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Inpatient Mortality Linked to Nurse Understaffing

Cheryl Clark, for HealthLeaders Media, 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."

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3 comments on "Inpatient Mortality Linked to Nurse Understaffing"


Mark Stambovsky (3/18/2011 at 4:17 PM)
Re comments from Phyllis Kritek, RN, PhD "Why do we automatically assume that somehow patient/nurse ratios are the preferred solution?" Since when do repeated studies concluding a similar result become an "automatic assumption?" I believe we would better characterize that as statement of fact. All things being equal, it is a matter of eyeballs on patients. The more eyeball time, the better the chances mistakes and/or patient deterioration will be spotted and reported. Ignoring or questioning repeating results in favor of yet further studies smacks of the kind of corporate behavior that serves no one except those who maintain that the bottom line trumps all other promises. I am also surprised and a little sickened, that in 2011 we are still asking, "Who benefits from this world view?" Let's see, how about starting with patients. We can then turn to the nurses who'll feel less like task monkeys and more able to spend actual face time with patients. Hospital nursing, at its core, is highly unpredictable involving fluid variables. Attempts at "nuanced" approaches, or those which hope micromanage what nurses do have always resulted in failure. The old mantra goes something like; "if we could just turn nursing into more of an assembly line, predictable practice we could then precisely staff for exactly what we know will happen." While most Hospital mission statement proclaim safety as job one, too many of them will delay, deny or discredit attempts at improving safety when it means hiring more nurses. After all, their responsibilities can't be all that complex, can they?

Rhonda S. Bell, DBA (3/17/2011 at 12:54 PM)
I respect Phyllis' comments regarding nurse/patient ratio not being the answer in all cases. However, what are some solutions to the nurse staffing challenges that are very real in most hospitals. The IOM reported in 2001, that there are 98,000 deaths due to preventable medical errors, and the 2011 preliminary reports do not show much improvement. This new report on staffing shortages does give merit to why some of these deaths are occurring. Intentional collaboration and communication between administration and nursing staff are essential to identify solutions for reducing preventable deaths. Why does that seem so difficult? True compassionate care does need to go beyond the bedside. Rhonda S. Bell, DBA

Phyllis Kritek, RN, PhD (3/17/2011 at 9:35 AM)
Thank you for posting this information. Two observations, coupled with suggestions: 1. Needleman, Buerhaus, Aiken, and others have amply documented what this study again demonstrates. It would be interesting to see an investigation about the push back their research evokes. It would appear that many want their outcomes to be untrue. What motivates those who challenge these outcomes? 2. When these studies emerge, there seems to be an automatic assumption that their outcomes point to patient/nurse ratios as a solution. Many highly creative nurse executive teams have [INVALID]d [INVALID]native models that provide more nuanced solutions. Patient-nurse ratios are a bit like using a chain saw for surgery. Ratios are an over-simplified solution to a very complex problem. It would be interesting to see investigation of some of the more nuanced responses to nurse staffing. Why do we automatically assume that somehow patient/nurse ratios are the preferred solution? Who benefits from this world view?