The relationship between nurse staffing and length of stay in acute-care: a one-year time-series data

Nursing Cost Analysis for Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the Intensive Care Unit

OBJECTIVE

To determine nursing costs for intensive care unit (ICU) patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), assess the correlation with diagnosis-related group (DRG) payments and identify cost determinants.

DESIGN

Prospective, descriptive and quantitative study.

METHODS

From January to December 2022, we selected ICU patients with AECOPD and used time-driven activity-based costing method to calculate the overall nursing costs. We examined the cost recovery rate, correlations between nursing costs and DRG Relative Weight, and factors influencing nursing costs using nonparametric tests, Spearman's rank correlation and quantile regression.

RESULTS

The median nursing charge was US$1001.88, the median nursing cost was US$678.51, and the average cost recovery rate was 68.39%. Nursing costs correlated with the DRG Relative Weight but not with payments. Length of stay, oxygen therapy mode and noninvasive ventilator use days impacted costs.

CONCLUSIONS

Nursing costs exceeded charges, with a moderate cost recovery rate. DRG payments do not fully reflect nursing cost variations.

RELEVANCE TO CLINICAL PRACTICE

Our findings indicate the need to enhance the reimbursement system for nursing costs and to manage ICU nursing expenses by addressing the determinants of these costs.

REPORTING METHOD

The authors adhered to the EQUATOR network guidelines STROBE to report observational cross-sectional studies.

The Effect of Nurse Staffing on Patient Outcomes in Acute Care Hospitals in Korea

Nurse staffing is an important factor influencing patient health outcomes. This study aimed to analyze the effects of nurse staffing on patient health outcomes, such as length of stay, mortality within 30 days of hospitalization, and readmission within 7 days of discharge, in acute care hospitals in Korea. Data from the first quarter of 2018 were collected using public and inpatient sample data from the Health Insurance Review and Assessment Service. The data of 46,196 patients admitted to 536 general wards of acute care hospitals were analyzed. A multilevel logistic analysis was performed for the patients' mortality and early readmission, and a multilevel zero-truncated negative binomial analysis was performed for the length of stay. The average length of stay in acute care hospitals was 6.54 ± 6.03 days, the mortality rate was 1.1%, and the early readmission rate was 7.1%. As the nurse staffing level increased, the length of stay and number of early readmissions were likely to decrease. It can be concluded that interventions to improve nurse staffing are required; for example, a policy that compels medical institutions to comply with Korea's medical law standards should be implemented. Additionally, continuous research and interventions are needed to establish an appropriate nurse staffing level according to patient severity.

Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review

OBJECTIVE

The objective of this review was to determine the effect of nurse staffing on patient and nurse workforce outcomes in acute care settings within low- and middle-income countries.

INTRODUCTION

Health care systems in low- and middle-income countries experience a high proportion of the global burden of disease, which is aggravated by several health care constraints. The high rates of both communicable and non-communicable diseases, low numbers in the workforce, poor distribution of qualified professionals, and constraints in medical supplies and resources make the provision of quality health care challenging in low- and middle-income countries. Health care systems in low- and middle-income countries, however, are still expected to address universal health care access and provide high-quality health care. Systematic reviews examining nurse staffing and its effect on patient and nurse workforce outcomes are largely from the perspective of high-income countries. There is a need to understand the evidence on nurse staffing and its impact in the context of low- and middle-income countries.

INCLUSION CRITERIA

Empirical studies that addressed acute care nurse staffing levels, such as nurse-to-patient ratio or nurses' qualifications, experience, and skill mix, and their influence on patient and nurse workforce outcomes were included in the review. Studies conducted in a low- or middle-income country were included. Outcomes must have been measured objectively using validated tools.

METHODS

Studies published until July 2019 were identified from CINAHL, PubMed, Scopus, Embase, PsycINFO, Cochrane Library, Web of Science, and ProQuest Dissertations and Theses. The JBI approach to critical appraisal, study selection, data extraction, and data synthesis was used for this review. Narrative synthesis was conducted due to high heterogeneity of included studies. The level of evidence was determined using GRADEpro.

RESULTS

Twenty-seven studies were included in this review and the level of evidence was low, mainly due to the design of included studies. Low nurse-to-patient ratio or high nurse workload was associated with higher rates of in-hospital mortality, hospital-acquired infection, medication errors, falls, and abandonment of treatment. Findings on the effect of nurse staffing on length of hospital stay and incidence of pressure ulcers were inconsistent. Extended work hours, less experience, and working night or weekend shifts all significantly increased medication errors. Higher nurse workload was linked to higher levels of nurses' burnout, needlestick and sharps injuries, intent to leave, and absenteeism.

CONCLUSIONS

Lower nurse-to-patient ratios and higher nurse workload are linked to in-hospital mortality, hospital-acquired infections, and medication errors among patients, and high levels of burnout, needlestick and sharps injuries, absenteeism, and intention to leave their job among nurses in low- and middle-income countries. The results of this review show similarities with the evidence from high-income countries regarding poor outcomes for patients and nurses. These findings should be considered in light of the lower nurse-to-patient ratios in most low- and middle-income countries.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018119428.

Nurse Staffing and Health Outcomes of Psychiatric Inpatients: A Secondary Analysis of National Health Insurance Claims Data

PURPOSE

The present study investigated the association between nurse staffing and health outcomes among psychiatric inpatients in Korea by assessing National Health Insurance claims data.

METHODS

The dataset included 70,136 patients aged 19 years who were inpatients in psychiatric wards for at least two days in 2016 and treated for mental and behavioral disorders due to use of alcohol; schizophrenia, schizotypal and delusional disorders; and mood disorders across 453 hospitals. Nurse staffing levels were measured in three ways: registered nurse-to-inpatient ratio, registered nurse-to-adjusted inpatient ratio, and nursing staff-to-adjusted inpatient ratio. Patient outcomes included length of stay, readmission within 30 days, psychiatric emergency treatment, use of injected psycholeptics for chemical restraint, and hypnotics use. Relationships between nurse staffing levels and patient outcomes were analyzed considering both patient and system characteristics using multilevel modeling.

RESULTS

Multilevel analyses revealed that more inpatients per registered nurse, adjusted inpatients per registered nurse, and adjusted inpatients per nursing staff were associated with longer lengths of stay as well as a higher risk of readmission. More adjusted inpatients per registered nurse and adjusted inpatients per nursing staff were also associated with increased hypnotics use but a lower risk of psychiatric emergency treatment. Nurse staffing levels were not significantly associated with the use of injected psycholeptics for chemical restraint.

CONCLUSION

Lower nurse staffing levels are associated with negative health outcomes of psychiatric inpatients. Policies for improving nurse staffing toward an optimal level should be enacted to facilitate better outcomes for psychiatric inpatients in Korea.

Understanding variations and influencing factors on length of stay for T2DM patients based on a multilevel model

Aim

Shortening the length of stay (LOS) is a potential and sustainable way to relieve the pressure that type 2 diabetes mellitus (T2DM) patients placed on the public health system.

Method

Multi-stage random sampling was used to obtain qualified hospitals and electronic medical records for patients discharged with T2DM in 2018. A box-cox transformation was adopted to normalize LOS. Multilevel model was used to verify hospital cluster effect on LOS variations and screen potential factors for LOS variations from both individual and hospital levels.

Result

50 hospitals and a total of 12,888 T2DM patients were included. Significant differences in LOS variations between hospitals, and a hospital cluster effect on LOS variations (t = 92.188, P<0.001) was detected. The results showed that female patients, patients with new rural cooperative’ medical insurance, hospitals with more beds, and hospitals with faster bed turnovers had shorter LOS. Conversely, elderly patients, patients with urban workers’ medical insurance, patients requiring surgery, patients with the International Classification of Diseases coded complication types E11.1, E11.2, E11.4, E11.5, and other complications cardiovascular diseases, grade III hospitals, hospitals with a lower doctor-to-nurse ratio, and hospitals with more daily visits per doctor had longer LOS.

Conclusions

The evidence proved that hospital cluster effect on LOS variation did exist. Complications and patients features at individual level, as well as organization and resource characteristics at hospital level, had impacted LOS variations to varying degrees. To shorten LOS and better meet the medical demand for T2DM patients, limited health resources must be allocated and utilized rationally at hospital level, and the patients with the characteristics of longer LOS risk must be identified in time. More influencing factors on LOS variations at different levels are still worth of comprehensive exploration in the future.

Acuity, nurse staffing and workforce, missed care and patient outcomes: A cluster-unit-level descriptive comparison

AIM

To compare the patient acuity, nurse staffing and workforce, missed nursing care and patient outcomes among hospital unit-clusters.

BACKGROUND

Relationships among acuity, nurse staffing and workforce, missed nursing care and patient outcomes are not completely understood.

METHOD

Descriptive design with data from four unit-clusters: medical, surgical, combined and step-down units. Descriptive statistics were used to compare acuity, nurse staffing coverage, education and expertise, missed nursing care and selected nurse-sensitive outcomes.

RESULTS

Patient acuity in general (medical, surgical and combined) floors is similar to step-down units, with an average of 5.6 required RN hours per patient day. In general wards, available RN hours per patient day reach only 50% of required RN hours to meet patient needs. Workforce measures are comparable among unit-clusters, and average missed nursing care is 21%. Patient outcomes vary among unit-clusters.

CONCLUSION

Patient acuity is similar among unit-clusters, while nurse staffing coverage is halved in general wards. While RN education, expertise and missed care are comparable among unit-clusters, mortality, skin injuries and risk of family compassion fatigue rates are higher in general wards.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers play a pivotal role in hustling policymakers to address structural understaffing in general wards, to maximize patient safety outcomes.

Nurse staffing and healthcare-associated infections in a national healthcare system that implemented a nurse staffing directive: Multi-level interrupted time series analyses

BACKGROUND

In 2010, the Veterans Health Administration Office of Nursing Services (VHA ONS) issued a Staffing Methodology (SM) Directive, standardizing the method of determining appropriate nurse staffing for VHA facilities.

OBJECTIVES

To assess associations between the Directive, nurse staffing trends, and healthcare-associated infections.

RESEARCH DESIGN

We conducted multi-level interrupted time series analyses of nurse staffing trends and the rates of two healthcare-associated infections before and after implementation of the Directive, October 1, 2008 - June 30, 2014.

SUBJECTS

Acute care, critical care, mental health acute care, and longterm care nursing units (called Community Living Centers, CLC in VHA) among 285 VHA facilities were included in nurse staffing trends analyses, while acute and critical care units in 123 facilities were used in the analysis of infection rates.

MEASURES

Monthly rates were calculated at the facility unit level and included nursing hours per patient day (NHPPD) for all nursing personnel and number of catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) per 1000 device days.

RESULTS

Nursing hours per patient day increased in both time periods. However, the differential change in rate of nursing hours per patient day following implementation of the Directive was not statistically significant. On average, we found a statistically significant decrease of 0.05 unit in the post-Directive central line-associated bloodstream infection rates associated with a unit increase in nursing hours per patient day.

CONCLUSIONS

System-wide implementation of Staffing Methodology may be one contributing factor impacting patient outcomes.

Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit

OBJECTIVE

To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes.

DATA SOURCES

Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases. We included 276 054 infants born 2008-2016 and cared for in 99 California neonatal intensive care units (NICUs).

STUDY DESIGN

Repeated-measures observational study. We developed a nurse staffing prediction model using machine learning and hierarchical linear regression and then quantified deviation from predicted nurse staffing in relation to health care-associated infections, length of stay, and mortality using hierarchical logistic and linear regression.

DATA COLLECTION METHODS

We linked NICU-level nurse staffing and organizational data to patient-level risk factors and outcomes using unique identifiers for NICUs and patients.

PRINCIPAL FINDINGS

An 11-factor prediction model explained 35 percent of the nurse staffing variation among NICUs. Higher-than-predicted nurse staffing was associated with decreased risk-adjusted odds of health care-associated infection (OR: 0.79, 95% CI: 0.63-0.98), but not with length of stay or mortality.

CONCLUSIONS

Organizational and patient factors explain much of the variation in nurse staffing. Higher-than-predicted nurse staffing was associated with fewer infections. Prospective studies are needed to determine causality and to quantify the impact of staffing reforms on health outcomes.

Activity-based funding for safety and quality: A policy discussion of issues and directions for nursing-focused health services outcomes research

Aims

A discussion of the implications and opportunities arising from the Commonwealth of Australia health care reform agenda; linking pricing with quality, with particular reference to directions for nursing‐focused health services outcomes research directed to improve the safety and quality of health care practices.

Background

National activity‐based funding in Australia is a policy‐focused development. As the relationship between cost and quality becomes apparent, the role of clinicians and their contribution to high quality care has become a pressing issue for leadership, teaching, and research.

Design

Discussion paper

Data Sources

This paper is based on seven years' experience as a member of a Commonwealth of Australia statutory committee—the Clinical Advisory Committee of the Independent Hospital Pricing Authority—and is supported by relevant literature and theory.

Implications for Nursing

To date, unravelling the linkage, especially causal relationships, between direct care nursing and patient safety outcomes has not been well established. New activity‐based funding data elements developed for national implementation in Australia provide accessible and meaningful standardised data for measurement of never events, hospital‐acquired complications, and preventable readmissions.

What is already known about this topic?

The advancement of research directed towards finding causal associations attributing nursing interventions to patient outcomes has been constrained by, amongst other things, methodological challenges

The attribution of nursing care interventions to specific patient‐related outcomes is difficult to isolate

Investigating how nursing care interventions contribute to safety and quality health care outcomes is often referred to as the “black box” of nursing‐focused health services outcomes research

What this paper adds?

Research into the impact of nursing interventions on patient outcomes, such as hospital‐acquired complications, remains immature

Activity‐based funding data provide safety and quality measures relevant to nursing‐focused health services outcomes research

Building clinical‐decision support, based on the Australian Commission for Safety and Quality in Healthcare hospital‐acquired complication outcome measures, may assist nurses engage with quality improvement as nurses are likely to act on data relevant to their practice

The implications of this paper:

The Australian Commission for Safety and Quality in Healthcare hospital‐acquired complication outcome measures have enhanced data specifications, useful to support development of nursing‐focused health services outcomes research

The potential for benchmarking of hospital‐acquired complications is high at least in Australia and in other countries that apply activity‐based funding models linked to ICD‐10‐AM codes

Collaboration among registered nurses and practical nurses in acute care hospitals: A scoping review

AIM

This study examined the extent, range, and nature of registered nurse (RN) and practical nurse (PN) collaboration in acute care hospitals and identified research gaps in the existing literature.

BACKGROUND

Optimal patient care requires collaboration between RNs and PNs. A lack of unity and unresolved tension among different types of nurses influences collaboration and has significant implications on practice and the organizations where nurses work.

METHODS

Using Arksey and O'Malley's (2005) framework, a scoping review was undertaken to answer the research question: what is known from the existing literature about the structures, processes, and outcomes of RN-PN collaboration in hospitals?

RESULTS

Twenty-nine studies were included with the majority coming from North America. Donabedian's model assisted with the identification of three themes: scope of practice, interpersonal skills, and nurse and patient-related outcomes.

CONCLUSION

The findings demonstrate there is a paucity of research specific to RN-PN collaboration. Nurse administrators/managers play an important role in addressing the interpersonal skills of nurses and providing an ongoing education on collaboration in the practice setting. Additional studies should focus on the development of nursing collaborative practice models of patient care, the examination of interventions to improve RN-PN collaborative practice, and the assessment of outcomes relating to collaboration among nurses.

Alternative work arrangements: Reshaping the future of nurses' workplace communication and relationships

AIM

This commentary advocates a research agenda for studying how alternative work arrangements (AWAs) affect nurse management and leadership.

BACKGROUND

AWAs mitigate burnout and the distributional imbalance of nurses. However, scholarship has shed limited light on how AWAs shape nurses' workplace communication and relationships.

EVALUATION

Peer-reviewed nursing and management scholarship.

KEY ISSUE

As healthcare systems in many countries move toward team-based care, communication becomes even more important for effective coordination and collaboration among healthcare team members.

CONCLUSION

Researchers should invest greater resources to understand the influence that AWAs have on different organizational settings as well as on the relational coordination among nurses and their managers.

IMPLICATIONS FOR NURSING MANAGEMENT

Because care delivery and workplace relations depend heavily upon effective collaboration, researchers must update scholarship on AWAs to inform nurses and their managers on how they may strategically and effectively adapt their communication to evolving work environments that undergo frequent changes in nursing staff and teams.

Patient Satisfaction Is Linked to Nursing Workload in a Singapore Hospital

No studies have examined the association between patient satisfaction and the allocation of nursing care hours using a workload management system. The aim of this study is to examine the correlation between inpatients’ perceived satisfaction with nursing care and nursing workload management in a Singapore hospital. A secondary data analysis was performed based on the results of 270 patients’ perceived satisfaction measured by the Revised Humane Caring Scale and nursing workload management data extracted from the TrendCare Patient Acuity System. Data were collected from March to October 2013. There were weak positive ( rs = .212 to rs = .120) and negative ( rs = −.120 to rs = −.196) correlations between patient satisfaction and nursing workload. Nursing leaders should build positive work environment through maximizing efficient resource allocation and adequate staffing to deliver safe patient care. Future studies could involve other patient outcomes such as incidences of fall and pressure ulcer.