Nurse Staffing and Patient Safety

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Nurse Staffing and Patient Safety

• Mary A. Blegen, R.N., Ph.D, FAAN
• Professor and Associate Dean for ResearchSchool
  of Nursing
• University of Colorado Health Science Center

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IOM Report on Patient Safety To Err is Human
(1999)

• Error rate not acceptable
• Errors in health care are more dangerous than
  some of the major killers
• Staffing and Error - Is there a relationship?

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Evidence of Effect on Safety

• Safety many aspects, many settings
• Focus here on the evidence for effect of Nurse
  staffing in hospitals Mortality rates
  Failure to Rescue Nosocomial Infections
  Skin Breakdown Medication Administration
  Errors Patient Falls

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Early studies Mortality AHA and HCFA data

• More RNs decreased mortality
• Scott, Forrest Brown (1976)
• Hartz et al (1989)
• Aiken, Smith Lake (1994)
• More RNs did not affect mortality
• Shortell Hughes (1988)
• Al-Haider Wan (1991)
• Shortell Others (1994)

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Later studies Mortalitystate data

• Schultz et al (1998) (N373 CA Hospitals) Higher
  RN hrs ppd had lower mortality rates
• Aiken, Clarke et al (2002) (N168 PA hospitals)
  Increased PtRN ratio increased mortality rate
  and failure to rescue rate
• Needleman, Buerhaus et al (2002) (N799 hospitals
  in 11 states) Higher staff mix lower rates of
  Failure to rescue after complication

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The Algebra of Effectiveness
CLINICAL FACTORS
Principal diagnosis
Severity/extent of principal diagnosis and
comorbidities
Complications, iatrogenic illness
Comorbid illness severity/extent
Severity/extent of principal diagnosis
Acute clinical stability
Physical functional status
Physical functional status
Acute clinical stability
Survival
Age, sex
PatientFactors

Random events
Treatment effectiveness

Outcomes
NONCLINICAL FACTORS
Patient attitudes and preferences
Health-related quality of life
Resource Use
Health-related quality of life
Cultural, ethnic, and socioeconomic attributes,
beliefs, and behaviors
Psychological, cognitive, psychosocial functioning
Satisfaction
From Lisa I. Iezzoni (1997), Risk Adjustment for
Measuring Healthcare Outcomes
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Medication Administration Errors

• Harvard (Leape et al 95 Bates et al 95) 38
  of errors are administration errors BUT, nurses
  prevent 42 physician errors
• Nurses are last line of defense in preventing
  medication errors.
• Reporting problems (Pepper, 1995 Wakefield et al
  1996 Blegen, Vaughn Pepper, 2002 Flynn et al
  2002)

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Medication Administration Errors

• Blegen, Goode Reed (1998)Higher staff mix
  associated with lower med error rates (up to 87)
• Blegen Vaughn (1998) Higher staff mix
  associated with lower med error rates (up to
  85)

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Measuring Medication Errors

• Flynn, Barker, Pepper, Bates (2002) Observation
  studies in 36 facilities show that medication
  administration error rate is higher than previous
  reports and few are reported as incidents.
  300 errors observed 17 chart review
  1 error incident report

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Incident Reporting

• Blegen/Vaughn current study - 45 med errors
  and - 77 patient falls reported.
• Linked to Quality Management Processes on the
  unit (r .340)In other words -- the use of data
  to manage quality on the unit improved the
  quality of the data available.
• Reporting also linked to staffing levels

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Reasons for Med Admin Errors

• Blegen new study (N1200 RNs from 280 units in 47
  hospitals)
• Asked about reasons that medication errors occur
  (in addition to handwriting/transcription)
• 1. Distractions and interruptions
• 2. RN to patient ratio
• 3. Many meds on many patients

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Patient Falls

• Wan Shukla (1987) Falls decreased with more RNs
• Blegen Vaughn (1998) Falls decreased with more
  RNs
• Sovie, Jawad (2001) Falls decreased with higher
  RN hrs and Total hours
• Langemo (2002) Falls lower on units with higher
  proportion RN / LPN hrs.
• Unruh (2003) Falls lower with higher licensed
  nurses

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Reasons for Patient Falls

• Blegen new study (N1200 RNs)
• Asked about reasons that patient falls occur
• 1. Patient Condition
• 2. RN to patient ratio

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Pressure Ulcers

• ANA (1997 and 2000) Higher staff mix -- lower
  rates of pressure ulcers
• Blegen, Goode Reed (1998) Higher staff mix --
  lower rates of pressure ulcers
• Sovie, Jawad (2001) Higher total hours lower
  rate of pressure ulcers
• Unruh (2003) Higher numbers of nurses and higher
  staff mix lower rates of pressure ulcers

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Nosocomial infectionshospital level staffing

• ANA (1997, 2000) RN negatively related to
  infection rates
• Kovner, Gergen, Jones et al (1998, 2002)RN
  staffing related to lower incidence of UTI and
  Pneumonia
• Needleman, Buerhaus, et al (2002)UTI reduced
  4-12 with high RN and 4-25 with high total
  hrsPneumonia reduced 6-8 with high RN and
  6-17 with high total hrs

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Nosocomial Infections

• Medical Surgical Units
• Flood Diers, (1988) Short staffed unit had
  more complications including infections
• Blegen, Goode, Reed (1998)UTIs and Respiratory
  infections decreased with RN and increased with
  total hours
• Sovie Jawad, (2001)UTIs decreased with higher
  total hrs

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Nosocomial Infections

• Intensive Care Units
• Giraud (1993)Nosocomial infections increased
  when nursing workload was high
• Archibald (1997) Nosocomial infections in PICU
  increased as RN hppd decreased
• Maryland ICU studies 3 patient to nurse ratio
  associated with higher pneumonia and septicemia
  (Pronovost, 1999 Dang, 2002, Dimick, 2001
  Amaravadi, 2000)

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Blood Stream Infections

• Intensive Care Units
• Central venous line infections related to patient
  to nurse ratios, controlling for TPN, severity of
  illness, days on vent, days in hospital (Fridkin,
  1996)
• Blood stream infections related to increase in
  use of agency/pool RNs, controlling for number of
  surgical procedures, number of CVC, TPN, ARDS,
  days of care (Robert, 2000)

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Specific Infections

• MRSA incidence higher with lower nurse staffing
  (Farrington, 2000 Vicca, 1999)
• During a 6 wk Enterobacter Cloacae outbreak there
  was overcrowding and understaffing (Harbarth,
  1999)
• Gram negative outbreak coincided with high
  nursing workload (Isaacs, 1988)

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Implications

• Growing body of evidence cant ignore!Skill
  mix (RN Proportion) and RN hppd are correlated
  with decrease in adverse occurrences
• Research evidence does not identify specific
  staffing levels
• Shortage is coming and
• Answers are needed

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RN Shortage Statistics

• 1,119,000 RNs short by 2020(US Dept of Health
  and Human Services)
• Jobs for RNs will grow 23 between1999 and 2006

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RN care increasing -- BUT

• Spetz (1998, 2000) California Data
• RNs Hrs ppd increased from 6 in 1984 to 8 in
  1995 thru 1998
• Inpatient units may still be understaffed
• Decrease LOS -- Acuity Increase during stay
• Increase of RNs in Outpatient units
• Minnick Pabst (1998) 77 nursing units in
  multiple Chicago hospitals
• Increase in staffing lt increase in acuity
• Nursing Hrs ppd adjusted for acuity actually
  decreased

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Nurse Staffing (Blegen / Vaughn new study)

• RN
• HPPD Vacancy RN Mix
• Quarter 1 7.60 10.4 72.5
• Quarter 2 7.74 11.7 72.2
• Quarter 3 7.75 12.4 72.0
• Quarter 4 7.64 13.8 71.9
• (All adult hospital units)

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NurseWeek /AONE Survey

• Conducted in Fall of 2001 3441 RNs
• 43 RNs planned to leave present position in next
  3 years
• Actions that would make nurses reconsider plans
  to leave or return to nursing 57 Higher salary
  or benefits 47 More respect from management
  47 Better staffing 46 Less stressful work
  environment

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NurseWeek/AONE Survey

• Quality of various working conditions
• Excellent/Good 54 Relationships with peers
  40 Relationships with patients
• Fair/Poor 56 Influence on workplace decisions
  55 Professional development and advancement
  54 Recognition of accomplishments and work
  well done

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NurseWeek /AONE Survey

• Actions that would help to solve the shortage
  87 Improved working conditions 81 Improved
  wages and benefits 74 Higher status of nurses
  62 Better Hours

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Conclusions Nursing Care in Hospitals

• Nurse Staffing ? patient safety
• High patient acuity and short stays
• Great volatility, patients in and out-new
  assessments and orders-many interruptions
  distractions-multiple preparations for
  discharge-high demands for 12 straight
  hours-vacant positions new and contract staff

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Conclusion Attracting more Nurses

• Maintain adequate stable staffing ?
• Less stressful work environment
• Recognize the complex and demanding job nurses do
• Respect and Status
• Wages and Benefits
• Hours

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Conclusions Patient Safety AND More Nurses

• The visible use of quality data to improve the
  system of care ? improves the voluntary
  reporting of incidents thus ? improving safety
• Involving nurses in workplace decisions and
  initiatives (i.e. patient safety) is positive
  workplace condition