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HOSPITAL STAFFING AND QUALITY OF CARE ARE RECEIVING NEW ATTENTION

Hospital staffing and its relation to inpatient quality of care were the subjects of 3 major studies this year.

Administrative databases from 799 hospitals were used to analyze associations between nurse staffing and the outcomes of medical and surgical patients (Journal Watch May 31 2002). In medical patients, a larger number of registered-nurse (RN) hours and a higher proportion of RN staffing were associated with shorter lengths of stay and lower rates of urinary tract infections and upper gastrointestinal bleeding. A higher proportion of RN care also was associated with lower rates of pneumonia, cardiac arrest, and failure to rescue (i.e., death caused by potentially treatable hospital complications). In surgical patients, a higher proportion of RN care was associated with a lower rate of urinary tract infections, and a larger number of RN hours were associated with a lower rate of failure to rescue.

Another research team examined the relation among outcomes of surgery patients, patient-nurse ratios, and nursing burnout and dissatisfaction in 168 Pennsylvania hospitals, most of which had patient-nurse ratios ranging from 5:1 to 7:1 (Journal Watch Nov 8 2002). Each increase of 1 patient in the staffing ratio increased the likelihood of nurse burnout by 23% and the risk for patient mortality by 7%. The authors calculated that an increase in patient-nurse ratios from 4:1 to 8:1 would result in 5 excess deaths per 1000 patients.

The effect of participation by critical care specialists (intensivists) on clinical outcomes in an intensive care unit was addressed in a meta-analysis of 27 cohort studies (Journal Watch Nov 19 2002). High-intensity staffing (all care directed by intensivists or mandatory intensivist consultation) was associated with significantly lower ICU mortality and hospital mortality and with significantly shorter lengths of stay than was low-intensity staffing (elective intensivist consultation or no intensivists available).

Health care is complex; inpatient care is more intensive than ever; and, increasingly, hospitals are like large ICUs. So, it shouldn't surprise us that nurse staffing levels and nurse experience should influence patient care outcomes or that increased presence of intensivists should affect ICU outcomes. What is less clear is how a price-competitive, fragmented health care system can deal with the consequences of such findings. Patient-nurse ratios have a substantial effect on nursing satisfaction and burnout; current nursing shortages probably will get worse before they get better; and staffing all ICUs with full-time intensivists neither is practical currently nor is likely to be accepted by some other physicians.

— Thomas L. Schwenk, MD

Published in Journal Watch General Medicine December 28, 2002

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