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Crane L, Merck A, Delanthamajalu S, Grieger K, Marshall AM, Boyer TH. Benchmarks for urine volume generation and phosphorus mass recovery in commercial and institutional buildings. WATER RESEARCH X 2024; 23:100227. [PMID: 38765691 PMCID: PMC11101975 DOI: 10.1016/j.wroa.2024.100227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/26/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024]
Abstract
Phosphorus (P) is a finite resource and necessary nutrient for agriculture. Urine contains a higher concentration of P than domestic wastewater, which can be recovered by source separation and treatment (hereafter urine diversion). Commercial and institutional (CI) buildings are a logical location for urine diversion since restrooms account for a substantial fraction of water use and wastewater generation. This study estimated the potential for P recovery from human urine and water savings from reduced flushing in CI buildings, and proposed an approach to identify building types and community layouts that are amenable to implementing urine diversion. The results showed that urine diversion is most advantageous in CI buildings with either high daily occupancy counts or times, such as hospitals, schools, office buildings, and airports. Per occupant P recovery benchmarks were estimated to be between 0.04-0.68 g/cap·d. Per building P recovery rates were estimated to be between 0.002-5.1 kg/d, and per building water savings were estimated to be between 3 and 23 % by volume. Recovered P in the form of phosphate fertilizer and potable water savings could accrue profits and cost reductions that could offset the capital costs of new urine diversion systems within 5 y of operation. Finally, urine diversion systems can be implemented at different levels of decentralization based on community layout and organizational structure, which will require socioeconomic and policy acceptance for wider adoption.
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Affiliation(s)
- Lucas Crane
- School of Sustainable Engineering and the Built Environment (SSEBE), Arizona State University, PO Box 873005, Tempe, AZ 85287-3005, USA
- NSF Science and Technologies for Phosphorus Sustainability (STEPS) Center, USA
| | - Ashton Merck
- Department of Applied Ecology, North Carolina State University, Raleigh NC 27606, USA
- NSF Science and Technologies for Phosphorus Sustainability (STEPS) Center, USA
| | - Shwetha Delanthamajalu
- Department of Sociology, University of Illinois Urbana-Champaign, USA
- NSF Science and Technologies for Phosphorus Sustainability (STEPS) Center, USA
| | - Khara Grieger
- Department of Applied Ecology, North Carolina State University, Raleigh NC 27606, USA
- NSF Science and Technologies for Phosphorus Sustainability (STEPS) Center, USA
| | - Anna-Maria Marshall
- Department of Sociology, University of Illinois Urbana-Champaign, USA
- NSF Science and Technologies for Phosphorus Sustainability (STEPS) Center, USA
| | - Treavor H. Boyer
- School of Sustainable Engineering and the Built Environment (SSEBE), Arizona State University, PO Box 873005, Tempe, AZ 85287-3005, USA
- NSF Science and Technologies for Phosphorus Sustainability (STEPS) Center, USA
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Cho DD, Bretthauer KM, Schoenfelder J. Patient-to-nurse ratios: Balancing quality, nurse turnover, and cost. Health Care Manag Sci 2023; 26:807-826. [PMID: 38019329 DOI: 10.1007/s10729-023-09659-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/04/2023] [Indexed: 11/30/2023]
Abstract
We consider the problem of setting appropriate patient-to-nurse ratios in a hospital, an issue that is both complex and widely debated. There has been only limited effort to take advantage of the extensive empirical results from the medical literature to help construct analytical decision models for developing upper limits on patient-to-nurse ratios that are more patient- and nurse-oriented. For example, empirical studies have shown that each additional patient assigned per nurse in a hospital is associated with increases in mortality rates, length-of-stay, and nurse burnout. Failure to consider these effects leads to disregarded potential cost savings resulting from providing higher quality of care and fewer nurse turnovers. Thus, we present a nurse staffing model that incorporates patient length-of-stay, nurse turnover, and costs related to patient-to-nurse ratios. We present results based on data collected from three participating hospitals, the American Hospital Association (AHA), and the California Office of Statewide Health Planning and Development (OSHPD). By incorporating patient and nurse outcomes, we show that lower patient-to-nurse ratios can potentially provide hospitals with financial benefits in addition to improving the quality of care. Furthermore, our results show that higher policy patient-to-nurse ratio upper limits may not be as harmful in smaller hospitals, but lower policy patient-to-nurse ratios may be necessary for larger hospitals. These results suggest that a "one ratio fits all" patient-to-nurse ratio is not optimal. A preferable policy would be to allow the ratio to be hospital-dependent.
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Affiliation(s)
- David D Cho
- Department of Management, College of Business and Economics, California State University, Fullerton, Fullerton, CA, 92831, USA.
| | - Kurt M Bretthauer
- Operations and Decision Technologies Department, Kelley School of Business, Indiana University, Bloomington, IN, 47405, USA
| | - Jan Schoenfelder
- Health Care Operations / Health Information Management, University of Augsburg, 86159, Augsburg, Germany
- School of Management, Lancaster University Leipzig, 04109, Leipzig, Germany
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Rubbo B, Saville C, Dall'Ora C, Turner L, Jones J, Ball J, Culliford D, Griffiths P. Staffing levels and hospital mortality in England: a national panel study using routinely collected data. BMJ Open 2023; 13:e066702. [PMID: 37197808 DOI: 10.1136/bmjopen-2022-066702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVES Examine the association between multiple clinical staff levels and case-mix adjusted patient mortality in English hospitals. Most studies investigating the association between hospital staffing levels and mortality have focused on single professional groups, in particular nursing. However, single staff group studies might overestimate effects or neglect important contributions to patient safety from other staff groups. DESIGN Retrospective observational study of routinely available data. SETTING AND PARTICIPANTS 138 National Health Service hospital trusts that provided general acute adult services in England between 2015 and 2019. OUTCOME MEASURE Standardised mortality rates were derived from the Summary Hospital level Mortality Indicator data set, with observed deaths as outcome in our models and expected deaths as offset. Staffing levels were calculated as the ratio of occupied beds per staff group. We developed negative binomial random-effects models with trust as random effects. RESULTS Hospitals with lower levels of medical and allied healthcare professional (AHP) staff (e.g, occupational therapy, physiotherapy, radiography, speech and language therapy) had significantly higher mortality rates (rate ratio: 1.04, 95% CI 1.02 to 1.06, and 1.04, 95% CI 1.02 to 1.06, respectively), while those with lower support staff had lower mortality rates (0.85, 95% CI 0.79 to 0.91 for nurse support, and 1.00, 95% CI 0.99 to 1.00 for AHP support). Estimates of the association between staffing levels and mortality were stronger between-hospitals than within-hospitals, which were not statistically significant in a within-between random effects model. CONCLUSIONS In additional to medicine and nursing, AHP staffing levels may influence hospital mortality rates. Considering multiple staff groups simultaneously when examining the association between hospital mortality and clinical staffing levels is crucial. TRIAL REGISTRATION NUMBER NCT04374812.
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Affiliation(s)
- Bruna Rubbo
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Christina Saville
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
- National Institute for Health Research Applied Research Collaboration (Wessex), University Hospital Southampton, Southampton, UK
| | - Chiara Dall'Ora
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
- National Institute for Health Research Applied Research Collaboration (Wessex), University Hospital Southampton, Southampton, UK
| | - Lesley Turner
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Jeremy Jones
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Jane Ball
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - David Culliford
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
- National Institute for Health Research Applied Research Collaboration (Wessex), University Hospital Southampton, Southampton, UK
| | - Peter Griffiths
- School of Health Sciences, University of Southampton, Southampton, Hampshire, UK
- National Institute for Health Research Applied Research Collaboration (Wessex), University Hospital Southampton, Southampton, UK
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Dall'Ora C, Rubbo B, Saville C, Turner L, Ball J, Ball C, Griffiths P. The association between multi-disciplinary staffing levels and mortality in acute hospitals: a systematic review. HUMAN RESOURCES FOR HEALTH 2023; 21:30. [PMID: 37081525 PMCID: PMC10116759 DOI: 10.1186/s12960-023-00817-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/11/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Health systems worldwide are faced with the challenge of adequately staffing their hospital services. Much of the current research and subsequent policy has been focusing on nurse staffing and minimum ratios to ensure quality and safety of patient care. Nonetheless, nurses are not the only profession who interact with patients, and, therefore, not the only professional group who has the potential to influence the outcomes of patients while in hospital. We aimed to synthesise the evidence on the relationship between multi-disciplinary staffing levels in hospital including nursing, medical and allied health professionals and the risk of death. METHODS Systematic review. We searched Embase, Medline, CINAHL, and the Cochrane Library for quantitative or mixed methods studies with a quantitative component exploring the association between multi-disciplinary hospital staffing levels and mortality. RESULTS We included 12 studies. Hospitals with more physicians and registered nurses had lower mortality rates. Higher levels of nursing assistants were associated with higher patient mortality. Only two studies included other health professionals, providing scant evidence about their effect. CONCLUSIONS Pathways for allied health professionals such as physiotherapists, occupational therapists, dietitians, pharmacists, to impact safety and other patient outcomes are plausible and should be explored in future studies.
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Affiliation(s)
- Chiara Dall'Ora
- School of Health Sciences, University of Southampton, Highfield Campus, Southampton, SO17 1BJ, UK.
- NIHR Applied Research Collaboration Wessex, University of Southampton, Southampton, UK.
| | - Bruna Rubbo
- School of Health Sciences, University of Southampton, Highfield Campus, Southampton, SO17 1BJ, UK
| | - Christina Saville
- School of Health Sciences, University of Southampton, Highfield Campus, Southampton, SO17 1BJ, UK
| | - Lesley Turner
- School of Health Sciences, University of Southampton, Highfield Campus, Southampton, SO17 1BJ, UK
| | - Jane Ball
- School of Health Sciences, University of Southampton, Highfield Campus, Southampton, SO17 1BJ, UK
- NIHR Applied Research Collaboration Wessex, University of Southampton, Southampton, UK
| | - Cheska Ball
- NIHR Applied Research Collaboration Wessex, University of Southampton, Southampton, UK
- Dorset County Hospital NHS Foundation Trust, Dorchester, UK
| | - Peter Griffiths
- School of Health Sciences, University of Southampton, Highfield Campus, Southampton, SO17 1BJ, UK
- NIHR Applied Research Collaboration Wessex, University of Southampton, Southampton, UK
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Ghosh AK, Ibrahim S, Lee J, Shapiro MF, Ancker J. Comparing Hospital Length of Stay Risk-Adjustment Models in US Value-Based Physician Payments. Qual Manag Health Care 2023; 32:22-29. [PMID: 35383715 PMCID: PMC9530068 DOI: 10.1097/qmh.0000000000000363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUNG AND OBJECTIVES Under the Affordable Care Act, the US Centers for Medicare & Medicaid Services created the Physician Value-Based Payment Modifier Program and its successor, the Merit-Based Incentive Payment System, to tie physician payments to quality and cost. The addition of hospital length of stay (LOS) to these value-based physician payment models reflects its increasing importance as a metric of health care cost and efficiency and its association with adverse health outcomes. This study compared the Centers for Medicare & Medicaid Services-endorsed LOS risk-adjustment methodology with a novel methodology that accounts for pre-hospitalization clinical, socioeconomic status (SES), and admission-related factors as influential factors of hospital LOS. METHODS Using the 2014 New York, Florida, and New Jersey State Inpatient Database, we compared the observed-to-expected LOS of 2373102 adult admissions for 742 medical and surgical diagnosis-related groups (DRGs) by 3 models: ( a ) current risk-adjustment model (CRM), which adjusted for age, sex, number of chronic conditions, Elixhauser comorbidity score, and DRG severity weight, ( b ) CRM but modeling LOS using a generalized linear model (C-GLM), and (c) novel risk-adjustment model (NRM), which added to the C-GLM covariates for race/ethnicity, SES, discharge destination, weekend admission, and individual intercepts for DRGs instead of severity weights. RESULTS The NRM disadvantaged physicians for fewer medical and surgical DRGs, compared with both the C-GLM and CRM models (medical DRGs: 0.49% vs 13.17% and 10.89%, respectively; surgical DRGs: 0.30% vs 13.17% and 10.98%, respectively). In subgroup analysis, the NRM reduced the proportion of physician-penalizing DRGs across all racial/ethnic and socioeconomic groups, with the highest reduction among Whites, followed by low SES patients, and the lowest reduction among Hispanic patients. CONCLUSIONS After accounting for pre-hospitalization socioeconomic and clinical factors, the adjusted LOS using the NRM was lower than estimates from the current Centers for Medicare & Medicaid Services-endorsed model. The current model may disadvantage physicians serving communities with higher socioeconomic risks.
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Affiliation(s)
- Arnab K. Ghosh
- Department of Medicine, Weill Cornell Medical College, Cornell University, 525 E 68 St., New York, New York, USA 10065
| | - Said Ibrahim
- Department of Population Health Sciences, Weill Cornell Medical College, Cornell University, 402 E 67 St., New York, NY USA 10065
| | - Jennifer Lee
- Department of Medicine, Weill Cornell Medical College, Cornell University, 525 E 68 St., New York, New York, USA 10065
| | - Martin F. Shapiro
- Department of Medicine, Weill Cornell Medical College, Cornell University, 525 E 68 St., New York, New York, USA 10065
| | - Jessica Ancker
- Department of Population Health Sciences, Weill Cornell Medical College, Cornell University, 402 E 67 St., New York, NY USA 10065
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Tello M, Reich ES, Puckey J, Maff R, Garcia-Arce A, Bhattacharya BS, Feijoo F. Machine learning based forecast for the prediction of inpatient bed demand. BMC Med Inform Decis Mak 2022; 22:55. [PMID: 35236345 PMCID: PMC8889525 DOI: 10.1186/s12911-022-01787-9] [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: 02/19/2021] [Accepted: 02/07/2022] [Indexed: 12/04/2022] Open
Abstract
Background Overcrowding is a serious problem that impacts the ability to provide optimal level of care in a timely manner. High patient volume is known to increase the boarding time at the emergency department (ED), as well as at post-anesthesia care unit (PACU). Furthermore, the same high volume increases inpatient bed transfer times, which causes delays in elective surgeries, increases the probability of near misses, patient safety incidents, and adverse events.
Objective The purpose of this study is to develop a Machine Learning (ML) based strategy to predict weekly forecasts of the inpatient bed demand in order to assist the resource planning for the ED and PACU, resulting in a more efficient utilization. Methods The data utilized included all adult inpatient encounters at Geisinger Medical Center (GMC) for the last 5 years. The variables considered were class of inpatient encounter, observation, or surgical overnight recovery (SORU) at the time of their discharge. The ML based strategy is built using the K-means clustering method and the Support Vector Machine Regression technique (K-SVR). Results The performance obtained by the K-SVR strategy in the retrospective cohort amounts to a mean absolute percentage error (MAPE) that ranges between 0.49 and 4.10% based on the test period. Additionally, results present a reduced variability, which translates into more stable forecasting results. Conclusions The results from this study demonstrate the capacity of ML techniques to forecast inpatient bed demand, particularly using K-SVR. It is expected that the implementation of this model in the workflow of bed capacity management will create efficiencies, which will translate in a more reliable, inexpensive and timely care for patients.
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Affiliation(s)
- Manuel Tello
- Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | | | | | | | | | | | - Felipe Feijoo
- Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile.
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Griffiths P, Saville C, Ball JE, Chable R, Dimech A, Jones J, Jeffrey Y, Pattison N, Saucedo AR, Sinden N, Monks T. The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08160] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BackgroundThe Safer Nursing Care Tool is a system designed to guide decisions about nurse staffing requirements on hospital wards, in particular the number of nurses to employ (establishment). The Safer Nursing Care Tool is widely used in English hospitals but there is a lack of evidence about how effective and cost-effective nurse staffing tools are at providing the staffing levels needed for safe and quality patient care.ObjectivesTo determine whether or not the Safer Nursing Care Tool corresponds to professional judgement, to assess a range of options for using the Safer Nursing Care Tool and to model the costs and consequences of various ward staffing policies based on Safer Nursing Care Tool acuity/dependency measure.DesignThis was an observational study on medical/surgical wards in four NHS hospital trusts using regression, computer simulations and economic modelling. We compared the effects and costs of a ‘high’ establishment (set to meet demand on 90% of days), the ‘standard’ (mean-based) establishment and a ‘flexible (low)’ establishment (80% of the mean) providing a core staff group that would be sufficient on days of low demand, with flexible staff re-deployed/hired to meet fluctuations in demand.SettingMedical/surgical wards in four NHS hospital trusts.Main outcome measuresThe main outcome measures were professional judgement of staffing adequacy and reports of omissions in care, shifts staffed more than 15% below the measured requirement, cost per patient-day and cost per life saved.Data sourcesThe data sources were hospital administrative systems, staff reports and national reference costs.ResultsIn total, 81 wards participated (85% response rate), with data linking Safer Nursing Care Tool ratings and staffing levels for 26,362 wards × days (96% response rate). According to Safer Nursing Care Tool measures, 26% of all ward-days were understaffed by ≥ 15%. Nurses reported that they had enough staff to provide quality care on 78% of shifts. When using the Safer Nursing Care Tool to set establishments, on average 60 days of observation would be needed for a 95% confidence interval spanning 1 whole-time equivalent either side of the mean. Staffing levels below the daily requirement estimated using the Safer Nursing Care Tool were associated with lower odds of nurses reporting ‘enough staff for quality’ and more reports of missed nursing care. However, the relationship was effectively linear, with staffing above the recommended level associated with further improvements. In simulation experiments, ‘flexible (low)’ establishments led to high rates of understaffing and adverse outcomes, even when temporary staff were readily available. Cost savings were small when high temporary staff availability was assumed. ‘High’ establishments were associated with substantial reductions in understaffing and improved outcomes but higher costs, although, under most assumptions, the cost per life saved was considerably less than £30,000.LimitationsThis was an observational study. Outcomes of staffing establishments are simulated.ConclusionsUnderstanding the effect on wards of variability of workload is important when planning staffing levels. The Safer Nursing Care Tool correlates with professional judgement but does not identify optimal staffing levels. Employing more permanent staff than recommended by the Safer Nursing Care Tool guidelines, meeting demand most days, could be cost-effective. Apparent cost savings from ‘flexible (low)’ establishments are achieved largely by below-adequate staffing. Cost savings are eroded under the conditions of high temporary staff availability that are required to make such policies function.Future workResearch is needed to identify cut-off points for required staffing. Prospective studies measuring patient outcomes and comparing the results of different systems are feasible.Trial registrationCurrent Controlled Trials ISRCTN12307968.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Peter Griffiths
- School of Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, University of Southampton, Southampton, UK
| | - Christina Saville
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Jane E Ball
- School of Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, University of Southampton, Southampton, UK
| | - Rosemary Chable
- Training, Development & Workforce, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrew Dimech
- Clinical Services, The Royal Marsden NHS Foundation Trust, London, UK
| | - Jeremy Jones
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Yvonne Jeffrey
- Nursing & Patient Services, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Natalie Pattison
- Clinical Services, The Royal Marsden NHS Foundation Trust, London, UK
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | | | - Nicola Sinden
- Nursing Directorate, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Thomas Monks
- School of Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, University of Southampton, Southampton, UK
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Griffiths P, Ball J, Bloor K, Böhning D, Briggs J, Dall’Ora C, Iongh AD, Jones J, Kovacs C, Maruotti A, Meredith P, Prytherch D, Saucedo AR, Redfern O, Schmidt P, Sinden N, Smith G. Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06380] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background
Low nurse staffing levels are associated with adverse patient outcomes from hospital care, but the causal relationship is unclear. Limited capacity to observe patients has been hypothesised as a causal mechanism.
Objectives
This study determines whether or not adverse outcomes are more likely to occur after patients experience low nurse staffing levels, and whether or not missed vital signs observations mediate any relationship.
Design
Retrospective longitudinal observational study. Multilevel/hierarchical mixed-effects regression models were used to explore the association between registered nurse (RN) and health-care assistant (HCA) staffing levels and outcomes, controlling for ward and patient factors.
Setting and participants
A total of 138,133 admissions to 32 general adult wards of an acute hospital from 2012 to 2015.
Main outcomes
Death in hospital, adverse event (death, cardiac arrest or unplanned intensive care unit admission), length of stay and missed vital signs observations.
Data sources
Patient administration system, cardiac arrest database, eRoster, temporary staff bookings and the Vitalpac system (System C Healthcare Ltd, Maidstone, Kent; formerly The Learning Clinic Limited) for observations.
Results
Over the first 5 days of stay, each additional hour of RN care was associated with a 3% reduction in the hazard of death [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.94 to 1.0]. Days on which the HCA staffing level fell below the mean were associated with an increased hazard of death (HR 1.04, 95% CI 1.02 to 1.07), but the hazard of death increased as cumulative staffing exposures varied from the mean in either direction. Higher levels of temporary staffing were associated with increased mortality. Adverse events and length of stay were reduced with higher RN staffing. Overall, 16% of observations were missed. Higher RN staffing was associated with fewer missed observations in high-acuity patients (incidence rate ratio 0.98, 95% CI 0.97 to 0.99), whereas the overall rate of missed observations was related to overall care hours (RN + HCA) but not to skill mix. The relationship between low RN staffing and mortality was mediated by missed observations, but other relationships between staffing and mortality were not. Changing average skill mix and staffing levels to the levels planned by the Trust, involving an increase of 0.32 RN hours per patient day (HPPD) and a similar decrease in HCA HPPD, would be associated with reduced mortality, an increase in staffing costs of £28 per patient and a saving of £0.52 per patient per hospital stay, after accounting for the value of reduced stays.
Limitations
This was an observational study in a single site. Evidence of cause is not definitive. Variation in staffing could be influenced by variation in the assessed need for staff. Our economic analysis did not consider quality or length of life.
Conclusions
Higher RN staffing levels are associated with lower mortality, and this study provides evidence of a causal mechanism. There may be several causal pathways and the absolute rate of missed observations cannot be used to guide staffing decisions. Increases in nursing skill mix may be cost-effective for improving patient safety.
Future work
More evidence is required to validate approaches to setting staffing levels. Other aspects of missed nursing care should be explored using objective data. The implications of findings about both costs and temporary staffing need further exploration.
Trial registration
This study is registered as ISRCTN17930973.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 38. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Peter Griffiths
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Jane Ball
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Karen Bloor
- Health Sciences, University of York, York, UK
| | - Dankmar Böhning
- Mathematical Sciences, University of Southampton, Southampton, UK
| | - Jim Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Chiara Dall’Ora
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Anya De Iongh
- Independent lay researcher c/o National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Southampton, UK
| | - Jeremy Jones
- Health Sciences, University of Southampton, Southampton, UK
| | - Caroline Kovacs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | | | - Paul Meredith
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - David Prytherch
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Alejandra Recio Saucedo
- Health Sciences, University of Southampton, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
| | - Oliver Redfern
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK
| | - Paul Schmidt
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Wessex, Southampton, UK
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Nicola Sinden
- Clinical Outcomes Research Group, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Gary Smith
- Health and Social Sciences, Bournemouth University, Bournemouth, UK
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Curry LA, Brault MA, Cherlin E, Smith M. Promoting integration of pharmacy expertise in care of hospitalized patients with acute myocardial infarction. Am J Health Syst Pharm 2018; 75:962-972. [PMID: 29752256 DOI: 10.2146/ajhp170727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE The substantive integration of pharmacists into quality-improvement initiatives aimed at improving the care of hospitalized patients with acute myocardial infarction (AMI) is described. METHODS A 2-year, mixed-methods, interventional study was conducted in 10 U.S. hospitals, directed at promoting the use of evidence-based strategies and fostering domains of hospital organizational culture associated with lower risk-standardized mortality rates (RSMRs) for patients with AMI. The adoption of 5 evidence-based strategies associated with reducing RSMRs for AMI was measured at baseline, 12, and 24 months. Data were collected via face-to-face interviews conducted at each hospital. Ethnographic observations were conducted at baseline and 18 months. RESULTS Significant changes in the use of evidence-based strategies were observed over the 2-year study period (p = 0.02), with the mean number of strategies used per hospital increasing from 2.4 at baseline to 3.9 at 24 months. Innovative approaches for integrating pharmacotherapy and pharmacy practice expertise included information technology solutions, targeted rounding for patients with AMI, medication-bridging programs, and education of patients with AMI. CONCLUSION A mixed-methods interventional study in 10 hospitals examined the substantive integration of pharmacists into quality-improvement initiatives aimed at improving the care of patients with AMI. The investigation revealed the ability of this integration to meet clinical challenges by generating novel, feasible solutions that were tailored for specific hospital contexts. Inclusion of pharmacists strengthened relationships across disciplines and allowed pharmacists to become routinely embedded in broader quality efforts.
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Affiliation(s)
- Leslie A Curry
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT .,Yale Global Health Leadership Institute, Yale University, New Haven, CT
| | - Marie A Brault
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT.,Yale Global Health Leadership Institute, Yale University, New Haven, CT
| | - Emily Cherlin
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT.,Yale Global Health Leadership Institute, Yale University, New Haven, CT
| | - Marie Smith
- University of Connecticut School of Pharmacy, Storrs, CT
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10
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Han L, Meacock R, Anselmi L, Kristensen SR, Sutton M, Doran T, Clough S, Power M. Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Patients admitted to hospital outside normal working hours suffer higher complication and mortality rates than patients admitted at times when the hospital is fully operational. This ‘weekend effect’ is well described but poorly understood. It is not clear whether or not the effect extends to other out-of-hours periods, or how far excess mortality for out-of-hours admissions reflects a different presenting population with higher severity of illness and how much is explained by poorer availability and quality of services.
Objectives
We aimed to assess (1) the costs and benefits of introducing 7-day services, (2) whether or not mortality rates are elevated during all out-of-hours periods, (3) whether or not selection of more severely ill patients for admission out of hours explains elevated mortality rates and (4) whether or not mortality rates out of hours are related to staffing levels.
Methods
We conducted a series of retrospective observational analyses of hospital episode data in England, using both national data and data from a single, large acute NHS trust. For the national studies, we analysed emergency admissions to all 140 non-specialist acute hospital trusts in England between April 2013 and February 2014 (over 12 million accident and emergency attendances and 4.5 million emergency admissions). For the single trust, we analysed emergency admissions between April 2004 and March 2014 (240,000 admissions). Deaths within 30 days of attendance or admission were compared for normal working hours and out-of-hours periods.
Results
We found that, in addition to elevated mortality for weekend admissions, mortality rates are also elevated for patients admitted during night-time periods. Elevated mortality was reduced for stroke patients in a large acute trust when more – and more experienced – nursing staff were present during the first hour of admission. Nationally, we found that excess mortality out of hours was largely explained by a sicker population of patients being selected for admission. However, mortality rates were still elevated on Sunday daytimes when we accounted for severity of patient illness. We also found that the estimated cost of implementing 7-day services exceeds the maximum amount that the National Institute for Health and Care Excellence would recommend the NHS should spend on eradicating excess mortality at weekends.
Limitations
Our results depend on the accuracy and completeness of data recording by hospital staff. If accuracy of recording is related to time of patient admission, our results may be biased. Results based on data from a single trust should be treated as indicative.
Conclusions
In addressing variations in patient outcomes across the week, a more nuanced approach, extending services for key specialties over critical periods – rather than implementing whole-system changes – is likely to be the most cost-effective.
Future work
Future research should aim to develop and use appropriate measures of severity of illness to facilitate meaningful analysis of variations in patient outcomes, and to identify candidate specialties and critical periods for which extending services is likely to be cost-effective.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Lu Han
- Department of Health Sciences, University of York, York, UK
| | - Rachel Meacock
- Centre for Health Economics, University of Manchester, Manchester, UK
| | - Laura Anselmi
- Centre for Health Economics, University of Manchester, Manchester, UK
| | | | - Matt Sutton
- Centre for Health Economics, University of Manchester, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Stuart Clough
- Haelo, Salford Royal NHS Foundation Trust, Salford, UK
| | - Maxine Power
- Haelo, Salford Royal NHS Foundation Trust, Salford, UK
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11
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Abstract
Concerns about nurse staffing in hospitals, nursing's influence on patient safety and health care outcomes, and nurses' work environment (e.g., equipment failures, documentation burden) have led to increased interest in measuring and reporting nursing's performance. This article reviews recent efforts and issues involved in identifying a set of nursing-sensitive performance measures. Sustaining and strengthening current efforts requires developing measures that address all the domains of nursing, addressing technical issues needed to analyze the impact of nursing on patient safety and health care outcomes, developing data systems that provide the information needed to implement the model system, regularly improving the set of endorsed standards to reflect the most current science and empirical evidence, and persuading all health care stakeholders that measurement and reporting nursing-sensitive standards make a difference in the care and quality that are delivered. Each of these tasks requires substantial development work and construction and maintenance of the infrastructure to sustain the performance measurement efforts.
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12
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Griffiths P, Ball J, Drennan J, Dall’Ora C, Jones J, Maruotti A, Pope C, Recio Saucedo A, Simon M. Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development. Int J Nurs Stud 2016; 63:213-225. [DOI: 10.1016/j.ijnurstu.2016.03.012] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/15/2016] [Accepted: 03/17/2016] [Indexed: 02/06/2023]
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13
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Griffiths P, Ball J, Murrells T, Jones S, Rafferty AM. Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study. BMJ Open 2016; 6:e008751. [PMID: 26861934 PMCID: PMC4762154 DOI: 10.1136/bmjopen-2015-008751] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To examine associations between mortality and registered nurse (RN) staffing in English hospital trusts taking account of medical and healthcare support worker (HCSW) staffing. SETTING Secondary care provided in acute hospital National Health Service (NHS) trusts in England. PARTICIPANTS Two data sets are examined: Administrative data from 137 NHS acute hospital trusts (staffing measured as beds per staff member). A cross-sectional survey of 2917 registered nurses in a subsample of 31 trusts (measured patients per ward nurse). OUTCOME MEASURE Risk-adjusted mortality rates for adult patients (administrative data). RESULTS For medical admissions, higher mortality was associated with more occupied beds per RN (RR 1.22, 95% CI 1.04 to 1.43, p=0.02) and per doctor (RR 1.10, 95% CI 1.05 to 1.15, p <0.01) employed by the trust whereas, lower HCSW staffing was associated with lower mortality (RR 0.95, 95% CI 0.91 to 1.00, p=0.04). In multivariable models the relationship was statistically significant for doctors (RR 1.08, 95% CI 1.02 to 1.15, p=0.02) and HCSWs (RR 0.93, 95% CI 0.89 to 0.98, p<01) but not RNs (RR 1.14, 95% CI 0.95 to 1.38, p=0.17). Trusts with an average of ≤ 6 patients per RN in medical wards had a 20% lower mortality rate compared to trusts with >10 patients per nurse (RR 0.80, 95% CI 0.76 to 0.85, p<0.01). The relationship remained significant in the multivariable model (RR 0.89, 95% CI 0.83 to 0.95, p<0.01). Results for surgical wards/admissions followed a similar pattern but with fewer significant results. CONCLUSIONS Ward-based RN staffing is significantly associated with reduced mortality for medical patients. There is little evidence for beneficial associations with HCSW staffing. Higher doctor staffing levels is associated with reduced mortality. The estimated association between RN staffing and mortality changes when medical and HCSW staffing is considered and depending on whether ward or trust wide staffing levels are considered.
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Affiliation(s)
- Peter Griffiths
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
- University of Southampton, Southampton, UK
| | - Jane Ball
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex, Southampton, UK
- Karolinska Institutet, Stockholm, Sweden
| | - Trevor Murrells
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Simon Jones
- Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
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14
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15
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Angst CM, Devaraj S, D'Arcy J. Dual Role of IT-Assisted Communication in Patient Care: A Validated Structure-Process-Outcome Framework. J MANAGE INFORM SYST 2014. [DOI: 10.2753/mis0742-1222290209] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Corey M. Angst
- a Management Department, Mendoza College of Business, University of Notre Dame
| | - Sarv Devaraj
- a Management Department, Mendoza College of Business, University of Notre Dame
| | - John D'Arcy
- b Lerner College of Business and Economics, University of Delaware
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16
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Ho CK, Mabasa VH, Leung VWY, Malyuk DL, Perrott JL. Assessment of clinical pharmacy interventions in the intensive care unit. Can J Hosp Pharm 2013; 66:212-8. [PMID: 23950604 DOI: 10.4212/cjhp.v66i4.1267] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Clinical pharmacy services have been shown to reduce adverse drug events and health care costs. However, few studies have assessed their effect on patient outcomes in the intensive care unit (ICU). OBJECTIVE To describe characteristics of ICU patients with documented pharmacist interventions and to evaluate the relationships between patients' complexity level and pharmacists' interventions and between pharmacists' interventions and mortality rate. METHODS Inpatient records of admissions between January 1, 2004, and March 31, 2007, were analyzed to identify the presence of clinical pharmacy notes (CPNs). The characteristics of patients with and without CPNs were compared using descriptive statistics. For primary analysis of the association between patient complexity level and presence of CPNs, logistic regression modelling was performed to adjust for potential confounding. Logistic regression was also used to explore the possible association between CPNs and mortality. Finally, mortality analysis was carried out for patients with and without CPNs, with matching by complexity level. RESULTS The main study cohort comprised 1561 patients: 333 (21.3%) with CPNs and 1228 (78.7%) with no CPNs. A greater proportion of those with a CPN had the highest complexity level: 295 (88.6%) of those with CPNs versus 660 (53.7%) of those with no CPNs. After adjustment for age and sex, the odds ratio for having a CPN among patients with complexity level 4 (relative to patients with lower complexity levels) was 8.20 (95% confidence interval 5.44-12.38). Mortality rates were not significantly different between the 2 groups: 26.7% (89/333) among patients with CPNs and 27.9% (343/1228) among those without CPNs (p = 0.66). After adjustment for age, sex, complexity level, and length of stay in the ICU, the presence of a CPN was not significantly associated with mortality. Mortality rates in the matched cohort (n = 1078) were also similar between patients with and without CPNs (89/333 [26.7%] and 226/745 [30.3%], respectively; p = 0.23), and the presence of a CPN was not significantly associated with mortality after adjustments for potential confounding factors. CONCLUSION Documenting clinical pharmacy activities is essential for assessing pharmacists' impact on patient outcomes. These data suggest that ICU pharmacists prioritize clinical activities to care for the sickest patients.
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Affiliation(s)
- Claudia K Ho
- , BSc(Pharm), is a Clinical Pharmacy Resident, Lower Mainland Pharmacy Services at Fraser Health, Vancouver, British Columbia
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17
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Milfred-LaForest SK, Chow SL, DiDomenico RJ, Dracup K, Ensor CR, Gattis-Stough W, Heywood JT, Lindenfeld J, Page RL, Patterson JH, Vardeny O, Massie BM. Clinical Pharmacy Services in Heart Failure: An Opinion Paper from the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network. Pharmacotherapy 2013; 33:529-48. [DOI: 10.1002/phar.1295] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | - Sheryl L. Chow
- College of Pharmacy; Western University of Health Sciences; Pomona California
| | | | - Kathleen Dracup
- School of Nursing; University of California; San Francisco California
| | | | - Wendy Gattis-Stough
- College of Pharmacy and Health Sciences; Department of Clinical Research; Campbell University; Buies Creek North Carolina
| | | | - JoAnn Lindenfeld
- Heart Transplantation Program; Division of Cardiology; Department of Medicine; University of Colorado Denver; Aurora Colorado
| | - Robert L. Page
- Schools of Pharmacy and Medicine; University of Colorado Denver; Aurora Colorado
| | - J. Herbert Patterson
- Eshelman School of Pharmacy; University of North Carolina; Chapel Hill North Carolina
| | - Orly Vardeny
- Schools of Pharmacy and Medicine; University of Wisconsin; Madison Wisconsin
| | - Barry M. Massie
- School of Medicine; University of California, and San Francisco VA Medical Center; San Francisco California
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18
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Clinical Pharmacy Services in Heart Failure: An Opinion Paper From the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network. J Card Fail 2013; 19:354-69. [DOI: 10.1016/j.cardfail.2013.02.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 02/24/2013] [Accepted: 02/25/2013] [Indexed: 11/20/2022]
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19
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Griffiths P, Jones S, Bottle A. Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? Observational study. Int J Nurs Stud 2013. [DOI: 10.1016/j.ijnurstu.2012.10.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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20
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Wang EHZ, Co M, Man D, Mabasa VH. Should there be a cap on the number of patients under the care of a clinical pharmacist? Can J Hosp Pharm 2012; 65:319-21. [PMID: 22919111 DOI: 10.4212/cjhp.v65i4.1164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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21
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Al-Hajje AH, Atoui F, Awada S, Rachidi S, Zein S, Salameh P. Drug-related problems identified by clinical pharmacist's students and pharmacist's interventions. ANNALES PHARMACEUTIQUES FRANÇAISES 2012; 70:169-76. [PMID: 22655585 DOI: 10.1016/j.pharma.2012.02.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 02/10/2012] [Accepted: 02/16/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Drug-related problems constitute a major public health problem, because of their consequences on morbidity, mortality and cost. PATIENTS AND METHODS A 6-month prospective study was conducted, including hospitalized patients in the internal medicine ward of the University Hospital of Beirut, in order to identify drug-related problems by clinical pharmacist's students participating in routine medical rounds, to assess the characteristics of patients presenting these drug-related problems and to analyze pharmacist's interventions. RESULTS Ninety patients presenting drug-related problems were identified. Thirty-two percent were hydro-electrolytic problems and 24% gastrointestinal. Cardiovascular drugs were the most frequently implicated (44%), followed by anticoagulants (17%) and corticosteroids (14%). The most commonly identified drug-related problems were drug interactions (37%), overdosage (28%), non-conformity to guidelines or contra-indications (23%), underdosage (10%) and improper administration (2%). The clinical pharmacist's interventions consisted of dose adjustment (38%), addition drugs (31%), changes in drugs (29%) and optimization of administration (2%). DISCUSSION AND CONCLUSION To decrease the risk of drug-related problems, drug treatment requires physicians to abide by prescribing recommendations, notably in elderly patients, as well as pharmacists' effective intervention at all levels. Routine participation of clinical pharmacists in clinical medical rounds facilitates the identification of drug-related problems and may prevent their occurrence.
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Affiliation(s)
- A H Al-Hajje
- Clinical Pharmacy Department, Faculty of Pharmacy, Lebanese University, Hadath, Beirut, Lebanon.
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22
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23
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Affiliation(s)
- Michelle Mourad
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco, 505 Parnassus Ave, M1287, Box 0131, San Francisco, CA 94143 USA
| | - Josh Adler
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA USA
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24
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Sedation and analgesia in intensive care: a comparison of fentanyl and remifentanil. PAIN RESEARCH AND TREATMENT 2011; 2011:650320. [PMID: 22110929 PMCID: PMC3197257 DOI: 10.1155/2011/650320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 04/18/2011] [Accepted: 05/01/2011] [Indexed: 12/19/2022]
Abstract
Optimal sedation and analgesia are of key importance in intensive care. The aim of this study was to assess the quality of sedoanalgesia and outcome parameters in regimens containing midazolam and either fentanyl or remifentanil. A prospective, randomized, open-label, controlled trial was carried out in the ICU unit of a large teaching hospital in Istanbul over a 9-month period. Thirty-four patients were randomly allocated to receive either a remifentanil-midazolam regimen (R group, n = 17) or a fentanyl-midazolam regimen (F group, n = 17). A strong correlation between Riker Sedation-Agitation Scale (SAS) and Ramsey Scale (RS) measurements was observed. Comparatively, remifentanil provided significantly more potent and rapid analgesia based on Behavioral-Physiological Scale (BPS) measurements and a statistically nonsignificantly shorter time to discharge. On the other hand, remifentanil also caused a significantly sharper fall in heart rate within the first six hours of treatment.
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25
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Detection of prescription errors by a unit-based clinical pharmacist in a nephrology ward. ACTA ACUST UNITED AC 2009; 32:59-65. [PMID: 19838816 DOI: 10.1007/s11096-009-9341-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 09/30/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the impact of a clinical pharmacist on detection and prevention of prescription errors at the nephrology ward of a referral hospital. SETTING Nephrology ward of a major referral hospital in Southern Iran. METHOD During a 4-month period, a clinical pharmacist was assigned to review medication order sheets and drug orders three times a week at the nephrology ward. Besides chart review, the clinical pharmacist participated in medical rounds once a week. The occurrence of prescribing errors, and related harm was determined on hospitalized patients in this ward during the 4 month period. When an error was detected, intervention was made after agreement of the attending physician. MAIN OUTCOME MEASURES Number and types of prescribing errors, level of harm, and number of interventions were determined. RESULTS Seventy six patient charts were reviewed during the 4-month period. A total of 818 medications were ordered in these patients. Eighty six prescribing errors were detected in 46 hospital admissions. The mean age of the patients was 47.7 +/- 17.2. Fifty five percent were male while 45% were female. Different types of prescribing errors and their frequencies were as follows: wrong frequency (37.2%), wrong drug selection (19.8%), overdose (12.8%), failure to discontinue (10.5%), failure to order (7 %), under- dose (3.5%), wrong time (3.5%), monitoring (3.5%), wrong route (1.2%), and drug interaction (1.2 %). The attending physician agreed to 96.5% of the prescription errors detected, and interventions were made. Although 89.5% of the detected errors caused no harm, 4(4.7%) of the errors increased the need for monitoring, 2 (2.3%) increased length of stay, and 2 (2.3%) led to permanent patient harm. CONCLUSION presence of a clinical pharmacist at the nephrology ward helps in early detection of prescription errors, and therefore potential prevention of negative consequences due to drug administration.
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Bertsche T, Kaltschmidt J, Haefeli WE. [Patient safety based on computer-assisted drug therapy. Electronic check-up of the patient]. Internist (Berl) 2009; 50:748-56. [PMID: 19430754 DOI: 10.1007/s00108-009-2398-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patients in internal medicine frequently experience adverse drug events. Many of those events, however, are avoidable because they are caused by medication errors, which are particularly frequent in drug prescribing. Therefore, practical concepts are needed to make the rapidly growing knowledge on drugs available already during prescription. But also when deviations from standards are intended access to up-to-date information is required. Computer-based systems can offer support for prescribing clinicians to meet these claims and thus improve the quality of pharmacotherapy. To reach this goal, such systems have to be interlinked among each other and with systems of primary, secondary, and tertiary care. They must be based on scientific published evidence and should consider as many factors as possible for individualization of drug therapy. Individualization and focusing on relevant information are prerequisites to prevent inappropriate alerts (over-alerting) and thus to increase acceptance in practical use.
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Affiliation(s)
- T Bertsche
- Abteilung Innere Medizin VI, Klinische Pharmakologie und Pharmakoepidemiologie, Universitätsklinikum Heidelberg
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27
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Nissen L. Current status of pharmacist influences on prescribing of medicines. Am J Health Syst Pharm 2009; 66:S29-34. [DOI: 10.2146/ajhp080607] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Lisa Nissen
- School of Pharmacy, The University of Queensland, St. Lucia, Queensland 4072, Australia
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Reeves MJ, Smith E, Fonarow G, Hernandez A, Pan W, Schwamm LH. Off-Hour Admission and In-Hospital Stroke Case Fatality in the Get With The Guidelines-Stroke Program. Stroke 2009; 40:569-76. [DOI: 10.1161/strokeaha.108.519355] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Previous reports have shown higher in-hospital mortality for patients with acute stroke who arrived on weekends compared with regular workdays. We analyzed the effect of presenting during off-hours, defined as weekends and weeknights (versus weekdays), on in-hospital mortality and on quality of care in the Get With The Guidelines (GWTG)-Stroke program.
Methods—
We analyzed data from 187 669 acute ischemic stroke and 34 845 acute hemorrhagic stroke admissions who presented to the emergency departments of 857 hospitals that participated in the GWTG-Stroke program during the 4-year period 2003 to 2007. Off-hour presentation was defined as presentation anytime outside of 7:00
am
to 6:00
pm
on weekdays. Quality of care was measured using standard GWTG quality indicators covering acute, subacute, and discharge measures. The relationship between off-hour presentation and in-hospital case fatality was examined using generalized estimating equation logistic regression adjusting for demographics, risk factors, arrival mode, and hospital characteristics.
Results—
Half of ischemic stroke admissions and 57% of hemorrhagic stroke admissions presented during off-hours. Among ischemic stroke admissions, the in-hospital case fatality rate was 5.8% for off-hour presentation compared with 5.2% for on-hour presentation (
P
<0.001). For hemorrhagic stroke admissions, in-hospital case fatality was 27.2% for off-hour presentation compared with 24.1% for on-hour presentation (
P
<0.001). After adjusting for patient-level and hospital-level factors, presentation during off-hours was significantly associated with higher in-hospital mortality for both ischemic stroke (adjusted OR, 1.09; 95% CI, 1.03 to 1.14) and hemorrhagic stroke admissions (adjusted OR, 1.19; 95% CI, 1.12 to 1.27). No differences were observed between off-hour presentation and any of the quality of care measures.
Conclusions—
Off-hour presentation was associated with an increased risk of dying in-hospital, although the absolute effect was small for ischemic stroke admissions (0.6% difference; number needed to harm=166) and moderate for hemorrhagic stroke (3.1% difference; number needed to harm=32). Reducing the disparity in hospital-based outcomes for admissions that present during off-hours represents a potential target for quality improvement efforts, although evidence of differences in the quality of care by time of presentation was lacking.
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Affiliation(s)
- Mathew J. Reeves
- From the Department of Epidemiology (M.J.R.), Michigan State University, East Lansing, Mich; the Division of Neurology (E.S., L.H.S.), Massachusetts General Hospital, Boston, Mass; Duke Clinical Research Center (A.H., W.P.), Durham, NC; and the Division of Cardiology (G.F.), University of California, Los Angeles, Calif
| | - Eric Smith
- From the Department of Epidemiology (M.J.R.), Michigan State University, East Lansing, Mich; the Division of Neurology (E.S., L.H.S.), Massachusetts General Hospital, Boston, Mass; Duke Clinical Research Center (A.H., W.P.), Durham, NC; and the Division of Cardiology (G.F.), University of California, Los Angeles, Calif
| | - Gregg Fonarow
- From the Department of Epidemiology (M.J.R.), Michigan State University, East Lansing, Mich; the Division of Neurology (E.S., L.H.S.), Massachusetts General Hospital, Boston, Mass; Duke Clinical Research Center (A.H., W.P.), Durham, NC; and the Division of Cardiology (G.F.), University of California, Los Angeles, Calif
| | - Adrian Hernandez
- From the Department of Epidemiology (M.J.R.), Michigan State University, East Lansing, Mich; the Division of Neurology (E.S., L.H.S.), Massachusetts General Hospital, Boston, Mass; Duke Clinical Research Center (A.H., W.P.), Durham, NC; and the Division of Cardiology (G.F.), University of California, Los Angeles, Calif
| | - Wenqin Pan
- From the Department of Epidemiology (M.J.R.), Michigan State University, East Lansing, Mich; the Division of Neurology (E.S., L.H.S.), Massachusetts General Hospital, Boston, Mass; Duke Clinical Research Center (A.H., W.P.), Durham, NC; and the Division of Cardiology (G.F.), University of California, Los Angeles, Calif
| | - Lee H. Schwamm
- From the Department of Epidemiology (M.J.R.), Michigan State University, East Lansing, Mich; the Division of Neurology (E.S., L.H.S.), Massachusetts General Hospital, Boston, Mass; Duke Clinical Research Center (A.H., W.P.), Durham, NC; and the Division of Cardiology (G.F.), University of California, Los Angeles, Calif
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Zhao M, Bazzoli GJ, Clement JP, Lindrooth RC, Nolin JM, Chukmaitov AS. Hospital Staffing Decisions: Does Financial Performance Matter? INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2008; 45:293-307. [DOI: 10.5034/inquiryjrnl_45.03.293] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This study assesses the impact of changes in hospitals' financial conditions on changes in hospitals' staffing decisions. The sample consisted of community hospitals operating between 1995 and 2000. The analysis employed a generalized method of moments (GMM) estimator for its dynamic panel data. Cash flow and patient margin were used to measure financial condition. We estimated the effect of changing financial condition on the number of full-time equivalent personnel (FTEs), registered nurses (RNs), and licensed practical nurses (LPNs) per 1,000 adjusted patient days. Our results suggest that declining financial performance led to cutbacks in LPN FTEs per adjusted patient day, but the effects on total hospital FTEs and RN FTEs were mixed.
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Ridley RT. The Relationship Between Nurse Education Level and Patient Safety: An Integrative Review. J Nurs Educ 2008; 47:149-56. [DOI: 10.3928/01484834-20080401-06] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Pilcher DV, Duke GJ, George C, Bailey MJ, Hart G. After-hours discharge from intensive care increases the risk of readmission and death. Anaesth Intensive Care 2008; 35:477-85. [PMID: 18020063 DOI: 10.1177/0310057x0703500403] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Despite reports showing night discharge from an intensive care unit (ICU) is associated with increased mortality, it is unknown if this has resulted in changes in practice in recent years. Our aim was to determine prevalence, trends and effect on patient outcome of discharge timing from ICU throughout Australia and New Zealand. Two datasets from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) were examined: (1) All submissions to the APD from 1.1.2003 to 31.12.2004 to determine contemporary practices. (2) Forty hospitals which had submitted continuous data between 1.1.2000 and 31.12.2004 to determine trends in practice over time. Outcomes investigated were hospital mortality and ICU readmission rate. Between 1.1.2003 and 31.12.2004, the ANZICS APD reported 76,690 patients discharged alive from ICU; 13,968 (18.2%) were discharged after-hours (between 1800 and 0559 hours). After-hours discharges had a higher readmission rate (6.3% vs. 5.1%; P < or = 0.0001) and higher mortality (8.0% vs. 5.3%; P = < 0.0001). Peak readmission (8.6%) and mortality rates (9.7%) were seen in patients discharged between 0300 and 0400 hours. After-hours discharge was a predictor of mortality (odds ratio 1.42, 95% confidence interval 1.32-1.52; P= < 0.0001) in multivariate analysis. Between 2000 and 2004, after-hours discharges increased (P = 0.0015) with seasonal peaks during winter The risk of death increased as the proportion of patients discharged after-hours rose. After-hours discharge from ICU is associated with increased risk of death and readmission to ICU. It has become more frequent. The risk of death increases as more after-hours discharges occur.
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Affiliation(s)
- D V Pilcher
- ANZICS Database Management Committee, Melbourne, Victoria, Australia
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Pharmacy manpower in Lebanon: An exploratory look at work-related satisfaction. Res Social Adm Pharm 2008; 3:336-50. [PMID: 17945162 DOI: 10.1016/j.sapharm.2006.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Revised: 09/30/2006] [Accepted: 09/30/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Pharmacy is a dynamic, growing, and increasingly diverse profession. It has a new patient orientation, especially in developed countries. There is a paucity of work examining pharmacists' satisfaction and professionalization in developing nations, such as Lebanon. OBJECTIVE The purpose this study is to explore the Lebanese pharmacists' professional satisfaction and applicable needs regarding their profession. Specific objectives aimed to examine Lebanese pharmacists' satisfaction and determine whether the Lebanese Order of Pharmacists helps pharmacists to meet their professional needs. METHODS This study is a cross-sectional descriptive analysis of Lebanese pharmacists working in all pharmacy practicing environments in Lebanon. A random sample was drawn from the list of registered pharmacists provided by the Lebanese Order of Pharmacists. Selected individuals were visited and interviewed in their workplace. Pharmacists who had no registered address were contacted and interviewed face to face. RESULTS Newly graduated pharmacists seemed more likely to work in community pharmacies or as medical representatives. Most interviewed pharmacists had no difficulty finding a job, but they all thought that the Order of Pharmacists should get more involved in advising and providing job opportunities, because the market is currently saturated. Most were financially satisfied, especially owners of community pharmacies. Although half of the pharmacists were psychologically satisfied, a great number of community, hospital, and medical representative pharmacists were not physically satisfied. CONCLUSIONS Further research is necessary for a thorough evaluation of Lebanese pharmacists' professional satisfaction and its specific determinants, with the ultimate goal of finding adequate solutions for their needs.
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Bond CA, Raehl CL. 2006 National Clinical Pharmacy Services Survey: Clinical Pharmacy Services, Collaborative Drug Management, Medication Errors, and Pharmacy Technology. Pharmacotherapy 2008; 28:1-13. [DOI: 10.1592/phco.28.1.1] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bond CAC, Raehl CL. Clinical and economic outcomes of pharmacist-managed antimicrobial prophylaxis in surgical patients. Am J Health Syst Pharm 2007; 64:1935-42. [PMID: 17823105 DOI: 10.2146/ajhp060631] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The associations between pharmacist-managed antimicrobial prophylaxis in Medicare patients who had surgical codes indicative of the need for antimicrobial prophylaxis and the major health care outcomes of death rate, length of stay, Medicare charges, drug charges, laboratory charges, and complications were explored. METHODS Pharmacist management of antimicrobial prophylaxis was evaluated in 242,704 Medicare patients from 860 [corrected] hospitals. RESULTS Patients who developed a surgical-site infection (SSI) had a 331.58% increased risk of death compared with patients who did not develop an SSI (chi2 = 743.471; df = 1; p < 0.0001; odds ratio [OR], 3.62; 95% confidence interval [CI], 3.28-3.99). Patients who developed an SSI also had a 167.16% increase in length of stay, 136.49% increase in total Medicare charges, 245.96% increase in drug charges, and 187.14% increase in laboratory charges. In hospitals without pharmacist-managed antimicrobial prophylaxis, death rates were 52.06% higher (105 excess deaths; p < 0.0001; OR, 1.54; 95% CI, 1.46-1.63), length of stay was 10.21% higher (167,941 excess patient days, p < 0.0001), mean +/- S.D. total Medicare charges were 3.10% higher ($980 +/- $1,109 more per patient) ($182,113,400 excess total Medicare charges, p < 0.0001), mean +/- S.D. drug charges were 7.24% higher ($292 +/- $492 more per patient) ($54,262,360 excess drug charges, p = 0.005), mean +/- S.D. laboratory charges were 2.72% higher ($74 +/- $151 more per patient) ($13,751,420 excess laboratory charges, p = 0.0056), and SSIs were 34.30% higher (chi2 = 95.48; df = 1; p < 0.0001; OR, 1.52; 95% CI, 1.40-1.66). CONCLUSION The provision of pharmacist-managed antimicrobial prophylaxis was associated with significant improvement in clinical and economic outcomes for Medicare patients with a surgical code indicative of the need for antimicrobial prophylaxis.
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Affiliation(s)
- C A Cab Bond
- Department of Pharmacy Practice, School of Pharmacy, Texas Tech University Health Sciences Center-Amarillo, 79106, USA.
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The Effects of Institutional and Market Factors on Nurse Staffing in Acute Care Hospitals. HEALTH POLICY AND MANAGEMENT 2007. [DOI: 10.4332/kjhpa.2007.17.2.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Malone DC, Abarca J, Skrepnek GH, Murphy JE, Armstrong EP, Grizzle AJ, Rehfeld RA, Woosley RL. Pharmacist workload and pharmacy characteristics associated with the dispensing of potentially clinically important drug-drug interactions. Med Care 2007; 45:456-62. [PMID: 17446832 DOI: 10.1097/01.mlr.0000257839.83765.07] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Drug-drug interactions (DDIs) are preventable medical errors, yet exposure to DDIs continues despite systems that are designed to prevent such exposures. The purpose of this study was to examine pharmacy characteristics that may be associated with dispensed potential DDIs. METHODS This study combined survey data from community pharmacies in 18 metropolitan statistical areas with pharmacy claims submitted to 4 pharmacy benefit managers (PBMs) over a 3-month period from January 1, 2003 to March 31, 2003. Pharmacy characteristics of interest included prescription volume, the number of full-time equivalent pharmacists and pharmacy staff, computer software programs, and the ability to modify those programs with respect to DDI alerts, the use of technologies to assist in receiving, filling and dispensing medication orders, and prescription volume. The dependent variable in this study was the rate of dispensed medications that may interact. RESULTS A total of 672 pharmacies were included in the analysis. On average (+/-SD), the respondents filled 1375 +/- 691 prescriptions per week, submitted 17,948 +/- 23,889 pharmacy claims to the participating PBMs, had 1.2 +/- 0.3 full-time equivalent pharmacists per hour open, and 545 (81%) were affiliated with a chain drug store organization. Factors significantly related to an increased risk of dispensing a potential DDI included pharmacist workload (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.028-1.048), pharmacy staffing (OR 1.10; 95% CI: 1.09-1.11), and various technologies (eg, sophisticated telephone systems, internet receipt of orders, and refill requests) that assist with order processing, and the ability to modify DDI alert-screening sensitivity and detailed pharmacological information about DDIs. CONCLUSIONS This study found that there was an increase in the risk of dispensing a potential DDI with higher pharmacist and pharmacy workload, use of specific automation, and dispensing software programs providing alerts and clinical information.
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Affiliation(s)
- Daniel C Malone
- College of Pharmacy, University of Arizona, Tucson 85721, USA.
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Bond CA, Raehl CL. Clinical Pharmacy Services, Pharmacy Staffing, and Hospital Mortality Rates. Pharmacotherapy 2007; 27:481-93. [PMID: 17381374 DOI: 10.1592/phco.27.4.481] [Citation(s) in RCA: 228] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine if hospital-based clinical pharmacy services and pharmacy staffing continue to be associated with mortality rates. METHODS A database was constructed from 1998 MedPAR, American Hospital Association's Annual Survey of Hospitals, and National Clinical Pharmacy Services databases, consisting of data from 2,836,991 patients in 885 hospitals. Data from hospitals that had 14 clinical pharmacy services were compared with data from hospitals that did not have these services; levels of hospital pharmacist staffing were also compared. A multiple regression analysis, controlling for severity of illness, was used. RESULTS Seven clinical pharmacy services were associated with reduced mortality rates: pharmacist-provided drug use evaluation (4491 reduced deaths, p=0.016), pharmacist-provided in-service education (10,660 reduced deaths, p=0.037), pharmacist-provided adverse drug reaction management (14,518 reduced deaths, p=0.012), pharmacist-provided drug protocol management (18,401 reduced deaths, p=0.017), pharmacist participation on the cardiopulmonary resuscitation team (12,880 reduced deaths, p=0.009), pharmacist participation on medical rounds (11,093 reduced deaths, p=0.021), and pharmacist-provided admission drug histories (3988 reduced deaths, p=0.001). Two staffing variables, number of pharmacy administrators/100 occupied beds (p=0.037) and number of clinical pharmacists/100 occupied beds (p=0.023), were also associated with reduced mortality rates. CONCLUSION The number of clinical pharmacy services and staffing variables associated with reduced mortality rates increased from two in 1989 to nine in 1998. The impact of clinical pharmacy on mortality rates mandates consideration of a core set of clinical pharmacy services to be offered in United States hospitals. These results have important implications for health care in general, as well as for our profession and discipline.
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Affiliation(s)
- C A Bond
- Department of Pharmacy Practice, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, Texas 79106, USA.
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Clark PA, Leddy K, Drain M, Kaldenberg D. State Nursing Shortages and Patient Satisfaction. J Nurs Care Qual 2007; 22:119-27; quiz 128-9. [PMID: 17353747 DOI: 10.1097/01.ncq.0000263100.29181.e3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study of 827,430 patients, 733 hospitals, and 25 states compares state performance in patient satisfaction with the supply of registered nurses. A significant, positive relationship exists between a state's supply of registered nurses and patients' evaluations of their care experiences. Hospitals in states with nursing shortages may be challenged by national comparisons of patient satisfaction and should take these results into account when devising their quality improvement strategy.
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Kleinpell R, Thompson D, Kelso L, Pronovost PJ. Targeting errors in the ICU: use of a national database. Crit Care Nurs Clin North Am 2007; 18:509-14. [PMID: 17118305 DOI: 10.1016/j.ccell.2006.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors believe that as we move from viewing adverse event reporting system as punitive, and as the safety culture improves, reporting will likely increase. Voluntary incident reporting systems can be used to improve patient safety in the ICU by identifying broken or inadequate systems that lead to adverse events [26]. Voluntary external reporting systems such as the ICUSRS can be used to target errors and produce evidence-based best practice measures to improve patient safety in the ICU.
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Affiliation(s)
- Ruth Kleinpell
- Rush University College of Nursing, Chicago, IL 60612, USA.
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Assadian O, Toma CD, Rowley SD. Implications of staffing ratios and workload limitations on healthcare-associated infections and the quality of patient care. Crit Care Med 2007; 35:296-8. [PMID: 17197771 DOI: 10.1097/01.ccm.0000251291.65097.8a] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals. Pharmacotherapy 2006; 26:735-47. [PMID: 16716127 DOI: 10.1592/phco.26.6.735] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Adverse drug reactions (ADRs) were examined in 1,960,059 hospitalized Medicare patients in 584 United States hospitals in 1998. A database was constructed from the MedPAR database and the National Clinical Pharmacy Services survey. The 584 hospitals were selected because they provided specific information on 14 clinical pharmacy services and on pharmacy staffing; they also had functional ADR reporting systems. The study population consisted of 35,193 Medicare patients who experienced an ADR (rate of 1.8%). Of the 14 clinical pharmacy services, 12 were associated with reduced ADR rates. The most significant reductions occurred in hospitals offering pharmacist-provided admission drug histories (odds ratio [OR] 1.864, 95% confidence interval [CI] 1.765-1.968), drug protocol management (OR 1.365, 95% CI 1.335-1.395), and ADR management (OR 1.360, 95% CI 1.328-1.392). Multivariate analysis, performed to further evaluate these findings, showed that nine variables were associated with ADR rate: pharmacist-provided in-service education (slope -0.469, p=0.018), drug information (slope -0.488, p=0.005), ADR management (slope -0.424, p=0.021), drug protocol management (slope -0.732, p=0.002), participation on the total parenteral nutrition team (slope 0.384, p=0.04), participation on the cardiopulmonary resuscitation team (slope -0.506, p=0.008), medical round participation (slope -0.422, p=0.037), admission drug histories (slope -0.712, p=0.008), and increased clinical pharmacist staffing (slope -4.345, p=0.009). As clinical pharmacist staffing increased from the 20th to the 100th percentile (from 0.93+/-0.77/100 to 5.16+/-4.11/100 occupied beds), ADRs decreased by 47.88%. In hospitals without pharmacist-provided ADR management, the following increases were noted: mean number of ADRs/100 admissions by 34.90% (OR 1.360, 95% CI 1.328-1.392), length of stay 13.64% (Mann-Whitney U test [U]=11047367, p=0.017), death rate 53.64% (OR 1.574, 95% CI 1.423-1.731), total Medicare charges 6.88% (U=111298871, p=0.018), and drug charges 8.16% (U=108979074, p<0.001). Patients in hospitals without pharmacist-provided ADR management had an excess of 4266 ADRs, 443 deaths, 85,554 patient-days, $11,745,342 in total Medicare charges, and $1,857,744 in drug charges. The implications of these findings are significant for our health care system, especially considering that the study population represented 15.55% of 12,261,737 Medicare patients and 5.71% of the 34,345,436 patients admitted to all U.S. hospitals.
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Affiliation(s)
- C A Bond
- Department of Pharmacy Practice, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, Texas 79106, USA.
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Bond CA, Raehl CL. Clinical and Economic Outcomes of Pharmacist-Managed Antiepileptic Drug Therapy. Pharmacotherapy 2006; 26:1369-78. [PMID: 16999646 DOI: 10.1592/phco.26.10.1369] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study explores the associations between pharmacist-managed antiepileptic drug therapy in hospitalized Medicare patients and diagnoses indicating the need for these drugs. It also explores the following major heath care outcomes: death rate, hospital length of stay (LOS), Medicare charges, drug charges, laboratory charges, complications, and adverse drug reactions. Data were drawn from the 1998 MedPAR and 1998 National Clinical Pharmacy Services databases. Pharmacist-managed antiepileptic drug therapy was evaluated in a study population of 9380 Medicare patients with diagnosed epilepsy or seizure disorders treated in 794 United States hospitals. This population was derived from the 38,311 hospitalized Medicare patients with epilepsy or seizure disorders (MedPAR). In hospitals without pharmacist-managed antiepileptic drug therapy, death rates were 120.61% higher, with 374 excess deaths (chi(2)=5.983, df=1, p=0.014, odds ratio [OR]=1.553, 95% confidence interval [CI] 1.102-2.189). Hospital LOS was 14.68% higher, with 8069 patient-days (Mann-Whitney U test [U]=3833132, p=0.0009); total Medicare charges were 11.19% higher, with 14,372,550 dollars in excess total charges (U=3644199, p=0.0003); per-patient drug charges were $115 +/- $92 higher (p=NS); laboratory charges were 32.24% higher, with 5,664,970 dollars in excess charges; and aspiration pneumonia rate was 54.61% higher (chi(2)=5.848, df=1, p=0.015, OR=1.233, 95% CI 1.081-1.901). Although the frequencies of other complications and adverse effects were higher, these differences were not statistically significant compared with hospitals with pharmacist-managed antiepileptic drug therapy. Clinical and economic outcomes were improved among hospitalized Medicare patients whose antiepileptic drug therapy was managed by pharmacists.
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Affiliation(s)
- C A Bond
- Department of Pharmacy Practice, School of Pharmacy, Texas Tech University Health Sciences Center-Amarillo, Amarillo, Texas 79106, USA.
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Numata Y, Schulzer M, van der Wal R, Globerman J, Semeniuk P, Balka E, Fitzgerald JM. Nurse staffing levels and hospital mortality in critical care settings: literature review and meta-analysis. J Adv Nurs 2006; 55:435-48. [PMID: 16866839 DOI: 10.1111/j.1365-2648.2006.03941.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM This paper reports a review of the literature on the association between critical care nurse staffing levels and patient mortality. BACKGROUND Statistically significant inverse associations between levels of nurse staffing and hospital mortality have not been consistently found in the literature. Critical care settings are ideal to address this relationship due to high patient acuity and mortality, high intensity of the nursing care required, and availability of individual risk adjustment methods. METHODS Major electronic databases were searched, including MEDLINE, EMBASE, and the Cumulative Index of Nursing and Allied Health Literature. The search terms included critical/intensive care, quality of health care, mortality/hospital mortality, personnel staffing and scheduling, and nursing staff (hospital). Only papers published in English were included. The original search was conducted in 2002 and updated in 2005. RESULTS Nine studies were selected from 251 references screened. All nine were observational. Six were conducted in the United States of America, one in Austria, one in Brazil, and one in Scotland. The unadjusted risk ratio of nurse staffing (high vs. low) on hospital mortality were combined meta-analytically (five studies). The pooled estimate was 0.65 (95% confidence interval 0.47-0.91). However, after adjusting for various covariates within each study, the individually reported associations between high nurse staffing and low hospital mortality became non-significant in all but one study. CONCLUSION The impact of nurse staffing levels on patients' hospital mortality in critical care settings was not evident in the reviewed studies. Methodological challenges that might have impeded correct assessment of the association include measurement problems in exposure status and confounding factors, often uncontrolled. The lack of association also indicates that hospital mortality may not be sensitive enough to detect the consequences of low nurse staffing levels in critical care settings.
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Affiliation(s)
- Yuka Numata
- Vancouver General Hospital, Vancouver, British Columbia, Canada.
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Withanachchi N, Uchida Y, Nanayakkara S, Samaranayake D, Okitsu A. Resource allocation in public hospitals: is it effective? Health Policy 2006; 80:308-13. [PMID: 16678297 DOI: 10.1016/j.healthpol.2006.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Accepted: 03/23/2006] [Indexed: 11/22/2022]
Abstract
The allocative inefficiency is a fundamental flaw in the public hospitals of the developing countries. The inefficiencies drain the limited public resources allotted for healthcare. Sri Lanka's public health system faces worsening budget constraints. The resource allocation practices of the Ministry of Health focus on increasing the cadre of hospital staff, consequently crowding out the investments on facility development. The purpose of the study is to assess the impact of resource allocation in the tertiary-care public hospitals that are under the central Ministry of Health. The model is based on the assumption that the hospital managers and other agents of a public hospital pursue the objective of quality maximization (in the absence of a profit motive). The inpatient mortality rate is selected as the indicator of quality. With the use of panel data fixed-effects, and first-differencing estimation methods, we study the impact of the resource allocation on the hospital mortality rates. The selected models are statistically significant at 0.1% level. The elasticity effect of the capital is considerably larger than the effects of the human resources, in servicing the patients. The results suggest that the human resource utilization is suboptimal, due to the inadequacy of the capital (i.e. medical equipment, etc.). The reorientation of the resource allocation towards the capital investments may save more lives.
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Affiliation(s)
- Nimnath Withanachchi
- Graduate School of International Cooperation Studies, Kobe University, Kobe, Japan.
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Matowe L, Abahussain EA, Al-Saffar N, Bihzad SM, Al-Foraih A, Al-Kandery AA. Physicians' perceptions and expectations of pharmacists' professional duties in government hospitals in Kuwait. Med Princ Pract 2006; 15:185-9. [PMID: 16651833 DOI: 10.1159/000092179] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2004] [Accepted: 10/02/2005] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The objectives of this study were to evaluate the perceptions, expectations and experience of physicians with hospital-based pharmacists in Kuwait. MATERIALS AND METHODS A piloted self-administered questionnaire was hand delivered to 200 physicians practicing in four government hospitals in Kuwait. Main sections of the questionnaire comprised a series of statements pertaining to physicians' perceptions, expectations and experiences with pharmacists. RESULTS One hundred and twenty (60%) questionnaires were returned. At least 57% of physicians in Kuwait appear comfortable with pharmacists carrying out patient-directed roles. In addition, they appeared to have high expectations of pharmacists, with 79% of them regarding pharmacists as knowledgeable drug therapy experts. Less than 60% considered pharmacists as applying their drug knowledge in practice and only 29% agreed that pharmacists routinely counselled their patients. There was no correlation between physician variables such as number of years since graduation from medical school, age, area of practice and their perceptions of pharmacists. CONCLUSION Physicians in Kuwait appear comfortable with pharmacists providing a broad range of services but appear somewhat less comfortable with pharmacists' provision of direct patient care. Physicians considered pharmacists knowledgeable drug therapy experts, but regarded them as not routinely providing a broad range of higher-level pharmacy services.
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Affiliation(s)
- L Matowe
- Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, Safat
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Bond CAC, Raehl CL. Clinical and economic outcomes of pharmacist-managed aminoglycoside or vancomycin therapy. Am J Health Syst Pharm 2005; 62:1596-605. [PMID: 16030370 DOI: 10.2146/ajhp040555] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The associations between pharmacist-managed aminoglycoside or vancomycin therapy for hospitalized Medicare patients who had diagnoses indicating probable treatment with these antibiotics and the major health care outcomes of death rate, length of stay, Medicare charges, hearing loss, and renal impairment were explored. METHODS Pharmacist management of drug therapy was evaluated in a study population composed of 199,082 Medicare patients treated in 961 hospitals. RESULTS In hospitals that did not have pharmacist-managed aminoglycoside or vancomycin therapy, death rates were 6.71% higher (1,048 excess deaths [chi(2) (1) = 43.801, p < 0.0001]), length of stay was 12.28% higher (131,660 excess patient days [U = 4.701 x 10(9), p < 0.0001]), total Medicare charges were 6.30% higher (140,745,924 US dollars in excess total Medicare charges [U = 4.864 x 10(9), p < 0.0001]), drug charges were 8.15% higher (34,769,250 US dollars in excess drug charges [U = 4.785 x 10(9), p < 0.0001]), laboratory charges were 7.80% higher (22,530,474 US dollars in excess laboratory charges [U = 4.860 x 10(9), p < 0.0001]), hearing loss was 46.42% higher (134 more patients with hearing loss [chi(2) = 54.423, df = 1, p < 0.0001]), renal impairment was 33.95% higher (2,801 more patients with renal impairment [chi(2) = 118.13, df = 1, p < 0.0001]), and the death rate in patients who developed complications was 10.15% higher (231 excess deaths [chi(2) = 22.345, df = 1, p < 0.0001]) than in hospitals with pharmacists managing these drugs. CONCLUSION The presence of pharmacist-managed aminoglycoside or vancomycin therapy was associated with significant improvement in health care and economic outcomes for Medicare patients who received these drugs.
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Affiliation(s)
- C A Cab Bond
- Department of Pharmacy Practice, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA.
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Gonzalez LS. What are pharmacists, and what do they do? Am J Health Syst Pharm 2005; 62:2039-40. [PMID: 16174842 DOI: 10.2146/ajhp050164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Luis S Gonzalez
- Memorial Medical Center IRB, Memorial Medical Center, 1086 Franklin Street, Johnstown, PA 15905, USA.
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Abstract
This article is an annotated bibliography on the topic of nurse staffing and patient care outcomes in the acute care setting. The authors have been involved in the developmental and pilot phase of the Veterans Affairs Nursing Outcomes Database project to build a database of acute care nursing-sensitive quality indicators. In the section preceding the annotated bibliography, a context for the development of this literature review is explained and a summary synthesizing key issues is presented.
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Lankshear AJ, Sheldon TA, Maynard A. Nurse staffing and healthcare outcomes: a systematic review of the international research evidence. ANS Adv Nurs Sci 2005; 28:163-74. [PMID: 15920362 DOI: 10.1097/00012272-200504000-00008] [Citation(s) in RCA: 162] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The relationship between quality of care and the cost of the nursing workforce is of concern to policymakers. This study assesses the evidence for a relationship between the nursing workforce and patient outcomes in the acute sector through a systematic review of international research produced since 1990 involving acute hospitals and adjusting for case mix. Twenty-two large studies of variable quality were included. They strongly suggest that higher nurse staffing and richer skill mix (especially of registered nurses) are associated with improved patient outcomes, although the effect size cannot be estimated reliably. The association appears to show diminishing marginal returns.
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Bond CA, Raehl CL. Pharmacist-provided anticoagulation management in United States hospitals: death rates, length of stay, Medicare charges, bleeding complications, and transfusions. Pharmacotherapy 2004; 24:953-63. [PMID: 15338843 DOI: 10.1592/phco.24.11.953.36133] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We explored the associations between pharmacist-provided anticoagulation management in hospitalized Medicare patients and several major heath care outcomes: death rate, length of stay, Medicare charges, bleeding complications, and transfusions. Using the 1995 National Clinical Pharmacy Services database and the 1995 Medicare database for hospitals, data were retrieved for 717,396 Medicare patients treated in 955 hospitals for conditions requiring anticoagulant therapy. In hospitals without pharmacist-provided heparin management, death rates were 11.41% higher (chi2 (1) = 122.84, p<0.0001), length of stay was 10.05% higher (Mann-Whitney U test = 40039529342, p<0.0001), Medicare charges were 6.60% higher (U = 41004749266, p<0.0001), bleeding complications were 3.1% higher (chi2 (1) = 10.996, p=0.0009) and the transfusion rate for bleeding complications was 5.47% higher (chi2 (1) = 11.24, p=0.0008) than in hospitals with pharmacist-provided heparin management. In hospitals without pharmacist-provided warfarin management, death rates were 6.20% higher (chi2 (1) = 19.20, p<0.0001), length of stay was 5.86% higher (U = 25730993838, p<0.0001), Medicare charges were 2.16% higher (U = 259955112970, p<0.0001), bleeding complications were 8.09% higher (chi2 (1) = 49.259, p<0.0001), and the transfusion rate for bleeding complications was 22.49% higher (chi2 (1) = 78.68, p<0.0001). Study hospitals without pharmacist-provided heparin management had 4664 more deaths, 494,855 more patient-days, 145 more patients with bleeding complications, and $651,274,844 more in patient charges; 9784 more units of whole blood were used in patients requiring transfusions for bleeding complications. Hospitals without pharmacist-provided warfarin management had 2786 more deaths, 316,589 more patient-days, 429 more patients with bleeding complications, and $234,275,490 more in patient charges; 8991 more units of whole blood were used in patients requiring transfusions for bleeding complications. The implications of these findings are significant for the health care system, especially considering that the study population represents 28.25% of hospitalized Medicare patients who should receive anticoagulants, and that total Medicare admissions represent 35.02% of total admissions to United States hospitals.
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Affiliation(s)
- C A Bond
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, Amarillo, 79106, USA.
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