17-05-2013, 04:54 PM
The Effect of Health Care Working Conditions on Patient Safety
The Effect of Health.doc (Size: 45.5 KB / Downloads: 32)
Hospital nurse staffing is a matter of major concern because of the effects it can have on patient safety and quality of care. Nursing-sensitive outcomes are one indicator of quality of care and may be defined as "variable patient or family caregiver state, condition, or perception responsive to nursing intervention."6 Some adverse patient outcomes potentially sensitive to nursing care are urinary tract infections (UTIs), pneumonia, shock, upper gastrointestinal bleeding, longer hospital stays, failure to rescue, and 30-day mortality.A Most research has focused on adverse rather than positive patient outcomes for the simple reason that adverse outcomes are much more likely to be documented in the medical record.
A broad array of research on this topic has found an association between lower nurse staffing levels and higher rates of some adverse patient outcomes. A new evidence report entitled The Effect of Health Care Working Conditions on Patient Safety, produced by an AHRQ-funded Evidence-based Practice Center (EPC), reviewed 26 studies on the relationship between nurse staffing levels and measures of patient safety.B Most of the studies examined nurse staffing levels and adverse occurrences in the hospital setting, including in-hospital deaths and nonfatal adverse outcomes such as nosocomial infections, pressure ulcers, or falls. The EPC's researchers found that lower nurse-to-patient ratios were associated with higher rates of nonfatal adverse outcomes.7 This was true at both the hospital level and the nursing unit level. With regard to in-hospital deaths, however, the evidence does not consistently show that lower nurse staffing levels are associated with higher mortality.
Lower Staffing Levels Are Linked to Higher Adverse Outcome Rates
The EPC report included five studies funded by AHRQ that examined the relationship between adverse patient outcomes and hospital nurse staffing. All five studies found at least some association between lower nurse staffing levels and one or more types of adverse patient outcomes.
How often do such adverse "nursing-sensitive" patient outcomes occur in hospital care? Different studies report varying adverse event rates, which vary by the type of patient (medical or surgical) as well as other factors. For example, UTIs occur in from 1.9 percent to 6.3 percent of surgical patients and pneumonia in 1.2 percent to 2.6 percent of surgical patients.8-10
The largest of these studies on nurse staffing (jointly funded by AHRQ, the Health Resources and Services Administration, the Centers for Medicare & Medicaid Services, and the National Institute of Nursing Research) examined the records of 5 million medical patients and 1.1 million surgical patients who had been treated at 799 hospitals during 1993.6,8 Among the study's principal findings:
In hospitals with high RN staffing, medical patients had lower rates of five adverse patient outcomes (UTIs, pneumonia, shock, upper gastrointestinal bleeding, and longer hospital stay) than patients in hospitals with low RN staffing.C
Major surgery patients in hospitals with high RN staffing had lower rates of two patient outcomes (UTIs and failure to rescue).
Higher rates of RN staffing were associated with a 3- to 12-percent reduction in adverse outcomes, depending on the outcome.
Higher staffing at all levels of nursing was associated with a 2- to 25-percent reduction in adverse outcomes, depending on the outcome.
Table 1 illustrates some of the major findings. For example, the researchers found that medical patients in hospitals with high RN staffing were 4-12 percent less likely to develop UTIs than medical patients in the comparison group. Medical patients in hospitals with high levels of total nurse staffing (RNs, LPNs, and aides) were 4-25 percent less likely to develop UTIs than patients in the comparison group.
A similar analysis was performed for the smaller group of surgical patients (Table 2). Surgical patients in hospitals with high RN staffing had a 5-6 percent lower rate of UTIs and a 4-6 percent lower rate of failure to rescue than surgical patients in the comparison group.D
A second study, funded jointly by AHRQ and the National Science Foundation, examined licensed nurse staffing (RNs and LPNs) and adverse outcomes among both medical and surgical patients in Pennsylvania acute-care hospitals.11 It found a lower incidence of nearly all adverse outcomes it studied in hospitals with more licensed nurses. For example, a 10-percent increase in the number of licensed nurses is estimated to decrease lung collapse by 1.5 percent, pressure ulcers by 2 percent, falls by 3 percent, and UTIs by less than 1 percent. Also, with a 10-percent higher proportion of licensed nurses, there was a 2-percent lower incidence of pressure ulcers.E,11
Pneumonia Rates Are Especially Sensitive to Staffing Levels
Three AHRQ-funded studies found a significant correlation between lower nurse staffing levels and higher rates of pneumonia.
The first study found that adding half an hour of RN staffing per patient day could reduce pneumonia in surgical patients by over 4 percent.12 This study covered 589 hospitals in 10 States during 1993.
A second study by the same researchers also found that fewer RN hours per patient day were significantly correlated with a higher incidence of pneumonia.13 The study examined administrative data on post-surgical patients in 11 States during 1990-96.
A study of nurse staffing levels and adverse outcomes in California found that an increase of 1 hour worked by RNs per patient day was associated with an 8.9-percent decrease in the odds of a surgical patient's contracting pneumonia.8
This study also found that a 10-percent increase in RN proportion was associated with a 9.5-percent decrease in the odds of pneumonia.
The researchers in the California study believe that the strong relationship between RN staffing and pneumonia can be attributed to the heavy responsibility RNs have for respiratory care in surgical patients. This study examined the effects of nurse staffing on adverse outcomes in 232 acute care hospitals from 1996 to 1999.F Unlike many earlier studies, the California study included only adverse outcomes that were not present at admission.7