Moving healthcare quality forward with nursing-sensitive value-based purchasing

Effects of intensive care unit quality assessment on changes in medical staff in medical institutions and in-hospital mortality

BACKGROUND

Quality assessments are being introduced in many countries to improve the quality of care and maintain acceptable quality levels. In South Korea, various quality assessments are being conducted to improve the quality of care, but there is insufficient evidence on intensive care units (ICUs). This study aims to evaluate the impact of ICU quality assessments on the structural indicators in medical institutions and the resulting in-hospital mortality of patients.

METHODS

This study used data collected in the 2nd and 3rd ICU quality assessments in 2017 and 2019. A total of 72,879 patients admitted to ICUs were included during this period, with 265 institutions that received both assessments. As for structural indicators, changes in medical personnel and equipment were assessed, and in-hospital deaths were evaluated as patient outcomes. To evaluate the association between medical staff and in-hospital mortality, a generalized estimating equation model was performed considering both hospital and patient variables.

RESULTS

Compared to the second quality evaluation, the number of intensivist physicians and experienced nurses increased in the third quality evaluation; however, there was still a gap in the workforce depending on the type of medical institution. Among all ICU patients admitted during the evaluation period, 12.0% of patients died in the hospital. In-hospital mortality decreased at the 3rd assessment, and hospitals employing intensivist physicians were associated with reduced in-hospital deaths. In addition, an increase in the number of experienced nurses was associated with a decrease in in-hospital mortality, while an increase in the nurse-to-bed ratio increased mortality.

CONCLUSIONS

ICU quality assessments improved overall structural indicators, but the gap between medical institutions has not improved and interventions are required to bridge this gap. In addition, it is important to maintain skilled medical personnel to bring about better results for patients, and various efforts should be considered. This requires continuous monitoring and further research on long-term effects.

A generalized interrupted time series model for assessing complex health care interventions

Assessing the impact of complex interventions on measurable health outcomes is a growing concern in health care and health policy. Interrupted time series (ITS) designs borrow from traditional case-crossover designs and function as quasi-experimental methodology able to retrospectively analyze the impact of an intervention. Statistical models used to analyze ITS designs primarily focus on continuous-valued outcomes. We propose the "Generalized Robust ITS" (GRITS) model appropriate for outcomes whose underlying distribution belongs to the exponential family of distributions, thereby expanding the available methodology to adequately model binary and count responses. GRITS formally implements a test for the existence of a change point in discrete ITS. The methodology proposed is able to test for the existence of and estimate the change point, borrow information across units in multi-unit settings, and test for differences in the mean function and correlation pre- and post-intervention. The methodology is illustrated by analyzing patient falls from a hospital that implemented and evaluated a new care delivery model in multiple units.

Analysis of Production Line Project Based on Value Sensitive Design

Value sensitive design is a new method to embed moral value into the design process and possesses broad research prospects. However, there is a gap between the industrial application and the practical application of VSD since its practical application focuses on human-computer interaction and medical ethics. In this paper, the conceptual, empirical, and technical investigation of VSD are analyzed, and the feasibility of VSD for production line design is demonstrated. It was applied to the production line design process in Shenyang, Liaoning Province, China. Then, specific design issues such as environmental sustainability and safety are solved by analyzing the value demands of stakeholders and balancing the value tension. Thus, the human value of the production line becomes more sensitive, and the value conflict between natural and technical artifact is alleviated. In this process, we reflect on the design problems to be solved and obtain valuable opinions, enabling VSD to better adapt to the industrial production line design.

The experience of Catalonia measuring nurse-sensitive indicators: Trends study 2012-2018

AIM

To describe nursing-sensitive indicators measured in Catalonia.

BACKGROUND

In Catalonia, since 2012, under the umbrella of the Results Centre, outcomes of every health care setting have been published and made open to health care professionals and citizens.

METHODS

Trends study of nursing-sensitive indicators was based on data collected systematically from each setting from 2012 to 2018. Percentages and rates were calculated for each of 14 indicators analysed from all primary care, hospitals and long-term care centres.

RESULTS

Percentage of population aged 60 years or older correctly vaccinated against flu has been decreasing, while percentage of population aged 14 years or under with correct vaccine status is high (over 91%) and has remained stable over time. Mortality in patients who have developed complications has increased, from 27.1% in 2012 to 34.0% in 2017. Most centres achieved functional improvements during the first 30 days of admission.

CONCLUSIONS

Among all indicators measured in primary care, hospital and long-term care, only 14 analysed are nursing-sensitive; no nursing-sensitive indicators regarding mental health are measured.

IMPLICATIONS FOR NURSING MANAGEMENT

Research focused on development of nursing-sensitive indicators offers an opportunity to measure and benchmark nurses' quality of care and their contribution in achieving populations' health improvement and health care system sustainability.

Collaborating to deliver value in health care: exploring conditions required for successful healthcare and life science sector collaboration

Purpose

The UK Government-funded National Health Service (NHS) is experiencing significant pressures because of the complexity of challenges to, and demands of, health-care provision. This situation has driven government policy level support for transformational change initiatives, such as value-based health care (VBHC), through closer alignment and collaboration across the health-care system-life science sector nexus. The purpose of this paper is to evaluate the necessary antecedents to collaboration in VBHC through a critical exploration of the existing literature, with a view to establishing the foundations for further development of policy, practice and theory in this field.

Design/methodology/approach

A literature review was conducted via searches on Scopus and Google Scholar between 2009 and 2019 for peer-reviewed articles containing keywords and phrases “Value-based healthcare industry” and “healthcare industry collaboration”. Refinement of the results led to the identification of “guiding conditions” (GCs) for collaboration in VBHC.

Findings

Five literature-derived GCs were identified as necessary for the successful implementation of initiatives such as VBHC through system-sector collaboration. These are: a multi-disciplinarity; use of appropriate technological infrastructure; capturing meaningful metrics; understanding the total cycle-of-care; and financial flexibility. This paper outlines research opportunities to empirically test the relevance of the five GCs with regard to improving system-sector collaboration on VBHC.

Originality/value

This paper has developed a practical and constructive framework that has the potential to inform both policy and further theoretical development on collaboration in VBHC.

Initial testing of the use of the Safer Nursing Care Tool in a Canadian acute care context

Aim

Initial testing of England's Safer Nursing Care Tool for adult in‐patient acute care wards in a university‐affiliated Canadian hospital.

Background

Safe‐nursing staffing decisions have significant impacts on patients' safety and quality of care. The Safer Nursing Care Tool was developed in England to provide managers with a validated formula for making appropriate nursing staffing decisions. The tool has been widely used and studied in the UK but has yet to be tested in a Canadian context.

Method

Ten high service quality acute care wards from a university‐affiliated Canadian hospital tested the use of the Safer Nursing Care Tool. Service quality, patients' dependency/acuity and staff activity data were benchmarked against information collected in 726 comparable UK wards.

Results

Higher bed occupancy and patient dependency/acuity mix were found in the 10 Canadian wards compared to their UK counterparts. Overall staff activity was comparable between UK and Canadian wards.

Conclusion

The Safer Nursing Care Tool can be applied in this Canadian hospital, and further testing in other hospitals and specialties is required.

Implication for Nursing Management

The Safer Nursing Care Tool is a valid staffing tool to use that, when combined with professional judgement, can help managers to properly establish nursing staff in acute care wards.

Performance of the Safer Nursing Care Tool to measure nurse staffing requirements in acute hospitals: a multicentre observational study

OBJECTIVES

The best way to determine nurse staffing requirements on hospital wards is unclear. This study explores the precision of estimates of nurse staffing requirements made using the Safer Nursing Care Tool (SNCT) patient classification system for different sample sizes and investigates whether recommended staff levels correspond with professional judgements of adequate staffing.

DESIGN

Observational study linking datasets of staffing requirements (estimated using a tool) to professional judgements of adequate staffing. Multilevel logistic regression modelling.

SETTING

81 medical/surgical units in four acute care hospitals.

PARTICIPANTS

22 364 unit days where staffing levels and SNCT ratings were linked to nurse reports of "enough staff for quality".

PRIMARY OUTCOME MEASURES

SNCT-estimated staffing requirements and nurses' assessments of staffing adequacy.

RESULTS

The recommended minimum sample of 20 days allowed the required number to employ (the establishment) to be estimated with a mean precision (defined as half the width of the CI as a percentage of the mean) of 4.1%. For most units, much larger samples were required to estimate establishments within ±1 whole time equivalent staff member. When staffing was lower than that required according to the SNCT, for each hour per patient day of registered nurse staffing below the required staffing level, the odds of nurses reporting that there were enough staff to provide quality care were reduced by 11%. Correspondingly, the odds of nurses reporting that necessary nursing care was left undone were increased by 14%. No threshold indicating an optimal staffing level was observed. Surgical specialty, patient turnover and more single rooms were associated with lower odds of staffing adequacy.

CONCLUSIONS

The SNCT can provide reliable estimates of the number of nurses to employ on a unit, but larger samples than the recommended minimum are usually required. The SNCT provides a measure of nursing workload that correlates with professional judgements, but the recommended staffing levels may not be optimal. Some important sources of systematic variations in staffing requirements for some units are not accounted for. SNCT measurements are a potentially useful adjunct to professional judgement but cannot replace it.

TRIAL REGISTRATION NUMBER

ISRCTN12307968.

Nursing Activities Score and the cost of nursing care required and available

OBJECTIVE

To estimate the cost of nursing care required and available through the use of the Nursing Activities Score.

METHOD

Quantitative study, direct costing of nursing care required and available in the Intensive Care Units. Data collection included variables of the patients, nursing professionals and nursing workload measured by the Nursing Activities Score. The cost of nursing care was estimated by multiplying the cost of each hour with the total number of hours of care per category.

RESULTS

The negative difference of R$ 94,791.5 between the cost of available and required nursing care indicated an increase of 3.2 nurses and 7.0 nursing technicians.

CONCLUSION

The cost of nursing care required identified through the application of the Nursing Activities Score, which is higher than the cost of available care, indicates the need to adjust the number of professionals to meet patients' demands.

Assessing health care interventions via an interrupted time series model: Study power and design considerations

The delivery and assessment of quality health care is complex with many interacting and interdependent components. In terms of research design and statistical analysis, this complexity and interdependency makes it difficult to assess the true impact of interventions designed to improve patient health care outcomes. Interrupted time series (ITS) is a quasi-experimental design developed for inferring the effectiveness of a health policy intervention while accounting for temporal dependence within a single system or unit. Current standardized ITS methods do not simultaneously analyze data for several units nor are there methods to test for the existence of a change point and to assess statistical power for study planning purposes in this context. To address this limitation, we propose the "Robust Multiple ITS" (R-MITS) model, appropriate for multiunit ITS data, that allows for inference regarding the estimation of a global change point across units in the presence of a potentially lagged (or anticipatory) treatment effect. Under the R-MITS model, one can formally test for the existence of a change point and estimate the time delay between the formal intervention implementation and the over-all-unit intervention effect. We conducted empirical simulation studies to assess the type one error rate of the testing procedure, power for detecting specified change-point alternatives, and accuracy of the proposed estimating methodology. R-MITS is illustrated by analyzing patient satisfaction data from a hospital that implemented and evaluated a new care delivery model in multiple units.

Applying the American Nurses Association Credentialing Center Accreditation Program in the Setting of Registered Nurse Remediation

The objective of this project was to use and evaluate the American Nurses Credentialing Center (ANCC) accreditation program in the context of registered nurse practice remediation using Just Culture. The quality improvement project intervention was aimed at educating nursing professional development educators about the accreditation program for registered nurse remedial education and implementing this program for remediation. It compared pre- and postintervention data for nurse educators using the nine key elements.

Resource Dependency and Hospital Performance in Hospital Value-Based Purchasing

To help influence the health care environment as well as the flow of resources into and out of hospitals, the Centers for Medicare & Medicaid Services has implemented a performance incentive initiative called the Hospital Value-Based Purchasing (HVBP) program. As such, this study utilizes the lens of Resource Dependency Theory to evaluate the effect of the external environment on hospital performance as measured by the HVBP program. This study utilizes data from the 2014 American Hospital Association (AHA) Annual Survey database, 2014 Area Health Resource File (AHRF), the 2014 Medicare Final Rule Standardizing File, and the 2014 Medicare Hospital Compare database. The associations between external environment and hospital performance are assessed through multiple regression analysis. Hospital performance scores in the HVBP program are sensitive to environmental factors; however, not all domains are influenced to the same degree. It would seem that hospitals do not have either the same ability or motivation to make changes in each of the value-based purchasing domains. Ultimately, the findings from this study indicate that environmental forces do play a role in hospitals' performance in the HVBP program.

Recent Advancement of Clinical Information Systems: Opportunities and Challenges

Objectives:  Clinical information systems (CISs) have generated opportunities for meaningful improvements both in patient care and workflow but there is still a long way to perfection. Healthcare providers are still facing challenges of data exchange, management, and integration due to lack of functionality among these systems. Our objective here is to systematically review, synthesize, and summarize the literature that describes the current stage of clinical information systems, so as to assess the current state of knowledge, and identify benefits and challenges.

Methods:  PubMed, EMBASE, and the bibliographies of articles were searched for studies published until September 1, 2017, which reported on significant advancement of clinical information systems, as well as problems and opportunities in this field. Studies providing the most detailed information were included and the others were kept only as references.

Results:  We selected 23 papers out of 1,026 unique abstracts for full-text review using our selection criteria, and 20 out of these 23 studies met all of our inclusion criteria. We focused on three major areas: 1) Ambulatory and inpatients clinical information systems; 2) Specialty information systems; and 3) Ancillary information systems. As CIS can support evidence-based practices that, in turn, improve patient's safety, quality and efficacy of care, advancement, acceptability, and adaptability of CIS have increased worldwide. Although, the demand for CIS functionality is rising fast, current CISs still have data integration challenges and lack of functionality to exchange patient information from all or some parts of the healthcare system. These limitations can be attributed to technical, human, and organizational factors

Conclusion:  Clinical information systems provide tremendous opportunities to reduce clinical errors such as medication errors and diagnostic errors and to support healthcare professionals by offering up-to-date patient information. They promise to improve workflow and efficiency of care, thus boosting the overall quality of healthcare.

The mindful nurse leader: Improving processes and outcomes; restoring joy to nursing

In this first installment of a three-part series on mindfulness, we describe a dynamic project aimed at elevating the importance of mindfulness, compassion, and presence as key competencies for professional nurses across the career span in all healthcare settings.

Using a Lean Six Sigma Approach to Yield Sustained Pressure Ulcer Prevention for Complex Critical Care Patients

BACKGROUND

Under value-based purchasing, Medicare withholds reimbursements for hospital-acquired pressure ulcer occurrence and rewards hospitals that meet performance standards. With little evidence of a validated prevention process, nurse managers are challenged to find evidence-based interventions.

OBJECTIVE

The aim of this study was to reduce the unit-acquired pressure ulcer (UAPU) rate on targeted intensive care and step-down units by 15% using Lean Six Sigma (LSS) methodology.

METHODS

An interdisciplinary team designed a pilot program using LSS methodology to test 4 interventions: standardized documentation, equipment monitoring, patient out-of-bed-to-chair monitoring, and a rounding checklist.

RESULTS

During the pilot, the UAPU rate decreased from 4.4% to 2.8%, exceeding the goal of a 15% reduction. The rate remained below the goal through the program control phase at 2.9%, demonstrating a statistically significant reduction after intervention implementation.

CONCLUSIONS

The program significantly reduced UAPU rates in high-risk populations. LSS methodologies are a sustainable approach to reducing hospital-acquired conditions that should be broadly tested and implemented.

Organization of Hospital Nursing and 30-Day Readmissions in Medicare Patients Undergoing Surgery

BACKGROUND

Growing scrutiny of readmissions has placed hospitals at the center of readmission prevention. Little is known, however, about hospital nursing—a critical organizational component of hospital service system—in relation to readmissions.

OBJECTIVES

To determine the relationships between hospital nursing factors—nurse work environment, nurse staffing, and nurse education—and 30-day readmissions among Medicare patients undergoing general, orthopedic, and vascular surgery.

METHOD AND DESIGN

We linked Medicare patient discharge data, multistate nurse survey data, and American Hospital Association Annual Survey data. Our sample included 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania). Risk-adjusted robust logistic regressions were used for analyses.

RESULTS

The average 30-day readmission rate was 10% in our sample (general surgery: 11%; orthopedic surgery: 8%; vascular surgery: 12%). Readmission rates varied widely across surgical procedures and could be as high as 26% (upper limb and toe amputation for circulatory system disorders). Each additional patient per nurse increased the odds of readmission by 3% (OR=1.03; 95% CI, 1.00-1.05). Patients cared in hospitals with better nurse work environments had lower odds of readmission (OR=0.97; 95% CI, 0.95-0.99). Administrative support to nursing practice (OR=0.96; 95% CI, 0.94-0.99) and nurse-physician relations (OR=0.97; 95% CI, 0.95-0.99) were 2 main attributes of the work environment that were associated with readmissions.

CONCLUSIONS

Better nurse staffing and work environment were significantly associated with 30-day readmission, and can be considered as system-level interventions to reduce readmissions and associated financial penalties.

Questionable validity of the catheter-associated urinary tract infection metric used for value-based purchasing

Catheter-associated urinary tract infections (CAUTIs) occur in 290,000 US hospital patients annually, with an estimated cost of $290 million. Two different measurement systems are being used to track the US health care system's performance in lowering the rate of CAUTIs. Since 2010, the Agency for Healthcare Research and Quality (AHRQ) metric has shown a 28.2% decrease in CAUTI, whereas the Centers for Disease Control and Prevention metric has shown a 3%-6% increase in CAUTI since 2009. Differences in data acquisition and the definition of the denominator may explain this discrepancy. The AHRQ metric analyzes chart-audited data and reflects both catheter use and care. The Centers for Disease Control and Prevention metric analyzes self-reported data and primarily reflects catheter care. Because analysis of the AHRQ metric showed a progressive change in performance over time and the scientific literature supports the importance of catheter use in the prevention of CAUTI, it is suggested that risk-adjusted catheter-use data be incorporated into metrics that are used for determining facility performance and for value-based purchasing initiatives.

Texas Nurse Staffing Trends Before and After Mandated Nurse Staffing Committees

This article describes the evolution of mandated nurse staffing committees in Texas from 2002 to 2009 and presents a study that analyzed nurse staffing trends in Texas using a secondary analysis of hospital staffing data (N = 313 hospitals) from 2000 to 2012 obtained from the American Hospital Association Annual Survey. Nurse staffing patterns based on three staffing variables for registered nurses (RNs), licensed vocational nurses (LVNs), and total licensed nurses were identified: full-time equivalents per 1,000 adjusted patient days, productive hours per adjusted patient day, and RN skill mix. Similar to national trends between 2000 and 2012, most Texas hospitals experienced an increase in RN and total nurse staffing, decrease in LVN staffing, and an increase in RN skill mix. The magnitude of total nurse staffing changes in Texas (5% increase) was smaller than national trends (13.6% increase). Texas's small, rural, government hospitals and those with the highest preregulation staffing levels experienced the least change in staffing between 2000 and 2012: median change of 0 to .13 full-time equivalents per 1,000 adjusted patient days and median change in productive hours per patient day of 0 to .23. The varying effects of staffing committees in different organizational contexts should be considered in future staffing legislative proposals and other policy initiatives.

Shared decision making in designing new healthcare environments-time to begin improving quality

BACKGROUND

Successful implementation of new methods and models of healthcare to achieve better patient outcomes and safe, person-centered care is dependent on the physical environment of the healthcare architecture in which the healthcare is provided. Thus, decisions concerning healthcare architecture are critical because it affects people and work processes for many years and requires a long-term financial commitment from society. In this paper, we describe and suggest several strategies (critical factors) to promote shared-decision making when planning and designing new healthcare environments.

DISCUSSION

This paper discusses challenges and hindrances observed in the literature and from the authors extensive experiences in the field of planning and designing healthcare environments. An overview is presented of the challenges and new approaches for a process that involves the mutual exchange of knowledge among various stakeholders. Additionally, design approaches that balance the influence of specific and local requirements with general knowledge and evidence that should be encouraged are discussed. We suggest a shared-decision making and collaborative planning and design process between representatives from healthcare, construction sector and architecture based on evidence and end-users' perspectives. If carefully and systematically applied, this approach will support and develop a framework for creating high quality healthcare environments.

Viewpoint: a response to "Screening and isolation to control methicillin-resistant Staphylococcus aureus: sense, nonsense, and evidence"

Surveillance and isolation for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) has become a controversial topic, one that causes heated debate and appears to be surrounded by both politics and industrial conflicts-of-interest. There have been calls from numerous authors for a movement away from rigid mandates and toward an evidence-based medicine approach. However, much of the evidence can be viewed with an entirely different interpretation. Two major studies with negative findings have had an adverse impact on recommendations regarding active detection and isolation (ADI) for MRSA. However the negative findings in these studies can be explained by shortcomings in study implementation rather than the ineffectiveness of ADI. The use of daily chlorhexidine bathing has also been proposed as an alternative to ADI in ICU settings. There are shortcomings regarding the evidence in the literature concerning the effectiveness of daily chlorhexidine bathing. One of the major concerns with universal daily chlorhexidine bathing is the development of bacterial resistance. The use of surveillance and isolation to address epidemics and common dangerous pathogens should solely depend upon surveillance and isolation's ability to prevent further spread to and infection of other patients through indirect contact. At present, there is a preponderance of evidence in the literature to support continuing use of surveillance and isolation to prevent the spread of MRSA.

Use of Electronic Health-Related Datasets in Nursing and Health-Related Research

Datasets of gigabyte size are common in medical sciences. There is increasing consensus that significant untapped knowledge lies hidden in these large datasets. This review article aims to discuss Electronic Health-Related Datasets (EHRDs) in terms of types, features, advantages, limitations, and possible use in nursing and health-related research. Major scientific databases, MEDLINE, ScienceDirect, and Scopus, were searched for studies or review articles regarding using EHRDs in research. A total number of 442 articles were located. After application of study inclusion criteria, 113 articles were included in the final review. EHRDs were categorized into Electronic Administrative Health-Related Datasets and Electronic Clinical Health-Related Datasets. Subcategories of each major category were identified. EHRDs are invaluable assets for nursing the health-related research. Advanced research skills such as using analytical softwares, advanced statistical procedures, dealing with missing data and missing variables will maximize the efficient utilization of EHRDs in research.

Organization of Hospital Nursing and 30-Day Readmissions in Medicare Patients Undergoing Surgery

BACKGROUND

Growing scrutiny of readmissions has placed hospitals at the center of readmission prevention. Little is known, however, about hospital nursing—a critical organizational component of hospital service system—in relation to readmissions.

OBJECTIVES

To determine the relationships between hospital nursing factors—nurse work environment, nurse staffing, and nurse education—and 30-day readmissions among Medicare patients undergoing general, orthopedic, and vascular surgery.

METHOD AND DESIGN

We linked Medicare patient discharge data, multistate nurse survey data, and American Hospital Association Annual Survey data. Our sample included 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania). Risk-adjusted robust logistic regressions were used for analyses.

RESULTS

The average 30-day readmission rate was 10% in our sample (general surgery: 11%; orthopedic surgery: 8%; vascular surgery: 12%). Readmission rates varied widely across surgical procedures and could be as high as 26% (upper limb and toe amputation for circulatory system disorders). Each additional patient per nurse increased the odds of readmission by 3% (OR=1.03; 95% CI, 1.00-1.05). Patients cared in hospitals with better nurse work environments had lower odds of readmission (OR=0.97; 95% CI, 0.95-0.99). Administrative support to nursing practice (OR=0.96; 95% CI, 0.94-0.99) and nurse-physician relations (OR=0.97; 95% CI, 0.95-0.99) were 2 main attributes of the work environment that were associated with readmissions.

CONCLUSIONS

Better nurse staffing and work environment were significantly associated with 30-day readmission, and can be considered as system-level interventions to reduce readmissions and associated financial penalties.

Nursing-sensitive indicators: a concept analysis

AIM

To report a concept analysis of nursing-sensitive indicators within the applied context of the acute care setting.

BACKGROUND

The concept of 'nursing sensitive indicators' is valuable to elaborate nursing care performance. The conceptual foundation, theoretical role, meaning, use and interpretation of the concept tend to differ. The elusiveness of the concept and the ambiguity of its attributes may have hindered research efforts to advance its application in practice.

DESIGN

Concept analysis.

DATA SOURCES

Using 'clinical indicators' or 'quality of nursing care' as subject headings and incorporating keyword combinations of 'acute care' and 'nurs*', CINAHL and MEDLINE with full text in EBSCOhost databases were searched for English language journal articles published between 2000-2012. Only primary research articles were selected.

METHODS

A hybrid approach was undertaken, incorporating traditional strategies as per Walker and Avant and a conceptual matrix based on Holzemer's Outcomes Model for Health Care Research.

RESULTS

The analysis revealed two main attributes of nursing-sensitive indicators. Structural attributes related to health service operation included: hours of nursing care per patient day, nurse staffing. Outcome attributes related to patient care included: the prevalence of pressure ulcer, falls and falls with injury, nosocomial selective infection and patient/family satisfaction with nursing care.

CONCLUSION

This concept analysis may be used as a basis to advance understandings of the theoretical structures that underpin both research and practical application of quality dimensions of nursing care performance.

Can inpatient hospital experiences predict central line-associated bloodstream infections?

Background

Factors that increase the risk of central line-associated bloodstream infections (CLABSIs) are not fully understood. Recently, Hospital Compare began compiling data from hospital-required reporting to the CDC's National Healthcare Safety Network on CLABSIs in intensive care units (ICUs), at over 4,000 Medicare-certified hospitals in the United States, and made this data accessible on a central website. Also available on the same website are results from the Hospital Consumer Assessment of Healthcare Providers and Systems survey of patients' hospital experiences. Utilizing both databases, our objective was to determine whether patients' hospital experiences were significantly associated with increased risk for reported ICU CLABSI.

Methods and Findings

We conducted a zero-inflated Poisson regression analysis at the hospital level on CLABSI-observed cases by ICUs in acute care hospitals (n = 1987) in the United States between January 1, 2011, and December 31, 2011. During this period there were a total of 10,866 CLABSI cases and 9,543,765 central line days. In our final model, the percent of patients who reported that they “sometimes” or “never” received help as soon as they wanted was significantly associated with an increased risk for CLABSIs.

Conclusions

Using national datasets, we found that inpatients' hospital experiences were significantly associated with an increased risk of ICU reported CLABSIs. This study suggests that hospitals with lower staff responsiveness, perhaps because of an understaffing of nurse and supportive personnel, are at an increased risk for CLABSIs. This study bolsters the evidence that patient surveys may be a useful surrogate to predicting the incidence of hospital acquired conditions, including CLABSIs. Moreover, our study found that poor staff responsiveness may be indicative of greater hospital problems and generally poorly performing hospitals; and that this finding may be a symptom of hospitals with a multitude of problems, including patient safety problems, and not a direct cause.