The economic impact of rostering junior doctors to triage to assist nursing staff in the early part of the patient journey through the emergency department

Objective

This study aims to determine whether redeploying junior doctors to assist at triage represents good value for money and a good use of finite staffing resources.

Methods

We undertook a cost-minimisation analysis to produce new evidence, from an economic perspective, about the costs associated with reallocating junior doctors in the emergency department. We built a decision-analytic model, using a mix of prospectively collected data, routinely collected administrative databases and hospital costings to furnish the model. To measure the impact of uncertainty on the model’s inputs and outputs, probabilistic sensitivity analysis was undertaken, using Monte Carlo simulation.

Results

The mean costs for usual care were $27,035 (95% CI $27,016 to $27,054), while the mean costs for the new model of care were $25,474, (95% CI $25,453 to $25,494). As a result, the mean difference was -$1,561 (95% CI -$1,533 to -$1,588), with the new model of care being a less costly approach to managing staffing allocations, in comparison to the usual approach.

Conclusion

Our study shows that redeploying a junior doctor from the fast-track area of the department to assist at triage provides a modest reduction in cost. Our findings give decision-makers who seek to maximise benefit from their finite budget, support to reallocate personnel within the ED.

Health-Care Workers' Perception of Reimbursement for Complex Surgical Oncology Procedures

Perception of physician reimbursement for surgical procedures is not well studied. The few existing studies illustrate that patients believe compensation to be higher than in reality. These studies focus on patient perceptions and have not assessed health-care workers' views. Our study examined health-care workers' perception of reimbursement for complex surgical oncology procedures. An anonymous online survey was distributed to employees at our cancer center with descriptions and illustrations of three oncology procedures-hepatectomy, gastrectomy, and pancreaticoduodenectomy. Participants estimated the Medicare fee and gave their perceived value of each procedure. Participants recorded their perception of surgeon compensation overall, both before and after revealing the Medicare fee schedule. Most of the 113 participants were physicians (33.6%) and nurses (28.3%). When blinded to the Medicare fee schedules, most felt that reimbursements were too low for all procedures (60-64%) and that surgeons were overall undercompensated (57%). Value predictions for each procedure were discordant from actual Medicare fee schedules, with overestimates up to 374 per cent. After revealing the Medicare fee schedules, 55 per cent of respondents felt that surgeons were undercompensated. Even among health-care workers, a large discrepancy exists between perceived and actual reimbursement. Revealing actual reimbursements did not alter perception on overall surgeon compensation.

From staff nurse to nurse consultant: Survival Guide part 8: Surviving on a basic wage

John Fowler, Educational Consultant, explores how to survive your nursing career.

Five-layer border dressings as part of a quality improvement bundle to prevent pressure injuries in US skilled nursing facilities and Australian nursing homes: A cost-effectiveness analysis

The BORDER III trial found that five-layer silicone border dressings effectively prevented pressure injuries in long-term care, but the value of this approach is unknown. Our objective was to analyse the cost-effectiveness of preventing facility-acquired pressure injuries with a quality improvement bundle, including prophylactic five-layer dressings in US and Australian long-term care. Markov models analysed the cost utility for pressure injuries acquired during long-term care from US and Australian perspectives. Models calibrated outcomes for standard care compared with a dressing-inclusive bundle over 18 monthly cycles or until death based on BORDER III outcomes. Patients who developed a pressure injury simulated advancement through stages 1 to 4. Univariate and multivariate probabilistic sensitivity analyses tested modelling uncertainty. Costs in 2017 USD and quality-adjusted life years (QALYs) were used to calculate an incremental cost-effectiveness ratio (ICER). Dressing use yielded greater QALYs at slightly higher costs from perspectives. The US ICER was $36 652/QALY, while the Australian ICER was $15 898/QALY, both of which fell below a willingness-to-pay threshold of $100 000/QALY. Probabilistic sensitivity analysis favoured dressings as cost-effective for most simulations. A quality improvement bundle, including prophylactic five-layer dressings, is a cost-effective approach for pressure injury prevention in all US and Australia long-term care residents.

Costs and effects of higher turnover of nurses and Aboriginal health practitioners and higher use of short-term nurses in remote Australian primary care services: an observational cohort study

OBJECTIVES

To compare the costs and effects of higher turnover of resident nurses and Aboriginal health practitioners and higher use of agency-employed nurses in remote primary care (PC) services and quantify associations between staffing patterns and health outcomes in remote PC clinics in the Northern Territory (NT) of Australia.

DESIGN

Observational cohort study, using hospital admission, financial and payroll data for the period 2013-2015.

SETTING

53 NT Government run PC clinics in remote communities.

OUTCOME MEASURES

Incremental cost-effectiveness ratios were calculated for higher compared with lower turnover and higher compared with lower use of agency-employed nurses. Costs comprised PC, travel and hospitalisation costs. Effect measures were total hospitalisations and years of life lost per 1000 person-months. Multiple regression was performed to investigate associations between overall health costs and turnover rates and use of agency-employed nurses, after adjusting for key confounders.

RESULTS

Higher turnover was associated with significantly higher hospitalisation rates (p<0.001) and higher average health costs (p=0.002) than lower turnover. Lower turnover was always more cost-effective. Average costs were significantly (p<0.001) higher when higher proportions of agency-employed nurses were employed. The probability that lower use of agency-employed nurses was more cost-effective was 0.84. Halving turnover and reducing use of a short-term workforce have the potential to save $32 million annually in the NT.

CONCLUSION

High turnover of health staff is costly and associated with poorer health outcomes for Aboriginal peoples living in remote communities. High reliance on agency nurses is also very likely to be cost-ineffective. Investment in a coordinated range of workforce strategies that support recruitment and retention of resident nurses and Aboriginal health practitioners in remote clinics is needed to stabilise the workforce, minimise the risks of high staff turnover and over-reliance on agency nurses and thereby significantly reduce expenditure and improve health outcomes.

Recommendations for Promoting Quality and Safety in Health Care Systems

Are you a nurse leader or professional development practitioner in a health care facility? This article provides recommendations to promote quality and safety education with a focus on systems thinking awareness among direct care nurses. A key point is error prevention, which requires a shared effort among all nurses. J Contin Educ Nurs. 2017;48(7):295-297.

The potential of task-shifting in scaling up services for prevention of mother-to-child transmission of HIV: a time and motion study in Dar es Salaam, Tanzania

BACKGROUND

In many African countries, prevention of mother-to-child transmission of HIV (PMTCT) services are predominantly delivered by nurses. Although task-shifting is not yet well established, community health workers (CHWs) are often informally used as part of PMTCT delivery. According to the 2008 World Health Organization (WHO) Task-shifting Guidelines, many PMTCT tasks can be shifted from nurses to CHWs.

METHODS

The aim of this time and motion study in Dar es Salaam, Tanzania, was to estimate the potential of task-shifting in PMTCT service delivery to reduce nurses' workload and health system costs. The time used by nurses to accomplish PMTCT activities during antenatal care (ANC) and postnatal care (PNC) visits was measured. These data were then used to estimate the costs that could be saved by shifting tasks from nurses to CHWs in the Tanzanian public-sector health system.

RESULTS

A total of 1121 PMTCT-related tasks carried out by nurses involving 179 patients at ANC and PNC visits were observed at 26 health facilities. The average time of the first ANC visit was the longest, 54 (95% confidence interval (CI) 42-65) min, followed by the first PNC visit which took 29 (95% CI 26-32) minutes on average. ANC and PNC follow-up visits were substantially shorter, 15 (95% CI 14-17) and 13 (95% CI 11-16) minutes, respectively. During both the first and the follow-up ANC visits, 94% of nurses' time could be shifted to CHWs, while 84% spent on the first PNC visit and 100% of the time spent on the follow-up PNC visit could be task-shifted. Depending on CHW salary estimates, the cost savings due to task-shifting in PMTCT ranged from US$ 1.3 to 2.0 (first ANC visit), US$ 0.4 to 0.6 (ANC follow-up visit), US$ 0.7 to 1.0 (first PNC visit), and US$ 0.4 to 0.5 (PNC follow-up visit).

CONCLUSIONS

Nurses working in PMTCT spend large proportions of their time on tasks that could be shifted to CHWs. Such task-shifting could allow nurses to spend more time on specialized PMTCT tasks and can substantially reduce the average cost per PMTCT patient.

Bridging the gender pay gap

Nursing may be a largely female profession, but men are vastly overrepresented in senior positions. Experts say the NHS has to take action to correct the huge gender imbalance - and female nurses need to learn how to help themselves.

A 'valued' profession?

Re your online article 'RCN calls government response to pay petition completely inadequate', I agree nurses have been given a poor deal.

Letter

In answer to your Readers' Panel question 'Is the 1% pay cap destroying nurses' morale?' (opinion, 23 November), it already has. Experienced nurses are leaving and it is almost impossible to fill their posts. Hence the shortage of nurses.

No wonder nurses feel demotivated

Nurses are expected to be highly educated and take on more medical-related tasks, but they get no recognition for their work or the skills they have.

Poor pay must be addressed

The government's response to an online petition calling for fair pay for nurses is disgusting (news, 16 November). Ministers should come to a trust unexpectedly - without the trust suddenly having enough staff just for the visit. Only then will they appreciate how nurses try to manage a ward with patients all with differing diagnoses, helped only by agency and bank staff who may not know the hospital, let alone the ward.

Shout louder about poor pay

It seems increasingly clear to me that the NHS pay campaign is not making waves either in the NHS or with the public.

A minister's average pay is nearly three times that of a nurse

The government argues that nurses' pay is already above the national average and that many of us receive pay progression increments.

Campaign for fair pay is a fight for the NHS

NHS finances are in a dire state. Some would say now is not the time to argue for a pay increase, but the RCN's reasons for asking the Pay Review Body to recommend a 2017 pay award above the 1% cap are compelling.

Readers' panel - Is the 1% pay cap for NHS staff destroying nurses' morale?

Our experts consider a hot topic of the day.

Politicians should try working a 12 hour shift

In response to the online story, RCN calls government response to pay petition 'completely inadequate', I challenge any politician to work for 12 hours, which is the length of most front-line shifts.

Student life - Get your finances in order

Qualifying as a nurse is an exciting time, but it can also be one of financial anxiety, as you swap the safety net of a bursary for the uncertainty of looking for work.

From Twitter

Nurses on Twitter.

How wages compare

In the autumn, the NHS Pay Review Body (RB) will take evidence from government, employers and nurses' unions. It will then deliberate before making recommendations on what should be a pay rise in April 2017. But as NHS nurses know only too well, this supposedly independent system has been compromised by top down pay freezes initiated by the Westminster government as part of its 'austerity' measures.

Rent crisis exposed as key workers hit with 20% hike

The RCN has called for more affordable accommodation for nurses as key workers in London faced a 20% rent hike.

Urgent action needed to address key worker housing crisis

We report this week that a group of nurses living in a block of flats in south east London faced with a 20% rent hike have been given just 8 weeks to pay up or move out.

Don't blame Brussels

Nadine Dorries claims that now we are leaving the EU we will have more control of our health service. She alludes to nursing staff enjoying better pay without the constraints from Brussels (opinion, 13 July).

Brexit will boost pay

Now that we are leaving the European Union we will have more control of our health service. This will allow us to increase the resources available and ensure we have the medical staff needed to keep it running.

RCN must flex its union muscles

The government wants to condemn nurses to an annual 1% 'pay rise' for the next four years. With inflation this amounts to a 20% pay cut between 2010 and 2020.

Leadership and efficiency - chief nurse's vision for better outcomes

Better patient outcomes and experience, as well as better use of resources for nurses and patients, are the aspirations of a new NHS England strategy.

Reality of pay rise gives little scope for celebration

Following our recent 1% pay rise, I opened my payslip with excitement, only to be sorely disappointed.