Do higher hospital-wide nurse staffing levels reduce in-hospital mortality in elderly patients with hip fractures: a pilot study

Does improved nurse staffing impact patient outcomes in cancer? Association between chronic diseases and mortality among older adult patients with lung cancer in Korea

BACKGROUND

Evidence regarding the impact of nurse staffing on the health outcomes of older adult patients with cancer is scarce. Therefore, this study aimed to evaluate the impact of nurse staffing on long-term and short-term mortality in elderly lung cancer patients.

METHODS

This study analyzed data from 5,832 patients with lung cancer in Korea from 2008 to 2018. Nursing grade was considered to assess the effect of nursing staff on mortality in older adult patients with lung cancer. The Cox proportional hazards model was used to evaluate the effect of the initial treatment hospital's nursing grade on one- and five-year mortality. Additionally, economic status and treatment type of patients were analyzed.

RESULTS

Approximately 31% of older adult patients with lung cancer died within one year post-diagnosis. Patients in hospitals with superior nursing grades (lower nurse-to-bed ratios) exhibited lower mortality rates. Hospitals with nursing grades 2 and 3 exhibited approximately 1.242-1.289 times higher mortality than grade 1 hospitals. Further, the lower the nursing grade (higher nurse-to-bed ratio), the higher the five-year mortality rate.

CONCLUSION

Both short- and long-term mortality rates for older adult patients with lung cancer increased at inferior nursing grades. Treatment in hospitals having inferior nursing grades, upon initial hospitalization, may yield better outcomes. This study provides valuable insight into the quality of adequate staffing to improve the quality of care for elderly cancer patients.

The influence of hospital-level variables on hip fracture outcomes

AIMS

The aim of this study was to determine the impact of hospital-level service characteristics on hip fracture outcomes and quality of care processes measures.

METHODS

This was a retrospective analysis of publicly available audit data obtained from the National Hip Fracture Database (NHFD) 2018 benchmark summary and Facilities Survey. Data extraction was performed using a dedicated proforma to identify relevant hospital-level care process and outcome variables for inclusion. The primary outcome measure was adjusted 30-day mortality rate. A random forest-based multivariate imputation by chained equation (MICE) algorithm was used for missing value imputation. Univariable analysis for each hospital level factor was performed using a combination of Tobit regression, Siegal non-parametric linear regression, and Mann-Whitney U test analyses, dependent on the data type. In all analyses, a p-value < 0.05 denoted statistical significance.

RESULTS

Analyses included 176 hospitals, with a median of 366 hip fracture cases per year (interquartile range (IQR) 280 to 457). Aggregated data from 66,578 patients were included. The only identified hospital-level variable associated with the primary outcome of 30-day mortality was hip fracture trial involvement (no trial involvement: median 6.3%; trial involvement: median 5.7%; p = 0.039). Significant key associations were also identified between prompt surgery and presence of dedicated hip fracture sessions; reduced acute length of stay and both a higher number of hip fracture cases per year and more dedicated hip fracture operating lists; Best Practice Tariff attainment and greater number of hip fracture cases per year, more dedicated hip fracture operating lists, presence of a dedicated hip fracture ward, and hip fracture trial involvement.

CONCLUSION

Exploratory analyses have identified that improved outcomes in hip fracture may be associated with hospital-level service characteristics, such as hip fracture research trial involvement, larger hip fracture volumes, and the use of theatre lists dedicated to hip fracture surgery. Further research using patient level data is warranted to corroborate these findings. Cite this article: Bone Joint J 2021;103-B(10):1627-1632.

Improvement Plan of Nurse Staffing Standards in Korea

PURPOSE

This study compares the expected nurse-to-patient ratio, penalties for violating these regulations, and the laws enacted in the medical and nursing fields in Korea and advanced countries like Germany, Australia, the United States, and Japan.

METHODS

This study deployed an integrative review method and used search terms such as "nursing law," "nurse ratio," "nurse," "nurse staffing," "health," and "staffing" to find articles published in English, Korean, German, or Japanese through Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, the Westlaw (International Materials-Jurisdiction) site, US government and state sites (federal parliament, National Conference of State Legislatures), and Google Scholar.

RESULTS

Compared with medical laws in other advanced countries, Korean laws are quite crude and its nurse-to-patient ratio does not reflect patients' status. Korea also lacks strict penalties for nurse staffing ratio violations.

CONCLUSION

Korea requires a strong regulatory apparatus for nurse staffing in health-care organizations to improve the quality of its health-care services and patient safety.

Seasonality in incidence and mortality of hip fracture

OBJECTIVES

To determine whether there is a seasonal relationship in the incidence and in-hospital mortality of patients with hip fracture.

PATIENTS AND METHODS

Longitudinal descriptive study of cases that included 1104 patients older than 64years admitted for fracture of the proximal extremity of the femur in the Hospital HCU Virgen de la Victoria during a period of 30months The epidemiological characteristics of the patients were recorded and the monthly incidence of fractures was related with the month of the year in which it occurred, as well as with the meteorological conditions, temperature and rainfall.

RESULTS

The study population comprised a total of 1104 patients, with a greater proportion of women (75.1%). The average age was 82.3years. A tendency towards an increased incidence of these fractures was found. The in-hospital annual mortality rate was 2.97%, higher for men and in the age group over 84years. Seasonality was found in terms of the incidence of fractures above the average in the month of October and below this in the month of February. On the other hand, mortality was lower than the average in the month of March and higher in August. In both, a low correlation with temperature and rainfall was found.

CONCLUSIONS

The seasonal distribution of hip fractures presented an increase over the average in the month of October and a decrease in February. Mortality increased over the average in the month of August and decreased in March.

Nurse-staffing level and quality of acute care services: Evidence from cross-national panel data analysis in OECD countries

Background

Most of previous studies aimed to estimate the effect of nurse staffing on quality of acute hospital care have used stochastic methods and their results are mixed.

Objective

To measure the magnitude of effect of nurse-staffing level on increasing quality of acute care services in long-run.

Data

The number of practicing nurses’ density per 1000 population as the proxy of nurse-staffing level and three Health Care Quality Indicators (HCQI) included 30-day mortality per 100 patients based on acute myocardial infarction (MORTAMIO), hemorrhagic stroke (MORTHSTO) and ischemic stroke (MORTISTO) were collected as a part of ongoing project by OECD.org in panels of 26 OECD countries over 2005–2015 period.

Method

Panel data analysis.

Results

There were committed relationships from nurse-staffing level to the enhancement of HCQI i.e. 1% increase in nurse-staffing level would reduce the rates of patient mortality based on MORTAMIO, MORTHSTO and MORTISTO by 0.65%, 0.60% and 0.80%, respectively. Furthermore, the role of nurse-staffing level in increasing overall HCQI were simulated at the highest level in Sweden (−3.53), Denmark (−3.31), Canada (−2.59), Netherlands (−2.33), Finland (−2.09), Switzerland (−1.72), Australia (−1.64) and United States (−1.53).

Conclusion

A higher proportion of nurses-staffing level is associated with higher quality of acute care services in OECD countries. Also, the nursing characteristics of Sweden, Denmark, Canada, Netherlands, Finland, Switzerland, Australia and United States would be good patterns for other countries to maximize nursing outcomes in the care of patients with acute and life-threatening conditions by reducing the risk of complication, mortality and adverse clinical outcomes.

The independent patient factors that affect length of stay following hip fractures

Introduction Management of hip fractures has evolved over recent years to drive better outcomes including length of hospital stay. We aimed to identify and quantify the effect that patient factors influence acute hospital and total health service length of stay. Methods A retrospective observational study based on National Hip Fracture Database data was conducted from 1 January 2014 to 31 December 2015. A multiple regression analysis of 330 patients was carried out to determine independent factors that affect acute hospital and total hospital length of stay. Results American Society of Anesthesiologists (ASA) grade 3 or above, Abbreviated Mental Test Score (AMTS) less than 8 and poor mobility status were independent factors, significantly increasing length of hospital stay in our population. Acute hospital length of stay can be predicted as 8.9 days longer when AMTS less than 8, 4.2 days longer when ASA grade was 3 or above and 20.4 days longer when unable to mobilise unaided (compared with independently mobile individuals). Other factors including total hip replacement compared with hemiarthroplasty did not independently affect length of stay. Conclusions Our analysis in a representative and generalisable population illustrates the importance of identifying these three patient characteristics in hip fracture patients. When recognised and targeted with orthogeriatric support, the length of hospital stay for these patients can be reduced and overall hip fracture care improved. Screening on admission for ASA grade, AMTS and mobility status allows prediction of length of stay and tailoring of care to match needs.

Seventy Years of RN Effectiveness: A Database Development Project to Inform Best Practice

BACKGROUND

The appropriate nursing staff mix is imperative to the provision of quality care. Nurse staffing levels and staff mix vary from country to country, as well as between care settings. Understanding how staffing skill mix impacts patient, organizational, and financial outcomes is critical in order to allow policymakers and clinicians to make evidence-informed staffing decisions.

AIMS

This paper reports on the methodology for creation of an electronic database of studies exploring the effectiveness of Registered Nurses (RNs) on clinical and patient outcomes, organizational and nurse outcomes, and financial outcomes.

METHODS

Comprehensive literature searches were conducted in four electronic databases. Inclusion criteria for the database included studies published from 1946 to 2016, peer-reviewed international literature, and studies focused on RNs in all health-care disciplines, settings, and sectors. Masters-prepared nurse researchers conducted title and abstract screening and relevance review to determine eligibility of studies for the database. High-level analysis was conducted to determine key outcomes and the frequency at which they appeared within the database.

RESULTS

Of the initial 90,352 records, a total of 626 abstracts were included within the database. Studies were organized into three groups corresponding to clinical and patient outcomes, organizational and nurse-related outcomes, and financial outcomes. Organizational and nurse-related outcomes represented the largest category in the database with 282 studies, followed by clinical and patient outcomes with 244 studies, and lastly financial outcomes, which included 124 studies.

LINKING EVIDENCE TO ACTION

The comprehensive database of evidence for RN effectiveness is freely available at https://rnao.ca/bpg/initiatives/RNEffectiveness. The database will serve as a resource for the Registered Nurses' Association of Ontario, as well as a tool for researchers, clinicians, and policymakers for making evidence-informed staffing decisions.

Socioeconomic Inequality in One-Year Mortality of Elderly People with Hip Fracture in Taiwan

Hip fracture commonly results in considerable consequences in terms of disability, mortality, long-term institutional care and cost. Taiwan launched its universal health insurance coverage in 1995, which largely removes financial barriers to health care. This study aims to investigate whether socioeconomic inequality in one-year mortality exists among Taiwanese elderly people. This population-based cohort study included 193,158 elderly patients (≥65 years) admitted for hip fracture between 2000 and 2012. With over a one-year follow-up, 10.52% of the participants died from all causes. The mortality rate was low in the northern part of Taiwan and in urban and high-family-income areas. Multiple Poisson regression models further suggested that the level of >Q1-Q3 and >Q3-Max showed significantly reduced odds ratio of one-year mortality at 0.90 (95% confidence interval (CI), 0.87-0.93) and 0.77 (95% CI, 0.74-0.81), respectively, compared with that of the lowest family income level (i.e., Min.-Q1). Despite a monotonic decline in overall one-year mortality during the study period, socioeconomic inequality in one-year mortality rate remained evident. The annual percentage change in one-year mortality was higher (-2.86) in elderly people from families with high income (>Q3-Max.) than that for elderly patients from family with low income (Min.-Q1, -1.94). Accessibility, rather than affordability, to health care for hip fracture is probably responsible for the observed socioeconomic inequality.

Mortality by Timing of Hip Fracture Surgery: Factors and Relationships at Play

In hip fracture care, it is disputed whether mortality worsens when surgery is delayed. This knowledge gap matters when hospital managers seek to justify resource allocation for prioritizing access to one procedure over another. Uncertainty over the surgical timing-death association leads to either surgical prioritization without benefit or the underuse of expedited surgery when it could save lives. The discrepancy in previous findings results in part from differences between patients who happened to undergo surgery at different times. Such differences may produce the statistical association between surgical timing and death in the absence of a causal relationship. Previous observational studies attempted to adjust for structure, process, and patient factors that contribute to death, but not for relationships between structure and process factors, or between patient and process factors. In this article, we (1) summarize what is known about the factors that influence, directly or indirectly, both the timing of surgery and the occurrence of death; (2) construct a dependency graph of relationships among these factors based explicitly on the existing literature; (3) consider factors with a potential to induce covariation of time to surgery and the occurrence of death, directly or through the network of relationships, thereby explaining a putative surgical timing-death association; and (4) show how age, sex, dependent living, fracture type, hospital type, surgery type, and calendar period can influence both time to surgery and occurrence of death through chains of dependencies. We conclude by discussing how these results can inform the allocation of surgical capacity to prevent the avoidable adverse consequences of delaying hip fracture surgery.

Factors increasing mortality of the elderly following hip fracture surgery: role of body mass index, age, and smoking

OBJECTIVES

Hip fracture is one of the most common public health problems with a significant financial burden on the patient and on the healthcare system. This study was conducted to assess the 3-month and 1-year mortality rates of patients with operated hip fractures and to determine the influence of predictors of mortality.

METHODS

In this prospective cross-sectional study, all admitted patients aged more than 50 years with hip fracture at Chamran Hospital from January 2008 to August 2013 were enrolled. The characteristic data obtained included demographic information, body mass index (BMI), smoking, any previous history of osteoporotic fracture, and comorbidities. In addition, the mechanism of fracture, fracture type, and treatment method were recorded. A follow-up with the patients was conducted at 3 months and 1 year through a telephonic interview to ask about possible mortalities. Statistical analyses were performed using SPSS software version 17.0 for Windows.

RESULTS

A total of 1015 patients aged 50 years and older with hip fracture underwent surgery. Only 724 patients (71.3 %) completed the survey and the 1-year follow-up interview. The mean age was 75.7 ± 10.6 years. Overall, the 3-month and 1-year mortality rates were 14.5 and 22.4 %, respectively. Multivariate logistic regression analysis recognized age (OR 1.08; 95 % CI 1.05, 1.11, p < 0.001), BMI (OR 0.88; 95 % CI 0.82, 0.96, p = 0.003), and smoking (OR 1.76; 95 % CI 1.05, 2.96, p = 0.03) as major independent risk factors for mortality.

CONCLUSION

It is clear that modifiable factors like quitting the habit of smoking and gaining more energy with better nutrition could reduce the mortality rate if hip fracture occurs in the elderly.

Patient and system factors of mortality after hip fracture: a scoping review

Background

Several patient and health system factors were associated with the risk of death among patients with hip fracture. However, without knowledge of underlying mechanisms interventions to improve survival post hip fracture can only be designed on the basis of the found statistical associations.

Methods

We used the framework developed by Arksey and O’Malley and Levac et al. for synthesis of factors and mechanisms of mortality post low energy hip fracture in adults over the age of 50 years, published in English, between September 1, 2009 and October 1, 2014 and indexed in MEDLINE. Proposed mechanisms for reported associations were extracted from the discussion sections.

Results

We synthesized the evidence from 56 articles that reported on 35 patient and 9 system factors of mortality post hip fracture. For 21 factors we found proposed biological mechanisms for their association with mortality which included complications, comorbidity, cardiorespiratory function, immune function, bone remodeling and glycemic control.

Conclusions

The majority of patient and system factors of mortality post hip fracture were reported by only one or two articles and with no proposed mechanisms for their effects on mortality. Where reported, underlying mechanisms are often based on a single article and should be confirmed with further study. Therefore, one cannot be certain whether intervening on such factors may produce expected results.

The influence of informal caregivers on the rehabilitation of the elderly in the postoperative period of proximal femoral fracture

Objective To analyze the influence of informal caregivers on the functional independence of older adults in the postoperative period of proximal femoral fracture due to falls. Method It is an integrative review of a corpus for analysis that gathered 23 articles, between 2002 and 2012, from databases "Literatura Latino-Americana e do Caribe em Ciências da Saúde" (Latin-American and Caribbean Health Sciences Literature in Health Sciences), Cumulative Index to Nursing and Allied Health Literature, US National Library of Medicine and Scopus. Results There was a predominance of studies by Chinese authors and nurses. The analysis of the studies evidenced that falls followed by fractures lead to dependence of older adults and, consequently, an overload to caregivers. Moreover, older adults and caregivers showed a need for support in the rehabilitation process. Conclusions Informal caregivers still need to be included in care planning and to be qualified for such care by health professionals, since they positively influence functional independence in the postoperative period.

Intensive care monitoring after total joint replacement

Patient safety is a critical issue in elective total joint replacement surgery. Identifying risk factors that might predict complications and intensive care unit (ICU) admission proves instrumental in reducing morbidity and mortality. The institution's experience with risk stratification and pre-operative ICU triage has resulted in a reduction in unplanned ICU admissions and post-operative complications after total hip replacement. The application of the prediction tools to total knee replacement has proven less robust so far. This work also reviews areas for future research in patient safety and cost containment.

Prospective study of unplanned admission to the intensive care unit after total hip arthroplasty

The morbidity associated with elective total hip arthroplasty (THA) may result in intensive care unit (ICU) admission. A total of 175 consecutive THA patients were prospectively triaged to either an ICU bed or routine post-operative floor according to admission criteria based on a prior published study of 1259 THA patients. Primary end points were a reduction in unplanned ICU admission, as well as major complications. With our triage model, the rate of unplanned ICU admissions dropped from 7.1% to 2.2% (P=0.013). The as-treated odds of unplanned admission pre- versus post-intervention were 3.2 (1.2, 10.6). The complication rate fell from 12.5% to 2%, and the mortality index decreased from 4.77 to 1.62. Triage according to selected risk factors affects a reduction in unplanned ICU admissions and major complications after THA.

Postdischarge outcomes in heart failure are better for teaching hospitals and weekday discharges

BACKGROUND

It is unclear whether teaching status or day of discharge influences outcomes after a heart failure hospitalization.

METHODS AND RESULTS

We evaluated adults discharged after a heart failure hospitalization between 1999 and 2009 in Alberta, Canada. The primary outcome was death or nonelective readmission 30 days postdischarge. Of 12 216 patients discharged from teaching hospitals and 12 157 patients from nonteaching hospitals, 20 524 (84%) discharges occurred on weekdays. Although they had greater comorbidity and used more healthcare resources before their heart failure hospitalization, patients discharged from teaching hospitals exhibited shorter lengths of stay (adjusted ratio, 0.83; 95% confidence interval [CI], 0.80-0.86) and significantly lower rates of death or readmission in the 30 days after discharge than those discharged from nonteaching hospitals (17.4% versus 22.1%; adjusted hazard ratio [aHR], 0.83; 95% CI, 0.77-0.89). Patients discharged on weekdays were older and had greater comorbidity, yet exhibited significantly lower rates of death or readmission at 30 days than those discharged on weekends (19.5% versus 21.1%; aHR, 0.87; 95% CI, 0.80-0.94). Compared with weekend discharge from a nonteaching hospital, 30-day death/readmission rates were lower for weekday discharge from a nonteaching hospital (aHR, 0.85; 95% CI, 0.77-0.94), weekend discharge from a teaching hospital (aHR, 0.80; 95% CI, 0.69-0.92), and weekday discharge from a teaching hospital (aHR, 0.71, 95% CI, 0.63-0.79).

CONCLUSIONS

Patients discharged from teaching hospitals or on weekdays exhibited better outcomes despite having higher risk profiles. Future studies should focus on distinguishing which discharge processes differ between teaching and nonteaching hospitals and between weekdays and weekends to define those that optimize patient outcomes.

Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: retrospective cohort study

OBJECTIVES

To identify rates of potentially preventable complications for dementia patients compared with non-dementia patients.

DESIGN

Retrospective cohort design using hospital discharge data for dementia patients, case matched on sex, age, comorbidity and surgical status on a 1 : 4 ratio to non-dementia patients.

SETTING

Public hospital discharge data from the state of New South Wales, Australia for 2006/2007.

PARTICIPANTS

426 276 overnight hospital episodes for patients aged 50 and above (census sample).

MAIN OUTCOME MEASURES

Rates of preventable complications, with episode-level risk adjustment for 12 complications that are known to be sensitive to nursing care.

RESULTS

Controlling for age and comorbidities, surgical dementia patients had higher rates than non-dementia patients in seven of the 12 complications: urinary tract infections, pressure ulcers, delirium, pneumonia, physiological and metabolic derangement (all at p<0.0001), sepsis and failure to rescue (at p<0.05). Medical dementia patients also had higher rates of these complications than did non-dementia patients. The highest rates and highest relative risk for dementia patients compared with non-dementia patients, in both medical and surgical populations, were found in four common complications: urinary tract infections, pressure areas, pneumonia and delirium.

CONCLUSIONS

Compared with non-dementia patients, hospitalised dementia patients have higher rates of potentially preventable complications that might be responsive to nursing interventions.

Risk factors affecting inhospital mortality after hip fracture: retrospective analysis using the Japanese Diagnosis Procedure Combination Database

OBJECTIVE

To identify risk factors for inhospital mortality in patients with hip fractures using the Japanese Diagnosis Procedure Combination (DPC) nationwide administrative claims database.

DESIGN

Retrospective observational study.

SETTING

Hospitals adopting the DPC system during 2007-2009.

PARTICIPANTS

The authors analysed a total of 80 800 eligible patients aged ≥60 years with a single hip fracture (International Classification of Diseases, 10th Revision codes: S72.0 and S72.1). The DPC database includes patients treated between July and December each year.

MAIN OUTCOME MEASURES

Inhospital mortality after hip fracture.

RESULTS

The overall inhospital mortality rate after hip fractures was 3.3%. Multivariate analysis indicated that inhospital mortality was significantly associated with male gender (OR 2.12, 95% CI 1.94 to 2.31), advancing age and number of comorbidities. Significantly higher mortality was observed in those treated conservatively (OR 4.25, 95% CI 3.92 to 4.61). Surgical delays of 5 days or more were significantly associated with higher rates of inhospital mortality (OR 1.34, 95% CI 1.20 to 1.50).

CONCLUSIONS

In patients with hip fractures, male gender, advancing age, high number of comorbidities, conservative treatment and the surgical delay of 5 days or more were associated with higher rates of inhospital mortality.