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

OBJECTIVE

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

L-arginine infusion increases basal but not activated cerebral blood flow in humans

Nitric oxide is a potent vasodilator. Infusion of its precursor, L-arginine, results in increased cerebral blood flow (CBF) in experimental animals. We examined the effects of L-arginine infusion on CBF in humans using positron emission tomography and the quantitative H2(15)O method. Six subjects received 500 ml of 0.9% NaCl solution, and six subjects received an infusion of L-arginine (16.7 mg/kg/min; 500 mg/kg). Before and after the i.v. infusion, paired CBF measurements were performed at baseline and with vibrotactile stimulation of the right hand. In scans performed without vibrotactile stimulation, mean whole-brain CBF increased from 34.9 +/- 3.7 ml 100 g-1 min-1 to 38.2 +/- 4.4 ml 100 g-1 min-1. (9.5%; p < 0.005) after L-arginine infusion. The temporal pattern of CBF changes differed from that of plasma growth hormone and insulin levels and of arterial pH. In contrast, in the saline group, mean whole-brain CBF did not change significantly (35.8 +/- 5.9 ml 100 g-1 min-1 to 35.9 +/- 6.4 ml 100 g-1 min-1; 0.3%). Vibrotactile stimulation produced significant focal increases in CBF, which were unaffected by L-arginine infusion. L-arginine infusion was associated with an increase in plasma L-citrulline, a byproduct of nitric oxide synthesis.