The study supplies further evidence for nurse leaders to make the case for nursing's role in achieving healthcare outcomes and metrics.
"Our study provides additional data that may help providers further engage hospital administration to supply adequate nurse staffing that allows EDs to better achieve performance goals and improve the patient experience," the researchers write. "This analysis is a pivotal step in identifying and ensuring appropriate nurse staffing to optimize ED quality metrics."
More Nurses, Better Outcomes
In a retrospective observational review of the electronic medical record database from a high-volume, urban public hospital, researchers compared nursing hours per day with door-to-discharge length of stay, door-to-admission LOS, and the percentage of patients who left without being seen.
From January to December 2015, more than 100,000 patients were seen in the ED at an average of 290 visits each day. During this time, the ED had an average of 465 nursing hours worked per day.
Regardless of daily patient volume, occupancy, and ED admission rates, days in the lowest quartile of nursing hours experienced a 28-minute increase per patient door-to-discharge LOS when compared with the highest quartile of nursing hours.
Door-to-admit LOS showed no significant change across quartiles.
There was an increase of 9 patients per day that left without being seen by a provider from the lowest to highest quartile of nursing hours.
The authors concluded:
Lower staffing rates contribute to a statistically significant increase in wait time for patients, which then impacts how many patients receive treatment each day.
In addition to the clear patient safety and patient satisfaction issues around patients failing to receive timely treatment, the decrease in patients seen can also impactthroughput metrics and decrease the overall revenue of facilities.
To move the needle on readmissions, hospitals need assistance from non-acute care partners. Nurses can meet the need.
Hospitals are increasingly on the hook for 30-day readmissions, but a recent study published in the Annals of Internal Medicine indicates that some rehospitalizations during that timeframe would be better prevented by outpatient clinics and homecare.
"Our findings suggest that the 30 days following hospital discharge are not the same with regard to what influences outcomes for sick patients, and that the current model over-simplifies this high-risk time," says the study's co-author Kelly Graham, MD, MPH, director of ambulatory residency training at Beth Israel Deaconess Medical Center and an instructor in medicine at Harvard Medical School.
The researchers found that readmissions within the first seven days after hospital discharge were more likely to be deemed preventable (36%) than those within eight to 30 days (23%). Hospitals were identified as better locations for preventing early readmissions, whereas outpatient clinics and homecare were better for preventing late readmissions.
"Patients discharged from a hospital are usually recovering from a serious medical condition as well as managing other chronic medical conditions, and they often encounter new logistical challenges adapting to this recovery period," Graham says. "Hospitals and outpatient clinics must work together more seamlessly to ensure that patients are equipped to manage these challenges at home."
Nurses Can Bridge the Gap
Since they can be found in all care settings, nurses are in a unique position to improve care transitions and reduce readmissions. Here are three HealthLeaders articles on how to accomplish those goals:
Solidify the Nurse Leader's Role in Care Coordination: Nurse leaders can use various strategies to improve care coordination and transition management including studying an organization's care transition model; clearly defining the key roles and responsibilities of care coordination; and engaging patients and families.
Hospital Cuts Readmissions in Half with Help from College Students: After one Ohio hospital trained liberal arts college students as community health workers, patients enrolled in the program had a 26% reduction of ED use and 51% reduction in hospital readmissions. The undergraduates received training as health coaches, and each student was assigned two patients to visit once a week. During the visit they helped patients set goals and reported any issues to the patients’ primary care provider.
More than half of patients and families expressed discomfort about raising patient safety concerns to the healthcare team.
Prior studies that when all clinical care team members are empowered to speak-up their performance improves. With the growing importance of patient- and family-centered care, patients and their families are a crucial component of the modern care team, as they can provide unique insight and knowledge into the discussion.
Unfortunately, patients and families are often hesitant to voice their concerns to the healthcare team, finds a new study published in BMJ Quality and Safety. When researchers at Beth Israel Deaconess Medical Center surveyed family members and patients that had a recent ICU experience about their ability to speak up about care concerns to their care team they found between 50 to 70% of family member respondents with a loved one in the ICU expressed hesitancy about voicing their concerns about common care situations with safety implications.
Methodology and Findings
The researchers used a questionnaire the was collaboratively designed by a multidisciplinary group of healthcare experts to survey 105 families of patients admitted to an urban academic hospital’s ICU over a period from July 2014 to February 2015. They also extended their research by surveying a panel of over 1,000 participants with recent ICU experience over the internet. The two groups were not compared statistically, but there were consistent trends across both groups.
Here are some of the key findings of the surveys:
About two-thirds of ICU patients and families felt very comfortable discussing medication.
About two-thirds of respondents said they did not feel comfortable about discussing disagreements about aggressiveness of care desired patients and families versus that proposed by clinicians.
Only half of the participants reported feeling very comfortable about asking for clarification about confusing or conflicting information, or raising concerns about possible errors.
The most common rationales for their discomfort were fear of being labeled a “troublemaker,” not knowing whom to talk to, and the busyness of the medical team.
Demographically, young people, men, and those without healthcare experience were less likely to speak up.
The researchers also noted that because the group surveyed at the urban academic hospital spoke only English and were disproportionately college educated, their study might actually underestimate the average patient and family member’s hesitancy to speak up during an ICU visit.
Patient Safety Concerns
Co-lead author Sigall K. Bell, the Director of Patient Safety and Discovery at OpenNotes, BIDMC and an associate professor of Medicine at Harvard Medical School expressed concerns about the patient safety implications. “Speaking up is a key component of safety culture, yet our study – the first to our knowledge to address this issue – revealed substantial challenges for patients and families speaking up during an ICU stay,” Bell says. “In the ICU setting in particular, families – who are also among the most vigilant stakeholders – may hold key information clinicians may have overlooked, and may be the first to detect a change in clinical status.”
Despite the troubling results, there might be a bright side to the problem. According to the authors, the findings represent relatively low-cost opportunities to improve patient outcomes. Clear instructions about whom to contact with concerns is a crucial first step, and creating an atmosphere of positive cooperation that reframes “being a troublemaker” to “being an engaged team member” is another essential component of reversing this issue.
Often considered the patient advocate among the care team, bedside nurses typically spend the most time with patients and families, so they could be the key to improving patient-clinician communication. Nurse leaders should encourage their nurses to listen to patients and families more, ask questions, and make sure they feel comfortable speaking up. Additionally, clinicians must make sure that bedside nurses play a role in decision-making, as nurses can act as a liaison between family members and other caretakers.
“The results highlight new areas for emphasis and improvement,” said co-lead author Stephanie Dawn Roche, MPH, Quality Research Analyst at BIDMC’s Center for Healthcare Delivery Science. “Empowering patients and families to speak up—especially given their unique knowledge of the patient and the potential to prevent catastrophic outcomes such as serious medication errors—has been identified as a critical next step in improving safety culture... We hope this research will open the door to new opportunities in patient-and-family-centered care and safety partnerships.”
A nursing professor teams up with research scientists to develop innovative and inexpensive simulations for the healthcare classroom.
Healthcare simulations are a time-tested and effective way of training new clinicians. They provide students with much-needed hands-on experience, allowing them to practice specific skills in a safe setting.
Unfortunately, the cost of developing a simulation program is prohibitive to many organizations, with components costing thousands of dollars with finite applications.
Faced with this conundrum, Dr. Lori Loice, a clinical associate professor in the College of Nursing at the University of Alabama in Huntsville (UAH), contacted Norven Goddard, a research scientist at UAH’s Systems Management and Production (SMAP) Center, about the growing trend of using 3D printing to develop healthcare simulations.
"Norven mentioned that the [UAH] has six 3D printers," says Lioce, who also serves as the executive director of the college’s Learning and Technology Resource Center. "So I gave him a long list of what we needed and a bag of samples, and we collaborated on what he and his students could print."
"These models cost more than a thousand dollars, but we wanted something that would save money, be cost effective, and use the university’s resources," says Goddard. "We asked ourselves, how cheaply can we do this?"
An Interdisciplinary Approach
Goddard assembled a team of undergraduate-student interns from a variety of disciplines to help tackle the problem. The students downloaded open-source digital design files for a circothyrotomy trainer, a simulation that is used to teach nurses how to perform an emergency procedure to clear a patient’s airway when traditional methods proved ineffective.
Loice worked with the students "to get the right texture and strength," and after just three prototypes, they successfully created a functional and accurate 3D printed circothyrotomy trainer. The entire process cost only $15, the price of the materials used. "Now we are using four of them in our class, with a savings of $6,000," Loice reports.
In addition to the circothyrotomy trainer, the team also built a 3D-printed vein finder; a typical vein finder costs $100, but the 3D-printed version cost only $6 to print. They're also working on a 3D-printed onychectomy trainer, a device used to teach nurses how to remove a thumbnail, and a 3D-printed injection pad, which is used to simulate injections.
Loice is proud of what the team has already accomplished and excited about what they can achieve going forward; she hopes to expand the collaboration between the College of Nursing and SMAP to benefit both programs.
"We’re trying to cross-pollinate so everyone knows how to 3D print, injection mold, solder, use the software, and do whatever else is needed," she says. "Diversity of thought and science stimulates needed growth and solutions… It’s precisely because we think differently that we are innovative together."
Researchers surveyed 359 home healthcare nurses in the U.S, and evaluated their knowledge of best practices in relation to their compliance with infection control measures.
Over 90% of nurses self-reported compliance for most of the measured behaviors. The researchers also found there was not a direct correlation between knowledge of infection control practices and compliance with those practices. However, there was a relationship between the level of compliance and the participants’ favorable attitude toward infection control.
Based on the findings of this study, the authors suggest that efforts to improve compliance with infection control practices should focus on strategies to alter perceptions about infection risk. Changes should start on an organizational level, and seek to create a culture of positivity in relation to infection control compliance.
Here are other notable takeaways from the study:
Protective equipment lapses: While most of the participants reported compliance on most issues, many reported lapses when it came to wearing protective equipment. Only 9% said they wear disposable facemasks when there is a possibility of a splash or splatter, and 6% said they wear goggles or eye shields when there is a possibility of exposure to bloody discharge or fluid.
A culture of presenteeism: Presenteeism, coming into work despite being sick, has become a patient safety issue over the last few years, especially as it relates to infection control. Only 4% of participants felt it was easy for them to stay at home when they were sick, which could be a major contributor to rates of infection.
Hand hygiene is still an issue: 30% of respondents failed to identify that hand hygiene should be performed after touching a nursing bag, which could transport infectious pathogens as nurses travel between patients.
“Infection is a leading cause of hospitalization among home healthcare patients, and nurses have a key role in reducing infection by compliance with infection control procedures in the home care setting,” Shang says.
According to a recent report, about a quarter of nurses, NPs, and PAs have experienced or witnessed sexual harassment at their workplace within the past three years.
The sexual misconduct cases of prominent men like Harvey Weinstein, Bill Cosby, and Matt Laurer, and the #MeToo movement, which encourages men and women to speak up about sexual harassment and assault, have pushed the issue of sexual harassment into the spotlight.
Now, findings from last month's Medscape report Sexual Harassment of Nurses and PAs Report 2018,by Leslie Kane and Sandra Levy, show that these clinicians are not immune to this pervasive issue. And some reported sexual harassment has interfered with their ability to do their job.
Rates of Sexual Harassment
More than 6,200 clinicians across the U.S. were surveyed on the topic of sexual harassment in the healthcare workplace. The surveyors limited their scope to just the past three years of practice, and they outlined what constituted sexual misconduct for the purposes of the survey:
Unwanted sexual text messages/emails
Comments about anatomy/body parts
Propositions to engage in sexual activity
Being asked repeatedly for a date
Offer of a promotion in exchange for a sexual favor
Threats of punishment for refusal of a sexual behavior
Deliberately infringing on body space
Unwanted groping/hugging/physical contact
Deliberate fondling of self
Grabbing body parts
Based on this criteria, 11% of nurses, NPs, and PAs reported personally experiencing sexual misconduct in the workplace, and 14% reported witnessing sexual misconduct in the workplace.
Just 1% of those surveyed reported being accused of sexual misconduct, and 79% answered none of the above. That leaves about 20% of the participants having experienced sexual misconduct, witnessed sexual misconduct, or both.
The most common behaviors reported were sexual comments or leering at body parts, deliberately infringing on personal space, and unwanted physical contact, such as groping or hugging. Unwanted advances, such as being asked repeatedly for a date, explicit or implicit propositions to engage in sexual activity, and receiving unwanted sexual texts or emails, were also a common complaint.
The Effects of Emotional Distress
In addition to measuring sexual misconduct quantitatively, the report also asked questions about how sexual misconduct affected the victim’s professional life. When asked to measure how upsetting the incident, almost 90% reported that incident was moderately to very upsetting, with one third report of respondents reporting that the incident was very upsetting. Emotional distress is often a major factor in determining job performance and quality of care, and 73% of respondents said that these incidents interfered with their ability to do their job, with 15% reporting that the event interfered significantly.
The incidents of sexual misconduct changed how the surveyed clinicians approached their work in a variety of ways. 36% said that they avoided working with specific colleagues when possible and 23% reported that they engaged less with colleagues. Other effects included difficulty concentrating, increased absenteeism, and 3% reported an increase in medical errors or mistakes. Significantly, 30% of victims said that sexual misconduct led to thoughts about quitting their job, and 16% ended up quitting their job because of the incidents.
Gender dynamics: Predictably, more female nurses, NPs, and PAs experienced harassment than their male counterparts, and a majority (94%) of the perpetrators were male. However, almost twice as many male participants reported witnessing sexual abuse, harassment, or misconduct in the workplace. 4% of participants reported being accused of sexual misconduct, all of which were male.
Age is not a factor: The survey found that harassment was spread relatively evenly across age lines. The largest age group that experienced harassment were nurses, NPs, and PAs aged 35-39, who composed 16% of victims surveyed; the second largest group were aged 50-54 at 15%. There were reports of harassment from participants of almost every age.
Power dynamics: When asked about the perpetrators, nurses and NPs reported that 33% of harassers were physicians, and 48% reported “others.” “Others” included administrators, healthcare personnel, and patients. Interestingly, almost three-quarters of the respondents reported that the perpetrator were of an equal or subordinate position.
Incidence reporting: A majority of the respondents (61%) did not report their perpetrator. Of those that did, 20% reported to their direct supervisor or department head, and only 8% reported the incident with human resources. Only 26% of reports led to an internal investigation, and many of them led to negative consequences for the victim; 28% said the perpetrator’s behavior was trivialized, 13% were retaliated against by management, and 12% were retaliated against by the perpetrator. Only 14% of reports led to the perpetrator being reprimanded, 9% of perpetrators were fired from the organization and practice, and 2% led to legal action against the perpetrator.
The greatest risk of patients acquiring a C. diff infection didn't come, surprisingly, when hospitals were at their fullest.
When researchers from the University of Michigan and RAND set out to explore the relationship between hospital occupancy and C. diff infection risk, they expected to find that high census would mean greater risk for infection.
But, after analyzing data for a new study published in the Journal of Hospital Medicine, they found some surprising results. Patients were more at risk for C. diff infections when the hospital was moderately Patfull.
"The theory that infection rates will go up with occupancy, because of staff cutting corners with steps like handwashing, may seem logical but this model shows it’s not as simple as that," says the study's lead author Mahshid Abir, MD, MSc.
The study used data from 558,829 patient discharges at 327 hospitals across California, between 2008 and 2012. It focused on patients who had come to the hospitals’ emergency departments for care for a heart attack, heart failure, or pneumonia.
In all, 2,045 patients developed a C. diff infection after reaching the hospital.
The authors compared C. diff infection rates to hospital occupancy information, and looked for a correlation between the two factors.
Occupancy was broken into four levels:
Low (0 to 25% occupied)
Two classes of moderate (25% to 50% occupied and 51% to 75% occupied)
High (76% occupied to completely full)
They found C. diff infection risk was highest when the hospital was in the moderate range of occupancy on the day the patient was admitted. And, when the researchers looked at the average occupancy over a patient’s stay, the risk of C. diff infection was more than three times higher when a hospital was moderately full compared to when they were at low or high occupancy.
Based on their initial findings, Abir and her co-authors call for collection of hospital occupancy data by infection control officers so that more precise measurements of occupancy can be used when examining HAIs and other preventable threats to patient health and safety.
They also recommend analysis of hospital protocols that might be triggered or modified when a hospital is in high or low occupancy.
"The impacts of emergency department crowding on patient outcomes have been studied extensively, but the effects of occupancy levels on inpatients has been neglected – despite the fact that a crowded ED is often a function of high inpatient occupancy," Abir says. "Some hospitals may be implementing operational factors during high occupancy that improve HAIs. We need to study what those are."
Modernizing the way Medicare pays for nurse training would increase APRNs in settings with provider shortages.
A new model has been found to cost-effectively train advanced practice registered nurses to practice in community-based primary care settings, University of Pennsylvania researchers report in the New England Journal of Medicine. Additionally, the researchers call for modernizing the way Medicare pays for nurse training.
In the article, the researchers share their findings from a five-state demonstration of an innovative model of graduate nurse education. The Graduate Nurse Education Demonstration, authorized by the Affordable Care Act, encompassed GNE sites managed by a single teaching-hospital hub that combined the training capacity of entire communities of healthcare providers, including health systems, hospitals, clinics, private practices, long-term care facilities, and universities. The demonstration offered payment to Medicare providers, which allowed communities to offer high-quality clinical training for APRNs in settings experiencing provider shortages.
The authors of the NEJM article would like to see Medicare adopt this nurse training model nationally.
APRNs: A Cost-Effective Solution to the Provider Shortage
Studies have shown that APRNs are capable of producing quality, financial, and clinical outcomes equal to or better than primary care physicians. The GNE Demonstration reinforces the financial benefits of APRNs, especially for Medicare providers. According to an independent evaluation of the demonstration, the cost of educating each APRN in the program ranged from $28,000 to $57,000, compared to the $158,000 per year over multiple years to train a primary care physician.
The researchers call for a shift in Medicare funding of diploma nursing programs that produce entry-level RNs to funding APRN training programs instead. Their research found that Medicare funds for nurse education have decreased 30% from 1991 to 2015, and most of that goes to diploma programs that train less than 5% of RNs.
The researchers also discovered that the current Medicare funding model for nurse training led to an inequitable distribution of Medicare funds by state. Hospitals in six states received 53% of Medicare nurse-training funds in 2015, because those states have a disproportionate number of diploma nursing schools, while other states did not receive funding for nurse education.
"The GNE Demonstration shows how Medicare could achieve greater value for its investments in nurse training while contributing to the development of a workforce that can better deliver the care that Medicare beneficiaries want and need," says co-author Barbara Todd, DNP, director of the Graduate Nurse Education Demonstration at the Hospital of the University of Pennsylvania. "The demonstration shows that it is feasible and affordable for Medicare to pay hospitals to facilitate the expansion of clinical training opportunities for APRNs in the community as well as hospital settings, similarly to Medicare’s support of clinical residency training for physicians."
At the time, the agency said there were no immediate and broad patient access challenges to anesthesia care across its health system and, therefore, it chose not to finalize the provision which included CRNAs as one of the APRN roles receiving full-practice authority.
But a new reportpublished last week by the VA's Office of the Inspector General tells a different story—one that has the American Association of Nurse Anesthetists calling for the agency to revise the rule and grant CRNAs full-practice authority.
The Extent of the Shortage
The report found there is a provider shortage in anesthesiology at 22% of the Veterans Health Administration facilities. This is in direct contrast to the rationale behind the VA’s final rule denying CRNAs nurse anesthetists full-practice authority.
As stated in the final rule, that denial was not due to any lack of capability on the part of CRNAs.
"The safety of CRNA services has long been recognized by the VHA and underscored by peer-reviewed scientific studies, including a major study published in Health Affairs which found that anesthesia care by CRNAs was equally safe with or without physician supervision," the rule says.
Rather full-practice authority was withheld because, according to the final rule, there was "no shortage of physician anesthesiologists in VA and the current system allows for sufficient flexibility to address the needs of all VA hospitals."
In a bit of foreshadowing, the final rule states that if the agency learns "of access problems in the area of anesthesia care in specific facilities… or if other relevant circumstances change, we will consider a follow-up rulemaking to address granting full-practice authority to CRNAs."
"Improving the VA’s ability to provide better, faster care to our veterans doesn’t require increasing budgets or staff," AANA President Bruce Weiner, DNP, MSNA, CRNA says in a news release. "One solution has been there all along, and is as simple as removing barriers to CRNAs’ ability to practice to the full extent of their education, training, certification, and licensure."
There are roughly 900 CRNAs in the system already, and granting them full practice authority would greatly increase the access to surgical and anesthesia care the VHA could provide for its veterans.
"Veterans are still waiting entirely too long to receive the quality healthcare they deserve and have earned in service to our country," Weiner says. "The AANA strongly urges the VA to solve this problem by using readily available healthcare resources – such as CRNAs – to the full extent of their practice authority."
The Patient Safety Act, which seeks to impose limits on the number of patients assigned to a nurse at one time, cleared a major legal hurdle and will likely go before voters in the fall.
Will Massachusetts follow in California's footsteps and establish limits on the number of patients a nurse can care for at one time? Bay State voters will have the chance to make that decision in November, when the Patient Safety Act appears as a ballot measure.
The coalition argued that Attorney General Maura Healey should not have certified the measure because the ballot initiative's two main provisions—the patient limits and a prohibition on any "reduction in the staffing levels of the health care workforce" due to the implementation of the patient limits—are not linked closely enough to be part of one ballot question.
In response, the attorney general’s office said the proposed question was approved because "all of its parts are operationally related to its common purpose of implementing patient-to-nurse assignment limits in hospitals."
Ultimately, the court agreed with the AG's office. Justice Barbara Lenk wrote as part of the court’s ruling: "This staffing reduction restriction represents a permissible choice of the law's drafters as to how the patient assignment limits may be implemented. As long as all parts of the proposed law are related, as they are here, such policy choices are committed to the drafters' discretion and will not be disturbed."
Norton added that the committee plans to submit a final round of about 26,000 signatures to local elections officials on Tuesday to ensure the question makes it onto the November ballot. At least 10,792 signatures must be certified by local officials and submitted to the secretary of state by July 3.
Up for Vote
The Patient Safety Act is a proposed law drafted by the Committee to Ensure Safe Patient Care, a coalition made up of advocates across Massachusetts, including registered nurses, patients and family members, health and safety organizations, community groups, unions, and elected officials. The Massachusetts Nurses Association also supports the initiative. For years, nurses have pushed staffing requirement legislation, but their proposals have failed to gain traction in the legislature.
The proposal outlines how it would limit the number of patients for each nurse based on unit type and level of care:
In units with step-down/intermediate care patients: three patients per nurse;
In units with post-anesthesia care or operating room patients: one patient under anesthesia per nurse; 2 patients post-anesthesia per nurse;
In the emergency services department: one critical or intensive care patient per nurse (or two if the nurse has assessed each patient’s condition as stable); two urgent non-stable patients per nurse; three urgent stable patients per nurse; or five non-urgent stable patients per nurse;
In units with maternity patients: (a) active labor patients: two patient per nurse; (b) during birth and for up to two hours immediately postpartum: one mother per nurse and one baby per nurse; (c) when the condition of the mother and baby are determined to be stable: one mother and her baby or babies per nurse; (d) postpartum: six patients per nurse; (e) intermediate care or continuing care babies: two babies per nurse; (f) well-babies: six babies per nurse;
In units with pediatric, medical, surgical, telemetry, or observational/outpatient treatment patients, or any other unit: four patients per nurse;
In units with psychiatric or rehabilitation patients: five patients per nurse.
The main criticism of the proposal has to do with the prohibition on reducing the staffing levels of the healthcare workforce.
“The Workforce Reduction Ban is not limited to nurses, bedside caregivers, or any similarly tailored category," the coalition wrote in its argument to the court. "Instead, the ban dictates the retention of virtually everybody who works for or at a subject facility, including many workers (e.g., lawyers and marketers) whose job functions could not possibly have an impact on the quality of nursing care in particular, or on patient safety in general."
Once the signatures are certified, the issue will be put to Massachusetts voters on November 6, and if approved, would take effect January 1, 2019.
Editor's Note: This story has been updated to clarify that the measure still needs to be certified before it can make the ballot.