Vital Signs Blog

Blog: Better nursing-staffing equals lower mortality

There's a 20% lower risk that a patient will die within 30 days of having general surgery at a hospital with above average nurse staffing levels, a study released Tuesday found. Researchers compared facilities that had a mean of about 1.5 nurses per bed to those that had a mean of less than one nurse per bed.

The findings, published this week in JAMA Surgery, come as nursing groups and hospitals remain in sharp disagreement over how to address inadequate nurse staffing in the U.S. Some experts say inadequate staffing can lead to higher readmission, infection, and mortality rates, staff burnout and lower patient satisfaction.

The biggest difference between hospitals with more nurses and those with fewer, was felt by the sickest patients getting the riskiest surgeries. The better staffed the hospital, the less likely the patient would die or need to be sent to intensive care services.

Moreover, the total cost of surgery remained about $27,000 in either environment. That means the better-staffed facilities had “a formula for excellent value,” said lead study author, Dr. Jeffrey Silber, director of the Center for Outcomes Research at the Children's Hospital of Philadelphia. “Identifying hospitals with good nursing environments and staffing levels makes sense (for patients),” he said.

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While it might seem obvious that sicker patients would benefit from better nurse ratios, the solution is not as cut and dry as just adding more nurses. The study found that facilities with better nursing environments are often academic medical centers, were recognized by the Magnet nursing excellence program, and also have access to “high-level technology,” which may positively impact outcomes. “In the real world, such characteristics often cluster together,” Silber said.

Some states, like California and Massachusetts, have instituted mandatory nurse-staffing ratios. Supporters like Bonnie Castillo, director of the Registered Nurse Response Network for the National Nurses United union, say that forces hospitals to staff up when needed. Regulation is stronger than excellence programs, “which are more about marketing than actual care.”

“Hospitals tend to want to do more with less,” Castillo said. “Everything is looked at in terms of cost effectiveness.”

But some say the mandates put financial strain on a healthcare system that is already overburdened by shortages of licensed practitioners and a tumultuous labor market. The demand for nurses- the industry's largest occupation- has some hospitals working aggressively to hire and retain them.

A more favorable job market could prevent shortages, because when general unemployment declines, nurse attrition goes up, one nurse staffing company told Modern Healthcare earlier this month.

Overall, the healthcare industry's hiring accelerated last year, adding roughly 470,000 workers, according to estimates this month.

The JAMA Surgery study included data from more than 25,752 Medicare general surgery patients treated at hospitals in Illinois, New York and Texas between 2004 and 2006. The states chosen represent a cross section of the U.S.

The findings show that patients undergoing general surgery at hospitals with better nursing environments generally receive a higher value of care, and the outcomes would likely be similar today as the characteristics of hospitals studied have not changed greatly, Silber says.

But when it comes to improving outcomes and making hospitals safer, it's not just a matter of adding staff. The term “culture of safety” has become commonplace within U.S. healthcare facilities, yet many still struggle to create the infrastructure needed to drive an integrated safety system.

“Thoughtful coordination of all the players” through teamwork, communication and leadership, are key to improving patient safety and quality, and lowering costs," wrote Dr. Amir Ghaferi and Christopher Friese of the University of Michigan's Center for Healthcare Outcomes & Policy in an editorial accompanying the study.

“Safety culture cannot be changed quickly,” they added.


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