the extent of nurses' reluctance to stay in their current jobs.

METHODS

This preliminary longitudinal study followed forty female nurses who engaged in shift work at a university hospital for 3 months. Data at enrollment were collected including demographics, working conditions, chronic fatigue (the Japanese version of the Occupational Fatigue/Exhaustion Recovery Scale), and burnout (Japanese Burnout scale). Salivary cortisol was measured before the three different day shifts (after awakening) during the first month, and the means of these measurements were used as the cortisol profile. The extent of reluctance to stay was assessed using the numerical rating scale at 3 months.

RESULTS

Among the forty female nurses (mean [SD] age, 28.3 [5.1]), all completed follow-up and were included in the analysis. The cortisol profile was associated with the extent of reluctance to stay (P = 0.017), and this association was significant despite adjustments for chronic fatigue and burnout (P = 0.005). A multiple regression model with chronic fatigue, burnout, and job tenure explained 41.5% of the variation in reluctance to stay. When the cortisol profile was added to this model, the association of the cortisol profile was significant (P = 0.006) with an R2 of 0.529 (ΔR2 = 0.114).

CONCLUSIONS

This preliminary study conducted in an actual clinical setting indicated the potential of the salivary cortisol profile across three different day shifts in a month to predict nurses' reluctance to stay in their current jobs. The combination of subjective indicators and the cortisol profile would be useful in predicting nurses' turnover risk.

Accuracy of intra-arterial line transducer levelling practice in a general intensive care unit

BACKGROUND

The intra-arterial line is a common device intervention used in the intensive care environment to provide continuous blood pressure measurement. The transducer line is levelled to the patient's phlebostatic axis to provide accurate measurements.

AIM

The aim of this study was to investigate registered nurses' accuracy at levelling the transducer to the correct anatomical position using visual judgement, compared to one done using a laser level.

METHODS

Patient transducers were levelled by visual judgement and then by using a laser level. Time and mean arterial pressure (MAP) were recorded with each measurement along with any difference in transducer level between the two methods and subsequent changes in inotrope administration.

RESULTS

A total of 577 MAP measurements were recorded from 178 patients; 70% of observations had a difference in transducer level, 30% of the time the inotrope rate was increased and 18% of the time the inotrope rate was reduced. The prevalence of clinically significant observations with an absolute difference of 50 mm or more in transducer placement was 25%. The mean difference in MAP measurements when a cut-off of 64 mmHg or more for laser was applied to the data was 0.22 (95% confidence interval: -0.14, 0.58, n = 513, p = 0.23), and for a cut-off of less than 64 for laser, a larger mean difference of 4.36 (95% confidence interval: 3.75, 5.28], n = 64, p < 0.001) was observed.

CONCLUSIONS

Transducers were unable to be accurately levelled for haemodynamic monitoring using visual means alone. Over the range of patient MAP values examined, 25% of all observations had a clinically significant absolute difference of 50 mm or more in the transducer level position between the two methods. The visual method became increasingly inaccurate and unreliable at low MAP levels requiring medical intervention.

Intensive care unit mortality and cost-effectiveness associated with intensivist staffing: a Japanese nationwide observational study

BACKGROUND

Japan has four types of intensive care units (ICUs) that are divided into two categories according to the management fee charged per day: ICU management fees 1 and 2 (ICU1/2) (equivalent to high-intensity staffing) and 3 and 4 (ICU3/4) (equivalent to low-intensity staffing). Although ICU1/2 charges a higher rate than ICU3/4, no cost-effectiveness analysis has been performed for ICU1/2. This study evaluated the clinical outcomes and cost-effectiveness of ICU1/2 compared with those of ICU3/4.

METHODS

This retrospective observational study used a nationwide Japanese administrative database to identify patients admitted to ICUs between April 2020 and March 2021 and divided them into the ICU1/2 and ICU3/4 groups. The ICU mortality rates and in-hospital mortality rates were determined, and the incremental cost-effectiveness ratio (ICER) (Japanese Yen (JPY)/QALY), defined as the difference between quality-adjusted life year (QALY) and medical costs, was compared between ICU1/2 and ICU3/4. Data analysis was performed using the Chi-squared test; an ICER of < 5 million JPY/QALY was considered cost-effective.

RESULTS

The ICU1/2 group (n = 71,412; 60.7%) had lower ICU mortality rates (ICU 1/2: 2.6% vs. ICU 3/4: 4.3%, p < 0.001) and lower in-hospital mortality rates (ICU 1/2: 6.1% vs. ICU 3/4: 8.9%, p < 0.001) than the ICU3/4 group (n = 46,330; 39.3%). The average cost per patient of ICU1/2 and ICU3/4 was 2,249,270 ± 1,955,953 JPY and 1,682,546 ± 1,588,928 JPY, respectively, with a difference of 566,724. The ICER was 718,659 JPY/QALY, which was below the cost-effectiveness threshold.

CONCLUSIONS

ICU1/2 is associated with lower ICU patient mortality than ICU3/4. Treatments under ICU1/2 are more cost-effective than those under ICU3/4, with an ICER of < 5 million JPY/QALY.

Differences between Registered Nurses and nurse assistants around missed nursing care-An observational, comparative study

BACKGROUND

From a nursing perspective, tasks that are not carried out, and the consequences of this, have been studied for over a decade. The difference between Registered Nurses (RNs) and nurse assistants (NAs) regarding qualifications and work tasks, and the profound knowledge around RN-to-patient ratios, warrants investigating missed nursing care (MNC) for each group rather than as one (nursing staff).

AIM

To describe and compare RNs and NAs ratings of and reasons for MNC at in-hospital wards.

METHODS

A cross-sectional study with a comparative approach. RNs and NAs at in-hospital medical and surgical wards for adults were invited to answer the MISSCARE Survey-Swedish version, including questions on patient safety and quality of care.

RESULTS

A total of 205 RNs and 219 NAs answered the questionnaire. Quality of care and patient safety was rated as good by both RNs and NAs. Compared to NAs, RNs reported more MNC, for example, in the item 'Turning patient every 2 h' (p < 0.001), 'Ambulation three times per day or as ordered' (p = 0.018), and 'Mouth care' (p < 0.001). NAs reported more MNC in the items 'Medications administered within 30 min before or after scheduled time' (p = 0.005), and 'Patient medication requests acted on within 15 min' (p < 0.001). No significant differences were found between the samples concerning reasons for MNC.

CONCLUSION

This study demonstrated that RNs' and NAs' ratings of MNC to a large extent differed between the groups. RNs and NAs should be viewed as separate groups based on their different knowledge levels and roles when caring for patients. Thus, viewing all nursing staff as a homogenous group in MNC research may mask important differences between the groups. These differences are important to address when taking actions to reduce MNC in the clinical setting.

Patient-to-nurse ratios: Balancing quality, nurse turnover, and cost

We consider the problem of setting appropriate patient-to-nurse ratios in a hospital, an issue that is both complex and widely debated. There has been only limited effort to take advantage of the extensive empirical results from the medical literature to help construct analytical decision models for developing upper limits on patient-to-nurse ratios that are more patient- and nurse-oriented. For example, empirical studies have shown that each additional patient assigned per nurse in a hospital is associated with increases in mortality rates, length-of-stay, and nurse burnout. Failure to consider these effects leads to disregarded potential cost savings resulting from providing higher quality of care and fewer nurse turnovers. Thus, we present a nurse staffing model that incorporates patient length-of-stay, nurse turnover, and costs related to patient-to-nurse ratios. We present results based on data collected from three participating hospitals, the American Hospital Association (AHA), and the California Office of Statewide Health Planning and Development (OSHPD). By incorporating patient and nurse outcomes, we show that lower patient-to-nurse ratios can potentially provide hospitals with financial benefits in addition to improving the quality of care. Furthermore, our results show that higher policy patient-to-nurse ratio upper limits may not be as harmful in smaller hospitals, but lower policy patient-to-nurse ratios may be necessary for larger hospitals. These results suggest that a "one ratio fits all" patient-to-nurse ratio is not optimal. A preferable policy would be to allow the ratio to be hospital-dependent.