Comparison of the Value of Nursing Work Environments in Hospitals Across Different Levels of Patient Risk

Hospital nurse staffing variation and Covid-19 deaths: A cross-sectional study

BACKGROUND

During the Covid-19 pandemic, Covid-19 mortality varied depending on the hospital where patients were admitted, but it is unknown what aspects of hospitals were important for mitigating preventable deaths.

OBJECTIVE

To determine whether hospital differences in pre-pandemic and during pandemic nursing resources-average patient-to-registered nurse (RN) staffing ratios, proportion of bachelor-qualified RNs, nurse work environments, Magnet recognition-explain differences in risk-adjusted Covid-19 mortality; and to estimate how many deaths may have been prevented if nurses were better resourced prior to and during the pandemic.

METHODS

This is a cross-sectional study of 87,936 Medicare beneficiaries (65-99 years old) hospitalized with Covid-19 and discharged (or died) between April 1 and December 31, 2020, in 237 general acute care hospitals in New York and Illinois. Measures of hospital nursing resources (i.e. patient-to-RN staffing ratios, proportion of bachelor-qualified RNs, nurse work environments, Magnet recognition) in the pre-pandemic period (December 2019 to February 2020) and during (April to June 2021) were used to predict in-hospital and 30-day mortality using adjusted logistic regression models.

RESULTS

The mean age of patients was 78 years (8.6 SD); 51 % were male (n = 44,998). 23 % of patients admitted to the hospital with Covid-19 died during the hospitalization (n = 20,243); 31.5 % died within 30-days of admission (n = 27,719). Patients admitted with Covid-19 to hospitals with better nursing resources pre-pandemic and during the pandemic were statistically significantly less likely to die. For example, each additional patient in the average nurses' workload pre-pandemic was associated with 20 % higher odds of in-hospital mortality (OR 1.20, 95 % CI [1.12-1.28], p < 0.001) and 15 % higher odds of 30-day mortality (OR 1.15, 95 % CI [1.09-1.21], p < 0.001). Hospitals with greater proportions of BSN-qualified RNs, better quality nurse work environments, and Magnet recognition offered similar protective benefits to patients during the pandemic. If all hospitals in the study had superior nursing resources prior to or during the pandemic, models estimate many thousands of deaths among patients hospitalized with Covid-19 could have been avoided.

CONCLUSIONS

Patients with Covid-19 admitted to hospitals with adequate numbers of RNs caring for patients, a workforce rich in BSN-qualified RNs, and high-quality nurse work environments (both prior to and during the Covid-19 pandemic) were more likely to survive the hospitalization. Bolstering these hospital nursing resources during ordinary times is necessary to ensure better patient outcomes and emergency-preparedness of hospitals for future public health emergencies.

Hospital Performance on Hospital Consumer Assessment of Healthcare Providers and System Ratings: Associations With Nursing Factors

OBJECTIVE

To determine which hospital nursing resources (staffing, skill mix, nurse education, and nurse work environment) are most predictive of hospital Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) performance.

BACKGROUND

HCAHPS surveying is designed to quantify patient experience, a measure of patient-centered care. Hospitals are financially incentivized through the Centers for Medicare and Medicaid Services to achieve high HCAHPS ratings, but little is known about what modifiable hospital factors are associated with higher HCAHPS ratings.

PATIENTS AND METHODS

Secondary analysis of multiple linked data sources in 2016 providing information on hospital HCAHPS ratings, hospital nursing resources, and other hospital attributes (eg, size, teaching, and technology status). Five hundred forty non-federal adult acute care hospitals in California, Florida, New Jersey, and Pennsylvania, and 11,786 registered nurses working in those hospitals. Predictor variables included staffing (ie, patient-to-nurse ratio), skill mix (ie, the proportion of registered nurses to all nursing staff), nurse education (ie, percentage of nurses with a bachelor's degree or higher), and nurse work environment (ie, the quality of the environment in which nurses work). HCAHPS ratings were the outcome variable.

RESULTS

More favorable staffing, higher proportions of bachelor-educated nurses, and better work environments were associated with higher HCAHPS ratings. The work environment had the largest association with higher HCAHPS ratings, followed by nurse education, and then staffing. Superior staffing and work environments were associated with higher odds of a hospital being a "higher HCAHPS performer" compared with peer hospitals.

CONCLUSION

Improving nursing resources is a strategic organizational intervention likely to improve HCAHPS ratings.

The Role of Hospital Characteristics in Clinical and Quality Outcomes for Gastrointestinal Bleeding in a National Cohort

INTRODUCTION

There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes.

METHODS

This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality.

RESULTS

Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services.

DISCUSSION

Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.

Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes

OBJECTIVE

To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls.

SUMMARY BACKGROUND DATA

It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients.

METHODS

Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality.

RESULTS

We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001].

CONCLUSIONS

Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.

A Review of Disparities in Outcomes of Hospitalized Patients with Limited English Proficiency: The Importance of Nursing Resources

Language barriers significantly affect communication between patients and health care staff and are associated with receipt of lower-quality care. Registered nurses are well positioned members of the health care team to reduce and eliminate disparities for patients with limited English proficiency (LEP). Current evidence recommends nurses use interpreters or translation devices to overcome language barriers; however, these recommendations fail to recognize that structural system-level factors, such as unsupportive work environments and poor nurse-to-patient staffing ratios, reduce nurses' ability to implement these recommendations. The Quality Health Outcomes Model (QHOM) is a useful framework for understanding relationships between hospital systems, the delivery of care interventions, and patient outcomes. The goal of this manuscript is to use the QHOM and existing empirical evidence to present a new perspective on the long-standing clinical challenge of reducing language-related health outcome disparities by considering the context in which nurses deliver patient care.

Patient-to-nurse ratios: Balancing quality, nurse turnover, and cost

We consider the problem of setting appropriate patient-to-nurse ratios in a hospital, an issue that is both complex and widely debated. There has been only limited effort to take advantage of the extensive empirical results from the medical literature to help construct analytical decision models for developing upper limits on patient-to-nurse ratios that are more patient- and nurse-oriented. For example, empirical studies have shown that each additional patient assigned per nurse in a hospital is associated with increases in mortality rates, length-of-stay, and nurse burnout. Failure to consider these effects leads to disregarded potential cost savings resulting from providing higher quality of care and fewer nurse turnovers. Thus, we present a nurse staffing model that incorporates patient length-of-stay, nurse turnover, and costs related to patient-to-nurse ratios. We present results based on data collected from three participating hospitals, the American Hospital Association (AHA), and the California Office of Statewide Health Planning and Development (OSHPD). By incorporating patient and nurse outcomes, we show that lower patient-to-nurse ratios can potentially provide hospitals with financial benefits in addition to improving the quality of care. Furthermore, our results show that higher policy patient-to-nurse ratio upper limits may not be as harmful in smaller hospitals, but lower policy patient-to-nurse ratios may be necessary for larger hospitals. These results suggest that a "one ratio fits all" patient-to-nurse ratio is not optimal. A preferable policy would be to allow the ratio to be hospital-dependent.

[Effects of Nursing Work Environment on Intention to Stay of Hospital Nurses: A Two-Mediator Serial Mediation Effect of Career Motivation and Job-Esteem]

PURPOSE

This study aimed to identify the mediating effects of career motivation and job-esteem and the effect of the nursing work environment on intention to stay among hospital nurses.

METHODS

Data were collected from 289 nurses working at an advanced general hospital. The research model design was based on the PROCESS macro proposed by Hayes and analyzed using SPSS 24.0 program.

RESULTS

The results showed a positive correlation between intention to stay and nursing work environment (r = .19, p = .001), career motivation (r= .34, p < .001), and job-esteem (r = .37, p < .001). Nursing work environment (B = 0.34 [.09~.59]) and job-esteem (B = 0.27 [.04~.49]) had a direct effect on intention to stay. There was a two-mediator sereal mediation effect of career motivation and job-esteem. The nursing work environment showed a significant effect on the intention to stay among hospital nurses through career motivation and job-esteem.

CONCLUSION

In order to increase the retention rate of hospital nurses, it is suggested that government and medical institutions provide multifaceted support that can increase nurses' motivation for career development and recognition of the nursing profession through improvement of the nursing work environment.

Explaining racial disparities in surgical survival: a tapered match analysis of patient and hospital factors

OBJECTIVES

Evaluate whether hospital factors, including nurse resources, explain racial differences in Medicare black and white patient surgical outcomes and whether disparities changed over time.

DESIGN

Retrospective tapered-match.

SETTING

571 hospitals at two time points (Early Era 2003-2005; Recent Era 2013-2015).

PARTICIPANTS

6752 black patients and three sets of 6752 white controls selected from 107 001 potential controls (Early Era). 4964 black patients and three sets of 4964 white controls selected from 74 108 potential controls (Recent Era).

INTERVENTIONS

Black patients were matched to white controls on demographics (age, sex, state and year of procedure), procedure (demographics variables plus 136 International Classification of Diseases (ICD)-9 principal procedure codes) and presentation (demographics and procedure variables plus 34 comorbidities, a mortality risk score, a propensity score for being black, emergency admission, transfer status, predicted procedure time).

OUTCOMES

30-day and 1-year mortality.

RESULTS

Before matching, black patients had more comorbidities, higher risk of mortality despite being younger and underwent procedures at different percentages than white patients. Whites in the demographics match had lower mortality at 30 days (5.6% vs 6.7% Early Era; 5.4% vs 5.7% Recent Era) and 1-year (15.5% vs 21.5% Early Era; 12.3% vs 15.9% Recent Era). Black-white 1-year mortality differences were equivalent after matching patients with respect to presentation, procedure and demographic factors. Black-white 30-day mortality differences were equivalent after matching on procedure and demographic factors. Racial disparities in outcomes remained unchanged between the two time periods spanning 10 years. All patients in hospitals with better nurse resources had lower odds of 30-day (OR 0.60, 95% CI 0.46 to 0.78, p<0.010) and 1-year mortality (OR 0.77, 95% CI 0.65 to 0.92, p<0.010) even after accounting for other hospital factors.

CONCLUSIONS

Survival disparities among black and white patients are largely explained by differences in demographic, procedure and presentation factors. Better nurse resources (eg, staffing, work environment) were associated with lower mortality for all patients.

Defining Multimorbidity in Older Patients Hospitalized with Medical Conditions

BACKGROUND

The term "multimorbidity" identifies high-risk, complex patients and is conventionally defined as ≥2 comorbidities. However, this labels almost all older patients as multimorbid, making this definition less useful for physicians, hospitals, and policymakers.

OBJECTIVE

Develop new medical condition-specific multimorbidity definitions for patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia patients. We developed three medical condition-specific multimorbidity definitions as the presence of single, double, or triple combinations of comorbidities - called Qualifying Comorbidity Sets (QCSs) - associated with at least doubling the risk of 30-day mortality for AMI and pneumonia, or one-and-a-half times for HF patients, compared to typical patients with these conditions.

DESIGN

Cohort-based matching study PARTICIPANTS: One hundred percent Medicare Fee-for-Service beneficiaries with inpatient admissions between 2016 and 2019 for AMI, HF, and pneumonia.

MAIN MEASURES

Thirty-day all-location mortality KEY RESULTS: We defined multimorbidity as the presence of ≥1 QCS. The new definitions labeled fewer patients as multimorbid with a much higher risk of death compared to the conventional definition (≥2 comorbidities). The proportions of patients labeled as multimorbid using the new definition versus the conventional definition were: for AMI 47% versus 87% (p value<0.0001), HF 53% versus 98% (p value<0.0001), and pneumonia 57% versus 91% (p value<0.0001). Thirty-day mortality was higher among patients with ≥1 QCS compared to ≥2 comorbidities: for AMI 15.0% versus 9.5% (p<0.0001), HF 9.9% versus 7.0% (p <0.0001), and pneumonia 18.4% versus 13.2% (p <0.0001).

CONCLUSION

The presence of ≥2 comorbidities identified almost all patients as multimorbid. In contrast, our new QCS-based definitions selected more specific combinations of comorbidities associated with substantial excess risk in older patients admitted for AMI, HF, and pneumonia. Thus, our new definitions offer a better approach to identifying multimorbid patients, allowing physicians, hospitals, and policymakers to more effectively use such information to consider focused interventions for these vulnerable patients.

Redefining Multimorbidity in Older Surgical Patients

BACKGROUND

Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations.

STUDY DESIGN

We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general = 230,410 patients, orthopaedic = 778,131 patients, vascular = 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching.

RESULTS

Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general = 85.0% (conventional) vs 55.9% (new) (p < 0.0001); orthopaedic = 66.6% vs 40.2% (p < 0.0001); and vascular = 96.2% vs 52.7% (p < 0.0001). Thirty-day mortality was higher by the new definitions: general = 3.96% (conventional) vs 5.64% (new) (p < 0.0001); orthopaedic = 0.13% vs 1.68% (p < 0.0001); and vascular = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference = -0.94% [-1.36%, -0.52%], p < 0.0001; orthopaedic = -0.20% [-0.34%, -0.05%], p = 0.0087; and vascular = -0.12% [-0.69%, 0.45%], p = 0.6795).

CONCLUSIONS

Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.

The association between nurse managers' transformational leadership and quality of patient care: A systematic review

AIM

To examine and summarize the reported association of nurse managers' transformational leadership and quality of patient care based on the perceptions of registered nurses.

BACKGROUND

Transformational leadership behaviors of nurse managers result in staff nurses' satisfaction and retention and patient satisfaction. Patient safety and quality of care are vital to high-performing healthcare organizations. Perceptions of registered nurses are important because nurses are frontline healthcare providers fundamental to patient safety and quality of care and are considered the final line of defense in preventing adverse events and errors and improving the safety of patients.

MATERIALS AND METHODS

We  searched the CINAHL, ProQuest, PubMed, Science Direct, and Web of Science databases for evidence published between 2018 and 2022 in the English language. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in carrying out this meta-analysis.

RESULTS

Nine quantitative studies were appraised using the Joanna Briggs Institute checklists and were included in the final review that involved a total sample of 3633 registered nurses. The included studies were reported across Asian, Middle East, and European countries within the past five years. The association between the transformational leadership behaviors of nurse managers and the quality of patient care was found in varying degrees (i.e., insignificant, weak, indirect, and strong direct association) based on the perceptions of registered nurses.

CONCLUSIONS

There is a direct and indirect association between the transformational leadership behaviors of nurse managers and the quality of patient care internationally. This association is influenced by confounding and mediating factors, including gender, organizational culture, structural empowerment, and job satisfaction.

IMPLICATIONS FOR NURSING AND HEALTH POLICIES

Healthcare organizations need to support nursing leaders to have a stronger transformational leadership style by considering several factors that influence their leadership to improve the quality of patient care their staff nurses provide at the bedside.

Nursing factors associated with length of stay and readmission rate of the elderly residents from nursing home based on LTCfocus database

OBJECTIVES

Nursing factors have been found to be associated with a reduction in readmission rates. Nevertheless, few attentions have been given to the effect of nursing factors on nursing home (NH) residents. This study was to assess the impact of nursing factors on the hospital readmissions and length of stay (LOS) of the elderly residents from the NH.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Data were extracted from the NH of the LTCFocus.org data set between 2011 and 2018. The study included residents aged ≥55 years who were admitted to NH in the United States, following a hospitalization event. The nursing factors included facility-level data elements and medical care personnel. An unsupervised machine learning algorithm (K-means) was used to cluster NH according to readmission rate and LOS. Multivariate logistic regression analysis was performed.

RESULTS

This study consisted of 107,000 NH-year observations. The median readmission rate was 17%, with a median LOS was 28.00 days. Three clusters were identified: cluster 1 was a high readmission rate with high LOS, cluster 2 was a low readmission rate with low LOS, and cluster 3 was a high readmission rate with low LOS. Multifacility and admission/bed were associated with a reduction in readmission rate and LOS in both cluster 1 vs cluster 2 and cluster 3 vs cluster 2. The special care unit and registered nurses' ratio were associated with decreased readmission rate and LOS in cluster 1 vs cluster 2. Total beds and Alzheimer unit decreased the readmission rate and LOS, whereas certified nursing assistant increased the readmission rate and LOS in cluster 3 vs cluster 2. NH for profit was associated with elevated readmission rate and LOS in cluster 1 vs cluster 2 and decreased readmission rate and LOS in cluster 3 vs cluster 2. Based on the subgroup analysis, the certified nursing assistant decreased readmission rate and LOS in cluster 1 vs cluster 2 and increased readmission rate and LOS in cluster 3 vs cluster 2 (all P < 0.005).

CONCLUSION

This study indicates the importance of the improvement of nurse number and level and the inputs of facility characteristics in NH.

Hemoglobin Levels Among Male Agricultural Workers: Analyses From the Demographic and Health Surveys to Investigate a Marker for Chronic Kidney Disease of Uncertain Etiology

OBJECTIVE

Estimate agricultural work's effect on hemoglobin (Hgb) level in men. A negative effect may indicate presence of chronic kidney disease of uncertain etiology.

METHODS

We use Demographic and Health Surveys data from seven African and Asian countries and use matching to control for seven confounders.

RESULTS

On average, Hgb levels were 0.09 g/dL lower among agricultural workers compared with matched controls. Significant effects were observed in Ethiopia, India, Lesotho, and Senegal, with effects from 0.07 to 0.30 g/dL lower Hgb level among agricultural workers. The findings were robust to multiple control groups and a modest amount of unmeasured confounding.

CONCLUSIONS

Men engaged in agricultural work in four of the seven countries studied have modestly lower Hgb levels. Our data support integrating kidney function assessments within Demographic and Health Surveys and other population-based surveys.

International variation in length of stay in intensive care units and the impact of patient-to-nurse ratios

OBJECTIVE

To assess variation in ICU length of stay between countries with varying patient-to-nurse ratios; to compare ICU length of stay of individual countries against an international benchmark.

DESIGN

Secondary analysis of the DecubICUs trial (performed on 15 May 2018).

SETTING

The study cohort included 12,794 adult ICU patients (57 countries). Only countries with minimally twenty patients discharged (or deceased) within 30 days of ICU admission were included.

MAIN OUTCOME MEASURE

Multivariate Cox regression was used to evaluate ICU length of stay, censored at 30 days, across countries and for patient-to-nurse ratio, adjusted for sex, age, admission type and Simplified Acute Physiology Score II. The resulting hazard ratios for countries, indicating longer or shorter length of stay than average, were plotted on a forest plot. Results by country were benchmarked against the overall length of stay using Kaplan-Meier curves.

RESULTS

Patients had a median ICU length of stay of 11 days (interquartile range, 4-27). Hazard ratio by country ranged from minimally 0.42 (95% confidence interval 0.35-0.51) for Greece, to maximaly1.94 (1.28-2.93) for Lithuania. The hazard ratio for patient-to-nurse was 0.96 (0.94-0.98), indicating that higher patient-to-nurse ratio results in longer length of stay.

CONCLUSIONS

Despite adjustment for case-mix, we observed significant heterogeneity of ICU length of stay in-between countries, and a significantly longer length of stay when patient-to-nurse ratio increases. Future studies determining underlying characteristics of individual ICUs and broader organisation of healthcare infrastructure within countries may further explain the observed heterogeneity in ICU length of stay.

Hospital nursing factors associated with decreased odds of mortality in older adult medicare surgical patients with depression

Background

Depression is common, costly, and has deleterious effects in older adult surgical patients. Little research exists examining older adult surgical patient outcomes and depression and the potential for nursing factors to affect these outcomes. The purpose of this study was to determine the relationship between hospital nursing resources, 30-day mortality; and the impact of depression on this relationship.

Methods

This was a retrospective cohort study employing a national nurse survey, hospital data, and Medicare claims data from 2006–2007. The sample included: 296,561 older adult patients, aged 65–90, who had general, orthopedic, or vascular surgery in acute care general hospitals from 2006–2007, 533 hospitals and 24,837 nurses. Random effects models were used to analyze the association between depression, hospital nursing resources, and mortality.

Results

Every added patient per nurse was associated with a 4% increase in the risk-adjusted odds of mortality in patients with depression (p < 0.05). Among all patients, every 10% increase in the proportion of bachelor’s prepared nurses was associated with a 4% decrease in the odds of mortality (p < 0.001) and a one standard deviation increase in the work environment was associated with a 5% decrease in the odds of mortality (p < 0.05).

Conclusions

For older adult patients hospitalized for surgery, the risk of mortality is associated with higher patient to nurse ratio, lower proportion of BSN prepared nurses in the hospital, and worse hospital work environment. Addressing the mental health care needs of older adults in the general care hospital setting is critical to ensuring positive outcomes after surgery. Hospital protocols to lower the risk of surgical mortality in older adults with and without depression could include improving nurse resources.

Achieving Universal Health Care in the Pacific: The need for nursing and midwifery leadership. Review Paper

The quality of healthcare services and outcomes in the Pacific vary widely, with some countries enjoying some of the world's longest life expectancies, others have high rates of maternal and child mortality and relatively low life expectancy. Nurses and midwives make up more than two thirds of the regional regulated healthcare workforce. This paper argues that if countries are to meet Universal Health Coverage  nursing and midwifery leaders need to be explicitly involved in shaping policy  at the highest levels of government to optimise individual and community health both now and in the future. Using United Nations 2019  declaration towards building a healthier world, this paper provides a rationale for inclusion of these leaders  into national and regional decisionmaking forums related to health policy to provide an informed voice in ministerial deliberations on health policy. We suggest that following several comprehensive regional and global studies, South Pacific Chief Nursing and Midwifery Officer Alliance  and the newly developed Pacific Heads of Nurses and Midwifery provide a vehicle for this to occur. As outlined in the WHO Strategic Directions, it is now time to embed Chief Nurses in national and regional health policy development.

Variations in nursing baccalaureate education and 30-day inpatient surgical mortality

BACKGROUND

In 2010, the IOM recommended an increase in the proportion of bachelor's-prepared (BSN) nurses to 80% by 2020. This goal was largely based on evidence linking hospitals with higher proportions of BSN nurses to better patient outcomes. Though, evidence is lacking on whether outcomes differ by a hospital's composition of initial BSN and transitional RN-to-BSN nurses.

PURPOSE

The purpose of this study is to determine whether risk-adjusted odds of surgical mortality are associated with a hospital's proportion of initial BSN and transitional RN-to-BSN nurses.

METHODS

Logistic regression models were used to analyze cross-sectional data of general surgical patients, nurses, and hospitals in four large states in 2015 to 2016.

FINDINGS

Higher hospital proportions of BSN nurses, regardless of educational pathway, are associated with lower odds of 30-day inpatient surgical mortality.

DISCUSSION

Findings support promoting multiple BSN educational pathways to reach the IOM's recommendation of at least an 80% BSN workforce.

Intensive Care Unit Utilization Following Major Surgery and the Nurse Work Environment

BACKGROUND

Across hospitals, there is wide variation in ICU utilization after surgery. However, it is unknown whether and to what extent the nurse work environment is associated with a patient's odds of admission to an intensive care unit.

PURPOSE

To estimate the relationship between hospitals' nurse work environment and a patient's likelihood of ICU admission and mortality following surgery.

METHODS

A cross-sectional study of 269 764 adult surgical patients in 453 hospitals was conducted. Logistic regression models were used to estimate the effects of the work environment on the odds of patients' admission to the intensive care unit and mortality.

RESULTS

Patients in hospitals with good work environments had 16% lower odds of intensive care unit admission and 15% lower odds of mortality or intensive care unit admission than patients in hospitals with mixed or poor environments.

CONCLUSIONS

Patients in hospitals with better nurse work environments were less likely to be admitted to an intensive care unit and less likely to die. Hospitals with better nurse work environments may be better equipped to provide postoperative patient care on lower acuity units.

Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study

OBJECTIVE

To evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals.

DESIGN

Cross-sectional analysis of multiple data sources including a 2020 survey of nurses linked to patient outcomes data.Setting: 87 acute care hospitals in Illinois.

PARTICIPANTS

210 493 Medicare patients, 65 years and older, who were hospitalised in a study hospital. 1391 registered nurses employed in direct patient care on a medical-surgical unit in a study hospital.

MAIN OUTCOME MEASURES

Primary outcomes were 30-day mortality and length of stay. Deaths avoided and cost savings to hospitals were predicted based on results from regression estimates if hospitals were to have staffed at a 4:1 ratio during the study period. Cost savings were computed from reductions in lengths of stay using cost-to-charge ratios.

RESULTS

Patient-to-nurse staffing ratios on medical-surgical units ranged from 4.2 to 7.6 (mean=5.4; SD=0.7). After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by 16% for each additional patient in the average nurse's workload (95% CI 1.04 to 1.28; p=0.006). The odds of staying in the hospital a day longer at all intervals increased by 5% for each additional patient in the nurse's workload (95% CI 1.00 to 1.09, p=0.041). If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million.

CONCLUSIONS

Patient-to-nurse staffing ratios vary considerably across Illinois hospitals. If nurses in Illinois hospital medical-surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.

Hospital-Acquired Conditions Reduction Program, Patient Safety, and Magnet Designation in the United States

OBJECTIVE

The aim of the study was to investigate the association between hospitals' nursing excellence accreditation and patient safety performance-measured by the Hospital-Acquired Conditions Reduction Program (HACRP).

METHODS

We linked data from the American Nursing Credentialing Center Magnet Recognition Program, Centers for Medicare and Medicaid Services HACRP, and the American Hospital Association annual survey from 2014 to 2016. We constrained the analysis to hospitals participating in Centers for Medicare and Medicaid Services' HACRP and deployed propensity score matching models to calculate the coefficients for our HACRP patient safety measures. These measures consisted of (a) patient safety indicator 90, (b) hospital-associated infection measures, and (c) total HAC scores. In addition, we used propensity score matching to assess HACRP scores between hospitals achieving Magnet recognition in the past 2 versus longer and within the past 5 years versus longer.

RESULTS

Our primary findings indicate that Magnet hospitals have an increased likelihood of experiencing lower patient safety indicator 90 scores, higher catheter-associated urinary tract infection and surgical site infection scores, and no different total HAC scores. Finally, when examining the impact of Magnet tenure, our analysis revealed that there were no differences in Magnet tenure.

CONCLUSIONS

Results indicate that the processes, procedures, and educational aspects associated with Magnet recognition seem to provide important improvements associated with care that is controlled by nursing practice. However, because these improvements do not differ when comparing total HAC scores nor Magnet hospitals with different tenure, there are likely opportunities for Magnet hospitals to continue process improvements focused on HACRP scores.

Matching One Sample According to Two Criteria in Observational Studies

Multivariate matching has two goals: (i) to construct treated and control groups that have similar distributions of observed covariates, and (ii) to produce matched pairs or sets that are homogeneous in a few key covariates. When there are only a few binary covariates, both goals may be achieved by matching exactly for these few covariates. Commonly, however, there are many covariates, so goals (i) and (ii) come apart, and must be achieved by different means. As is also true in a randomized experiment, similar distributions can be achieved for a high-dimensional covariate, but close pairs can be achieved for only a few covariates. We introduce a new polynomial-time method for achieving both goals that substantially generalizes several existing methods; in particular, it can minimize the earthmover distance between two marginal distributions. The method involves minimum cost flow optimization in a network built around a tripartite graph, unlike the usual network built around a bipartite graph. In the tripartite graph, treated subjects appear twice, on the far left and the far right, with controls sandwiched between them, and efforts to balance covariates are represented on the right, while efforts to find close individual pairs are represented on the left. In this way, the two efforts may be pursued simultaneously without conflict. The method is applied to our on-going study in the Medicare population of the relationship between superior nursing and sepsis mortality. The match2C package in R implements the method.

Association of hospital nursing and postsurgical sepsis

Despite concerted research and clinical efforts, sepsis remains a common, costly, and often fatal occurrence. Little evidence exists for the relationship between institutional nursing resources and the incidence and outcomes of sepsis after surgery. The objective of this study was to examine whether hospital nursing resource quality is associated with postsurgical sepsis incidence and survival. This cross-sectional, secondary data analysis used registered nurses' reports on hospital nursing resources-staffing, education, and work environment-and multivariate logistic regressions to model their association with risk-adjusted postsurgical sepsis and mortality in 568 hospitals across four states. Better work environment quality was associated with lower odds of sepsis. While the likelihood of death among septic patients was nearly seven times that of non-septic patients, better nursing resources were associated with reduced mortality for all patients. Whereas the preponderance of sepsis research has focused on clinical interventions to prevent and treat sepsis, this study describes organizational characteristics hospital administrators may modify through organizational change targeting nurse staffing, education, and work environments to improve patient outcomes.

Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional study

BACKGROUND

Unrest in Chile over inequalities has underscored the need to improve public hospitals. Nursing has been overlooked as a solution to quality and access concerns, and nurse staffing is poor by international standards. Using Chile's new diagnosis-related groups system and surveys of nurses and patients, we provide information to policy makers on feasibility, net costs, and estimated improved outcomes associated with increasing nursing resources in public hospitals.

METHODS

For this multilevel cross-sectional study, we used data from surveys of hospital nurses to measure staffing and work environments in public and private Chilean adult high-complexity hospitals, which were linked with patient satisfaction survey and discharge data from the national diagnosis-related groups database for inpatients. All adult patients on medical and surgical units whose conditions permitted and who had been hospitalised for more than 48 h were invited to participate in the patient experience survey until 50 responses were obtained in each hospital. We estimated associations between nurse staffing and work environment quality with inpatient 30-day mortality, 30-day readmission, length of stay (LOS), patient experience, and care quality using multilevel random-effects logistic regression models and zero-truncated negative binomial regression models, with clustering of patients within hospitals.

FINDINGS

We collected and analysed surveys of 1652 hospital nurses from 40 hospitals (34 public and six private), satisfaction surveys of 2013 patients, and discharge data for 761 948 inpatients. Nurse staffing was significantly related to all outcomes, including mortality, after adjusting for patient characteristics, and the work environment was related to patient experience and nurses' quality assessments. Each patient added to nurses' workloads increased mortality (odds ratio 1·04, 95% CI 1·01-1·07, p<0·01), readmissions (1·02, 1·01-1·03, p<0·01), and LOS (incident rate ratio 1·04, 95% CI 1·01-1·06, p<0·05). Nurse workloads across hospitals varied from six to 24 patients per nurse. Patients in hospitals with 18 patients per nurse, compared with those in hospitals with eight patients per nurse, had 41% higher odds of dying, 20% higher odds of being readmitted, 41% higher odds of staying longer, and 68% lower odds of rating their hospital highly. We estimated that savings from reduced readmissions and shorter stays would exceed the costs of adding nurses by US$1·2 million and $5·4 million if the additional nurses resulted in average workloads of 12 or ten patients per nurse, respectively.

INTERPRETATION

Improved hospital nurse staffing in Chile was associated with lower inpatient mortality, higher patient satisfaction, fewer readmissions, and shorter hospital stays, suggesting that greater investments in nurses could return higher quality of care and greater value.

FUNDING

Sigma Theta Tau International, University of Pennsylvania Global Engagement Fund, University of Pennsylvania School of Nursing's Center for Health Outcomes, and Policy Research and Population Research Center.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals

BACKGROUND

Substantial evidence indicates that patient outcomes are more favourable in hospitals with better nurse staffing. One policy designed to achieve better staffing is minimum nurse-to-patient ratio mandates, but such policies have rarely been implemented or evaluated. In 2016, Queensland (Australia) implemented minimum nurse-to-patient ratios in selected hospitals. We aimed to assess the effects of this policy on staffing levels and patient outcomes and whether both were associated.

METHODS

For this prospective panel study, we compared Queensland hospitals subject to the ratio policy (27 intervention hospitals) and those that discharged similar patients but were not subject to ratios (28 comparison hospitals) at two timepoints: before implementation of ratios (baseline) and 2 years after implementation (post-implementation). We used standardised Queensland Hospital Admitted Patient Data, linked with death records, to obtain data on patient characteristics and outcomes (30-day mortality, 7-day readmissions, and length of stay [LOS]) for medical-surgical patients and survey data from 17 010 medical-surgical nurses in the study hospitals before and after policy implementation. Survey data from nurses were used to measure nurse staffing and, after linking with standardised patient data, to estimate the differential change in outcomes between patients in intervention and comparison hospitals, and determine whether nurse staffing changes were related to it.

FINDINGS

We included 231 902 patients (142 986 in intervention hospitals and 88 916 in comparison hospitals) assessed at baseline (2016) and 257 253 patients (160 167 in intervention hospitals and 97 086 in comparison hospitals) assessed in the post-implementation period (2018). After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio [OR] 1·07, 95% CI 0·97-1·17, p=0·18), but were significantly lower than at baseline in intervention hospitals (0·89, 0·84-0·95, p=0·0003). From baseline to post-implementation, readmissions increased in comparison hospitals (1·06, 1·01-1·12, p=0·015), but not in intervention hospitals (1·00, 0·95-1·04, p=0·92). Although LOS decreased in both groups post-implementation, the reduction was more pronounced in intervention hospitals than in comparison hospitals (adjusted incident rate ratio [IRR] 0·95, 95% CI 0·92-0·99, p=0·010). Staffing changed in hospitals from baseline to post-implementation: of the 36 hospitals with reliable staffing measures, 30 (83%) had more than 4·5 patients per nurse at baseline, with the number decreasing to 21 (58%) post-implementation. The majority of change was at intervention hospitals, and staffing improvements by one patient per nurse produced reductions in mortality (OR 0·93, 95% CI 0·86-0·99, p=0·045), readmissions (0·93, 0·89-0·97, p<0·0001), and LOS (IRR 0·97, 0·94-0·99, p=0·035). In addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing.

INTERPRETATION

Minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment.

FUNDING

Queensland Health, National Institutes of Health, National Institute of Nursing Research.

Health care costs of rheumatoid arthritis: A longitudinal population study

Quantifying the contribution of rheumatoid arthritis to the acquisition of subsequent health care costs is an emerging focus of the rheumatologic community and payers of health care. Our objective was to determine the healthcare costs before and after diagnosis of rheumatoid arthritis (RA) from the public payer's perspective. The study design was a longitudinal observational administrative data-based cohort with RA cases from Ontario Canada (n = 104,933) and two control groups, matched 1:1 on year of cohort entry from 2001 to 2016. The first control group was matched on age, sex and calendar year of cohort entry (diagnosis year for those with RA); the second group added medical history to the match before RA diagnosis year. The main exposure was new onset RA. The secondary exposure was calendar year of RA diagnosis to compare attributable costs over the study observation window. Main outcomes were health care costs in 2015 Canadian dollars, overall and by cost category. We used attribution methods to classify costs into those associated with RA, those associated with comorbidities, and age/sex-related underlying costs. Health care costs associated with RA increased up to the year of diagnosis, where they reached $8,591: $4,142 in RA associated costs; $1,242 in RA comorbidity associated costs; and $3,207 in underlying costs. In the eighth-year post diagnosis, the RA costs declined to $2,567 while the RA comorbidity associated costs remained relatively constant at $1,142, and the underlying age/sex related cost increased to $4,426. RA patients had lower costs when diagnosed in later calendar years. Our results suggest a large proportion of disease related health care costs are a result of costs associated with RA comorbidities, which may appear many years before diagnosis.

Is Hospital Nurse Staffing Legislation in the Public's Interest?: An Observational Study in New York State

BACKGROUND

The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown.

OBJECTIVES

To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs).

RESEARCH DESIGN

Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data.

SUBJECTS

A total of 417,861 Medicare medical and surgical patients.

MEASURES

Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios.

RESULTS

Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions.

CONCLUSIONS

Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.

A National Comparison of Operative Outcomes of New and Experienced Surgeons

OBJECTIVE

To determine whether outcomes achieved by new surgeons are attributable to inexperience or to differences in the context in which care is delivered and patient complexity.

BACKGROUND

Although prior studies suggest that new surgeon outcomes are worse than those of experienced surgeons, factors that underlie these phenomena are poorly understood.

METHODS

A nationwide observational tapered matching study of outcomes of Medicare patients treated by new and experienced surgeons in 1221 US hospitals (2009-2013). The primary outcome studied is 30-day mortality. Secondary outcomes were examined.

RESULTS

In total, 694,165 patients treated by 8503 experienced surgeons were matched to 68,036 patients treated by 2119 new surgeons working in the same hospitals. New surgeons' patients were older (25.8% aged ≥85 vs 16.3%,P<0.0001) with more emergency admissions (53.9% vs 25.8%,P<0.0001) than experienced surgeons' patients. Patients of new surgeons had a significantly higher baseline 30-day mortality rate compared with patients of experienced surgeons (6.2% vs 4.5%,P<0.0001;OR 1.42 (1.33, 1.52)). The difference remained significant after matching the types of operations performed (6.2% vs 5.1%, P<0.0001; OR 1.24 (1.16, 1.32)) and after further matching on a combination of operation type and emergency admission status (6.2% vs 5.6%, P=0.0007; OR 1.12 (1.05, 1.19)). After matching on operation type, emergency admission status, and patient complexity, the difference between new and experienced surgeons' patients' 30-day mortality became indistinguishable (6.2% vs 5.9%,P=0.2391;OR 1.06 (0.97, 1.16)).

CONCLUSIONS

Among Medicare beneficiaries, the majority of the differences in outcomes between new and experienced surgeons are related to the context in which care is delivered and patient complexity rather than new surgeon inexperience.

Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions

BACKGROUND

Nursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear.

OBJECTIVE

To determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources.

DESIGN

Matched cohort study of patients in 306 acute care hospitals.

PATIENTS

A total of 74,045 matched pairs of fee-for-service Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status.

MAIN MEASURES

Better (n = 76) and worse (n = 230) nursing resourced hospitals were defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs.

KEY RESULTS

Patients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%, p < 0.0001) and fewer readmissions (32.3% vs 33.6%, p < 0.0001) yet costs were not significantly different ($18,848 vs 18,671, p = 0.133). The greatest outcomes and cost advantage of better nursing resourced hospitals were in patients with sepsis who had lower mortality (25.3% vs 27.6%, p < 0.0001). Overall, patients with the highest risk of mortality on admission experienced the greatest reductions in mortality and readmission from better nursing at no difference in cost.

CONCLUSIONS

Medicare beneficiaries with common medical conditions admitted to hospitals with better nursing resources experienced more favorable outcomes at almost no difference in cost.

Comorbidities Before and After the Diagnosis of Rheumatoid Arthritis: A Matched Longitudinal Study

OBJECTIVE

To determine the contribution of rheumatoid arthritis (RA) to conditions and medical events. A secondary objective is to quantify this association before and after the introduction of biologic medications.

METHODS

All data were collected as health administrative data in Ontario, Canada. Patients with RA (n = 136 678) matched 1:1 to a pool of possible controls without RA from 1995 to 2016. The study was a retrospective longitudinal observational administrative data-based cohort study with cases (RA) and controls (two non-RA comparator groups). The main exposure was new-onset RA identified by a validated diagnosis algorithm. The secondary exposure was the calendar year, which provided a natural experiment to compare years in which biologics were unavailable (pre-2001) to increasing utilization over time. The main outcomes were counts of 27 Johns Hopkins Expanded Diagnostic Cluster Comorbid Conditions. Outcomes were reported as counts and percentage differences between cases and matched controls.

RESULTS

Patients experienced increases in conditions and medical events up to 5 years before RA disease incidence-4.9 conditions per patient-year compared with 4.6 conditions per patient-year in matched controls. Comorbidities increased to 8.7 conditions per patient-year in the year of RA incidence but were lower in the years after diagnosis-6.9 conditions per patient-year at 5 years postdiagnosis.

CONCLUSION

This study reframes the clinical manifestations of RA with detailed data on the marginal contribution of RA to conditions and medical events. These results show that a large portion of disease burden is due to the indirect effects of RA.

Measuring organizational context in Australian emergency departments and its impact on stroke care and patient outcomes

BACKGROUND

Emergency departments (ED) are challenging environments but critical for early management of patients with stroke.

PURPOSE

To identify how context affects the provision of stroke care in 26 Australian EDs.

METHOD

Nurses perceptions of ED context was assessed with the Alberta Context Tool. Medical records were audited for quality of stroke care and patient outcomes.

FINDINGS

Collectively, emergency nurses (n = 558) rated context positively with several nurse and hospital characteristics impacting these ratings. Despite these positive ratings, regression analysis showed no significant differences in the quality of stroke care (n = 1591 patients) and death or dependency (n = 1165 patients) for patients in EDs with high or low rated context.

DISCUSSION

Future assessments of ED context may need to examine contextual factors beyond the scope of the Alberta Context Tool which may play an important role for the understanding of stroke care and patient outcomes in EDs.

Case for hospital nurse-to-patient ratio legislation in Queensland, Australia, hospitals: an observational study

OBJECTIVES

To determine whether there was variation in nurse staffing across hospitals in Queensland prior to implementation of nurse-to-patient ratio legislation targeting medical-surgical wards, and if so, the extent to which nurse staffing variation was associated with poor outcomes for patients and nurses.

DESIGN

Analysis of cross-sectional data derived from nurse surveys linked with admitted patient outcomes data.

SETTING

Public hospitals in Queensland.

PARTICIPANTS

4372 medical-surgical nurses and 146 456 patients in 68 public hospitals.

MAIN OUTCOME MEASURES

30-day mortality, quality and safety indicators, nurse outcomes including emotional exhaustion and job dissatisfaction.

RESULTS

Medical-surgical nurse-to-patient ratios before implementation of ratio legislation varied significantly across hospitals (mean 5.52 patients per nurse; SD=2.03). After accounting for patient characteristics and hospital size, each additional patient per nurse was associated with 12% higher odds of 30-day mortality (OR=1.12; 95% CI 1.01 to 1.26). Each additional patient per nurse was associated with poorer outcomes for nurses including 15% higher odds of emotional exhaustion (OR=1.15; 95% CI 1.07 to 1.23) and 14% higher odds of job dissatisfaction (OR=1.14; 95% CI 1.02 to 1.28), as well as higher odds of concerns about quality of care (OR=1.12; 95% CI 1.01 to 1.25) and patient safety (OR=1.32; 95% CI 1.11 to 1.57).

CONCLUSIONS

Before ratios were implemented, nurse staffing varied considerably across Queensland hospital medical-surgical wards and higher nurse workloads were associated with patient mortality, low quality of care, nurse emotional exhaustion and job dissatisfaction. The considerable variation across hospitals and the link with outcomes suggests that taking action to improve staffing levels was prudent.

Chronic hospital nurse understaffing meets COVID-19: an observational study

Introduction

Efforts to enact nurse staffing legislation often lack timely, local evidence about how specific policies could directly impact the public’s health. Despite numerous studies indicating better staffing is associated with more favourable patient outcomes, only one US state (California) sets patient-to-nurse staffing standards. To inform staffing legislation actively under consideration in two other US states (New York, Illinois), we sought to determine whether staffing varies across hospitals and the consequences for patient outcomes. Coincidentally, data collection occurred just prior to the COVID-19 outbreak; thus, these data also provide a real-time example of the public health implications of chronic hospital nurse understaffing.

Methods

Survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 document associations of nurse staffing with care quality, patient experiences and nurse burnout.

Results

Mean staffing in medical-surgical units varied from 3.3 to 9.7 patients per nurse, with the worst mean staffing in New York City. Over half the nurses in both states experienced high burnout. Half gave their hospitals unfavourable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent and would not definitely recommend it to others. After adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavourable reports; ORs ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units.

Conclusions

Hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public’s health. Such risks could be addressed by safe nurse staffing policies currently under consideration.

Nurse Staffing, the Clinical Work Environment, and Burn Patient Mortality

The complexity of modern burn care requires an integrated team of specialty providers working together to achieve the best possible outcome for each burn survivor. Nurses are central to many aspects of a burn survivor's care, including physiologic monitoring, fluid resuscitation, pain management, infection prevention, complex wound care, and rehabilitation. Research suggests that in general, hospital nursing resources, defined as nurse staffing and the quality of the work environment, relate to patient mortality. Still, the relationship between those resources and burn mortality has not been previously examined. This study used a multivariable risk-adjusted regression model and a linked, cross-sectional claims database of more than 14,000 adults (≥18 years) thermal burn patients admitted to 653 hospitals to evaluate these relationships. Hospital nursing resources were independently reported by more than 29,000 bedside nurses working in the study hospitals. In the high burn patient-volume hospitals (≥100/y) that care for the most severe burn injuries, each additional patient added to a nurse's workload is associated with 30% higher odds of mortality (P < .05, 95% CI: 1.02-1.94), and improving the work environment is associated with 28% lower odds of death (P < .05, 95% CI: 0.07-0.99). Nursing resources are vital in the care of burn patients and are a critical, yet previously omitted, variable in the evaluation of burn outcomes. Attention to nurse staffing and improvement to the nurse work environment is warranted to promote optimal recovery for burn survivors. Given the influence of nursing on mortality, future research evaluating burn patient outcomes should account for nursing resources.

Comparing Outcomes and Costs of Surgical Patients Treated at Major Teaching and Nonteaching Hospitals: A National Matched Analysis

OBJECTIVE

To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics.

BACKGROUND

Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear.

METHODS

A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios < 0.05).We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery.

RESULTS

In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of -0.95%, <0.0001), and overall paired cost difference = $915 (P < 0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = -2.24%, P < 0.0001), and paired cost difference = $3773 (P < 0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals.

CONCLUSIONS

Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.

Patient safety attitudes among critical care nurses: A case study in North Cyprus

INTRODUCTION

Patient safety has become a crucial priority in quality healthcare. Adverse events and serious errors involving critically ill patients are common and can be potentially life-threatening. Thus, this study aimed to examine patient safety attitudes among critical care nurses.

METHODS

This cross-sectional study was conducted in two hospitals in North Cyprus. Eighty nurses working in critical care units participated in the study. Following ethical approval, data were collected between September and October 2018, using the Demographic Characteristics Questionnaire and Safety Attitudes Questionnaire.

FINDINGS

Nurses' overall scores regarding patient safety attitudes were found to be negative. The highest positive rate was for safety climate, followed by perception of management, teamwork, working conditions, job satisfaction, and stress recognition, respectively. There were significant differences among working conditions, perception of management, and stress recognition based on participants' positions and event reporting.

CONCLUSION

Our findings indicate safety culture needs to be improved in the hospitals included in the study. Healthcare managers and decision-makers should foster patient safety culture through in-service education, management support, institutional regulations, and updated guidelines.

Valuing hospital investments in nursing: multistate matched-cohort study of surgical patients

BACKGROUND

There are known clinical benefits associated with investments in nursing. Less is known about their value.

AIMS

To compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks.

METHODS

Retrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital's size category, teaching and technology status, and were closely matched on comorbidities and other risk factors.

RESULTS

Patients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (p<0.001), lower failure-to-rescue: 5.4% vs 6.2% (p<0.001), lower readmissions: 12.6% vs 13.5% (p<0.001), shorter lengths of stay: 4.70 days vs 4.76 days (p<0.001), more intensive care unit admissions: 17.2% vs 15.4% (p<0.001) and marginally higher nurse-adjusted costs (which account for the costs of better nursing resources): $20 096 vs $19 358 (p<0.001), as compared with patients in worse nursing resourced hospitals. The nurse-adjusted cost associated with a 1% improvement in mortality at better nursing hospitals was $2035. Patients with the highest mortality risk realised the greatest value from nursing resources.

CONCLUSION

Hospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.

Association between the bed-to-nurse ratio and 30-day post-discharge mortality in patients undergoing surgery: a cross-sectional analysis using Korean administrative data

Background

The likelihood of inpatient mortality has been found to be reduced by increased nurse staffing in several settings, including general wards, emergency departments, and intensive care units. However, less research has investigated cases where patients die in the community setting due to a health problem that occurred after they were discharged post-surgery, because it is difficult to integrate hospital data and local community data. Therefore, this study investigated the association between the bed-to-nurse ratio and 30-day post-discharge mortality in patients undergoing surgery using national administrative data.

Methods

The study analyzed data from 129,923 patients who underwent surgery between January 2014 and December 2015. The bed-to-nurse ratio was categorized as level 1 (less than 2.5), level 2 (2.5–3.4), level 3 (3.5–4.4), and level 4 (4.5 or greater). The chi-square test and GEE logistic regression analyses were used to explore the association between the bed-to-nurse ratio and 30-day post-discharge mortality.

Results

1355 (0.01%) patients died within 30 days post-discharge. The 30-day post-discharge mortality rate in hospitals with a level 4 was 2.5%, representing a statistically significant difference from the rates of 0.8, 2 and 1.8% in hospitals with level 1, level 2, and level 3 staffing, respectively. In addition, the death rate was significantly lower at hospitals with a level 1 (OR = 0.62) or level 2 (OR = 0.63) bed-to-nurse ratio, using level 4 as reference.

Conclusion

The results of this study are highly meaningful in that they underscore the necessity of in-hospital discharge nursing and continued post-discharge nursing care as a way to reduce post-discharge mortality risk. Furthermore, the relationship between nurse staffing levels and 30-day post-discharge mortality implies the need for a greater focus on discharge education. Policies are required to achieve proper nurse staffing levels in Korea, and thereby to enhance patient outcomes.

Comparing Outcomes and Costs of Medical Patients Treated at Major Teaching and Non-teaching Hospitals: A National Matched Analysis

BACKGROUND

Teaching hospitals typically pioneer investment in new technology and cultivate workforce characteristics generally associated with better quality, but the value of this extra investment is unclear.

OBJECTIVE

Compare outcomes and costs between major teaching and non-teaching hospitals by closely matching on patient characteristics.

DESIGN

Medicare patients at 339 major teaching hospitals (resident-to-bed (RTB) ratios ≥ 0.25); matched patient controls from 2439 non-teaching hospitals (RTB ratios < 0.05).

PARTICIPANTS

Forty-three thousand nine hundred ninety pairs of patients (one from a major teaching hospital and one from a non-teaching hospital) admitted for acute myocardial infarction (AMI), 84,985 pairs admitted for heart failure (HF), and 74,947 pairs admitted for pneumonia (PNA).

EXPOSURE

Treatment at major teaching hospitals versus non-teaching hospitals.

MAIN MEASURES

Thirty-day all-cause mortality, readmissions, ICU utilization, costs, payments, and value expressed as extra cost for a 1% improvement in survival.

KEY RESULTS

Thirty-day mortality was lower in teaching than non-teaching hospitals (10.7% versus 12.0%, difference = - 1.3%, P < 0.0001). The paired cost difference (teaching - non-teaching) was $273 (P < 0.0001), yielding $211 per 1% mortality improvement. For the quintile of pairs with highest risk on admission, mortality differences were larger (24.6% versus 27.6%, difference = - 3.0%, P < 0.0001), and paired cost difference = $1289 (P < 0.0001), yielding $427 per 1% mortality improvement at 30 days. Readmissions and ICU utilization were lower in teaching hospitals (both P < 0.0001), but length of stay was longer (5.5 versus 5.1 days, P < 0.0001). Finally, individual results for AMI, HF, and PNA showed similar findings as in the combined results.

CONCLUSIONS AND RELEVANCE

Among Medicare patients admitted for common medical conditions, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used.

Impact of certification status of the institute and surgeon on short-term outcomes after surgery for thoracic esophageal cancer: evaluation using data on 16,752 patients from the National Clinical Database in Japan

BACKGROUND

In 2009, the Japan Esophageal Society (JES) established a system for certification of qualified surgeons as "Board Certified Esophageal Surgeons" (BCESs) or institutes as "Authorized Institutes for Board Certified Esophageal Surgeons" (AIBCESs). We examined the short-term outcomes after esophagectomy, taking into consideration the certifications statuses of the institutes and surgeons.

METHODS

This study investigated patients who underwent esophagectomy for thoracic esophageal cancer and who were registered in the Japanese National Clinical Database (NCD) between 2015 and 2017. Using hierarchical multivariable logistic regression analysis adjusted for patient-level risk factors, we determined whether the institute's or surgeon's certification status had greater influence on surgery-related mortality or postoperative complications.

RESULTS

Enrolled were 16,752 patients operated on at 854 institutes by 1879 surgeons. There were significant differences in the backgrounds and incidences of postoperative complications and surgery-related mortality rates between the 11,162 patients treated at AIBCESs and the 5590 treated at Non-AIBCESs (surgery-related mortality rates: 1.6% vs 2.8%). There were also differences between the 6854 patients operated on by a BCES and the 9898 treated by a Non-BCES (1.7% vs 2.2%). Hierarchical logistic regression analysis revealed that surgery-related mortality was significantly lower among patients treated at AIBCESs. The institute's certification had greater influence on short-term surgical outcomes than the operating surgeon's certification.

CONCLUSIONS

The certification system for surgeons and institutes established by the JES appears to be appropriate, as indicated by the improved surgery-related mortality rate. It also appears that the JES certification system contributes to a more appropriate medical delivery system for thoracic esophageal cancer in Japan.

Nursing home work environment, care quality, registered nurse burnout and job dissatisfaction

The objective of this cross-sectional study was to examine the relationships between work environment, care quality, registered nurse (RN) burnout, and job dissatisfaction in nursing homes. We linked 2015 RN4CAST-US nurse survey data with LTCfocus and Nursing Home Compare. The sample included 245 Medicare and Medicaid-certified nursing homes in four states, and 674 of their RN employees. Nursing homes with good vs. poor work environments, had 1.8% fewer residents with pressure ulcers (p = .02) and 16 fewer hospitalizations per 100 residents per year (p = .05). They also had lower antipsychotic use, but the difference was not statistically significant. RNs were one-tenth as likely to report job dissatisfaction (p < .001) and one-eighth as likely to exhibit burnout (p < .001) when employed in good vs. poor work environments. These results suggest that the work environment is an important area to target for interventions to improve care quality and nurse retention in nursing homes.