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Nurse Staffing and Quality of Care: What Does Current Research Tell Us? . Michigan Health and Safety Coalition April 14, 2004 Peter I. Buerhaus, PhD, RN, FAAN. Agenda. Overview of research on nurse staffing and quality of care Is there a business case for nursing?

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nurse staffing and quality of care what does current research tell us

Nurse Staffing and Quality of Care: What Does Current Research Tell Us?

Michigan Health and Safety Coalition

April 14, 2004

Peter I. Buerhaus, PhD, RN, FAAN

agenda
Agenda
  • Overview of research on nurse staffing and quality of care
  • Is there a business case for nursing?
  • Important developments in improving quality and safety related to nursing
  • Research on nurse staffing: Serious threats facing the nursing profession – and the quality and safety of care
  • Recommendations
evidence linking nurse staffing patient outcomes comes from
Evidence Linking Nurse Staffing & Patient Outcomes Comes from
  • Many small sample studies of nursing units
  • About 15 published, hospital-level, large sample studies
large sample studies
Large Sample Studies
  • L. Aiken, H. Smith, E. Lake, “Lower Medicare mortality among a set of hospitals known for good nursing care,” Medical Care (1994) Vol. 32, No. 8. pp 60-772
  • L. Aiken, S. Clarke, D. Sloane, J. Sochalski, J. Silber, “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction” JAMA (2002); 288:1987-1993.
large sample studies6
Large Sample Studies
  • C. Kovner and P. Gergen, “Nurse Staffing Levels and Adverse Events Following Surgery in US Hospitals,” IMAGE: Journal of nursing scholarship (1998), Vol. 30, No. 4, pp. 315-321
  • L. Lichtig, et al. “Some Impacts of Nursing on Acute Care Hospital Outcomes,” Journal of Nursing Administration(1999), vol. 29, No. 2, pp: 25-33
large sample studies7
Large Sample Studies
  • N. Donaldson, et al. “Nurse staffing in California hospitals 1928-200: Findings from the California nursing outcomes coalition database project,” Policy, Politics, & Nursing Practice(February 2001)
  • Network, Inc., “Nurse Staffing and Patient Outcomes in the Inpatient Hospital Setting,” (Washington, DC: American Nurses Association, 2000).
large sample studies8
Large Sample Studies
  • J. Needleman, P. Buerhaus, S. Mattke, M. Stewart, K. Zelevinsky, Nurse Staffing and Patient Outcomes in Hospitals. Final Report: US Department of Health and Human Services, Health Resources and Services Administration Contract (2001)
  • J. Needleman, P. Buerhaus, S. Mattke, M. Stewart, K. Zelevinsky, “Nurse Staffing and Quality of Care in Hospitals in the United States,” The New England Journal of Medicine (May 30, 2002)
large sample studies9
Large Sample Studies
  • Ulrich, L. “Licensed nurse staffing and adverse events in hospitals” Medical Care, 41(1), 142-152.
  • Person, S. et al. “Nurse staffing and mortality for Medicare patients with acute myocardial infarction” Medical Care 42(1) 4-12.
  • Kovner, C, Jones, C. et al. Nurse staffing and postsurgical adverse events: An analysis of administrated data from a sample of US hospitals. Health Services Research 2002: 37; 611-629.
hrsa study
HRSA Study
  • Co-sponsored by HRSA, NINR, HCFA, AHRQ (Needleman & Buerhaus)
  • Purpose of Study: Develop the evidence base on the relationship between patient outcomes potentially sensitive to nurse staffing in inpatient units in acute care hospitals
  • Three analyses based on hospital discharge abstracts, testing 14 patient outcomes
1 all patient analysis hrsa
1. All-patient Analysis (HRSA)

Questions:

  • Is there an association between nurse staffing and outcomes?
  • What is impact of different nursing staff (RNs, LPNs, and Aides)?
1 summary of all patient analysis
1. Summary of All-Patient Analysis

Sample: 799 hospitals in 11 states, > 5 million

Discharges

  • Medical patients:

Length of stay, pneumonia, UGI bleeding,

shock/cardiac arrest, failure to rescue

  • Major surgery patients:

Urinary tract infection, failure to rescue,

Pneumonia (weak)

  • Relationships strongest for RNs; shift from low to high RN staffing results in:

3-12% reduction in risk of adverse outcome

2 analysis of unit level versus hospital level staffing
2. Analysis of Unit Level Versus Hospital Level Staffing

Questions:

  • Is hospital nursing unit level more precise?
  • Does unit level Identify more outcomes related to nursing?

Sample: 256 California Hospitals

Conclusion: No to both questions

3 medicare only vs all patients
3. Medicare Only vs. All-Patients

Question: Can Medicare only data (MedPAR) substitute for all-patient data?

Sample: > 12 million Medicare discharges

Conclusions:

  • For medical patients, similar results using national MedPAR and 11 state all-patient data
  • For surgical patients, MedPAR and 11 state all-patient identify additional outcomes
    • UGI, Shock, Sepsis, Pneumonia stronger

See: J. Needleman, J., Buerhaus, P. Stewart, M., Zelevinsky, K. “Measuring Hospital Quality: Can Medicare Data Substitute for All-Payer Data?” Health Services Research 2003 38(6):1487-1508.

trends in adverse hospital inpatient outcomes associated with nurse staffing 1988 1997
Trends in adverse hospital inpatient outcomes associated with nurse staffing (1988-1997)

Purpose: Determine whether quality of hospital care related to nursing has improved or worsened over time

Data: Approximately 50 million discharge abstracts

Funded by Agency for HealthCare Research and Quality

trends in outcomes using hospital discharge data
States

California

Florida

Massachusetts

New York

Washington

Wisconsin

Outcomes Examined

UTI

Pneumonia

Sepsis

Shock/cardiac arrest

UGI bleeding

DVT

Trends in Outcomes Using Hospital Discharge Data
tentative conclusions
Tentative Conclusions
  • At this point in our analysis, we see no evidence of across the board improvement in these outcomes over this time period
  • Work remaining
    • Control for changes in market conditions
    • Determine year by year associations with nurse staffing
other current work impact of nursing on outcomes in nursing home residents
Other Current Work: Impact of Nursing on Outcomes in Nursing Home Residents
  • Susan Horn, Peter Buerhaus, Nancy Bergstrom, Randall Smout
  • 1,376 residents (mean age 81.5, mostly women) at risk for developing pressure ulcers in 109 nursing homes in 23 states
  • Controls for diagnosis, severity, and patient characteristics
preliminary results under journal review
Preliminary Results(Under Journal Review)

More RN time associated with …

  • Fewer UTIs, catheterizations, pressure ulcers, hospitalizations, and deaths
  • More nutritional supplements
  • Less weight loss
agenda20
Agenda
  • Overview of research on nurse staffing and quality of care
  • Is there a business case for nursing?
  • Important developments and improving quality and safety related to nursing care
  • Research on nurse staffing: Serious threats to the nursing profession
  • Recommendations
is there a business case for nursing
Is there a business case for nursing?
  • Jack Needleman, PhD, UCLA School of Public Health
  • Peter Buerhaus, RN, PhD, Vanderbilt University School of Nursing
  • Maureen Stewart, BA, Heller School, Brandeis University
  • Katya Zelevinsky, BA, Harvard School of Public Health
approach
Approach
  • Determine cost of increasing RN and LPN staffing in US hospitals staffed below 75th percentile
  • Estimate national cost savings associated with decreased number of adverse outcomes, avoided deaths, and avoided hospital days
  • Based on NEJM analysis (799 hospitals, > 5 million discharges)

Funded by The Commonwealth Fund

agenda23
Agenda
  • Overview of research on nurse staffing and quality of care
  • Is there a business case for nursing?
  • Important developments in improving quality and safety related to nursing care
  • Research on nurse staffing : Serious threats facing the nursing profession
  • Recommendations
important nursing quality related developments
Important Nursing Quality-Related Developments
  • JCAHO – shortage task force, nurse sensitive outcomes, Nursing Advisory Council, conference in Sept
  • IOM – Committee on Work Environment for Nurses and Patient Safety
  • National Quality Forum – Steering Committee on Nursing Care Performance Measures
national quality forum
National Quality Forum
  • Identify and endorse a set of performance measures for evaluating the quality of nursing care in acute care hospitals
  • Identify a framework for measuring nursing care performance… attention to nurses’ contribution to effective care teams
  • Identify and prioritize unresolved issues and develop research agenda
screening evaluation and recommendation
Screening, Evaluation, and Recommendation
  • Initially more than 100 measures identified and screened for relevance to the purpose, framework, scope, and priorities
  • Steering committee selected 57 for detailed evaluation
  • Evaluations based on NQF criteria: importance, scientific, acceptability, usability, and feasibility
19 nqf voluntary nursing performance measures
Failure to rescue (surgical patients)

Pressure ulcer prevalence

Pneumonia prevalence

Falls prevalence

Falls with injury

Restraint prevalence

Restraint prevalence (vest and limb only)

Urinary tract infection

UTI – catheter associated

Central line associated blood stream infection

Ventilator associated pneumonia

Smoking cessation for AMI

Smoking cessation counseling for heart failure

Smoking cessation for pneumonia

Skill mix (RN, LPN, UAP and contract)

Nursing care hours per patient day (RN, LPN, UAP)

Practice environment (Nursing Work Index)

Voluntary turnover

Nurses’ education preparation

19 NQF Voluntary Nursing Performance Measures
nqf steps
NQF Steps
  • October – NQF member and public comment period
  • November – distribution of consensus report and ballots to NQF members
  • December – voting period ends
  • January 26, 2004 – Final ballots due
  • Spring – release of set of initial voluntary measures of nursing performance
other important developments
Other Important Developments
  • IHI/AHA – IMPACT on Workforce
  • California – Nurse staffing ratios
  • Johnson & Johnson Campaign for Nursing’s Future – private sector leadership, others getting involved
  • Congress – has done NOTHING!
agenda30
Agenda
  • Overview of research on nurse staffing and quality of care
  • Is there a business case for nursing?
  • Important developments and improving quality and safety related to nursing care
  • Research on Nurse Staffing: Serious threats facing the nursing profession
  • Recommendations
key facts
Key Facts
  • Average age of RN workforce is increasing more than twice as fast as all other occupations in US workforce
  • Between 1983-1998, number of RNs under 30 years decreased 41 percent; the number of working people in the US workforce under 30 years of age dropped by only 1 percent

Source: Buerhaus, Staiger, Auerbach. Implications of a rapidly aging RN workforce. JAMA 2000; 283 (22): 2948-2954.

slide34

HRSA: Health Resources and Services Administration, 2002

B/S/A: Buerhaus, Staiger, Auerbach, 2002, updated forecasts originally published in JAMA, June 2000

impact of shortage on nursing practice
Impact of Shortage on Nursing Practice

Inpatient RN vs. Other RN’s

slide37

C5. How would you rate the quality of your current work setting in each of the

following areas?

slide38

C5. How would you rate the quality of your current work setting in each of the

following areas?

slide39

C5. How would you rate the quality of your current work setting in each of the

following areas?

agenda40
Agenda
  • Overview of research on nurse staffing and quality of care
  • Is there a business case for nursing?
  • Important developments in improving quality and safety related to nursing care
  • Research on nurse staffing: Serious threats facing the nursing profession
  • Recommendations
    • Quality and safety
    • RN Workforce
improving quality and safety
Improving Quality and Safety
  • The evidence establishes that low RN staffing increases the risk of adverse outcomes
  • This information is meaningless unless nurses apply it in their daily nursing practice to improve nursing care and inform their practice
actions to improve quality and safety
Actions to Improve Quality and Safety
  • Develop team (physicians, nurses, HR, administration, pharmacy, medical records) to select patient outcomes related to nursing (e.g., consider National Quality Forum measures)
  • Determine capability to measure outcomes
actions to improve quality and safety43
Actions to Improve Quality and Safety
  • Determine and test changes in nursing practice or system that are likely to improve outcomes
  • Implement changes and record results
  • Collect data over time
  • Report results to constituents: nurses, physicians, administration, HR, medical records, pharmacy, others
but without enough rns in the future
But Without Enough RNsin the Future
  • Access to care will be compromised
    • Delays in admissions, discharges
    • Inability to staff current programs, let alone open new ones
  • Quality of care will be jeopardized
    • Increased adverse outcomes, deaths, longer hospitals stays
  • Safety will be threatened
    • From falls, medication errors, oversight and coordination, etc.
to ensure enough rns
To Ensure Enough RNs
  • Get tough on Congress, election coming up, and this is an issue that looms very large and negative for the hospital industry, nursing profession, and those concerned with quality and safety of care
    • Focus government relations team on getting Congress to
  • Immediately increase capacity of nursing education programs through faculty raises, loans and scholarships, capitation programs
    • Set state and national goals
  • Establish and maintain relationships with local schools and nursing programs
to ensure enough rns46
To Ensure Enough RNs
  • Prepare for an older RN workforce (economics and ergonomics)
    • Survey ergonomic environment and make improvements
    • Engage suppliers, pharmaceuticals, and medical device manufactures
to ensure enough rns47
To Ensure Enough RNs
  • Improve workplace climate quickly and decisively, act on AHA Workplace Commission report (April 2002), JCAHO white paper (July 2002), RWJF report (August 2000), AONE/NurseWeek National Survey of RNs, and IOM report
    • Find ways to decrease/smooth demand on RNs via patient scheduling, good management
to ensure enough rns48
To Ensure Enough RNs
  • Avoid legislation regulating nurse staffing
  • CMS must help hospitals with resources, but tie to developing better data on nurse staffing and patient outcomes, monitoring, and actual improvements in workplace
  • Stimulate greater private sector involvement; Johnson & Johnson Campaign can’t do it alone