Hospitals with fewer nurses on staff saw a greater likelihood of elderly patients dying due to sepsis, according to a new study that shined a light on how understaffing affects care quality.
About 26% of Medicare patients with sepsis die within 60 days of admission. Each additional hour of care that nurses provide to sepsis patients is linked to a 3% decrease in mortality within 60 days of admission, the study published in JAMA Network Open on May 27 found.
The study used 2018 data from Medicare claims, the American Hospital Association's annual survey and the Centers for Medicare and Medicaid Services' Hospital Compare report to analyze 1,958 acute-care hospitals and 702,140 Medicare beneficiaries diagnosed with sepsis.
On average, these patients received 6.2 hours of care per day from registered nurses.
Hospitals need adequate nurse staffing, as nurses take on the majority of care for sepsis patients and ensure health systems are compliant with CMS' sepsis management measures, said Jeannie Cimiotti, corresponding author of the study and associate professor at Emory University's School of Nursing.
Within three hours of a sepsis diagnosis, healthcare workers are expected to draw blood cultures, measure lactate levels and administer antibiotics and intravenous fluids, Cimiotti said.
"If you don't deliver within that window of time, then you increase the odds of a poor outcome," she said.
This issue is especially troubling as the COVID-19 pandemic has further depleted hospital staffing and caused isolation efforts that have likely led to delayed sepsis diagnosis and treatment, said Linda Dickey, president of the Association for Professionals in Infection Control and Epidemiology.
Rather than being overloaded and stretched to their limits, nurses should be rested, focused and at the height of their ability when caring for sepsis patients, she said.
"Sepsis can cascade pretty quickly, so you need to have someone who is well trained, who is confident and who can work very well as a team with the physician and be able to take action appropriately within that time frame," Dickey said.
Overall, 182,346 Medicare patients died due to sepsis in 2018. The study predicted that if all hospitals were staffed at 6 registered nurse hours per patient day or higher, there could be 1,266 fewer deaths. If all hospitals were staffed at 9 nurse care hours or higher, an estimated 6,360 patient deaths could be avoided.
Even before the pandemic, research showed how staffing could affect sepsis care. Nearly two decades ago, a Critical Care Medicine survey of emergency departments nationwide found that 58% of physician directors and 48% of nurse managers identified nurse staffing as the primary cause of delays in treating sepsis.
Each patient added to a nurse's workload is associated with a 12% increase in the likelihood of an in-hospital death and a 7% increase in 60-day mortality and 60-day readmission for patients with sepsis, according to a 2020 study published in the American Journal of Infection Control.
One necessary component to improve sepsis care is effective communication between nurses—including those in the pharmacy and laboratory—and physicians, Cimiotti said.
The implementation of early sepsis screening tools and response protocols as well as nurse education and training are also associated with significant decreases in sepsis-related mortality and improved Severe Sepsis and Septic Shock Early Management Bundle compliance scores from CMS.
Patient exposure to a 10% increase in a hospital's SEP-1 score is associated with a 2% decrease in the odds of 60-day mortality for those with sepsis. Having a doctor with experience in treating critically ill patients on staff leads to a 16% decrease.
"If we're going to keep SEP-1 as a metric of performance, and if CMS decides that there will be a financial incentive or penalty associated with it, then that demands we look at the workload of nurses to see how we can get that treatment initiated as quickly as possible," Cimiotti said.
Hospitals should add patient acuity as a factor in their staffing equation to determine how many nurses are needed to care for a patient population, she said. Also, critical care units and other units should make sepsis management a priority for nurses.
