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Inpatient Mortality Linked to Nurse Understaffing

 |  By cclark@healthleadersmedia.com  
   March 17, 2011

Inpatient mortality goes up significantly when a hospital has greater patient turnover and when it fails to meet its own nurse staffing targets by at least eight hours, says a report that strongly suggests hospitals measure and adjust nurse staffing to patient needs.

"We estimate that the risk of death increased by 2% for each below-target (8-hour) shift and 4% for each high turnover shift to which a patient was exposed," said the report, by first author Jack Needleman, professor of health services at UCLA School of Public Health, and colleagues at the University of California Los Angeles, Vanderbilt University, the Mayo Clinic and Duke University Medical Center.

The mortality risk for patients exposed to three nursing shifts that fell below target levels was 6% higher than for patients on units that were fully staffed.

"Staffing projection models rarely account for the effect on workload of admissions, discharges and transfers," the report said, which greatly increase the amount of time required for each patient.

The reportis published Thursday's New England Journal of Medicine.

The team looked at 197,961 electronic rather than administrative records for patients across 43 patient care units at an unnamed large academic U.S. tertiary hospital for the period between 2003 and 2006, comparing a hospital against itself.

In an interview, Needleman says that previous studies that evaluated mortality and nursing staff compared hospitals with high staffing ratios against ones with low staffing.

"People pushed back on that," Needleman says. "They said well, maybe it's not the staffing, maybe something else about the hospitals: the doctors and nurses aren't as good or the equipment wasn't good or hospital management   doesn't have the same commitment to quality. And this is just an artifact of data. Or you can't do enough risk adjustment across the hospitals."

"This work is partly intended to answer that question because it's the same unit, the same nurses, same doctors and same equipment," Needleman says. "And it's a great hospital, with mortality lower than you would expect, a magnet hospital that hits target 85% of the time. We asked what happens in the best of circumstances what happens when, as sometimes happens, you don't reach (staffing) target. So these other arguments are substantially put to bed."

A hospital that hits its own nurse staffing targets 85% of the time, he says "is pretty damn good."

The research paper stopped short of recommending nurse-patient ratios such as those in California, saying that the study was not designed to do that for a variety of reasons.

Needleman says that hospitals do not traditionally adjust their RN hours needed or workload to account "for new patients coming on and old patients leaving. They don't adjust for admissions, discharges or internal transfers in or out of the hospital and we felt that was also a potential situation.

"If you had an unusually large number of those, much more than typical number of admissions, discharges or transfers, the workload for the nurses would also be much higher than planned for in the system, and higher workload, would increase the risk of nurses trying to speed things up or (limit) the time or attention given to the individual patient...to observe how they're doing and identify whether something is not quite right."

For hospitals that know what its staffing levels are, the message from this study is to continue to be diligent, and for hospitals that don't know it or fail to hit those targets substantial amount of the time, the message is to do better," Needleman says.

For the California Nurses Association, which successfully lobbied for RN staff-inpatient ratios, the study reinforced "what nurses are seeing throughout the U.S., that safe RN staffing and patient ratios save lives," said Melinda Markowitz, one of CNA's presidents.

However, she says, the study "didn't specify a number," and because of that, it didn't really go far enough."

"What we have found in many hospitals outside of California is that hospitals will use all sorts of pretexts. They'll say staffing is budget-driven and the budget won't allow it. But I believe that kind of thought process really does put the patient at unnecessary risk for death and more adverse events."

Markowitz adds that RN- to-patient ratios save lives and save them money, not just in avoided nurse burnout, which may result in the need for training new staff, but also in avoidance of negative outcomes, which may no longer be reimbursed by federal payers. Sen. Barbara Boxer, D-CA, has introduced a bill that would require even more stringent ratios than the California law requires, Markowitz says.

The American Hospital Association, and its subsidiary, the American Association of Nurse Executives, which in the past expressed objections to mandatory nurse-staff ratios, issued this statement:

The study "highlights what hospitals know: nurses are on the frontline of care and naturally affect the care patients in need receive.  

"To ensure high quality care for patients it is critically important that staffing decisions be the responsibility of nursing leadership at the bedside.  

"Many factors influence a hospital's staffing plan, including the experience and education of its nursing staff, the availability of other caregivers, patients' needs and the severity of their illnesses, and the availability of technology.

"Nurses are striving every day to provide the best care possible – that's not an easy job.  All hospitals are concerned with maintaining safe, quality care and work hard every day to achieve this mission.  The real challenge is how we make sure patients get the care they need and that nurses can provide care in an appropriate setting.  

"We've seen hospitals create a range of innovative solutions from reorganizing care teams to limiting patient admissions. AHA and AONE will continue working within the nursing community to assess their impact and find ways to do even more."

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