Characteristics and mortality rates among patients requiring intermediate care: a national cohort study using linked databases

Effects of the nursing practice environment, nurse staffing, patient surveillance and escalation of care on patient mortality: A multi-source quantitative study

BACKGROUND

A favourable nursing practice environment and adequate nurse staffing have been linked to reduced patient mortality. However, the contribution of nursing care processes such as patient surveillance and escalation of care, on patient mortality is not well understood.

OBJECTIVE

The aim of this study was to investigate the effect of the nursing practice environment, nurse staffing, missed care related to patient surveillance and escalation of care on 30-day inpatient mortality.

DESIGN

A multi-source quantitative study including a cross-sectional survey of nurses, and retrospective data extracted from an audit of medical and admission records.

SETTING(S)

A large tertiary teaching hospital (600 beds) in metropolitan Sydney, Australia.

METHODS

Data on the nursing practice environment, nurse staffing and missed care were obtained from the nursing survey. Patient deterioration data and patient outcome data were collected from the medical and admission records respectively. Logistic regression models were used to examine the association between the nursing practice environment, patient deterioration and 30-day inpatient mortality accounting for clustering of episodes within patients using generalised estimating equations.

RESULTS

Surveys were completed by 304 nurses (84.5 % female, mean age 34.4 years, 93.4 % Registered Nurses) from 16 wards. Patient deterioration data was collected for 30,011 patient deterioration events and 63,847 admitted patient episodes of care. Each additional patient per nurse (OR = 1.22, 95 % CI = 1.04-1.43) and the presence of increased missed care for patient surveillance (OR = 1.13, 95 % CI = 1.03-1.23) were associated with higher risk of 30-day inpatient mortality. The use of a clinical emergency response system reduced the risk of mortality (OR = 0.82, 95 % CI = 0.76-0.89). A sub-group analysis excluding aged care units identified a 38 % increase in 30-day inpatient mortality for each additional patient per nurse (OR = 1.38, 95 % CI = 1.15-1.65). The nursing practice environment was also significantly associated with mortality (OR = 0.79, 95 % CI: 0.72-0.88) when aged care wards were excluded.

CONCLUSIONS

Patient mortality can be reduced by increasing nurse staffing levels and improving the nursing practice environment. Nurses play a pivotal role in patient safety and improving nursing care processes to minimise missed care related to patient surveillance and ensuring timely clinical review for deteriorating patients reduces inpatient mortality.

TWEETABLE ABSTRACT

Patient mortality can be reduced by improving the nursing practice environment & increasing the number of nurses so that nurses have more time to monitor patients. Investing in nurses results in lower mortality and better outcomes. #PatientSafety #NurseStaffing #WorkEnvironment #Mortality.

Mortality rate and its determinants among people with dementia receiving home healthcare: a nationwide cohort study

People with dementia (PwD) who receive home healthcare (HHC) may have distressing symptoms, complex care needs and high mortality rates. However, there are few studies investigating the determinants of mortality in HHC recipients. To identify end-of-life care needs and tailor individualized care goals, we aim to explore the mortality rate and its determinants among PwD receiving HHC. We conducted a retrospective cohort study using a Taiwanese national population database. People with new dementia diagnosis in 2007-2016 who received HHC were included. We calculated the accumulative mortality rate and applied Poisson regression model to estimate the risk of mortality for each variable (adjusted risk ratios, aRR) with a 95% confidence interval (CI). We included 95,831 PwD and 57,036 (59.5%) of them died during the follow-up period (30.5% died in the first-year). Among comorbidities, cirrhosis was associated with the highest mortality risks (aRR 1.65, 95% CI 1.49-1.83). Among HHC-related factors, higher visit frequency of HHC (> 2 versus ≦1 times/month, aRR 3.52, 95% CI 3.39-3.66) and higher level of resource utilization group (RUG, RUG 4 versus 1, aRR = 1.38, 95% CI 1.25-1.51) were risk factor of mortality risk. Meanwhile, HHC provided by physician and nurse was related to reduced mortality risk (aRR 0.79, 95% CI 0.77-0.81) compared to those provided by nurse only. Anticipatory care planning and timely end-of life care should be integrated in light of the high mortality rate among PwD receiving HHC. Determinants associated with increased mortality risk facilitate the identification of high risk group and tailoring the appropriate care goals. Trial registration number: ClinicalTrials.gov Identifier is NCT04250103 which has been registered on 31st January 2020.

Preferences and priorities to manage clinical uncertainty for older people with frailty and multimorbidity: a discrete choice experiment and stakeholder consultations

BACKGROUND

Clinical uncertainty is inherent for people with frailty and multimorbidity. Depleted physiological reserves increase vulnerability to a decline in health and adverse outcomes from a stressor event. Evidence-based tools can improve care processes and outcomes, but little is known about priorities to deliver care for older people with frailty and multimorbidity. This study aimed to explore the preferences and priorities for patients, family carers and healthcare practitioners to enhance care processes of comprehensive assessment, communication and continuity of care in managing clinical uncertainty using evidence-based tools.

METHODS

A parallel mixed method observational study in four inpatient intermediate care units (community hospitals) for patients in transition between hospital and home. We used a discrete choice experiment (DCE) to examine patient and family preferences and priorities on the attributes of enhanced services; and stakeholder consultations with practitioners to discuss and generate recommendations on using tools to augment care processes. Data analysis used logit modelling in the DCE, and framework analysis for consultation data.

RESULTS

Thirty-three patients participated in the DCE (mean age 84 years, SD 7.76). Patients preferred a service where family were contacted on admission and discharge (β 0.36, 95% CI 0.10 to 0.61), care received closer to home (β - 0.04, 95% CI - 0.06 to - 0.02) and the GP is fully informed about care (β 0.29, 95% CI 0.05-0.52). Four stakeholder consultations (n = 48 participants) generated 20 recommendations centred around three main themes: tailoring care processes to manage multiple care needs for an ageing population with frailty and multimorbidity; the importance of ongoing communication with patient and family; and clear and concise evidence-based tools to enhance communication between clinical teams and continuity of care on discharge.

CONCLUSION

Family engagement is vital to manage clinical uncertainty. Both patients and practitioners prioritise engaging the family to support person-centred care and continuity of care within and across care settings. Patients wished to maximise family involvement by enabling their support with a preference for care close to home. Evidence-based tools used across disciplines and services can provide a shared succinct language to facilitate communication and continuity of care at points of transition in care settings.