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Riman KA, Davis BS, Seaman JB, Kahn JM. Association Between Nurse Copatient Illness Severity and Mortality in the ICU. Crit Care Med 2024; 52:182-189. [PMID: 37846937 PMCID: PMC10840670 DOI: 10.1097/ccm.0000000000006066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
OBJECTIVES In the context of traditional nurse-to-patient ratios, ICU patients are typically paired with one or more copatients, creating interdependencies that may affect clinical outcomes. We aimed to examine the effect of copatient illness severity on ICU mortality. DESIGN We conducted a retrospective cohort study using electronic health records from a multihospital health system from 2018 to 2020. We identified nurse-to-patient assignments for each 12-hour shift using a validated algorithm. We defined copatient illness severity as whether the index patient's copatient received mechanical ventilation or vasoactive support during the shift. We used proportional hazards regression with time-varying covariates to assess the relationship between copatient illness severity and 28-day ICU mortality. SETTING Twenty-four ICUs in eight hospitals. PATIENTS Patients hospitalized in the ICU between January 1, 2018, and August 31, 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The main analysis included 20,650 patients and 84,544 patient-shifts. Regression analyses showed a patient's risk of death increased when their copatient received both mechanical ventilation and vasoactive support (hazard ratio [HR]: 1.30; 95% CI, 1.05-1.61; p = 0.02) or vasoactive support alone (HR: 1.82; 95% CI, 1.39-2.38; p < 0.001), compared with situations in which the copatient received neither treatment. However, if the copatient was solely on mechanical ventilation, there was no significant increase in the risk of death (HR: 1.03; 95% CI, 0.86-1.23; p = 0.78). Sensitivity analyses conducted on cohorts with varying numbers of copatients consistently showed an increased risk of death when a copatient received vasoactive support. CONCLUSIONS Our findings suggest that considering copatient illness severity, alongside the existing practice of considering individual patient conditions, during the nurse-to-patient assignment process may be an opportunity to improve ICU outcomes.
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Affiliation(s)
- Kathryn A Riman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Billie S Davis
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jennifer B Seaman
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Xue X, Qiao J, Li Y, Zhang Q, Wang Y, Wang J, Xu C. Relationship between work engagement and healthy work environment among Chinese ICU nurses: The mediating role of psychological capital. Nurs Open 2023; 10:6248-6257. [PMID: 37340687 PMCID: PMC10416072 DOI: 10.1002/nop2.1866] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 03/02/2023] [Accepted: 05/09/2023] [Indexed: 06/22/2023] Open
Abstract
AIM To evaluate the relationship between healthy work environment and work engagement considering the effect of psychological capital among ICU nurses. DESIGN The study was cross-sectional design. METHODS The subjects were 671 registered nurses from 20 ICUs in 18 general hospitals in Shandong province between October 2021 and December 2021. The questionnaires testing nurses' perception of healthy work environment, their work engagement, and psychological capital were used. Structural equation modeling was used to explore their relationship. RESULTS Work engagement was positively affected by a healthy work environment and psychological capital. The structural equation modeling showed psychological capital mediated the relationship between healthy work environment and their work engagement. PATIENT OR PUBLIC CONTRIBUTION There were 681 clinical nurses reported at public contribution for responding to the questionnaires and providing valuable data for the study and there was no patient contribution in this study.
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Affiliation(s)
- Xiujuan Xue
- Department of Critical Care MedicineThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
| | - Jianhong Qiao
- Department of NursingThe First Affiliated Hospital of Shandong First Medical. University & Shandong Provincial Qianfoshan HospitalJinanChina
| | - Yupei Li
- School of NursingShandong First Medical University & Shandong Academy of Medical SciencesJinanChina
| | - Qiuyue Zhang
- School of NursingShandong First Medical University & Shandong Academy of Medical SciencesJinanChina
| | - Yeqing Wang
- Department of Critical Care MedicineThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
| | - Jianhao Wang
- Department of Critical Care MedicineThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
| | - Cuiping Xu
- Department of NursingThe First Affiliated Hospital of Shandong First Medical. University & Shandong Provincial Qianfoshan HospitalJinanChina
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Keats K, Sikora A, Heavner MS, Chen X, Smith SE. Optimizing Pharmacist Team-Integration for ICU Patient Management: Rationale, Study Design, and Methods for a Multicentered Exploration of Pharmacist-to-Patient Ratio. Crit Care Explor 2023; 5:e0956. [PMID: 37644971 PMCID: PMC10461940 DOI: 10.1097/cce.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The workload of healthcare professionals including physicians and nurses in the ICU has an established relationship to patient outcomes, including mortality, length of stay, and other quality indicators; however, the relationship of critical care pharmacist workload to outcomes has not been rigorously evaluated and determined. The objective of our study is to characterize the relationship of critical care pharmacist workload in the ICU as it relates to patient-centered outcomes of critically ill patients. METHODS Optimizing Pharmacist Team-Integration for ICU patient Management is a multicenter, observational cohort study with a target enrollment of 20,000 critically ill patients. Participating critical care pharmacists will enroll patients managed in the ICU. Data collection will consist of two observational phases: prospective and retrospective. During the prospective phase, critical care pharmacists will record daily workload data (e.g., census, number of rounding teams). During the retrospective phase, patient demographics, severity of illness, medication regimen complexity, and outcomes will be recorded. The primary outcome is mortality. Multiple methods will be used to explore the primary outcome including multilevel multiple logistic regression with stepwise variable selection to exclude nonsignificant covariates from the final model, supervised and unsupervised machine learning techniques, and Bayesian analysis. RESULTS Our protocol describes the processes and methods for an observational study in the ICU. CONCLUSIONS This study seeks to determine the relationship between pharmacist workload, as measured by pharmacist-to-patient ratio and the pharmacist clinical burden index, and patient-centered outcomes, including mortality and length of stay.
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Affiliation(s)
- Kelli Keats
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA
| | - Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA
| | - Mojdeh S Heavner
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Xianyan Chen
- Department of Statistics, University of Georgia Franklin College of Arts and Sciences, Athens, GA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA
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McLean B, Thompson D. MRI and the Critical Care Patient: Clinical, Operational, and Financial Challenges. Crit Care Res Pract 2023; 2023:2772181. [PMID: 37325272 PMCID: PMC10264715 DOI: 10.1155/2023/2772181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/03/2023] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
Neuroimaging in conjunction with a neurologic examination has become a valuable resource for today's intensive care unit (ICU) physicians. Imaging provides critical information during the assessment and ongoing neuromonitoring of patients for toxic-metabolic or structural injury of the brain. A patient's condition can change rapidly, and interventions may require imaging. When making this determination, the benefit must be weighed against possible risks associated with intrahospital transport. The patient's condition is assessed to decide if they are stable enough to leave the ICU for an extended period. Intrahospital transport risks include adverse events related to the physical nature of the transport, the change in the environment, or relocating equipment used to monitor the patient. Adverse events can be categorized as minor (e.g., clinical decompensation) or major (e.g., requiring immediate intervention) and may occur in preparation or during transport. Regardless of the type of event experienced, any intervention during transport impacts the patient and may lead to delayed treatment and disruption of critical care. This review summarizes the commentary on the current literature on the associated risks and provides insight into the costs as well as provider experiences. Approximately, one-third of patients who are transported from the ICU to an imaging suite may experience an adverse event. This creates an additional risk for extending a patient's stay in the ICU. The delay in obtaining imaging can negatively impact the patient's treatment plan and affect long-term outcomes as increased disability or mortality. Disruption of ICU therapy can decrease respiratory function after the patient returns from transport. Because of the complex care team needed for patient transport, the staff time alone can cost $200 or more. New technologies and advancements are needed to reduce patient risk and improve safety.
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Affiliation(s)
- Barbara McLean
- Division of Emergency Services and Critical Care, Grady Health System, Atlanta, GA, USA
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Kim Y, Kim SH. The Relationship of Nurse and Physician Staffing in Intensive Care Units with Patient Outcomes in Postoperative Patients on Ventilators: An Analysis Using Korean National Health Insurance Data. Healthcare (Basel) 2023; 11:healthcare11081124. [PMID: 37107958 PMCID: PMC10138417 DOI: 10.3390/healthcare11081124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/17/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
This study examined the associations of nurse and physician staffing in intensive care units (ICUs) with hospital-acquired pneumonia (HAP) incidence and in-hospital mortality in postoperative patients on ventilators. National Health Insurance claims data and death statistics were used to investigate the nurse staffing level and the presence or absence of a dedicated resident and specialist in each ICU. The participants were patients aged 20-85 who underwent any of 13 surgical procedures and were placed on a ventilator in the ICU after the procedure. Of 11,693 patients, 307 (2.6%) experienced HAP and 1280 (10.9%) died during hospitalization. Compared to hospitals with lower nurse-to-patient ratios, patients in hospitals with higher ratios had statistically significantly higher risks of HAP and in-hospital mortality. The presence of a dedicated resident in the ICU did not statistically significantly affect HAP incidence or in-hospital mortality. The presence of an ICU specialist was statistically significantly associated with in-hospital mortality but not HAP incidence. Our findings suggest that a higher level of nursing staff in the ICU is inversely associated with HAP incidence. The legal standards for nurse staffing in the ICU should be strengthened in order to improve the quality of care and patient safety.
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Affiliation(s)
- Yunmi Kim
- Department of Nursing, Eulji University, Seongnam 13135, Republic of Korea
| | - Seon-Ha Kim
- Department of Nursing, Dankook University, Cheonan 31116, Republic of Korea
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Nursing Work Environment Staffing Councils: An Alternative to Mandatory Regulated Staffing Ratios. J Nurs Adm 2022; 52:419-426. [PMID: 35857913 DOI: 10.1097/nna.0000000000001175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to examine the self-reported perceptions of the healthy work environment (HWE) of nurses who are members of Nursing Workplace Environment and Staffing Councils (NWESCs). BACKGROUND In a statewide initiative, NWESCs were established at hospitals throughout the state of New Jersey as an alternative to nurse staffing ratio laws and to provide clinical nurses a voice in determining resources needed for patient care and support an HWE. METHODS This quantitative descriptive study presents the results of the Healthy Workplace Environment Assessment Tool (HWEAT) and open-ended questions about NWESCs among a sample of 352 nurses. RESULTS Three years after NWESC implementation, all HWEAT standard mean scores increased and were rated higher than the American Association of Critical-Care Nurses benchmark. There were statistically significant differences in clinical nurses' perceptions of an HWE compared with nurse leaders. Respondents also shared their NWESC's best practices and challenges. Responses to questions identified NWESC best practices and challenges. CONCLUSION This study offers insight into the improvement in nurses' perceptions of the HWE after the introduction of a statewide NWESCs. Structures such as the NWESCs may provide an alternative to mandated staffing ratios.
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Abstract
OBJECTIVES To describe hospital variation in use of "guideline-based care" for acute respiratory distress syndrome (ARDS) due to COVID-19. DESIGN Retrospective, observational study. SETTING The Society of Critical Care Medicine's Discovery Viral Infection and RESPIRATORY ILLNESS UNIVERSAL STUDY COVID-19 REGISTRY. PATIENTS Adult patients with ARDS due to COVID-19 between February 15, 2020, and April 12, 2021. INTERVENTIONS Hospital-level use of "guideline-based care" for ARDS including low-tidal-volume ventilation, plateau pressure less than 30 cm H2O, and prone ventilation for a Pao2/Fio2 ratio less than 100. MEASUREMENTS AND MAIN RESULTS Among 1,495 adults with COVID-19 ARDS receiving care across 42 hospitals, 50.4% ever received care consistent with ARDS clinical practice guidelines. After adjusting for patient demographics and severity of illness, hospital characteristics, and pandemic timing, hospital of admission contributed to 14% of the risk-adjusted variation in "guideline-based care." A patient treated at a randomly selected hospital with higher use of guideline-based care had a median odds ratio of 2.0 (95% CI, 1.1-3.4) for receipt of "guideline-based care" compared with a patient receiving treatment at a randomly selected hospital with low use of recommended therapies. Median-adjusted inhospital mortality was 53% (interquartile range, 47-62%), with a nonsignificantly decreased risk of mortality for patients admitted to hospitals in the highest use "guideline-based care" quartile (49%) compared with the lowest use quartile (60%) (odds ratio, 0.7; 95% CI, 0.3-1.9; p = 0.49). CONCLUSIONS During the first year of the COVID-19 pandemic, only half of patients received "guideline-based care" for ARDS management, with wide practice variation across hospitals. Strategies that improve adherence to recommended ARDS management strategies are needed.
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Han X, Pittman P, Barnow B. Alternative Approaches to Ensuring Adequate Nurse Staffing: The Effect of State Legislation on Hospital Nurse Staffing. Med Care 2021; 59:S463-S470. [PMID: 34524244 PMCID: PMC8428863 DOI: 10.1097/mlr.0000000000001614] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this study was to addresses the basic question of whether alternative legislative approaches are effective in encouraging hospitals to increase nurse staffing. METHODS Using 16 years of nationally representative hospital-level data from the American Hospital Association (AHA) annual survey, we employed a difference-in-difference design to compare changes in productive hours per patient day for registered nurses (RNs), licensed practical/vocational nurses (LPNs), and nursing assistive personnel (NAP) in the state that mandated staffing ratios, states that legislated staffing committees, and states that legislated public reporting, to changes in states that did not implement any nurse staffing legislation before and after the legislation was implemented. We constructed multivariate linear regression models to assess the effects with hospital and year fixed effects, controlling for hospital-level characteristics and state-level factors. RESULTS Compared with states with no legislation, the state that legislated minimum staffing ratios had an 0.996 (P<0.01) increase in RN hours per patient day and 0.224 (P<0.01) increase in NAP hours after the legislation was implemented, but no statistically significant changes in RN or NAP hours were found in states that legislated a staffing committee or public reporting. The staffing committee approach had a negative effect on LPN hours (difference-in-difference=-0.076, P<0.01), while the public reporting approach had a positive effect on LPN hours (difference-in-difference=0.115, P<0.01). There was no statistically significant effect of staffing mandate on LPN hours. CONCLUSIONS When we included California in the comparison, our model suggests that neither the staffing committee nor the public reporting approach alone are effective in increasing hospital RN staffing, although the public reporting approach appeared to have a positive effect on LPN staffing. When we excluded California form the model, public reporting also had a positive effect on RN staffing. Future research should examine patient outcomes associated with these policies, as well as potential cost savings for hospitals from reduced nurse turnover rates.
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Affiliation(s)
- Xinxin Han
- School of Medicine, Tsinghua University, Beijing, China
| | - Patricia Pittman
- Fitzhugh Mullan Institute Health Workforce Equity, Milken Institute School of Public Health
| | - Burt Barnow
- Trachtenberg School of Public Policy and Public Administration, The George Washington University, Washington, DC
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Unoki T, Kawai Y, Hamamoto M, Tamoto M, Miyamoto T, Sakuramoto H, Ito Y, Moro E, Tatsuno J, Nishida O. Workforce and Task Sharing of Nurses in the Japanese Intensive Care Unit-Cross-Sectional Postal Survey. Healthcare (Basel) 2021; 9:healthcare9081017. [PMID: 34442154 PMCID: PMC8394815 DOI: 10.3390/healthcare9081017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 11/22/2022] Open
Abstract
This study aimed to estimate the number of nurses who independently care for patients with severe respiratory failure receiving mechanical ventilation (MV) or veno-venous extracorporeal membrane oxygenation (VV-ECMO). Additionally, the study analyzed the actual role of nurses in the treatment of patients with MV and VV-ECMO. We performed a cross-sectional study using postal questionnaire surveys. The study included 725 Japanese intensive care units (ICUs). Data were analyzed using descriptive statistics. Among the 725 ICUs, we obtained 302 responses (41.7%) and analyzed 282 responses. The median number of nurses per bed was 3.25. The median proportion of nurses who independently cared for patients with MV was 60% (IQR: 42.3–77.3). The median proportion of nurses who independently cared for patients with VV-ECMO was 46.9 (35.7–63.3%) in the ICUs that had experience with VV-ECMO use. With regard to task-sharing, 33.8% of ICUs and nurses did not facilitate weaning from MV. Nurses always titrated sedative dosage in 44.5% of ICUs. Nurse staffing might be inadequate in all ICUs, especially for the management of patients with severe respiratory failure. The proportion of competent nurses to care for severe respiratory failure in ICUs should be considered when determining the workforce of nurses.
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Affiliation(s)
- Takeshi Unoki
- Department of Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Kita 11 Nishi 13, Chuo-ku, Sapporo 060-0011, Japan
- Correspondence:
| | - Yusuke Kawai
- Department of Nursing, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake, Toyoake 470-1192, Japan;
| | - Miya Hamamoto
- Intensive Care Unit, Tosei General Hospital, 160 Nishioiwake, Seto 489-8642, Japan;
| | - Mitsuhiro Tamoto
- Intensive Care Unit, Kyoto University Hospital, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan;
| | - Takeharu Miyamoto
- Department of Nursing, Faculty of Health Sciences, Junshin Gakuen University, 1-1-1 Chikushigaoka, Minami-ku, Fukuoka 815-1510, Japan;
| | - Hideaki Sakuramoto
- Department of Adult Health Nursing, College of Nursing, Ibaraki Christian University, 6-11 Omika, Hitachi 319-1295, Japan;
| | - Yumi Ito
- Department of Nursing, Faculty of Health Sciences, Kyorin University, 6-20-2 Shinkawa, Mitaka 181-8611, Japan;
| | - Etsuko Moro
- Intensive Care Unit, Jichi Medical University Hospital, 3311-1 Yakushiji, Shimotsuke 329-0498, Japan;
| | - Junko Tatsuno
- Department of Nursing, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu 802-8555, Japan;
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake 470-1192, Japan;
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Twigg DE, Whitehead L, Doleman G, El-Zaemey S. The impact of nurse staffing methodologies on nurse and patient outcomes: A systematic review. J Adv Nurs 2021; 77:4599-4611. [PMID: 34081369 PMCID: PMC9291075 DOI: 10.1111/jan.14909] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 11/30/2022]
Abstract
Aim Aim of this study is to systematically review and synthesize available evidence to identify the association between nurse staffing methodologies and nurse and patient outcomes. Design Systematic review and narrative synthesis. Data sources A search of MEDLINE (EBSCO), CINAHL (EBSCO) and Web of Science was conducted for studies published in English between January 2000 and January 2020. Review methods The reporting of this review and narrative synthesis was guided by the preferred reporting items for systematic and meta‐analysis guidelines (PRISMA) statement and data synthesis guided by the Synthesis Without Meta‐analysis (SWiM) guideline. The quality of each article was assessed using the Mixed Methods Appraisal Tool. Results Twenty‐two studies met the inclusion criteria. Twenty‐one used the mandated minimum nurse‐to‐patient ratio methodology and one study assessed the number of nurse hours per patient day staffing methodology. Both methodologies were mandated. All studies that reported on nurse outcomes demonstrated an improvement associated with the implementation of mandated minimum nurse‐to‐patient ratio, but findings related to patient outcomes were inconclusive. Conclusions Evidence on the impact of specific nurse staffing methodologies and patient and nurse outcomes remains highly limited. Future studies that examine the impact of specific staffing methodologies on outcomes are required to inform this fundamental area of management and practice.
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Affiliation(s)
- Diane E Twigg
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Perth, WA, Australia
| | - Lisa Whitehead
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Perth, WA, Australia
| | - Gemma Doleman
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Perth, WA, Australia.,Centre for Nursing Research, Sir Charles Gardiner Hospital, Nedlands, WA, Australia
| | - Sonia El-Zaemey
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Perth, WA, Australia
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Physical Rehabilitation in Critically Ill Children: A Multicenter Point Prevalence Study in the United States. Crit Care Med 2021; 48:634-644. [PMID: 32168030 DOI: 10.1097/ccm.0000000000004291] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES With decreasing mortality in PICUs, a growing number of survivors experience long-lasting physical impairments. Early physical rehabilitation and mobilization during critical illness are safe and feasible, but little is known about the prevalence in PICUs. We aimed to evaluate the prevalence of rehabilitation for critically ill children and associated barriers. DESIGN National 2-day point prevalence study. SETTING Eighty-two PICUs in 65 hospitals across the United States. PATIENTS All patients admitted to a participating PICU for greater than or equal to 72 hours on each point prevalence day. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was prevalence of physical therapy- or occupational therapy-provided mobility on the study days. PICUs also prospectively collected timing of initial rehabilitation team consultation, clinical and patient mobility data, potential mobility-associated safety events, and barriers to mobility. The point prevalence of physical therapy- or occupational therapy-provided mobility during 1,769 patient-days was 35% and associated with older age (adjusted odds ratio for 13-17 vs < 3 yr, 2.1; 95% CI, 1.5-3.1) and male gender (adjusted odds ratio for females, 0.76; 95% CI, 0.61-0.95). Patients with higher baseline function (Pediatric Cerebral Performance Category, ≤ 2 vs > 2) less often had rehabilitation consultation within the first 72 hours (27% vs 38%; p < 0.001). Patients were completely immobile on 19% of patient-days. A potential safety event occurred in only 4% of 4,700 mobility sessions, most commonly a transient change in vital signs. Out-of-bed mobility was negatively associated with the presence of an endotracheal tube (adjusted odds ratio, 0.13; 95% CI, 0.1-0.2) and urinary catheter (adjusted odds ratio, 0.28; 95% CI, 0.1-0.6). Positive associations included family presence in children less than 3 years old (adjusted odds ratio, 4.55; 95% CI, 3.1-6.6). CONCLUSIONS Younger children, females, and patients with higher baseline function less commonly receive rehabilitation in U.S. PICUs, and early rehabilitation consultation is infrequent. These findings highlight the need for systematic design of rehabilitation interventions for all critically ill children at risk of functional impairments.
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12
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Bartmess M, Myers CR, Thomas SP. Nurse staffing legislation: Empirical evidence and policy analysis. Nurs Forum 2021; 56:660-675. [PMID: 33982311 DOI: 10.1111/nuf.12594] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/21/2021] [Accepted: 04/29/2021] [Indexed: 12/31/2022]
Abstract
Unsafe nurse staffing conditions in hospitals have been shown to increase the risk of adverse patient events, including mortality. Consequently, United States and international professional nursing organizations often advocate for safer staffing conditions. There are a variety of factors to consider when staffing nurses for patient safety, such as the number of patients per nurse, nurse preparation, patient acuity, and nurse autonomy. The complex issue of staffing nurses often is compounded by cost issues and can become politicized. When nurse organizations' recommendations for safe staffing measures are disregarded by hospital administrations, nurse lobbyists and interest groups often pursue legislative action to protect patients and nurses from unsafe staffing conditions. This article presents a narrative review of safe nurse staffing factors and an analysis of nurse staffing legislation. Using a patient-centric lens, three state-level nurse staffing policies (mandated nurse-to-patient ratios, public reporting of staffing plans, and nurse staffing committees) were evaluated by empirical evidence, cost to hospitals and state governments, political feasibility, and potential to affect patient populations. Although nurse staffing policy analysis can be conducted in several ways, it is crucial that nurses consider empirical evidence related to staffing policies as well as evaluations of implemented policies and political influences.
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Affiliation(s)
- Marissa Bartmess
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
| | - Carole R Myers
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
| | - Sandra P Thomas
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
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13
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Ostberg N, Ling J, Winter SG, Som S, Vasilakis C, Shin AY, Cornell TT, Scheinker D. Quantifying paediatric intensive care unit staffing levels at a paediatric academic medical centre: A mixed-methods approach. J Nurs Manag 2021; 29:2278-2287. [PMID: 33894027 DOI: 10.1111/jonm.13346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/08/2021] [Accepted: 04/16/2021] [Indexed: 11/30/2022]
Abstract
AIM To identify, simulate and evaluate the formal and informal patient-level and unit-level factors that nurse managers use to determine the number of nurses for each shift. BACKGROUND Nurse staffing schedules are commonly set based on metrics such as midnight census that do not account for seasonality or midday turnover, resulting in last-minute adjustments or inappropriate staffing levels. METHODS Staffing schedules at a paediatric intensive care unit (PICU) were simulated based on nurse-to-patient assignment rules from interviews with nursing management. Multivariate regression modelled the discrepancies between scheduled and historical staffing levels and constructed rules to reduce these discrepancies. The primary outcome was the median difference between simulated and historical staffing levels. RESULTS Nurse-to-patient ratios underestimated staffing by a median of 1.5 nurses per shift. Multivariate regression identified patient turnover as the primary factor accounting for this difference and subgroup analysis revealed that patient age and weight were also important. New rules reduced the difference to a median of 0.07 nurses per shift. CONCLUSION Measurable, predictable indicators of patient acuity and historical trends may allow for schedules that better match demand. IMPLICATIONS FOR NURSING MANAGEMENT Data-driven methods can quantify what drives unit demand and generate nurse schedules that require fewer last-minute adjustments.
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Affiliation(s)
- Nicolai Ostberg
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA, USA
| | - Jonathan Ling
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Shira G Winter
- Center for Health Policy, Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA.,VA Palo Alto Health Care System, Center for Innovation to Implementation, Health Services Research & Development, Palo Alto, CA, USA
| | - Sreeroopa Som
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Christos Vasilakis
- Centre for Healthcare Innovation and Improvement, School of Management, University of Bath, Bath, UK
| | - Andrew Y Shin
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Stanford, CA, USA
| | - Timothy T Cornell
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Stanford, CA, USA
| | - David Scheinker
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA.,Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
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14
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Bae SH. Intensive care nurse staffing and nurse outcomes: A systematic review. Nurs Crit Care 2021; 26:457-466. [PMID: 33403791 DOI: 10.1111/nicc.12588] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 12/04/2020] [Accepted: 12/21/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Intensive care units (ICU) are associated with significant work stress and exert continuous physical and emotional demand upon health care providers. The health and well-being of care providers, including ICU nurses, is a matter of great concern. However, to the researcher's knowledge, there have been no reviews synthesizing the evidence about the relationship between nurse staffing and nurse outcomes in the ICU. PURPOSE The purpose of this systematic review was to examine nurse staffing in the ICU and synthesize literature to examine the relationship with nurse outcomes such as job satisfaction, burnout, fatigue, and intent to leave. METHODS This review was reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Peer-reviewed articles published between January 2000 and September 2019 were identified via eight electronic bibliographic databases. Articles were included and reviewed if they were correlational studies examining the relationships between nurse staffing and nurse outcomes in the ICU, and were published in peer-reviewed journals written in either English or Korean. The Quality Assessment and Validity Tool for Correlation Studies was used for quality appraisal. RESULTS From 5086 articles, eight published between 2006 and 2019 were included in this review. Three studies found expected relationships between worse nurse staffing and adverse nurse outcomes (high burnout, fatigue state, emotional exhaustion, depersonalization, and stress). However, the relationships between nurse staffing and other adverse nurse outcomes were not significant. Perceived adequate staffing was negatively related to adverse nurse outcomes. However, a non-significant relationship also was found. CONCLUSION This study found limited evidence on relationships between nurse staffing and nurse outcomes in the ICU. More studies are needed to conduct to find a conclusive relationship. RELEVANCE TO CLINICAL PRACTICE Given high demands and workload in the ICU, nurse staffing levels should be closely monitored to prevent adverse nurse outcomes.
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Affiliation(s)
- Sung-Heui Bae
- College of Nursing, System Health & Engineering Major in Graduate School (BK21), Ewha Womans University, Seoul, South Korea
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15
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Nurse staffing and outcomes for pulmonary lobectomy: Cost and mortality trade-offs. Heart Lung 2020; 50:206-212. [PMID: 33302148 DOI: 10.1016/j.hrtlng.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Nurse staffing impacts patient outcomes, but little is known about the relationship between nurse staffing and outcomes for lung cancer patients undergoing pulmonary lobectomy. OBJECTIVES To examine the association between nurse staffing and outcomes following lobectomy for lung cancer. METHODS Patients (N = 16,994) with lung cancer between who underwent lobectomy between 2008-2011 were identified in the National Inpatient Sample. Nurse staffing was quantified using registered nurse full-time equivalents per adjusted patient days. Multivariable models were used to estimate the effect of RN FTEs on mortality, length of stay, and costs, controlling for covariates. RESULTS Patients treated at hospitals using 5.6 or more RN FTEs had shorter hospitals stays by 0.37 days (p = 0.008), had 36% lower odds of mortality (OR = 0.64, p = 0.014), but incurred $4,388 (p < 0.0001) in additional costs. CONCLUSIONS Hospital administrators face a troubling trade-off between costs and outcomes in decisions about nurse staffing mix for pulmonary lobectomy.
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16
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Kelly Costa D, Liu H, Boltey EM, Yakusheva O. The Structure of Critical Care Nursing Teams and Patient Outcomes: A Network Analysis. Am J Respir Crit Care Med 2020; 201:483-485. [PMID: 31626555 PMCID: PMC7049918 DOI: 10.1164/rccm.201903-0543le] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Deena Kelly Costa
- University of Michigan School of NursingAnn Arbor, Michigan
- University of Michigan Institute for Healthcare Policy and InnovationAnn Arbor, Michiganand
| | - Haiyin Liu
- University of Michigan School of NursingAnn Arbor, Michigan
| | | | - Olga Yakusheva
- University of Michigan School of NursingAnn Arbor, Michigan
- University of Michigan Institute for Healthcare Policy and InnovationAnn Arbor, Michiganand
- University of Michigan School of Public HealthAnn Arbor, Michigan
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17
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Tawfik DS, Profit J, Lake ET, Liu JB, Sanders LM, Phibbs CS. Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit. Health Serv Res 2019; 55:190-200. [PMID: 31869865 DOI: 10.1111/1475-6773.13249] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes. DATA SOURCES Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases. We included 276 054 infants born 2008-2016 and cared for in 99 California neonatal intensive care units (NICUs). STUDY DESIGN Repeated-measures observational study. We developed a nurse staffing prediction model using machine learning and hierarchical linear regression and then quantified deviation from predicted nurse staffing in relation to health care-associated infections, length of stay, and mortality using hierarchical logistic and linear regression. DATA COLLECTION METHODS We linked NICU-level nurse staffing and organizational data to patient-level risk factors and outcomes using unique identifiers for NICUs and patients. PRINCIPAL FINDINGS An 11-factor prediction model explained 35 percent of the nurse staffing variation among NICUs. Higher-than-predicted nurse staffing was associated with decreased risk-adjusted odds of health care-associated infection (OR: 0.79, 95% CI: 0.63-0.98), but not with length of stay or mortality. CONCLUSIONS Organizational and patient factors explain much of the variation in nurse staffing. Higher-than-predicted nurse staffing was associated with fewer infections. Prospective studies are needed to determine causality and to quantify the impact of staffing reforms on health outcomes.
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Affiliation(s)
- Daniel S Tawfik
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jochen Profit
- California Perinatal Quality Care Collaborative, Palo Alto, California.,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Eileen T Lake
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Jessica B Liu
- California Perinatal Quality Care Collaborative, Palo Alto, California.,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Lee M Sanders
- Division of General Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Ciaran S Phibbs
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Health Economics Research Center and Center for Innovation to Implementation, Veteran's Affairs Palo Alto Health Care System, Palo Alto, California
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18
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Abstract
OBJECTIVE The purpose of this review is to comment on the association between hospital nursing personnel staffing and patient outcomes, including the avoidance of errors and complications. METHODS A literature search was carried out in the Medline database on publications from the last 10 years on nursing personnel staffing. RESULTS Only overviews and observational studies on the topic were available and no controlled or prospective surveys. Most investigators assumed that there was an inverse relationship between low nursing staff levels of hospital wards and intensive care and adverse outcomes, including higher mortality rates; however, there is no clear significance for this assumption and evidence-based definitive lower limits for nursing staff cannot be given due to a lack of randomized trials. The causes for unfavorable results in the case of inadequate nursing personnel staffing include hygiene deficiencies, orders not followed and unfulfilled nursing and monitoring measures. Furthermore, staff overload leads to staff dissatisfaction and burnout, which also has a negative impact on the results. Most studies required a maximum patient to nurse ratio of 2:1 for the intensive care unit and an average ratio of not more than 8:1 for surgical wards. With respect to these requirements, changing personnel needs must be considered depending on the current state of the patients being cared for, which enabled all investigators to require a flexible roster design; approval for fixed statutory lower limits for nursing staff was low. The level of education of the nursing staff also played an essential role as qualified nursing staff cannot be replaced at will by less qualified assistant staff. CONCLUSION The level of training and the number of the nursing personnel influence hospital mortality and adverse outcomes; however, there are no evidence-based lower levels for nursing staff for inpatient care and perhaps this cannot be the case due to the changing complexity of the patients admitted, the comorbidities and possible treatment complications. There is a considerable need for research.
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19
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Why Did Massachusetts Enact Universal ICU Maximal Patient Nurse Staffing Ratios? Crit Care Med 2019; 46:1683-1684. [PMID: 30179885 DOI: 10.1097/ccm.0000000000003316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Halm M. The Influence of Appropriate Staffing and Healthy Work Environments on Patient and Nurse Outcomes. Am J Crit Care 2019; 28:152-156. [PMID: 30824521 DOI: 10.4037/ajcc2019938] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Margo Halm
- Margo A. Halm is associate chief nurse executive, nursing research and evidence-based practice, VA Portland HealthCare System, Portland, Oregon
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21
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