Nurse Staffing and Patient Safety in Hospitals: New Variable and Longitudinal Approaches

Nurse's experience working 12-hour shift in a tertiary level hospital in Qatar: a mixed method study

BACKGROUND

The use of 12-h shifts for nursing staff has become common in many healthcare settings, including tertiary hospitals, due to its potential benefits such as reduced handover time and increased continuity of care. However, there is limited research on the experiences of nurses working 12-h shifts, particularly in the context of Qatar, where the healthcare system and nursing workforce may have unique characteristics and challenges. This study aimed to explore the experiences of nurses working 12-h shifts in a tertiary hospital in Qatar, including their perceptions of physical health, fatigue, stress, job satisfaction, service quality, and patient safety.

METHODS

A mixed method study design was applied consisting of a survey and semi-structured interviews. Data was collected from 350 nurses through an online survey and from 11 nurses through semi-structured interviews. Data was analyzed using Shapiro-Wilk test and the difference between demographic variables and scores were examined using Whitney U test and Kruskal- Wallis test. Thematic analysis was used for qualitative interviews.

RESULTS

The results from quantitative study revealed nurses perception in working 12-h shift has negative impact in their wellbeing, satisfaction as well as patient care outcomes. Thematic analysis revealed real stress and burnout and experienced an enormous amount of pressure going for work.

CONCLUSIONS

Our study provides an understanding of the nurse's experience working 12-h shift in a tertiary level hospital in Qatar. A mixed method approach informed us that, nurses are not satisfied with the 12-h shift and interviews revealed high level of stress and burnout among nurses resulting in job dissatisfaction and negative health concerns. Nurses also reported that it is challenging to stay productive and focused throughout their new shift pattern.

How slack resource affects hospital financial performance: The evidence from public hospitals in Beijing

Background

Beijing is a city with high concentration and congestion of quality medical resources in China. While moderate slack seems to be beneficial to the improvement of medical quality. The actual relationship between hospital slack resources and their performance deserves further exploration. The study aims to analyze the slack resources of public hospitals in Beijing and investigate the relationship between slack and hospital financial performance. Finding a reasonable range of slack to optimize resource allocation.

Methods

The panel data of 22 public hospitals in Beijing from 2005 to 2011 were selected as the sample, and the DEA model was applied to measure the main variable using DEAP 2.1. Descriptive statistical analysis was performed using Excel and STATA 15. Pearson correlation coefficient analysis and variance inflation factor test were performed for each variable to avoid multicollinearity. The HAUSMAN test was used to determine the appropriate panel regression model, and then to analyze the influence relationship between the variables.

Results

From 2005 to 2011, hospital slack resource transitioned from high to low. The slack measured by the DEA model has an inverted U-shaped relationship with financial performance, with ROA increasing from 4.088 to 8.083 when slack increases from 0 to about 0.378, and then showing a decreasing trend; slack measured by financial indicators has a transposed S-shaped relationship with financial performance, with ROA increasing when slack increase from 3.772 to 5.933.

Conclusions

The slack resources of Beijing public hospitals decreased year by year from 2005 to 2011. Moderate slack resources are conducive to the improvement of healthcare quality, but when slack resources increase to a certain level, it will have a negative impact on healthcare quality. Therefore, hospital managers should control the slack within a moderate range according to the hospital operation policy and development plan to obtain the best performance.

Cost-quality tradeoff in nurse staffing: an exploration of USA hospitals facing market competition

Purpose

This research aims to explore the fine-grained relationships between nurse staffing and hospital operational performance with respect to care quality and operating costs. The authors also investigate the moderation effect of competition in local hospital markets on these relationships.

Design/methodology/approach

A six-year panel data is assembled from five separate sources to obtain information of 2,524 USA hospitals. Fixed-effect (FE) models are used to test the proposed hypotheses.

Findings

First, nurse staffing is initially associated with improved care quality until nurse staffing reaches a turning point, beyond which nurse staffing is associated with worse care quality. Second, a similar pattern applies to the relationship between nurse staffing and operating costs, although the turning point is at a much lower nurse staffing level. Third, market competition moderates the relationship between nurse staffing and care quality so that the turning point of nurse staffing will be higher when the degree of competition is higher. This shift of turning point is also observed in the relationship between nurse staffing and operating costs.

Practical implications

The study identifies three ranges of nurse staffing in which hospitals will likely experience simultaneous improvements, a tradeoff or simultaneous decline of care quality and operating costs when investing in more nursing capacity. Hospitals should adjust nurse staffing levels to the right directions to achieve better care or reduce operating costs.

Originality/value

Nurses constitute the largest provider group in hospitals and profoundly impact care quality and operating costs among all health care professionals. Optimizing the level of nurse staffing, therefore, can significantly impact the care quality and operating costs of 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.

Secondary Traumatic Stress Among Labor and Delivery Nurses

PURPOSE

To describe the prevalence and severity of secondary traumatic stress (STS) among labor and delivery nurses within a Northeastern United States academic health system.

STUDY DESIGN AND METHODS

Using a cross-sectional, descriptive correlational design, a convenience sample of labor and delivery nurses (288 nurses) were invited to complete Secondary Traumatic Stress Scale (STSS), a 17-item Likert-type instrument, that measures intrusion, avoidance, and the arousal symptoms associated with indirect exposure to traumatic events. Five additional questions about potential consequences of STS were also asked.

RESULTS

N = 144 completed the survey (50% response rate). Average STSS score was 33.74 (SD, 11.8), with 35% of respondents meeting symptom severity scores associated with STS. STSS Scores ≥ 38 were significantly correlated with nurses considering leaving their jobs, calling out sick, or requesting an assignment change after witnessing a traumatic birth (p < 0.001). The majority of respondents (84.7%) reported witnessing a traumatic birth. After witnessing a traumatic birth, respondents used co-workers, family, and friends as sources of support.

CLINICAL IMPLICATIONS

This study offers insight into the frequency and severity of STS among labor and delivery nurses, as well as the potential workforce-related consequences and provides a foundation for future work aimed at developing interventions to prevent or alleviate STS.

Systematic review of the evidence related to mandated nurse staffing ratios in acute hospitals

Objective The purpose of this systematic review was to evaluate and summarise available research on nurse staffing methods and relate these to outcomes under three overarching themes of: (1) management of clinical risk, quality and safety; (2) development of a new or innovative staffing methodology; and (3) equity of nursing workload. Methods The PRISMA method was used. Relevant articles were located by searching via the Griffith University Library electronic catalogue, including articles on PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline. Only English language publications published between 1 January 2010 and 30 April 2016 focusing on methodologies in acute hospital in-patient units were included in the present review. Results Two of the four staffing methods were found to have evidenced-based articles from empirical studies within the parameters set for inclusion. Of the four staffing methodologies searched, supply and demand returned 10 studies and staffing ratios returned 11. Conclusions There is a need to develop an evidence-based nurse-sensitive outcomes measure upon which staffing for safety, quality and workplace equity, as well as an instrument that reliability and validly projects nurse staffing requirements in a variety of clinical settings. Nurse-sensitive indicators reflect elements of patient care that are directly affected by nursing practice In addition, these measures must take into account patient satisfaction, workload and staffing, clinical risks and other measures of the quality and safety of care and nurses' work satisfaction. i. What is known about the topic? Nurse staffing is a controversial topic that has significant patient safety, quality of care, human resources and financial implications. In acute care services, nursing accounts for approximately 70% of salaries and wages paid by health services budgets, and evidence as to the efficacy and effectiveness of any staffing methodology is required because it has workforce and industrial relations implications. Although there is significant literature available on the topic, there is a paucity of empirical evidence supporting claims of increased patient safety in the acute hospital setting, but some evidence exists relating to equity of workload for nurses. What does this paper add? This paper provides a contemporary qualitative analysis of empirical evidence using PRISMA methodology to conduct a systematic review of the available literature. It demonstrates a significant research gap to support claims of increased patient safety in the acute hospital setting. The paper calls for greatly improved datasets upon which research can be undertaken to determine any associations between mandated patient to nurse ratios and other staffing methodologies and patient safety and quality of care. What are the implications for practitioners? There is insufficient contemporary research to support staffing methodologies for appropriate staffing, balanced workloads and quality, safe care. Such research would include the establishment of nurse-sensitive patient outcomes measures, and more robust datasets are needed for empirical analysis to produce such evidence.

Effect of preventive care interventions on pressure ulcer rates in a national sample of rural and urban nursing units: Longitudinal associations over 4 years

BACKGROUND

Pressure ulcer rates are persistently high despite years of research and practice policies focused on prevention. Prior research found crosssectional associations between care interventions, hospital and nursing unit characteristics and pressure ulcer rates. Whether these associations persist over time is unknown. Finally, comparisons of quality measures across rural and urban location have mixed findings.

OBJECTIVE

Our study examined effects of care interventions on unit-acquired pressure ulcer rates over 4 years controlling for community, hospital, and nursing unit characteristics in rural and urban locations.

DESIGN

Guided by contingency theory a longitudinal study was conducted to examine associations between context, staffing, care interventions, nurse outcomes, and pressure ulcer rates, using unit-level data from the National Database of Nursing Quality Indicators^Ⓡ 2010-2013 (16 quarters) augmented with data on rural classifications and case mix index. Ulcer rates were measured as percentage of patients with a nursing unit-acquired pressure ulcer. The three care interventions were unit-percentage of patients receiving skin assessment on admission, receiving risk assessment on admission, and receiving any risk assessment before the pressure ulcer. Nursing unit characteristics were RN staffing, education, and experience. Nurse outcomes were job satisfaction and intent-to-stay.

PARTICIPANTS

We included 5761 units (332 rural and 5429 urban) in 772 hospitals (89 rural and 683 urban) that reported ulcer rates in two or more quarters during the study period.

METHODS

Rural and urban units were examined separately using multilevel binomial regression in which within-unit changes in pressure ulcer rates were related to the within-unit changes in the explanatory variables, controlling for region, hospital size, unit type, case mix index, and percentage of patients at risk for pressure ulcers.

RESULTS

An increase in the three care interventions, RN skill mix, and the two nurse outcomes were associated with a decrease in unit-acquired pressure ulcers. For example, in rural units a 10% increase in unit-percentage of any risk assessment and in urban units a 10% increase in skin assessment on admission were associated with a 21% and 5% decrease in the odds of developing an ulcer. A 10% increase in RN skill mix was associated with 17-18% and 5-6% decrease in ulcer rates in rural and urban units respectively.

CONCLUSION

Hospitals aiming to improve pressure ulcer prevention should focus on organizational structures that support improved nurses work environments and workflow that will enhance nursing care interventions. Future studies should include both contextual and patient characteristics along with care interventions.

A quantitative systematic review of the association between nurse skill mix and nursing-sensitive patient outcomes in the acute care setting

AIMS

To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.

DESIGN

A quantitative systematic review included studies published in English between January 2000 - September 2018.

DATA SOURCES

Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix-methods designs were included if the quantitative component met the criteria.

REVIEW METHODS

The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy-five percent or more of studies with significant results found this association.

RESULTS

Sixty-three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure-to-rescue; pneumonia; sepsis; urinary tract infection; mortality/30-day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.

CONCLUSION

Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.

IMPACT

Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.

A psychometric analysis of the Caring Assessment Tool version V

AIM

The aim of this study was to examine the factor structure and construct validity of the Caring Assessment Tool version V (CAT-V) for patients in Australian hospitals.

DESIGN

Secondary analysis of CAT-V surveys from the Australian Nursing Outcomes Collaborative (AUSNOC) data set was used. The CAT was originally developed in the United States of America.

METHODS

The 27-item CAT-V was administered to patients prior to discharge from eight wards in three Australian hospitals in 2016. The psychometric properties of the CAT were evaluated using item analysis and exploratory factor analyses.

RESULTS

Item analysis of surveys from 476 participants showed high levels of perceived caring behaviours and actions. Exploratory factor analysis revealed a two-factor structure consisting of: Nurse-patient communication; and Feeling cared for. The CAT-V is a reliable and valid instrument for measuring patients' perceptions of the attitudes and actions of nurses in Australia.

Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to demonstrate the effect of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries.

Hospital Staffing and Health Care-Associated Infections: A Systematic Review of the Literature

BACKGROUND

Previous literature has linked the level and types of staffing of health facilities to the risk of acquiring a health care-associated infection (HAI). Investigating this relationship is challenging because of the lack of rigorous study designs and the use of varying definitions and measures of both staffing and HAIs.

METHODS

The objective of this study was to understand and synthesize the most recent research on the relationship of hospital staffing and HAI risk. A systematic review was undertaken. Electronic databases MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for studies published between January 1, 2000, and November 30, 2015.

RESULTS

Fifty-four articles were included in the review. The majority of studies examined the relationship between nurse staffing and HAIs (n = 50, 92.6%) and found nurse staffing variables to be associated with an increase in HAI rates (n = 40, 74.1%). Only 5 studies addressed non-nurse staffing, and those had mixed results. Physician staffing was associated with an increased HAI risk in 1 of 3 studies. Studies varied in design and methodology, as well as in their use of operational definitions and measures of staffing and HAIs.

CONCLUSION

Despite the lack of consistency of the included studies, overall, the results of this systematic review demonstrate that increased staffing is related to decreased risk of acquiring HAIs. More rigorous and consistent research designs, definitions, and risk-adjusted HAI data are needed in future studies exploring this area.

Patient Safety Incidents and Nursing Workload

Objective

to identify the relationship between the workload of the nursing team and the occurrence of patient safety incidents linked to nursing care in a public hospital in Chile.

Method

quantitative, analytical, cross-sectional research through review of medical records. The estimation of workload in Intensive Care Units (ICUs) was performed using the Therapeutic Interventions Scoring System (TISS-28) and for the other services, we used the nurse/patient and nursing assistant/patient ratios. Descriptive univariate and multivariate analysis were performed. For the multivariate analysis we used principal component analysis and Pearson correlation.

Results

879 post-discharge clinical records and the workload of 85 nurses and 157 nursing assistants were analyzed. The overall incident rate was 71.1%. It was found a high positive correlation between variables workload (r = 0.9611 to r = 0.9919) and rate of falls (r = 0.8770). The medication error rates, mechanical containment incidents and self-removal of invasive devices were not correlated with the workload.

Conclusions

the workload was high in all units except the intermediate care unit. Only the rate of falls was associated with the workload.

Nursing workloads in family health: implications for universal access

Objective

to identify the workloads of nursing professionals of the Family Health Strategy, considering its implications for the effectiveness of universal access.

Method

qualitative study with nursing professionals of the Family Health Strategy of the South, Central West and North regions of Brazil, using methodological triangulation. For the analysis, resources of the Atlas.ti software and Thematic Content Analysis were associated; and the data were interpreted based on the labor process and workloads as theorical approaches.

Results

the way of working in the Family Health Strategy has predominantly resulted in an increase in the workloads of the nursing professionals, with emphasis on the work overload, excess of demand, problems in the physical infrastructure of the units and failures in the care network, which hinders its effectiveness as a preferred strategy to achieve universal access to health. On the other hand, teamwork, affinity for the work performed, bond with the user, and effectiveness of the assistance contributed to reduce their workloads.

Conclusions

investments on elements that reduce the nursing workloads, such as changes in working conditions and management, can contribute to the effectiveness of the Family Health Strategy and achieving the goal of universal access to health.

The relationship between nurse staffing and length of stay in acute-care: a one-year time-series data

AIM

To examine the relationship between nurse staffing and patient length of stay in an acute-care hospital over a 1-year period.

BACKGROUND

Although there has been prior research on the relationship between nurse staffing and length of stay in acute-care hospitals, there is a need for more information on how nurse staffing is related to length of stay longitudinally.

METHODS

Retrospective time-series registry data from 20 acute-care inpatient units of a Finnish university hospital as a monthly time series in 2008 were analysed by linear mixed models.

RESULTS

The ratio of registered nurses to all nurses was 72.4%. Nurses worked mainly (96%) full time, and 63% had permanent employment contracts. Statistically significant variation was found in time series of five variables. Statistically significant relationships were found between length of stay and patient acuity, diagnosis-related group-volume, census and nursing hours per patient day at the unit level. Nursing hours per patient day had the strongest correlation with length of stay.

CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT

A rational response to the variations in patient care needs and intensity in the complex care environment is flexible nurse staffing. Increasing nursing hours per patient day to achieve shorter length of stays is not the only solution, well-functioning care processes are also essential.

Comparison of Nurse Staffing Measurements in Staffing-Outcomes Research

BACKGROUND

Investigators have used a variety of operational definitions of nursing hours of care in measuring nurse staffing for health services research. However, little is known about which approach is best for nurse staffing measurement.

OBJECTIVE

To examine whether various nursing hours measures yield different model estimations when predicting patient outcomes and to determine the best method to measure nurse staffing based on the model estimations.

DATA SOURCES/SETTING

We analyzed data from the University HealthSystem Consortium for 2005. The sample comprised 208 hospital-quarter observations from 54 hospitals, representing information on 971 adult-care units and about 1 million inpatient discharges.

METHODS

We compared regression models using different combinations of staffing measures based on productive/nonproductive and direct-care/indirect-care hours. Akaike Information Criterion and Bayesian Information Criterion were used in the assessment of staffing measure performance.

RESULTS

The models that included the staffing measure calculated from productive hours by direct-care providers were best, in general. However, the Akaike Information Criterion and Bayesian Information Criterion differences between models were small, indicating that distinguishing nonproductive and indirect-care hours from productive direct-care hours does not substantially affect the approximation of the relationship between nurse staffing and patient outcomes.

CONCLUSIONS

This study is the first to explicitly evaluate various measures of nurse staffing. Productive hours by direct-care providers are the strongest measure related to patient outcomes and thus should be preferred in research on nurse staffing and patient outcomes.

Studies on nurse staffing and health care-associated infection: methodologic challenges and potential solutions

BACKGROUND

Researchers have been studying hospital nurse staffing in relation to health care-associated infections (HAIs) for >2 decades, and the results have been mixed. We summarized published research examining these issues, critically analyzed the commonly used approaches, identified methodologic challenges, proposed potential solutions, and suggested the possible benefits of applying an electronic health record (EHR) system.

METHODS

A scoping review was conducted using MEDLINE and CINAHL from 1990 onward. Original research studies examining relationships between nurse staffing and HAIs in the hospital setting and published in peer-reviewed English-language journals were selected.

RESULTS

A total of 125 articles and abstracts were identified, and 45 met inclusion criteria. Findings from these studies were mixed. The methodologic challenges identified included database selection, variable measurement, methods to link the nurse staffing and HAI data, and temporality. Administrative staffing data were often not precise or specific. The most common method to link staffing and HAI data did not assess the temporal relationship. We proposed using daily staffing information 2-4 days prior to HAI onset linked to individual patient HAI data.

CONCLUSION

To assess the relationships between nurse staffing and HAIs, methodologic decisions are necessary based on what data are available and feasible to obtain. National efforts to promote an EHR may offer solutions for future studies by providing more comprehensive data on HAIs and nurse staffing.

Non-linear relationships between nurse staffing and patients' length of stay in acute care units: Bayesian dependence modelling

AIMS

This study sought to analyse relationships between nurse staffing and patients' length of stay in acute care units and to determine whether non-linear relationships exist between variables.

BACKGROUND

Healthcare systems are complex and it could be assumed that they comprise non-linear associations. However, current planning and evaluation of nurse staffing are based primary on linear reasoning.

DESIGN

This quantitative study adopted a retrospective longitudinal design.

METHOD

Retrospective register data, consisting of information relating to 35,306 patient episodes and administrative information concerning 381 nurses, were used. Data were collected in 2009 from 20 somatic inpatient units at a university hospital in Finland as a monthly time series of 2008 data and analysed using Bayesian dependency modelling.

RESULTS

Patients' acuity was the most important agent that connected all eleven variables in the dependency network of nurse staffing and short length of stay. Non-linear associations were found between short length of stay and the proportion of Registered Nurses. Skill mix consisting of an average proportion of Registered Nurses (65-80%) was conducive to a short length of stay and predicted a 66% likelihood of short length of stay. Higher and lower percentages of Registered Nurses predicted lower likelihood of short length of stay.

CONCLUSION

Flexible nurse staffing is preferable to fixed staffing to provide patients with shorter length of stay in acute care units. In the present research, the Bayesian method revealed non-linear relationships between nurse staffing and patient and care outcomes.

Geographic variation of failure-to-rescue in public acute hospitals in New South Wales, Australia

Despite the wide acceptance of Failure-to-Rescue (FTR) as a patient safety indicator (defined as the deaths among surgical patients with treatable complications), no study has explored the geographic variation of FTR in a large health jurisdiction. Our study aimed to explore the spatiotemporal variations of FTR rates across New South Wales (NSW), Australia. We conducted a population-based study using all admitted surgical patients in public acute hospitals during 2002-2009 in NSW, Australia. We developed a spatiotemporal Poisson model using Integrated Nested Laplace Approximation (INLA) methods in a Bayesian framework to obtain area-specific adjusted relative risk. Local Government Area (LGA) was chosen as the areal unit. LGA-aggregated covariates included age, gender, socio-economic and remoteness index scores, distance between patient residential postcode and the treating hospital, and a quadratic time trend. We studied 4,285,494 elective surgical admissions in 82 acute public hospitals over eight years in NSW. Around 14% of patients who developed at least one of the six FTR-related complications (58,590) died during hospitalization. Of 153 LGAs, patients who lived in 31 LGAs, accommodating 48% of NSW patients at risk, were exposed to an excessive adjusted FTR risk (10% to 50%) compared to the state-average. They were mostly located in state's centre and western Sydney. Thirty LGAs with a lower adjusted FTR risk (10% to 30%), accommodating 8% of patients at risk, were mostly found in the southern parts of NSW and Sydney east and south. There were significant spatiotemporal variations of FTR rates across NSW over an eight-year span. Areas identified with significantly high and low FTR risks provide potential opportunities for policy-makers, clinicians and researchers to learn from the success or failure of adopting the best care for surgical patients and build a self-learning organisation and health system.

Modeling hospital-acquired pressure ulcer prevalence on medical-surgical units: nurse workload, expertise, and clinical processes of care

OBJECTIVE

This study modeled the predictive power of unit/patient characteristics, nurse workload, nurse expertise, and hospital-acquired pressure ulcer (HAPU) preventive clinical processes of care on unit-level prevalence of HAPUs.

DATA SOURCES

Seven hundred and eighty-nine medical-surgical units (215 hospitals) in 2009.

STUDY DESIGN

Using unit-level data, HAPUs were modeled with Poisson regression with zero-inflation (due to low prevalence of HAPUs) with significant covariates as predictors.

DATA COLLECTION/EXTRACTION METHODS

Hospitals submitted data on NQF endorsed ongoing performance measures to CALNOC registry.

PRINCIPAL FINDINGS

Fewer HAPUs were predicted by a combination of unit/patient characteristics (shorter length of stay, fewer patients at-risk, fewer male patients), RN workload (more hours of care, greater patient [bed] turnover), RN expertise (more years of experience, fewer contract staff hours), and processes of care (more risk assessment completed).

CONCLUSIONS

Unit/patient characteristics were potent HAPU predictors yet generally are not modifiable. RN workload, nurse expertise, and processes of care (risk assessment/interventions) are significant predictors that can be addressed to reduce HAPU. Support strategies may be needed for units where experienced full-time nurses are not available for HAPU prevention. Further research is warranted to test these finding in the context of higher HAPU prevalence.

Determinants of hospital fall rate trajectory groups: a longitudinal assessment of nurse staffing and organizational characteristics

BACKGROUND

Patient falls in acute care hospitals represent a significant patient safety concern. Although cross-sectional studies have shown that fall rates vary widely between acute care hospitals, it is not clear whether hospital fall rates remain consistent over time.

PURPOSE

The aim of this study was to determine whether hospitals can be categorized into fall rate trajectory groups over time and to identify nurse staffing and hospital characteristics associated with hospital fall rate trajectory groups.

METHODOLOGY/APPROACH

We conducted a 54-month (July 2006-December 2010) longitudinal study of U.S. acute care general hospitals participating in the National Database for Nursing Quality Indicators (2007). We used latent class growth modeling to categorize hospitals into groups based on their long-term fall rates. Nurse staffing and hospital characteristics associated with membership in the highest hospital fall rate group were identified using logistic regression.

FINDINGS

A sample of 1,529 hospitals (mean fall rate of 3.65 per 1,000 patient days) contributed data to the analysis. Latent class growth modeling findings classified hospital into three groups based on fall rate trajectories: consistently high (mean fall rate of 4.96 per 1,000 patient days), consistently medium (mean fall rate of 3.63 per 1,000 patient days), and consistently low (mean fall rate of 2.50 per 1,000 patient days). Hospitals with higher total nurse staffing (odds ratio [OR] = 0.92, 95% confidence interval [CI] [0.85, 0.99]), Magnet status (OR = 0.49, 95% CI [0.35, 0.70]), and bed size greater than 300 beds (OR = 0.70, 95% CI [0.51, 0.94]) were significantly less likely to be categorized in the "consistently high" fall rate group.

PRACTICE IMPLICATIONS

Over this 54-month period, hospitals were categorized into three groups based on long-term fall rates. Hospital-level factors differed among these three groups. This suggests that there may be hospitals in which "best practices" for fall prevention might be identified. In addition, administrators may be able to reduce fall rates by maintaining greater nurse staffing ratios as well as fostering an environment consistent with that of Magnet hospitals.

Trends and variations in the rates of hospital complications, failure-to-rescue and 30-day mortality in surgical patients in New South Wales, Australia, 2002-2009

BACKGROUND

Despite the increased acceptance of failure-to-rescue (FTR) as an important patient safety indicator (defined as the percentage of deaths among surgical patients with treatable complications), there has not been any large epidemiological study reporting FTR in an Australian setting nor any evaluation on its suitability as a performance indicator.

METHODS

We conducted a population-based study on elective surgical patients from 82 public acute hospitals in New South Wales, Australia between 2002 and 2009, exploring the trends and variations in rates of hospital complications, FTR and 30-day mortality. We used Poisson regression models to derive relative risk ratios (RRs) after adjusting for a range of patient and hospital characteristics.

RESULTS

The average rates of complications, FTR and 30-day mortality were 13.8 per 1000 admissions, 14.1% and 6.1 per 1000 admission, respectively. The rates of complications and 30-day mortality were stable throughout the study period however there was a significant decrease in FTR rate after 2006, coinciding with the establishment of national and state-level peak patient safety agencies. There were marked variations in the three rates within the top 20% of hospitals (best) and bottom 20% of hospitals (worst) for each of the four peer-hospital groups. The group comprising the largest volume hospitals (principal referral/teaching hospitals) had a significantly higher rate of FTR in comparison to the other three groups of smaller-sized peer hospital groups (RR = 0.78, 0.57, and 0.61, respectively). Adjusted rates of complications, FTR and 30-day mortality varied widely for individual surgical procedures between the best and worst quintile hospitals within the principal referral hospital group.

CONCLUSIONS

The decrease in FTR rate over the study period appears to be associated with a wide range of patient safety programs. The marked variations in the three rates between- and within- peer hospital groups highlight the potential for further quality improvement intervention opportunities.

The effect of health information technology implementation in Veterans Health Administration hospitals on patient outcomes

BACKGROUND

The impact of health information technology (HIT) in hospitals is dependent in large part on how it is used by nurses. This study examines the impact of HIT on the quality of care in hospitals in the Veterans Health Administration (VA), focusing on nurse-sensitive outcomes from 1995 to 2005.

METHODS

Data were obtained from VA databases and original data collection. Fixed-effects Poisson regression was used, with the dependent variables measured using the Agency for Healthcare Research and Quality Inpatient Quality Indicators and Patient Safety Indicators software. Dummy variables indicated when each facility began and completed implementation of each type of HIT. Other explanatory variables included hospital volume, patient characteristics, nurse characteristics, and a quadratic time trend.

RESULTS

The start of computerized patient record implementation was associated with significantly lower mortality for two diagnoses but significantly higher pressure ulcer rates, and full implementation was associated with significantly more hospital-acquired infections. The start of bar-code medication administration implementation was linked to significantly lower mortality for one diagnosis, but full implementation was not linked to any change in patient outcomes.

CONCLUSIONS

The commencement of HIT implementation had mixed effects on patient outcomes, and the completion of implementation had little or no effect on outcomes.

IMPLICATIONS

This longitudinal study provides little support for the perception of VA staff and leaders that HIT has improved mortality rates or nurse-sensitive patient outcomes. Future research should examine patient outcomes associated with specific care processes affected by HIT.

The need to establish a national patient safety program in Brazil

The aim of the study was to promote reflection on the need to create a national incident notification system based on a brazilian patient safety program. Incidents in health care harm patients and encumber the health care system. Although a quality assessment program has been recently launched in health care institutions, the Brazilian Ministry of Health does not yet have a program which systematically assesses negative outcomes of health care. This article discusses the need to establish a national patient safety program in Brazil, aiming to promote a culture of patient safety and quality health care in the Brazilian Unified Health System.

Patient turnover and nursing employment in Massachusetts hospitals before and after health insurance reform: implications for the Patient Protection and Affordable Care Act

The Affordable Care Act is modeled after Massachusetts insurance reforms enacted in 2006. A linear mixed effect model examined trends in patient turnover and nurse employment in Massachusetts, New York, and California nonfederal hospitals from 2000 to 2011. The linear mixed effect analysis found that the rate of increase in hospital admissions was significantly higher in Massachusetts hospitals (p<.001) than that in California and New York (p=.007). The rate of change in registered nurses full-time equivalent hours per patient day was significantly less (p=.02) in Massachusetts than that in California and was not different from zero. The rate of change in admissions to registered nurses full-time equivalent hours per patient day was significantly greater in Massachusetts than California (p=.001) and New York (p<.01). Nurse staffing remained flat in Massachusetts, despite a significant increase in hospital admissions. The implications of the findings for nurse employment and hospital utilization following the implementation of national health insurance reform are discussed.