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Hospital Use of Supplemental Nurses and Patient Mortality and Failure to Rescue. Jingjing Shang, PhD, RN Columbia University School of Nursing Ying Xue , DNS, RN University of Rochester School of Nursing Linda Aiken, PhD, RN, FAAN

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Hospital use of supplemental nurses and patient mortality and failure to rescue

Hospital Use of Supplemental Nurses and Patient Mortality and Failure to Rescue

Jingjing Shang, PhD, RN

Columbia University School of Nursing

Ying Xue, DNS, RN

University of Rochester School of Nursing

Linda Aiken, PhD, RN, FAAN

University of Pennsylvania Center for Health Outcome and Policy Research


Hospital use of supplemental nurses and patient mortality and failure to rescue

  • This study was funded by and Failure to RescueCouncil for the Advancement of Nursing Science (CANS) / American Nurse Foundation (ANF) grant (grant # 2010-024)


Background
Background and Failure to Rescue

  • The nation has faced a cyclical nursing shortage for decades*;

  • Hospitals have opted to use supplemental nurses (SRNs) as a temporary solution to maintain an adequate nurse workforce**;

    • SRN staffing is a $3.6 billion per year market***

  • The use of SRNs has been involved in a long-term debate.

* Buerhause et al. 2009; ** May et al. 2006; *** Gregorie 2011


Background1
Background and Failure to Rescue

  • Some studies show association between SRNs and adverse outcomes such as: needle-stick injury to nurses, bloodstream infection, and medication errors*;

  • Other studies have found that SRNs work more efficiently on some clinical practices – patient evaluation, developing nursing diagnosis, therapeutic plans, and documentation, and were related to reduced patient falls**;

  • Aiken et al. 1997, Alonso-Echanove et al 2003, Roseman et al.

  • ** Hughes et al. 1991, Strzalkaet al. 1996, Bolton et al. 2007


Objectives
Objectives and Failure to Rescue

  • To determine the association between the use of SRNs in hospital and patient mortality and failure-to-rescue (FTR);

    • To the extent that a relationship is found between level of using SRNs and negative patient outcomes, to examine the effect of hospital nursing practice environments on the relationship between RSNs and patient outcomes.


Methods
Methods and Failure to Rescue

  • A secondary analysis of cross-sectional data in 4 states – CA, FL, NJ, & PA in 2006

    • Nurse survey

      • Random sample: 50% in NJ, 40% in PA, CA, 25% in FL

    • American Hospital Association (AHA) Annual Survey

    • Inpatient discharge data from state agencies


Methods1
Methods and Failure to Rescue

  • General surgical, orthopedic, and vascular surgical patients, ages of 19-90

  • Patient outcomes

    • 30-day inpatient mortality

    • 30-day inpatient failure to rescue (FTR)

      • Patient death with 30 days of hospital admission after a postoperative complication


Methods2
Methods and Failure to Rescue

  • SRNs: nurses employed by an external agency & involved in direct in-patient care;

  • Surveyed nurses reported the number of SRNs, and number of RNs on duty on their unit on the last shift;

  • Hospital use of SRN = total SRNs / total RNs


Methods3
Methods and Failure to Rescue

  • Nurse practice environment:

    • Measured by Practice Environment Scale of the Nursing Work Index (PES-NWI)

    • Composite score – mean of the subscales scores

      • Range from 1 to 4

      • Higher scores indicate better practice environment


Methods4
Methods and Failure to Rescue

  • Descriptive statistics compare SRNs with Permanently employed RNs

  • Multilevel logistic regression models to examine the relationship between SRNs & patient outcomes

    • Using a Huber White procedure to control for clustering within hospitals

    • Models were risk adjusted by patient characteristics (including age, sex, race, admission type, transfer status, insurance type, 27 Elixhauser comorbidities), hospital characteristics (teaching status, high-tech status, bed size, urban/rural location, ownership), & other nursing organizational factors (nurse staffing, nurse education, working environment).


Result
Result and Failure to Rescue

  • The final analysis include 40,356 nurses, 1,295,068 patients from 665 hospitals;

  • The utilization of SRNs in hospitals ranged 0% -- 56%, with an average of 9%.

    • 39.54% hospitals used less than 5% SRNs ,

    • 42% hospitals used 5%-15% SRNs,

    • 19% hospitals used more than 15% SRNs

Count of Hospitals by Proportion SRNs


Hospital use of supplemental nurses and patient mortality and failure to rescue

Table 1. Characteristics of Supplemental Nurses and Permanently Employed Nurses

  • Notes: RN = Registered Nurse, BSN = Bachelor of Science in Nursing; T-tests and chi-squared tests were used for the group comparisons.


Hospital use of supplemental nurses and patient mortality and failure to rescue

Table 2. Associations between 30-day In-Hospital Surgical Mortality and Failure to Rescue and the Use of

Supplemental Nurses (SRNs), Before and After Controlling for Other Characteristics of Nursing

Notes: All models controlled for patient factors (including age, sex, admission type, transfer status, DRG group, and 27 Elixhausercomorbidities)

and hospital characteristics (technology status, teaching status, bed size, urban/rural, and indicator variables for the states in which hospitals were located)

†p<0.10,*p < 0.05, ** p < 0.01, *** p < 0.001


Hospital use of supplemental nurses and patient mortality and failure to rescue

Table 2. Associations between 30-day In-Hospital Surgical Mortality and Failure to Rescue and the Use of

Supplemental Nurses (SRNs), Before and After Controlling for Other Characteristics of Nursing

Notes: All models controlled for patient factors (including age, sex, admission type, transfer status, DRG group, and 27 Elixhausercomorbidities)

and hospital characteristics (technology status, teaching status, bed size, urban/rural, and indicator variables for the states in which hospitals were located)

†p<0.10,*p < 0.05, ** p < 0.01, *** p < 0.001


Hospital use of supplemental nurses and patient mortality and failure to rescue

Table 2. Associations between 30-day In-Hospital Surgical Mortality and Failure to Rescue and the Use of

Supplemental Nurses (SRNs), Before and After Controlling for Other Characteristics of Nursing

Notes: All models controlled for patient factors (including age, sex, admission type, transfer status, DRG group, and 27 Elixhausercomorbidities)

and hospital characteristics (technology status, teaching status, bed size, urban/rural, and indicator variables for the states in which hospitals were located)

†p<0.10,*p < 0.05, ** p < 0.01, *** p < 0.001


Hospital use of supplemental nurses and patient mortality and failure to rescue

Table 2. Associations between 30-day In-Hospital Surgical Mortality and Failure to Rescue and the Use of

Supplemental Nurses (SRNs), Before and After Controlling for Other Characteristics of Nursing

Notes: All models controlled for patient factors (including age, sex, admission type, transfer status, DRG group, and 27 Elixhausercomorbidities)

and hospital characteristics (technology status, teaching status, bed size, urban/rural, and indicator variables for the states in which hospitals were located)

†p<0.10,*p < 0.05, ** p < 0.01, *** p < 0.001


Hospital use of supplemental nurses and patient mortality and failure to rescue

Table 2. Associations between 30-day In-Hospital Surgical Mortality and Failure to Rescue and the Use of

Supplemental Nurses (SRNs), Before and After Controlling for Other Characteristics of Nursing

Notes: All models controlled for patient factors (including age, sex, admission type, transfer status, DRG group, and 27 Elixhausercomorbidities)

and hospital characteristics (technology status, teaching status, bed size, urban/rural, and indicator variables for the states in which hospitals were located)

†p<0.10,*p < 0.05, ** p < 0.01, *** p < 0.001


Hospital use of supplemental nurses and patient mortality and failure to rescue

Table 2. Associations between 30-day In-Hospital Surgical Mortality and Failure to Rescue and the Use of

Supplemental Nurses (SRNs), Before and After Controlling for Other Characteristics of Nursing

Notes: All models controlled for patient factors (including age, sex, admission type, transfer status, DRG group, and 27 Elixhausercomorbidities)

and hospital characteristics (technology status, teaching status, bed size, urban/rural, and indicator variables for the states in which hospitals were located)

†p<0.10,*p < 0.05, ** p < 0.01, *** p < 0.001


Conclusions implications
Conclusions & Implications Mortality and Failure to Rescue and the Use of

  • SRNs are equally or even more qualified than Permanently Employed Nurses ;

  • Our findings suggest that deficient hospital work environments may explain the poor patient outcomes associated with higher use of SRNs rather than anything about SRNs themselves;

  • Policymakers and administrators should invest resources in nursing to improve the aspects of the practice environment which have been linked to the attraction and retention of permanent nurses and the quality of patient care.


Limitations
Limitations Mortality and Failure to Rescue and the Use of

  • We may be lacking one or more critical explanatory variables that might alter our conclusion.

  • The findings may not generalize to other patient outcomes or to patients other than surgical patients;