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Better Nurse Staffing and Nurse Work Environments Associated With Increased Survival of In-Hospital Cardiac Arrest Patients
Abstract
Background:
Although nurses are the most likely first responders to witness an in-hospital cardiac arrest (IHCA) and provide treatment, little research has been undertaken to determine what features of nursing are related to cardiac arrest outcomes.
Objectives:
To determine the association between nurse staffing, nurse work environments, and IHCA survival.
Research design:
Cross-sectional study of data from: (1) the American Heart Association's Get With The Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and and Patient Safety; and (3) the American Hospital Association annual survey. Logistic regression models were used to determine the association of the features of nursing and IHCA survival to discharge after adjusting for hospital and patient characteristics.
Subjects:
A total of 11,160 adult patients aged 18 and older between 2005 and 2007 in 75 hospitals in 4 states (Pennsylvania, Florida, California, and New Jersey).
Results:
Each additional patient per nurse on medical-surgical units was associated with a 5% lower likelihood of surviving IHCA to discharge (odds ratio=0.95; 95% confidence interval, 0.91-0.99). Further, patients cared for in hospitals with poor work environments had a 16% lower likelihood of IHCA survival (odds ratio=0.84; 95% confidence interval, 0.71-0.99) than patients cared for in hospitals with better work environments.
Conclusions:
Better work environments and decreased patient-to-nurse ratios on medical-surgical units are associated with higher odds of patient survival after an IHCA. These results add to a large body of literature suggesting that outcomes are better when nurses have a more reasonable workload and work in good hospital work environments. Improving nurse working conditions holds promise for improving survival following IHCA.
... Nine studies used two different versions of the PES-NWI. The 31-item PES-NWI was used in seven studies (Aiken et al., , 2011Flynn et al., 2012;Friese et al., 2008;Ma & Park, 2015;McHugh et al., 2016;Olds et al., 2017), and the 29-item PES-NWI was used in two studies (Cho et al., 2015;Fasolino & Snyder, 2012). ...
... The PES-NWI consists of five subscales; nurse participation in hospital affairs; nursing foundations of quality care; nurse manager ability, leadership and support of nurses; staffing and resource adequacy; and collegial nurse-physician relationships. For the studies which used PES-NWI, six studies used all subscales to measure the NPE (Cho et al., 2015;Fasolino & Snyder, 2012;Flynn et al., 2012;Friese et al., 2008;Ma & Park, 2015;Olds et al., 2017), and two studies used four subscales (Aiken et al., 2011;McHugh et al., 2016). One study examined three subscales (nursing foundation for quality of care; nurse manager ability, leadership, and support; and collegial/ physician relations; Aiken et al., 2008). ...
... One study examined three subscales (nursing foundation for quality of care; nurse manager ability, leadership, and support; and collegial/ physician relations; Aiken et al., 2008). All studies using the PES-NWI used a four-point Likert scale (1 = strongly disagree to 4 = strongly agree), and scores were aggregated to either the unit level (Flynn et al., 2012;Ma & Park, 2015) or hospital level (Aiken et al., , 2011Cho et al., 2015;Fasolino & Snyder, 2012;Friese et al., 2008;McHugh et al., 2016;Olds et al., 2017). ...
Aim:
To synthesize the available evidence on the relationship between the nursing practice environment in acute care hospitals and five selected nursing-sensitive patient outcomes (mortality, medication error, pressure injury, hospital-acquired infection and patient fall).
Design:
A quantitative systematic review of literature was conducted using the PRISMA reporting guidelines (PROSPERO: CRD42020143104).
Methods:
A systematic review was undertaken up to October 2020 using: CINAHL, MEDLINE and Scopus. The review included studies exploring the relationship between the nursing practice environment in adult acute care settings and one of five selected patient outcomes using administrative data sources. Studies were published in English since 2000.
Results:
Ten studies were included. Seven studies reported that a favourable nursing practice environment reduced the likelihood of mortality in acute care hospitals, but estimates of the effect size varied. Evidence on the association between the nursing practice environment and medication administration error, pressure injury and hospital-acquired infection was mixed.
... Few studies have explored the association between nonpatient factors and outcomes in pediatric patients. Increased provider workload has been shown to adversely affect patient outcomes in multiple settings (6,7,12). For example, in the study by Tubbs-Cooley et al (6), neonatal ICU nurses with higher workloads had a higher likelihood of reporting missed care for their patients. ...
... First, our study focuses on PICU patients who are cared for in settings that have a higher nurse to patient ratio and are generally better equipped to deal with critical events in comparison to an adult inpatient ward. For example, a recent cross-sectional study by McHugh et al (12) demonstrated that although adult ward patients had a higher risk of mortality after in-hospital cardiac arrest with increased workload for nurses, outcomes in patients in the ICU were not dependent on ICU nurse workload. Thus, it is possible that hospital ICUs are more resilient to disruptive events. ...
PICU patients who experience critical illness events, such as intubation, are at high risk for morbidity and mortality. Little is known about the impact of these events, which require significant resources, on outcomes in other patients. Therefore, we aimed to assess the association between critical events in PICU patients and the risk of similar events in neighboring patients over the next 6 hours.
Design:
Retrospective observational cohort study.
Setting:
Quaternary care PICU at the University of Chicago.
Patients:
All children admitted to the PICU between 2012 and 2019.
Interventions:
None.
Measurements and main results:
The primary outcome was a critical event defined as the initiation of invasive ventilation, initiating vasoactive medications, cardiac arrest, or death. The exposure was the occurrence of a critical event among other patients in the PICU within the preceding 6 hours. Discrete-time survival analysis using fixed 6-hour blocks beginning at the time of PICU admission was used to model the risk of experiencing a critical event in the PICU when an event occurred in the prior 6 hours. There were 13,628 admissions, of which 1,886 (14%) had a critical event. The initiation of mechanical ventilation was the most frequent event (n = 1585; 59%). In the fully adjusted analysis, there was a decreased risk of critical events (odds ratio, 0.82; 95% CI, 0.70-0.96) in the 6 hours following exposure to a critical event. This association was not present when considering longer intervals and was more pronounced in patients younger than 6 years old when compared with patients 7 years and older.
Conclusion:
Critical events in PICU patients are associated with decreased risk of similar events in neighboring patients. Further studies targeted toward exploring the mechanism behind this effect as well as identification of other nonpatient factors that adversely affect outcomes in children are warranted.
... These results were in the same line with Aiken (2018) (37) and Busse (2012) (38) who reported that nearly half of the staff nurses described their units as providing fair patients safety and quality of care. This finding was contraindicated by McHugh (2016) (39) who stated that most of staff nurses perceived a poor level of patients' safety work environments which made complete involvement to evidencebased safety interventions hard. Correlation and relation between factors affecting quality of nursing handover process among ICU staff nurses and patients' safety issues. ...
Background: Intensive Care Unit ﴾ICU﴿ staff nurses role includes maintaining the continuity of patients care around the clock. High-quality nursing handover helps them to accomplish their role efficiently. Aim: This study aimed to assess factors affecting quality of nursing handover among staff nurses and its relation to patients' safety in ICUs. Subjects and Method: Design: A descriptive correlational study design was used to achieve the aim of the present study. Setting: The study was conducted at Tanta International Teaching Hospital (ICUs). Subjects: 255 staff nurses were involved in the study. Tools: Two tools were used to collect the data. Tool I: Factors Affecting Quality of Nursing Handover in ICUs Questionnaire. Tool II: Patients' Safety Issues in ICUs Questionnaire. Results: ICU staff nurses' highest mean percent of factors affecting nursing handover process quality were regarding relations with outgoing nurse 86.66, last handover experience 80.64 and unit safety climate 71.18. According to total ICU staff nurses' perceptions about patients' safety, 51.8% perceived a fair level in their work environment. 53.8% of staff nurses perceived a good level of patients' safety issues in their supervisors' expectations and actions promoting safety. Conclusion: There was a positive correlation between total factors affecting quality of nursing handover process and patients' safety issues in ICUs. Recommendations: Hospital management need to conduct continuous updating of handover policies and strategies to ensure its efficiency to keep patients' safety. Also, ICU staff nurses require allocating enough time every shift for the handover process. Intensive care is a multidisciplinary and inter-professional specialty dedicated to the overall management of patients' needs or acute and life-threatening organ dysfunction. While the underlying disease is being treated and resolved, the primary goal of intensive care is to prevent additional physiologic deterioration .(1) Nursing care is provided around the clock in intensive care by nurses having special qualifications and specialized training. The nurse to patient ratio is higher than in other areas of the hospital. (2) ICU staff nurses role includes protection, promotion and optimization of health and abilities .(3) There is a significant nursing shortage in ICUs which has led to concerns about the adverse impact of this shortage on the quality of patients' care .(4) Maintaining the continuity of care between working shifts is one of the most important aspects of patient care in ICUs. (5) Effective nurse handover can reduce the amount of time spent searching for information. (6) Nursing handover is considered to be a communication pattern used in the daily nursing procedures, to fulfill the goals of healthcare organization, continuity, consistency and patients' safety. (7) Factors affecting quality of nursing handover in ICUs consist of five dimensions , last handover experience, work environment, relationship with the outgoing nurse, staff nurses' feelings about work in general and unit safety climate .(8) Last nursing handover experience characteristics are key factors for the reinforcement of a wider understanding
... Schlak et al. (3) found that the work environment had a significant effect on patient outcomes, as a change in the work environment from poor to mixed or mixed to good was associated with a 14% drop in the odds of 30-day in-hospital mortality. Addressing staffing without improving the practice environment would be ineffective (12), because better staffing and practice environments are associated with improved patient outcomes (1, 3, 8, 13 -15). The cumulative evidence suggests that interventions to improve hospital work environments and patient-tonurse staffing ratios may be key to addressing quality, safety, and nurse workforce concerns (4), and staffing is a key variable for patient mortality within 30 days of admission, readmission, and hospitalisation time (15). ...
Introduction
Higher nursing workload increases the odds of patient deaths, as the work environment has a significant effect on patient outcomes. The aim of the study was to explore the relation between patient outcomes and nurses’ working conditions in hospitals.
Methods
Administrative data on discharges of surgical patients for the year 2019 in eight general hospitals and two university medical centres in Slovenia were collected to determine in-hospital mortality within 30 days of admission. The RN4CAST survey questionnaire was used to gather data from nurses in these hospitals, with 1,010 nurses participating. Data was collected at the beginning of 2020. The number of nurses per shift and the nurse-to-patient ratio per shift were calculated. Univariate, bivariate and multivariate statistical methods were used to analyse the data.
Results
The 30-day in-hospital mortality for surgical patients was 1.00% in the hospitals sampled and ranged from 0.27% to 1.62%. The odds ratio for staffing suggests that each increase of one patient per RN is associated with a 6% increase in the likelihood of a patient dying within 30 days of admission. The mean patient-to-RN ratio was 15.56 (SD=2.50) and varied from 10.29 to 19.39. Four of the 13 tasks checked were not performed on patients during the last shift.
Conclusion
The results are not encouraging, with an extremely critical shortage of RNs and thus a high RN workload. The number of patients per RN is the highest in Europe and also higher than in some non-European countries, and represents an extreme risk to the quality of nursing and healthcare as a whole. The recommendation for acute non-emergency internal medicine and surgery departments is four patients per RN per shift.
... Greater intensive nursing workloads have been associated with a negative impact on patient outcomes (MacPhee et al., 2017). Studies comparing the number of nurses and patient outcomes have linked increased numbers of patients per nurse with higher rates of mortality (Fagerstrom, Kinnunen and Saarela, 2018;Lee, Cheung, Joynt, Leung, Wong and Gomersall, 2017;McHugh et al., 2016), urinary tract infections, hospital-acquired pneumonia, pressure ulcers, sepsis, nosocomial infections, shock, upper gastrointestinal bleeding and cardiac arrest (Türkmen, 2015). A meta-analysis conducted in 2018 reported that a rising in the number of nurses led to a 14% reduce in the in-hospital mortality of patients (Driscoll et al., 2018). ...
... It also provides all workforce members with physical, psychological, social, and organizational conditions that protect and promote their health and safety [2]. In fact, some studies have reported that a poor work environment is associated with the provision of low-quality care [3,4]. In turn, a healthy work environment, such as an environment with higher perceptions of authentic leadership, was associated with lower burnout and higher compassion satisfaction [5]. ...
Aim
This study aims to translate the Healthy Work Environment Assessment Tool (HWE-AT) into Japanese and evaluate its validity and reliability.
Design and methods
The authors followed the guidelines for scale translation, adaptation, and validation in cross-cultural healthcare research. After translation and back-translation, a series of pilot studies were conducted to assess comprehensibility. Subsequently, an expert panel established the content validity. Content validity was calculated using the content validity index (CVI). Finally, we verified the construct validity and calculated the test-retest reliability.
Results
The updated HWE-AT achieved sufficient comprehensibility after conducting the two pilot tests. Content validity was calculated using the scale-level CVI/average and all the items were 1.00. The content validity indices CFI and RMSEA were 0.918 and 0.082, respectively. Intraclass correlation coefficients for all dimensions ranged from 0.618 to 0.903, indicating acceptable test-retest reliability. Our findings suggest that the Japanese version of the HWE-AT has good validity and reliability.
... First, in previous research, these had the highest need for improvement. 38 Second, staffing has been found to have strong predictive value on health personnel's perception of patient safety [38][39][40] and patient safety outcomes [41][42][43] in different settings and countries. Thirdly, we consider non-punitive responses to mistakes important due to considerable variation between countries and clinical settings in blame culture, 16 which may significantly influence patient safety culture. ...
Objectives:
Measure patient safety culture in homecare services; test the psychometric properties of the Nursing Home Survey on Patient Safety Culture (NHSOPSC) instrument; and propose a short-version Homecare Services Survey on Patient Safety Culture instrument for use in homecare services.
Design:
Cross-sectional survey with psychometric testing.
Setting:
Twenty-seven publicly funded homecare units in eight municipalities (six counties) in Norway.
Participants:
Five-hundred and forty health personnel working in homecare services.
Interventions:
Not applicable.
Primary and secondary outcome measures:
Primary: Patient safety culture assessed using the NHSOPSC instrument. Secondary: Overall perception of service users' safety, service safety and overall care.
Methods:
Psychometric testing of the NHSOPSC instrument using factor analysis and optimal test assembly with generalised partial credit model to develop a short-version instrument proposal.
Results:
Most healthcare personnel rated patient safety culture in homecare services positively. A 19-item short-version instrument for assessing patient safety culture had high internal consistency, and was considered to have sufficient concurrent and convergent validity. It explained a greater proportion of variance (59%) than the full version (50%). Short-version factors included safety improvement actions, teamwork, information flow and management support.
Conclusion:
This study provides a first proposal for a short-version Homecare Services Survey on Patient Safety Culture instrument to assess patient safety culture within homecare services. It needs further improvement, but provides a starting point for developing an improved valid and reliable short-version instrument as part of assessment of patient safety and quality improvement processes.
... Another problem that pre-dated the pandemic is that most RNs report not having enough staff to provide safe care. Understaffing of RNs is a threat to patient safety because high patient-to-nurse staffing ratios are associated with more missed nursing care in hospitals (Ball et al., 2018) and nursing homes (White et al., 2019) and worse outcomes for both patients and RNs (Aiken et al., 2002;Aiken et al., 2011;Aiken, Cerón, et al., 2018;Brooks Carthon et al., 2012;Brooks Carthon et al., 2021;Lasater, Aiken, Sloane, French, Anusiewicz, et al., 2021;McHugh et al., 2016;McHugh et al., 2021). Safe nurse staffing legislation is an evidencebased policy intervention that could be adopted at either the state or federal level to ensure there are enough RNs in hospitals and nursing homes to safely care for patients. ...
Background
The COVID-19 pandemic has stimulated interest in potential policy solutions to improve working conditions in hospitals and nursing homes. Policy action in the pandemic recovery period must be informed by pre-pandemic conditions.
Purpose
To describe registered nurses’ (RNs’) working conditions, job outcomes, and measures of patient safety and care quality in hospitals and nursing homes just before the pandemic.
Methods
Cross-sectional study using descriptive statistics to analyze survey data from RNs in New York and Illinois collected December 2019 through February 2020.
Results
A total of 33,462 RNs were included in the final analysis. Before the pandemic, more than 40% of RNs reported high burnout, one in four were dissatisfied with their job, and one in five planned to leave their employer within 1 year. Among nursing home RNs, one in three planned to leave their employer. RNs reported poor working conditions characterized by not having enough staff (56%), administrators who did not listen/respond to RNs’ concerns (42%), frequently missed nursing care (ranging from 8% to 34% depending on the nursing task in question), work that was interrupted or delayed by insufficient staff (88%), and performing non-nursing tasks (82%). Most RNs (68%) rated care quality at their workplace as less than excellent, and 41% gave their hospital an unfavorable patient safety rating.
Conclusion
Hospitals and nursing homes were understaffed before the COVID-19 pandemic, and many RNs were dissatisfied with their employers’ contribution to the widespread observed shortage of nursing care during the pandemic. Policy interventions to address understaffing include the implementation of safe nurse staffing standards and passage of the Nurse Licensure Compact to permit RNs to move expeditiously to locales with the greatest needs.
... Hospital nurse staffing has been linked to patient mortality, nurse burnout, job dissatisfaction [41,42], patient safety [43,44], and patient survival [45]. It is reasonable to assume that low staffing is related to high individual physical workload and high work pace. ...
Background
Although sick leave is a complex phenomenon, it is believed that there is potential for prevention at the workplace. However, little is known about this potential and what specific measures should be implemented. The purpose of the study was to identify perceived reasons for taking work-related sick leave and to suggest preventive measures. The study was completed before the COVID-19 pandemic emerged and the risk factors identified may have been amplified during the pandemic.
Methods
An in-depth cross-sectional survey was conducted across a randomly selected sample of hospital nurses in Norway. The national sample comprised 1,297 nurses who participated in a survey about their sick leave during the previous 6 months. An open-ended question about perceived reasons for work-related sick leave was included to gather qualitative information.
Results
Among hospital nurses, 27% of the last occurring sick leave incidents were perceived to be work related. The most common reasons were high physical workload, high work pace, sleep problems, catching a viral or bacterial infection from patients or colleagues, and low staffing.
Conclusions
Over a quarter of the last occurring sick leave incidents among Norwegian hospital nurses are potentially preventable. To retain and optimize scarce hospital nursing resources, strategies to reduce work-related sick leave may provide human and financial benefits. Preventive measures may include careful monitoring of nurses’ workload and pace, optimizing work schedules to reduce the risk of sleep problems and increasing staffing to prevent stress and work overload.
... critical care units have common features that are known to be associated with improved patient outcomes, for example, electrocardiogram monitoring at the time of cardiac arrest is associated with a 38% decrease in risk of death after IHCA. 4 Better patient to nurse ratios are also associated with higher probability of survival following IHCA. 5 In addition, the skill mix of the critical care multidisciplinary team is suited to delivering advanced life support. It is likely therefore that delays in initiation of cardiopulmonary resuscitation (CPR), defibrillation and adrenaline administration, all of which are associated with decreased survival, 6 will be minimised. ...
Critical illness-related cardiac arrest (CIRCA) as a distinct entity is not well described epidemiologically. There is currently a knowledge gap regarding how many occur in the UK or the impact on patient outcome. The CIRCA study is a prospective multi-centre observational cohort study of patients in the United Kingdom experiencing a cardiac arrest while in a Critical Care Unit embedded in the Case Mix Programme and National Cardiac Arrest Audit. The duration of data collection is 12 months, with surviving patients and family members receiving questionnaire follow-up at 90 days, 180 days and 12 months. This paper describes the protocol for the CIRCA study which received favourable ethical opinion from South Central – Berkshire Research Ethics Committee and approval from the Health Research Authority. Study registration is on clinicaltrials.gov (NCT04219384).
... The following elements of the safety culture were rated the worst: teamwork across hospital units, non-punitive response to errors, hospital management support for patient safety, and staffing [31]. Foreign researchers have reached conclusions that a better hospital work environment for nurses increases the chance of survival of patients with cardiac arrest by 16% [32]. In another study, it was shown that there is an 11% increased chance of 30-day survival in elderly patients on mechanical ventilation in better work environments, and if more graduate nurses are present [33]. ...
Introduction
The safety and quality of patient care are basic guidelines in finding new and improved solutions in nursing. Important and influential factors shape the nurses’ work environment in hospitals.
Purpose
With the study, we intended to investigate whether the perception of nurses’ work environment is related to the safety culture and the quality of patient care and whether it differs according to nurses’ level of education.
Methods of work
The study with a quantitative research method was conducted at the six clinical departments of the University Medical Centre, Ljubljana in 2019. We used a survey questionnaire from the European survey Nurse forecasting in Europe (RN4CAST).
Results
270 nurses were included in the study. The response rate was 54%. The study confirmed that there is a correlation between the assessment of the nurses’ work environment and the general assessment of patient safety (r = 0.36; p <0.001), the general assessment of the quality of nursing care (r = 0.32; p <0.001), the confidence in patient self-care at discharge (r = 0.29; p <0.001) and the quality of patient care in the previous year (r = 0.27; p = 0.001). The results showed frequent verbal abuse of nurses, in 44.9% by patients and their relatives and in 35.4% by staff. Graduate nurses rated the work environment more negatively than healthcare technicians (p = 0.003).
Discussion and conclusion
We confirmed the correlation between the assessment of nurses’ work environment and patient safety and the quality of health care, and that employees’ education influences the assessment and perception of the work environment.
... Other studies by Wagner et al. and McHugh et al. showed that working in good conditions correlates to greater satisfaction and motivation to work, lower stress level among employees and higher patients' safety [36,37]. Under Polish conditions, the present results indicate the need for management actions aimed at improving working conditions and reducing work stress by the hospital. ...
Introduction
The attitudes of healthcare staff towards patients’ safety, including awareness of the risk for adverse events, are significant elements of an organization’s safety culture.
Aim of research
To evaluate nurses and physicians’ attitudes towards factors influencing hospitalized patient safety.
Materials and methods
The research included 606 nurses and 527 physicians employed in surgical and medical wards in 21 Polish hospitals around the country. The Polish adaptation of the Safety Attitudes Questionnaire (SAQ) was used to evaluate the factors influencing attitudes towards patient safety.
Results
Both nurses and physicians scored highest in stress recognition (SR) (71.6 and 80.86), while they evaluated working conditions (WC) the lowest (45.82 and 52,09). Nurses achieved statistically significantly lower scores compared to physicians in every aspect of the safety attitudes evaluation (p<0.05). The staff working in surgical wards obtained higher scores within stress recognition (SR) compared to the staff working in medical wards (78.12 vs. 73.72; p = 0.001). Overall, positive working conditions and effective teamwork can contribute to improving employees’ attitudes towards patient safety.
Conclusions
The results help identify unit level vulnerabilities associated with staff attitudes toward patient safety. They underscore the importance of management strategies that account for staff coping with occupational stressors to improve patient safety.
... When nurses care for fewer patients at time, they are able to spend more time at each patient's bedside, and as a result, patients are less likely to experience an adverse outcome such as a hospital-acquired infection, 7 poor glycaemic control, 8 readmission 9 and even death. [10][11][12][13][14] The clinical benefits of nurse staffing have primarily been studied in adult medical and surgical populations, but have also been observed in special populations including babies in neonatal intensive care units 15 and children; 16 and may also be key to reducing racial disparities in outcomes. 9 17-19 The benefits of better nurse staff extend to nurses as well; with nurses in better-staffed hospitals reporting less burnout, less job dissatisfaction and being less likely to intend to leave their employer. ...
Objective
To evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals.
Design
Cross-sectional analysis of multiple data sources including a 2020 survey of nurses linked to patient outcomes data.
Setting : 87 acute care hospitals in Illinois.
Participants
210 493 Medicare patients, 65 years and older, who were hospitalised in a study hospital. 1391 registered nurses employed in direct patient care on a medical–surgical unit in a study hospital.
Main outcome measures
Primary outcomes were 30-day mortality and length of stay. Deaths avoided and cost savings to hospitals were predicted based on results from regression estimates if hospitals were to have staffed at a 4:1 ratio during the study period. Cost savings were computed from reductions in lengths of stay using cost-to-charge ratios.
Results
Patient-to-nurse staffing ratios on medical-surgical units ranged from 4.2 to 7.6 (mean=5.4; SD=0.7). After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by 16% for each additional patient in the average nurse’s workload (95% CI 1.04 to 1.28; p=0.006). The odds of staying in the hospital a day longer at all intervals increased by 5% for each additional patient in the nurse’s workload (95% CI 1.00 to 1.09, p=0.041). If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million.
Conclusions
Patient-to-nurse staffing ratios vary considerably across Illinois hospitals. If nurses in Illinois hospital medical–surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.
... Before the SARS-CoV-2 pandemic, some studies suggested a relationship between critical care sta ng and critically ill patients mortality [18][19][20]. An increase of either patient-to-nurse ratio or patient-tophysician ratio was associated with worse patient outcomes such as transmission of infections, postoperative complications, including pulmonary failure and reintubation, and increased mortality [21][22][23][24][25][26]. Only few reports evaluated the impact of critical care sta ng on ICU mortality during a pandemic [27]. ...
Background
The modifications to the standard intensive care unit (ICU) organization that had to be urgently implemented worldwide to overcome the surge of ICU admissions due to patients with a severe coronavirus disease 2019 (COVID-19) have resulted in increased workload and patients-to-nurse ratio. The aim of this study was to investigate whether level of critical care staffing could be associated with an increased risk of ICU mortality (primary endpoint), length of stay, mechanical ventilation and the evolution of disease (secondary study endpoints) in critically ill patients with COVID-19.
Methods
Retrospective multicenter analysis of the international Risk Stratification in COVID-19 patients in the Intensive Care Unit (RISC-19-ICU) registry that prospectively enrolls patients developing critical illness due to COVID-19 in several countries worldwide. The analysis was limited to the period between March 1st, 2020 and May 31st, 2020, to ICUs in Switzerland that have collected additional data on nurse and physician staffing. Hierarchical regression models were used to investigate crude and adjusted effects of critical care staffing ratio on study endpoints. We adjusted for diseases severity and weekly caseload.
Results
Among the 38 Swiss participating ICUs, 17 recorded critical care staffing information. The study population included 437 patients and 2342 daily assessments of patient-to-nurse/physician ratio. Median of daily patient-to-nurse ratio started at 1.0 ([IQR] 0.5–1.5; calendar week 9) and peaked at 2.4 (IQR 0.4-2.0; calendar week 16), while the median of daily patient-to-physician ratio started at 4.0 (IQR 2.1-5.0; calendar week 9) and peaked at 6.8 (IQR 6.3–7.3; calendar week 19). Neither the patient-to-nurse ratio [adjusted Odds Ratio (OR) 1.28, 95% confidence interval (CI) 0.85–1.94; doubling of ratio] nor the patient-to-physician ratio [adjusted OR 1.08, 95% CI 0.87–1.32; doubling of ratio] was associated with ICU mortality. We found no association of critical care staffing on the investigated secondary study endpoints in adjusted models.
COnclusion
The Swiss health care system successfully overcame the first wave of the COVID-19 pandemic with regards to the unprecedented demand for ICU treatments. The reduced availability of critical care staffing resources per critically ill patient in Swiss ICUs did not translate in an overall increased risk of mortality.
... Hospital administrators have seldom evaluated nurses' physical and mental health in China for purposes of error management [11]. A strategy is needed to establish an environment that would not penalize nurses and help reduce work-related fatigue and promote patient safety [43][44][45]. The present study found that nurses with proper sleep time and weekly exercise showed lower work-related fatigue scores (Table 1). ...
Background
Poor quality of care would significantly increase adverse patient outcomes. Improving the quality of care is an urgent priority. The relationship between work-related fatigue and quality of care has not been systematically explored. This paper explores the occurrence of work-related fatigue, job satisfaction, and its relationship with quality of care.
Methods
Self-report questionnaires assessing work-related fatigue and job satisfaction were distributed among 1,299 nurses from 20 hospitals in North-Eastern China. Regression analysis was performed to assess the associations between work-related fatigue, job satisfaction, and quality of care. Mediate effect analysis was used to explore the mediating role of job satisfaction.
Results
Approximately 55% of nurses got moderate or severe work-related fatigue. The results from the t-test indicated that nurses with a high level of work-related fatigue were more prone to nursing errors. The mediation analysis showed that work-related fatigue indirectly affected the quality of care through job satisfaction (indirect effect: β 0.047, 95%Cl 0.040-0-054), while the direct effect was β 0.059, 95%Cl 0.050-0.068.
Conclusions
The present study concluded that more than half of the nurses surveyed were moderate to severe work-related fatigue. Nurses with a high level of work-related fatigue were likely to provide significantly more nursing errors. We confirmed that job satisfaction was a mediator for the relationship between work-related fatigue and quality of care. Therefore, hospitals managers and relevant management departments should consider work-related fatigue and job satisfaction among nurses to improve health services in the future.
... Estas necesidades de atención, en el caso del paciente crítico, están vinculadas a la necesidad de unos cuidados que se establecen como de alto requerimiento, y que según muchos autores se consideran extremadamente dinámicos, además Brilli et al. (150) , consideran que todos los cuidados de enfermería deben ser proporcionados por enfermeras entrenadas en cuidados críticos. Los estudios de la vinculación entre las necesidades asistenciales y el área de ingreso hospitalario han sido y son ampliamente analizados en el contexto total hospitalario (22,(154)(155)(156) . Van Oostveen et al. (157) , menciona la necesidad de definir en cada área una intensidad de cuidados adecuada para conseguir que las enfermeras puedan desarrollar sus potencialidades y su liderazgo de la mejor manera posible, marcando como horizonte el logro de mejores resultados en salud y maximizando la autonomía de los cuidados. ...
This thesis explores the training needs of intensive care nurses through a mixed methodology study. A literature search was developed based on previous studies to make a semi-structured interview. This interview allowed us to get closer to the experiences of this concept of nurses in a multipurpose unit (n=15). These interviews were used by the research team to create a 66-item questionnaire that it was later distributed nationwide. 85 ICUs participated in this study for which we recruited a total of 568 nurses. Statistical analyses determined a high awareness of the need for prior training focused on 13 factors that generated differences between the compared groups. The conclusion is that specific training is required that all areas of care were included. Furthermore, it is the nurses with the most training and experience who most demand this qualification.
... This is congruent with studies that reported better work environments were associated with lower patient mortality and lower death from a treatable complication in hospital settings. 29 You and 00 2021 • Volume 000 • Number 000 www.jncqjournal.com 5 colleagues 30 found that 38% of nurses in China experienced a high level of burnout and a significant percentage of nurses rated their work environment as poor (36%) and graded their patient safety in the hospital as low (36%). ...
Background:
Burnout impacts nurses' health as well as brain structures and functions including cognitive function, which could lead to work performance and patient safety issues. Yet, few organization-level factors related to patient safety have been identified.
Purpose:
This study examined nurse-reported patient safety grade and its relationship to both burnout and the nursing work environment.
Methods:
A cross-sectional electronic survey was conducted among nurses (N = 928) in acute care Alabama hospitals.
Results:
In multilevel ordinal mixed-effects models with nurses nested within hospitals, all burnout dimensions of the Copenhagen Burnout Inventory (OR for +1 SD ranging 0.63-0.78; P < .05) and work environment (OR for +1 SD ranging 4.35-4.89; P < .001) were related to the outcome of patient safety grade after controlling for nurse characteristics.
Conclusions:
Results indicate that health care organizations may reduce negative patient safety ratings by reducing nurse burnout and improving the work environment at the organization level.
... 13 Successful practice interventions include nursing handoffs, hourly rounding, interdisciplinary rounding, time-outs prior to surgical procedures, and creative solutions to decrease medication errors and falls. A positive work environment has been identified as a facilitator of engagement, 6,14,15 whereas heavy workload, lack of managerial support, and lack of professional autonomy are barriers. 13,16 Purpose While there is some evidence addressing the barriers for frontline staff engagement, further clarity to understand what constitutes a barrier and/or facilitator of nurse engagement in QI, as well as testing implementation strategies in clinical practice, is warranted. ...
Background:
Nurse engagement in quality improvement (QI) improves health care quality and outcomes but is typically low in clinical settings.
Purpose:
An integrative review was conducted to identify facilitators and barriers of nurse engagement in QI.
Methods:
This integrative review was conducted using an electronic search of databases with search terms specific to nursing engagement in QI. The Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide was used to rate quality and level of evidence.
Results:
Nine articles met the criteria for review. Top barriers were leadership, education and training, resource constraints, data, culture, and time. Top facilitators were leadership, education and training, culture, mentors, and champions.
Conclusion:
High-quality literature exploring barriers and facilitators of nurse engagement in QI is lacking. Research is needed to examine the degree to which these barriers and facilitators impact engagement and how they can be addressed to increase it.
... Improved outcomes associated with shared governance include but are not limited to improved nurse control over practice, 10,11 job satisfaction, 12,13 nurse retention, 14,15 patient satisfaction, 16 and patient care quality. 17,18 Measuring DI Comprehensive tools are available to measure shared governance. One example is the Index of Professional Nursing Governance 19 used to determine the spectrum of decision-making from traditional (primarily administration), shared (equally shared by management and clinical nurses), and self-governance (clinical nurses only). ...
Objective:
The purpose of this study was to evaluate nurses' perceptions of decisional involvement (DI).
Background:
Decisional involvement is a measure or gauge of nurses' perceived shared leadership. There has been limited research examining factors associated with actual and preferred DI.
Methods:
A descriptive, observational study design was used. A total of 189 RNs completed the Decisional Involvement Scale and Evidence-Based Practice Implementation Scale. Nurses' preferred DI (DI-P) and actual DI (DI-A) were analyzed, and DI total and subscale scores were compared based on nurses' demographic and clinical practice characteristics.
Results:
The DI-A and DI-P total scores were significantly different, including subscales for DI-A compared with DI-P score. Dissonance scores by subscale were highest for recruitment, governance, and support. Unit-based council (UBC) participants had significantly higher actual DI, compared with non-UBC participants. Nurses' perceptions of implementing evidence-based practice (EBP) was not significantly different by low versus high EBP implementation; nor were the scores significantly correlated with their DI-A or DI-P scores.
Conclusions:
Findings indicate nurses' perceptions of DI-A and DI-P. This study provided further examination of the differences and interrelationships between DI and nurses' demographic and clinical practice characteristics. Dissonance DI scores provide opportunities for targeting interventions to engage nurses in shared leadership.
... Furthermore, patients are more likely to have adverse outcomes when nurses are understaffed. 29 Patients benefit and hospital readmissions are lower when nurses are appropriately staffed and are able to provide patient education and case management support during discharge. 30 In a commodified health care system, nurses have no choice but to contribute to a growing environmental crisis, contributing to profligate medical waste related to employer policies and product choices. ...
We wish to advance a theory of nursing that intentionally engages in questions of politics and economics, centering equity and justice as a foundation for the provision of nursing care. As health care costs rise and health disparities widen, nurses have a clear imperative to develop alternative health care delivery models unmoored from the conventional employment and profit-driven structures that now disappoint us. This mandate arises from our disciplinary focus that emphasizes social justice as a social and moral good linked to the human services nurses provide. This kind of sociopolitical engagement is not auxiliary to nursing but rather central to our ethos. A health care environment that prioritizes profit over the well-being of people is an anathema to our disciplinary focus which, we believe, should center communities and people. The health care system that has forged nursing in the United States, transforms nursing into a commodity. This reinscribes inequality for those who are unable to access care, contributes to environmental harm through profligate hospital pollution and waste, and exploits nursing staff as workers. Nurses have a history of both upholding oppressive systems that disenfranchise segments of the public, usually poor, often People of Color, and engaging in innovative alternatives to the status quo. We wish to foster revolutionary alternative care delivery models that free us from the neoliberal confines of for-profit health care. Ultimately, we argue, nursing as a discipline and a science cannot neglect our role as whistleblowers and change agents. Nor can we presuppose that our dysfunctional and harmful health care structure in the United States is a foregone conclusion. Health care is constructed, which means it can be reconstructed. If we wish to realize our emancipatory potential as nurses, critically examining our role in upholding oppressive structures is a critical step toward a more robust future of nursing.
... The descriptive statistics of the analyzed indicators stratified according to the relative number of nurses/midwives are presented in Table 1 The appropriate and optimal number of nurses and midwives/1000 inhabitants is a crucial factor. Much evidence indicates that appropriate nurse staffing and patient-tonurse ratios in healthcare facilities are associated with lower mortality rates [19][20][21]. The results of this study are in line with the need to provide evidence of the role of nurses and midwives in the healthcare system. ...
Objectives:
Increased life expectancy results in greater challenges posed to healthcare. Concurrently, a shortage of healthcare workforce, including nurses, has been observed. Thus, an urgent need exists to implement improvements in healthcare services based on sufficient evidence. The aim of the study was to evaluate the influence of the relative number of nurses/midwives on life expectancy, and the influence of selected economic variables: gross domestic product (GDP), health expenditure as a percentage of GDP, and health expenditure per capita, on this number. The aim of the study was to evaluate the influence of the relative number of nurses/midwives on life expectancy, and the influence of select economic variables: GDP, health expenditure as a percentage of GDP, and health expenditure per capita on this number.
Material and methods:
A retrospective analysis based on data from 46 countries was performed. Correlations between the relative number of nurses/midwives and life expectancy as well as economic variables were evaluated. To trace the differences between the countries with different relative numbers of nurses/ midwives, the countries were divided into groups as follows - group 1: <5 nurses and midwives/1000 nurses inhabitants, group 2: 5-10 nurses and midwives/1000 inhabitants, and group 3: >10 nurses and midwives/1000 inhabitants.
Results:
Correlations were found between the relative number of nurses/midwives and life expectancy (p < 0.001, r = 0.68), and economic variables (p < 0.001, r = 0.82; p < 0.001, r = 0.62, and p < 0.001, r = 0.8, respectively). Life expectancy was higher in group 3 vs. groups 1 and 2 (p < 0.001 and p = 0.036, respectively), and in group 2 vs. group 1 (p = 0.006). Economic variables were higher in group 3 vs. group 1 (p < 0.001 for all) and group 2 (p = 0.016, p = 0.025, p = 0.022, respectively), and in group 2 vs. group 1 (p = 002, p = 0.024, p = 0.002, respectively).
Conclusions:
The relative number of nurses/midwives correlates with life expectancy and relies on the country's income and level of healthcare system financing.
... The mean NSL in our study was 10.3, which meant that for each additional patient, in-hospital mortality increased by 19%. A meta-analysis placed this percentage at 14% on average [11] based on studies with values ranging from 5% [48] to 31% [49]. The RN4CAST study found that the mean nurse staffing in European hospitals was 8.3, with Spain being the country with the highest level of nurse staffing (12.7) [21,28]. ...
Background: In-hospital mortality is a key indicator of the quality of care. Studies so far have demonstrated the influence of patient and hospital-related factors on in-hospital mortality. Currently, new variables, such as nursing workload or the level of dependency, are being incorporated. We aimed to identify which individual, clinical and hospital characteristics are related to hospital mortality. Methods: A multicentre prospective observational study design was used. Sampling was conducted between February 2015 and October 2017. Patients over 16 years, admitted to medical or surgical units at 11 public hospitals in Andalusia (Spain), with a foreseeable stay of at least 48 h were included. Multivariate regression analyses were performed to analyse the data. Results: The sample consisted of 3821 assessments conducted in 1004 patients. The mean profile was that of a male (52%), mean age of 64.5 years old, admitted to a medical unit (56.5%), with an informal caregiver (60%). In-hospital mortality was 4%. The INICIARE (Inventario del Nivel de Cuidados Mediante Indicadores de Clasificación de Resultados de Enfermería) scale yielded an adjusted odds ratio [AOR] of 0.987 (95% confidence interval [CI]: 0.97–0.99) and the nurse staffing level (NSL) yielded an AOR of 1.197 (95% CI: 1.02–1.4). Conclusion: Nursing care dependency measured by INICIARE and nurse staffing level was associated with in-hospital mortality.
... The nurse work environment is defined as "the organizational characteristics of a work setting that facilitate or constrain professional nursing practice" (Lake, 2002, p. 178). High-quality nurse work environments are associated with better patient outcomes for adult surgical patients (Aiken et al., 2008), in-hospital cardiac arrest patients (McHugh et al., 2016), and infants in neonatal intensive care (Aiken et al., 2008(Aiken et al., , 2011. Although better nurse work environments relate to higher odds of patient satisfaction on a global scale, lower odds of poor nurse job outcomes, better patient safety and quality ratings, and less negative patient outcomes , it is unclear how nurse work environments relate to SMM. ...
Aim
To identify evidence related to association between the nurse work environment and severe maternal morbidity in high‐income countries.
Design
Quantitative Systematic review.
Data Sources
Cumulative Index of Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, PubMed/Medline, and Scopus were systematically searched for studies published in English from January 1990‐December 2019. Studies were selected based on a priori eligibility criteria.
Review Methods
Two independent reviewers used a two‐phase screening process. First, the reviewers assessed the eligibility of studies based on titles and abstracts; followed by assessing the full text of all remaining studies based on the eligibility criteria. An adapted version of the Joanna Briggs Institute data extraction tool was created to extract relevant information from studies reviewed during the second screening phase.
Results
Of the 535 de‐duplicated articles examined by two independent reviewers, there were no eligible empirical studies that assessed the association between nurse work environment and severe maternal morbidity.
Conclusion
There is a critical gap in knowledge regarding how characteristics of the nurse work environment may influence severe maternal morbidity in high‐income countries. Future directions for nursing research include using available maternal health surveillance hospital‐level data, conducting high‐quality studies, and using evidence‐based frameworks to guide future studies. Future directions for nursing practice include leveraging professional learning communities for nursing education and training and leveraging quality improvement initiatives.
Impact
As the first known systematic review of its kind, this ‘empty review’ provides evidence of a lacking body of literature on the association between nurse work environment, as a modifiable organizational characteristic and preventable severe maternal morbidity in high‐income countries. This article provides a call to action in the form of five recommendations for future nursing research and practice, which could serve to elucidate research, practice, and policy opportunities to reduce preventable severe maternal morbidity in high‐income countries.
... Positive working conditions are one of the cornerstones of patient safety. Studies have shown that in positive work conditions, the employees report higher job satisfaction and motivation, reduced stress levels, and better patient safety [37,38]. Poor working conditions have been reported in studies on the Kenyan public health systems [39] as well as globally [40,41]. ...
Background
Patient safety has recently been declared a global health priority. Achievement and sustenance of a culture of patient safety require a regular and timely assessment of the organization. The Safety Attitudes Questionnaire is a patient safety culture assessment tool whose usefulness has been established in countries, but a few studies have been published from Africa, more so, in Kenyan settings.
Objective
To evaluate the reliability of the Safety Attitudes Questionnaire in assessing the patient safety culture in a Kenyan setting and to assess healthcare workers' perceptions of patient safety culture.
Methods
A descriptive quantitative approach was utilized whereby the Safety Attitudes Questionnaire was administered to 241 healthcare workers in two public hospitals. The Cronbach’s α was calculated to determine the internal consistency of the SAQ. Descriptive and inferential statistics were used to analyze and describe the data on patient safety culture.
Results
The total scale Cronbach’s alpha of the SAQ was 0.86, while that of the six dimensions was 0.65 to 0.90. The overall mean score of the total SAQ was 65.8 (9.9). Participants had the highest positive perception for Job Satisfaction with a mean score of 78.3 (16.1) while the lowest was evaluated for Stress Recognition with a mean score of 53.8 (28.6).
Conclusion
The SAQ demonstrated satisfactory internal consistency and is suitable for use in the Kenyan context. The perception of patient safety culture in the Kenyan hospital is below international recommendations. There is a need for implementation of strategies for the improvement of the organization culture in Kenyan hospitals.
The complexities of acute and critical care cardiovascular management demand specialty trained and experienced nurses to ensure quality patient outcomes. An ongoing nurse labor shortage threatens to destabilize the healthcare system and presents a twofold challenge: a decreasing supply of registered nurses and increasing demand for nursing services. This article describes the numerous forces driving the current nursing shortage as well as the impact of the coronavirus-19 pandemic on nurse job satisfaction and turnover. We present a reinvented model of nursing care as a framework for healthcare organizations to address nurse staffing challenges.
This Element reviews the evidence for three workplace conditions that matter for improving quality and safety in healthcare: staffing; psychological safety, teamwork, and speaking up; and staff health and well-being at work. The authors propose that these are environmental prerequisites for improvement. They examine the relationship between staff numbers and skills in delivering care and the attainment of quality of care and the ability to improve it. They present evidence for the importance of psychological safety, teamwork, and speaking up, noting that these are interrelated and critical for healthcare improvement. They present evidence of associations between staff well-being at work and patient outcomes. Finally, they suggest healthcare improvement should be embedded into the day-to-day work of frontline staff; adequate time and resources must be provided, with quality as the mainstay of professionals' work. Every day at every level, the working context must support the question 'how could we do this better?' This title is also available as Open Access on Cambridge Core.
BACKGROUND
Safely minimizing postoperative mechanical ventilation duration after congenital heart surgery could be a cardiac intensive care unit (CICU) quality measure. We aimed to measure CICU performance using duration of postoperative mechanical ventilation and identify organizational factors associated with this metric.
METHODS
Observational analysis of 16,848 surgical hospitalizations of patients invasively ventilated on admission from the operating room from 26 Pediatric Cardiac Critical Care Consortium (PC⁴) CICUs. We fitted a multivariable model to predict duration of postoperative mechanical ventilation adjusting for pre- and postoperative factors to measure CICU performance accounting for postoperative illness severity. We used our model to calculate observed-to-expected (adjusted) ventilation duration ratios for each CICU, describe variation across CICUs, and characterize outliers based on bias-corrected bootstrap 95% confidence intervals. We explored associations between organizational characteristics and patient-level adjusted ventilation duration by adding these as independent variables to the model.
RESULTS
We observed wide variation across CICUs in adjusted ventilation duration ratios ranging from 0.7 to 1.7. Nine of 26 CICUs had statistically better than expected ventilation duration, while ten were significantly worse than expected. Organizational characteristics associated with shorter adjusted ventilation duration included mixed (60-90%) staffing by critical care or anesthesia-trained attendings, lower average attending-to-patient ratio, average CICU daily occupancy 80-90%, and greater nurse staffing ratios and experience.
CONCLUSIONS
CICU performance in postoperative duration of mechanical ventilation varies widely across PC⁴ centers. Several potentially modifiable organizational factors are associated with this metric. Taken together, these findings could spur efforts to improve ventilation duration at outlier hospitals.
Objective:
To identify nurse staffing and patient care outcome literature in published systematic reviews and map out the evidence gaps for low/middle-income countries (LMICs).
Methods:
We included quantitative systematic reviews on nurse staffing levels and patient care outcomes in regular ward settings published in English. We excluded qualitative reviews or reviews on nursing skill mix. We searched the Cochrane Register of Systematic Reviews, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Medline, Embase and Cumulative Index to Nursing and Allied Health Literature from inception until July 2021. We used the A Measurement Tool to Assess Systematic Reviews -2 (AMSTAR-2) criteria for risk of bias assessment and conducted a narrative synthesis.
Results:
From 843 papers, we included 14 in our final synthesis. There were overlaps in primary studies summarised across reviews, but overall, the reviews summarised 136 unique primary articles. Only 4 out of 14 reviews had data on LMIC publications and only 9 (6.6%) of 136 unique primary articles were conducted in LMICs. Only 8 of 23 patient care outcomes were reported from LMICs. Less research was conducted in contexts with staffing levels that are typical of many LMIC contexts.
Discussion:
Our umbrella review identified very limited data for nurse staffing and patient care outcomes in LMICs. We also identified data from high-income countries might not be good proxies for LMICs as staffing levels where this research was conducted had comparatively better staffing levels than the few LMIC studies. This highlights a critical need for the conduct of nurse staffing research in LMIC contexts.
Limitations:
We included data on systematic reviews that scored low on our risk of bias assessment because we sought to provide a broad description of the research area. We only considered systematic reviews published in English and did not include any qualitative reviews in our synthesis.
Prospero registration number:
CRD42021286908.
This chapter discusses factors contributing to outcomes of in‐hospital cardiac arrest. It describes the in‐hospital resuscitation process and explores how it might differ from a pre‐hospital situation. The chapter discusses the need to adopt uniform reporting of outcome after cardiac arrest. Cardiac arrest (CA) refers to the cessation of cardiac mechanical activity, as confirmed by the absence of signs of circulation. Hospitals have experienced an increase in acuity over recent years, resulting from a larger volume of patients presenting with more complex disease states and healthcare needs. For many patients who are admitted to hospital, CA may be a terminal event. Acute clinical deterioration can occur at any phase of a patient's hospitalisation. Clinical deterioration is common prior to in‐hospital CA and many in‐hospital cardiac arrests are considered preventable or avoidable on retrospective review. Equipment used should be consistent across the institution where possible.
Objective:
To assess variation in ICU length of stay between countries with varying patient-to-nurse ratios; to compare ICU length of stay of individual countries against an international benchmark.
Design:
Secondary analysis of the DecubICUs trial (performed on 15 May 2018).
Setting:
The study cohort included 12,794 adult ICU patients (57 countries). Only countries with minimally twenty patients discharged (or deceased) within 30 days of ICU admission were included.
Main outcome measure:
Multivariate Cox regression was used to evaluate ICU length of stay, censored at 30 days, across countries and for patient-to-nurse ratio, adjusted for sex, age, admission type and Simplified Acute Physiology Score II. The resulting hazard ratios for countries, indicating longer or shorter length of stay than average, were plotted on a forest plot. Results by country were benchmarked against the overall length of stay using Kaplan-Meier curves.
Results:
Patients had a median ICU length of stay of 11 days (interquartile range, 4-27). Hazard ratio by country ranged from minimally 0.42 (95% confidence interval 0.35-0.51) for Greece, to maximaly1.94 (1.28-2.93) for Lithuania. The hazard ratio for patient-to-nurse was 0.96 (0.94-0.98), indicating that higher patient-to-nurse ratio results in longer length of stay.
Conclusions:
Despite adjustment for case-mix, we observed significant heterogeneity of ICU length of stay in-between countries, and a significantly longer length of stay when patient-to-nurse ratio increases. Future studies determining underlying characteristics of individual ICUs and broader organisation of healthcare infrastructure within countries may further explain the observed heterogeneity in ICU length of stay.
Patient safety in health care is the cornerstone of quality in nursing care. It is a duty of nurses and an objective of the health organizations. This article aims to analyze the scientific evidence on the nurses’ perception and opinion on patient safety in the emergency department. Systematic literature review with 3 steps. 1) Primary search at CINHAL and MEDLINE. 2) A broader search, using the same keywords and search terms in the remaining database of the EBSCOHost platform. 3) Search the bibliographic references of the selected articles. The selected studies were published between 2014 and 2019. Five articles were selected. The nurses’ perception reveal that the work environment, teamwork and matters related to the leadership of hierarchical superiors are fundamental factors to improve the quality of care provided and patient safety. Promoting teamwork improves patient care, reduces adverse events and improves quality. Recognizing the nurses’ perception on patient safety culture in emergency services, contributes to improving the quality of care provided.
Resumo A segurança do paciente é uma dimensão essencial da qualidade dos cuidados de enfermagem. É um dever dos enfermeiros e um objetivo das organizações de saúde. O objetivo deste artigo é analisar a evidência científica acerca da segurança do paciente em hospital - serviço de urgência, na opinião dos enfermeiros. Trata-se de uma revisão sistemática da literatura com três etapas. 1) Pesquisa inicial nas bases CINAHL e MEDLINE. 2) Pesquisa mais alargada, nas restantes bases de dados da plataforma EBSCOHost. 3) Pesquisa nas referências bibliográficas dos artigos selecionados. Os estudos selecionados compreendem o período entre 2014 e 2019, resultando em cinco artigos. Os enfermeiros consideram que o ambiente de prática de enfermagem, o trabalho em equipa e as questões relacionadas com a liderança dos enfermeiros gerentes são fatores fundamentais para se melhorar a qualidade dos cuidados prestados e a segurança do paciente. Incentivar o trabalho em equipa melhora a assistência ao paciente, reduz os eventos adversos e incrementa a qualidade. Conhecer a opinião dos enfermeiros sobre a segurança do paciente nos serviços de urgência contribui para melhorar a qualidade dos cuidados de enfermagem.
Being an effective and well-rounded nurse in Australia is not just about technical skills - it's also about thinking like a nurse. The Road to Nursing helps students develop clinical reasoning and critical reflection skills, understand the philosophical and ethical considerations necessary to care for clients and reflect on how to provide care that meets the unique needs of clients. This edition retains three parts which guide students through their transition to university, formation of a professional identity and progression to professional practice. A revised chapter order improves the transition between topics and a new chapter explores the ever-changing Australian health landscape, including recent technological innovations. Each chapter includes definitions of key terms, reflection questions, perspectives from nurses, end-of-chapter review questions, research topics and resources that connect students with the real-world practice of nursing. Written by healthcare experts, The Road to Nursing is a fundamental resource for students beginning a nursing career.
Background:
Across hospitals, there is wide variation in ICU utilization after surgery. However, it is unknown whether and to what extent the nurse work environment is associated with a patient's odds of admission to an intensive care unit.
Purpose:
To estimate the relationship between hospitals' nurse work environment and a patient's likelihood of ICU admission and mortality following surgery.
Methods:
A cross-sectional study of 269 764 adult surgical patients in 453 hospitals was conducted. Logistic regression models were used to estimate the effects of the work environment on the odds of patients' admission to the intensive care unit and mortality.
Results:
Patients in hospitals with good work environments had 16% lower odds of intensive care unit admission and 15% lower odds of mortality or intensive care unit admission than patients in hospitals with mixed or poor environments.
Conclusions:
Patients in hospitals with better nurse work environments were less likely to be admitted to an intensive care unit and less likely to die. Hospitals with better nurse work environments may be better equipped to provide postoperative patient care on lower acuity units.
Introdução: A Síndrome Pós-Parada Cardíaca (SPPC) caracteriza-se pela inflamação sistêmica, seguida de risco de falência de múltiplos órgãos, em decorrência do estresse oxidativo gerado após o período de isquemia. A enfermagem no manejo clínico da SPPC atua diretamente na identificação precoce e em condutas que resultem em circunstâncias de risco reduzido. Objetivo: Identificar, através da literatura, a atuação da Enfermagem intensivista frente aos sinais clínicos da SPPC. Metodologia: Revisão integrativa da literatura. Realizou-se a busca dos artigos por meio da Biblioteca Virtual de Saúde (BVS), na Base de Dados de Enfermagem (BDENF), Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS) e Medical Literature Review and Online Recovery System (MEDLINE). Resultados e Discussão: A enfermagem em UTI diante da SPPC, atua por intermédio de intervenções com o objetivo de alcançar a estabilização desse quadro clínico. Dessa forma, a educação continuada é uma ferramenta relevante na qualidade desse atendimento, pois faz-se necessário o conhecimento acerca do processo fisiopatológico e da adequada assistência. Conclusão: A atuação da enfermagem frente à SPPC e a destreza em seu manejo encontram limitações na deficiência de padronização e no estabelecimento de escores específicos para essa enfermidade e, o dimensionamento inadequado da equipe, colabora com a piora no prognóstico do paciente, pois um bom atendimento se baseia na tríade previsibilidade-assistência-equipe.
The health system is based on major pillars that it cannot continue without, the most important of which are doctors and qualified nursing staff. The departure of nursing staff is one of the dilemmas that threaten the health system. Another place, especially leaving work in intensive care. The current scoping review aims to identify relevant evidence related to the factors influencing nurses' intentions to leave critical care units at governmental hospitals at Saudi Arabia. In this study, the researcher explored that some factors were not covered, so the most of the knowledge gap regarding the factors that contribute to nurses’ intentions to leave their current occupations in critical care units at governmental hospitals in Saudi Arabia, are motivation and communication among staff members. As well as, conflict among staff members, Nurse Manager Ability, leadership and support of nurses, and nurse-physician relationships are some of the important factors that contribute to nurses’ intentions to leave their current occupations that needs to be studied.
Objectives
Staffing is the single biggest cost component in the critical care budgets. Due to the fluctuation in both bed occupancy and the level of care needs, nursing staff requirement can vary considerably from day to day. This makes the traditional ‘fixed roster’ staffing system inefficient, costly and potentially unsafe. In this study, we used the existing bed occupancy data to test the viability two ‘dynamic’ workforce management models.
Research methodology
Nursing requirement data were prospectively collected over one year at a thirty-two-bed critical care unit. Using mathematical models, we then tested the concept of two alternative workforce management models and compared the level of staffing, as well as the estimated cost per year. The first was an ‘on-call’ model, which was a two-tier roster with a standard staffing level and an additional on-call component; the second was a ‘predictive’ model, which estimated the staffing requirement based on the bed occupancy a few days prior.
Setting
Single centre study in a busy district general hospital with a 32-bed critical care unit.
Main outcome measures
The number of days with safe staffing levels and the cost of the alternative workforce management models.
Results
Data were collected over 331 days. The on-call model was estimated to cost 16% less per year (£431,320, or 2,630 nurse-shift equivalent) compared to the fixed roster, while fulfilling the adequate staffing standards in 97% of the days. While the predictive model could also be used to improve the workforce efficiency, this was overall less efficient than the on-call model.
Conclusion
The modelled data suggests that the implementation of an ‘on-call’ model in critical care nursing rostering could potentially improve coverage and appear to be cost effective.
Unsafe nurse staffing conditions in hospitals have been shown to increase the risk of adverse patient events, including mortality. Consequently, United States and international professional nursing organizations often advocate for safer staffing conditions. There are a variety of factors to consider when staffing nurses for patient safety, such as the number of patients per nurse, nurse preparation, patient acuity, and nurse autonomy. The complex issue of staffing nurses often is compounded by cost issues and can become politicized. When nurse organizations' recommendations for safe staffing measures are disregarded by hospital administrations, nurse lobbyists and interest groups often pursue legislative action to protect patients and nurses from unsafe staffing conditions. This article presents a narrative review of safe nurse staffing factors and an analysis of nurse staffing legislation. Using a patient‐centric lens, three state‐level nurse staffing policies (mandated nurse‐to‐patient ratios, public reporting of staffing plans, and nurse staffing committees) were evaluated by empirical evidence, cost to hospitals and state governments, political feasibility, and potential to affect patient populations. Although nurse staffing policy analysis can be conducted in several ways, it is crucial that nurses consider empirical evidence related to staffing policies as well as evaluations of implemented policies and political influences.
Aims and objectives
To examine the relationships between nurses’ perceptions of their practice environment, other working conditions and reported adverse events in two private management hospitals.
Background
Patient safety is influenced by knowledge, available resources and the context in which nursing care is provided. In this sense, it has been found that certain work environments (e.g., workload, nurse turnover level, patient-to-nurse ratio, nurse staffing, nurse manager ability) influence patient outcomes. The association between nursing practice environment and reported adverse events has not been explored in private management hospitals.
Design
A cross-sectional study. The STROBE was selected as the checklist in this study.
Methods
A total of 219 nurses were included in the study. This study was conducted from June 2018–June 2019 in Spain. Data were collected through questionnaires focusing on work conditions, reported adverse events (falls, medication errors, catheter-related sepsis and pressure ulcer) and Practice Environment Scale of the Nursing Work Index. Binary logistic regression analysis was performed to determine the factors influencing the occurrence of errors.
Results
Nurses reported poor perception of the professional environment, and 62.1% reported having made at least one error in the previous year. Manager support and leadership and nurse–physician relations were the most favourable aspects of work environment. Medical–surgical units, rotating in the same shift and favourable work environment, were associated with more reporting of adverse events.
Conclusion
The factors of nursing practice (hospital area workload, staff rotating and perception of work environment) associated with reporting adverse events can be worked upon from the organisation and provided an opportunity for safety culture improvement and safer healthcare services.
Relevance to clinical practice
Improving the nurse work environment may reduce adverse patient events in private management hospitals.
Stroke is among the most common reasons for disability and death. Avoiding readmissions and long lengths of stay among ischemic stroke patients has benefits for patients and health care systems alike. Although reduced readmission rates among a variety of medical patients have been associated with better nurse work environments, it is unknown how the work environment might influence readmissions and length of stay for ischemic stroke patients. Using linked data sources, we conducted a cross-sectional analysis of 543 hospitals to evaluate the association between the nurse work environment and readmissions and length of stay for 175,467 hospitalized adult ischemic stroke patients. We utilized logistic regression models for readmission to estimate odds ratios (OR) and zero-truncated negative binomial models for length of stay to estimate the incident-rate ratio (IRR). Final models accounted for hospital and patient characteristics. Seven and 30-day readmission rates were 3.9% and 10.1% respectively and the average length of stay was 4.9 days. In hospitals with better nurse work environments ischemic stroke patients experienced lower odds of 7- and 30-day readmission (7-day OR, 0.96; 95% confidence interval [CI]: 0.93-0.99 and 30-day OR, 0.97; 95% CI: 0.94-0.99) and lower length of stay (IRR, 0.97; 95% CI: 0.95-0.99). The work environment is a modifiable feature of hospitals that should be considered when providing comprehensive stroke care and improving post-stroke outcomes.
Interprofessional collaboration (IPC) is crucial to efficient patient management in the modern healthcare setting. We sought to determine the attitudes of physicians and nurses working in different hospitals in the Islamabad–Rawalpindi region of Pakistan. We employed the Jefferson Scale of Attitudes toward Physician–Nurse Collaboration (JSAPNC), a 15-item questionnaire that quantifies these attitudes in a meaningful way. Higher scores indicate a more positive attitude toward IPC. Four domains (shared education and teamwork, caring vs. curing, nurses’ autonomy, and physicians’ dominance) represent the intricate factors that influence IPC in a hospital setting. A total of 374 healthcare professionals responded. Nurses had significantly better opinions about IPC compared to physicians (mean: 50.81 vs. 47.48, p<.01). Nurses also outscored physicians in all four domains of the JSAPNC (education and collaboration 24.87 vs. 23.72 p<.001, caring vs. curing 10.88 vs. 9.42 p<.001, nurse’s autonomy 10.89 vs. 10.51 p=.004, and physician’s authority 4.17 vs. 3.82 p=.044). The results show that nurses in Pakistan value IPC more than their physician colleagues. Inculcating the importance of IPC through educational methods might help improve these attitudes.
Background
As the main group of healthcare providers in hospitals, nurses have more frequent contacts than any other clinician and thus are in a better position to improve patient safety. With the purpose of cultivating competent nurses, nursing educators have the responsibility to promote patient safety. A better understanding of educational factors affecting nursing adverse events by nursing students undergoing clinical practice can help nursing educators find appropriate ways to fulfil their duty.
Objective
To examine the status quo of nursing adverse events and to discuss the major educational factors concerned in different regions of China.
Design
A descriptive study design was undertaken in 2018.
Participants and Setting
A convenience sample of 1173 nursing students undergoing clinical practice was recruited from 22 hospitals in different regions of China.
Methods
The Chinese version of the Medical Student Safety Attitudes and Professionalism Survey (MSSAPS) was administered to and demographic and professional data were collected from clinical nursing students after obtaining informed consent.
Results
The incidence of nursing adverse events in clinical student nurses was 17.8%. Approximately 87.01% of nursing adverse events were near miss. The positive response rate of safety attitudes and professionalism by clinical nursing students ranged from 57.5% to 96.9%. Logistic analysis indicated that gender, educational level, hospital regions, safety culture and professional behavior experience dimensions were the major factors influencing nursing adverse events.
Conclusion
Attention should be paid to the situation in which clinical nursing students are prone to nursing adverse events. Cooperation between nursing colleges and hospitals should be strengthened to promote patient safety in clinical nursing students. We suggest that nursing educators implement patient safety education in both theoretical and practical teaching and use multiple forms, especially simulation-based training, to strengthen safe nursing behavior to reduce the incidence of nursing adverse events.
Background:
Racial disparities in survival among patients who had an in-hospital cardiac arrest (IHCA) have been linked to hospital-level factors.
Objectives:
To determine whether nurse staffing is associated with survival disparities after IHCA.
Research design:
Cross-sectional data from (1) the American Heart Association's Get With the Guidelines-Resuscitation database; (2) the University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey; and (3) The American Hospital Association annual survey. Risk-adjusted logistic regression models, which took account of the hospital and patient characteristics, were used to determine the association of nurse staffing and survival to discharge for black and white patients.
Subjects:
A total of 14,132 adult patients aged 18 and older between 2004 and 2010 in 75 hospitals in 4 states.
Results:
In models that accounted for hospital and patient characteristics, the odds of survival to discharge was lower for black patients than white patients [odds ratio (OR)=0.70; 95% confidence interval (CI), 0.61-0.82]. A significant interaction was found between race and medical-surgical nurse staffing for survival to discharge, such that each additional patient per nurse lowered the odds of survival for black patients (OR=0.92; 95% CI, 0.87-0.97) more than white patients (OR=0.97; 95% CI, 0.93-1.00).
Conclusions:
Our findings suggest that disparities in IHCA survival between black and white patients may be linked to the level of medical-surgical nurse staffing in the hospitals in which they receive care and that the benefit of being admitted to hospitals with better staffing may be especially pronounced for black patients.
Purpose:
This study aimed to explore turnover rates for Korean acute care hospital nurses and identify factors influencing their turnover.
Methods:
The study was retrospective in nature. Nurse cohort data were obtained from hospital status data from Korea's Health Insurance Review Assessment Service. The observation period was January 1, 2012 to December 31, 2016, and data for 96,158 nurses were analyzed. Independent variables included nurses' age and sex and hospital setting, type, ownership, and nurse staffing level. Kaplan-Meier analysis was performed to estimate survival curves, and factors influencing turnover were analyzed using Cox's proportional hazard regression.
Results:
The cumulative turnover probability for all nurses was 0.17, 0.29, 0.38, 0.45, and 0.50 for the first, second, third, fourth, and fifth years, respectively. The results showed that the longer the career duration, the lower the turnover rates. According to the factors influencing nurse turnover, both nurses' (i.e., sex and career duration) and hospitals' (i.e., hospital setting, type, ownership, and nurse staffing level) characteristics were statistically significant.
Conclusions:
It should be noted that the turnover rate of nurses with less than three year of career duration as well as those with less than one years has been shown to be quite high. Therefore, target populations for acute care hospital nurse turnover should be expanded from new graduate nurses to experienced nurses with less than 3 years of career. Further studies are required to examine the causes of high turnover rates in hospitals that are small and/or have low nurse staffing levels.
Background:
Complex human and system factors impact the effectiveness of Rapid Response Systems (RRS). Emergency Department (ED) specific RRS are relatively new and the factors associated with their effectiveness are largely unknown. This study describes the period prevalence of deterioration and characteristics of care for deteriorating patients in an Australia ED and examine relationships between system factors and escalation of care.
Methods:
A retrospective medical record audit of all patients presenting to an Australian ED in two weeks.
Results:
Period prevalence of deterioration was 10.08% (n=269). Failure to escalate care occurred in nearly half (n=52, 47.3%) of the patients requiring a response (n=110). Appropriate escalation practices were associated with where the patient was being cared for (p=0.01), and the competence level of the person documenting deterioration (p=0.005). Intermediate competence level nurses were nine times more likely to escalate care than novices and experts (p=0.005). While there was variance in escalation practice related to system factors, these associations were not statistically significant.
Conclusion:
The safety of deteriorating ED patients may be improved by informing care based on the escalation practices of staff with intermediate ED experience and competence levels.
When the "Standards for Establishing and Sustaining Healthy Work Environments" set forth by the American Association of Critical-Care Nurses are met in a health care system, there is enhanced safety and quality care for the patient, better job satisfaction, and less turnover by the staff. The American Association of Critical-Care Nurses started the Beacon Award for Excellence not only to recognize those who have such high standards but also to encourage units who already have achieved this distinction or are applying for it to do better.
Background:
Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures.
Methods:
For this observational study, we obtained discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26,516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics.
Findings:
An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031-1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886-0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients.
Interpretation:
Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths.
Funding:
European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.
In-hospital cardiac arrest (IHCA) is common and often fatal. However, the extent to which hospitals vary in survival outcomes and the degree to which this variation is explained by patient and hospital factors is unknown.
Within Get with the Guidelines-Resuscitation, we identified 135 896 index IHCA events at 468 hospitals. Using hierarchical models, we adjusted for demographics comorbidities and arrest characteristics (eg, initial rhythm, etiology, arrest location) to generate risk-adjusted rates of in-hospital survival. To quantify the extent of hospital-level variation in risk-adjusted rates, we calculated the median odds ratio (OR). Among study hospitals, there was significant variation in unadjusted survival rates. The median unadjusted rate for the bottom decile was 8.3% (range: 0% to 10.7%) and for the top decile was 31.4% (28.6% to 51.7%). After adjusting for 36 predictors of in-hospital survival, there remained substantial variation in rates of in-hospital survival across sites: bottom decile (median rate, 12.4% [0% to 15.6%]) versus top decile (median rate, 22.7% [21.0% to 36.2%]). The median OR for risk-adjusted survival was 1.42 (95% CI: 1.37 to 1.46), which suggests a substantial 42% difference in the odds of survival for patients with similar case-mix at similar hospitals. Further, significant variation persisted within hospital subgroups (eg, bed size, academic).
Significant variability in IHCA survival exists across hospitals, and this variation persists despite adjustment for measured patient factors and within hospital subgroups. These findings suggest that other hospital factors may account for the observed site-level variations in IHCA survival.
Despite several advances in resuscitation care over the last decade, in-hospital cardiac arrest (IHCA) remains common and is linked to poor survival. Approximately 200 000 hospitalized patients suffer IHCA and undergo cardiopulmonary resuscitation in the United States annually, with fewer than 20%
We sought to generate national estimates for post-cardiac arrest mortality, to assess trends, and to identify hospital factors associated with survival.
We used a national sample of US hospitals to identify patients resuscitated after cardiac arrest from 2000 to 2004 to describe the association between hospital factors (teaching status, location, size) and mortality, length of stay, and hospital charges. Analyses were performed using logistic regression.
A total of 109,739 patients were identified. In-hospital mortality was 70.6%. A 2% decrease in unadjusted mortality from 71.6% in 2000 to 69.6% in 2004 (OR 0.96, P < 0.001) was observed. Mortality was lower at teaching hospitals (OR 0.58, P = 0.001), urban hospitals (OR 0.63, P = 0.004), and large hospitals (OR 0.55, P < 0.001).
Mortality after in-hospital cardiac arrest decreased over 5 years. Mortality was lower at urban, teaching, and large hospitals. There are implications for dissemination of best practices or regionalization of post-cardiac arrest care.
Cardiac arrests in adults are often due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), which are associated with better outcomes than asystole or pulseless electrical activity (PEA). Cardiac arrests in children are typically asystole or PEA.
To test the hypothesis that children have relatively fewer in-hospital cardiac arrests associated with VF or pulseless VT compared with adults and, therefore, worse survival outcomes.
A prospective observational study from a multicenter registry (National Registry of Cardiopulmonary Resuscitation) of cardiac arrests in 253 US and Canadian hospitals between January 1, 2000, and March 30, 2004. A total of 36,902 adults (> or =18 years) and 880 children (<18 years) with pulseless cardiac arrests requiring chest compressions, defibrillation, or both were assessed. Cardiac arrests occurring in the delivery department, neonatal intensive care unit, and in the out-of-hospital setting were excluded.
Survival to hospital discharge.
The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults (27% [236/880] vs 18% [6485/36,902]; adjusted odds ratio [OR], 2.29; 95% confidence interval [CI], 1.95-2.68). Of these survivors, 65% (154/236) of children and 73% (4737/6485) of adults had good neurological outcome. The prevalence of VF or pulseless VT as the first documented pulseless rhythm was 14% (120/880) in children and 23% (8361/36,902) in adults (OR, 0.54; 95% CI, 0.44-0.65; P<.001). The prevalence of asystole was 40% (350) in children and 35% (13 024) in adults (OR, 1.20; 95% CI, 1.10-1.40; P = .006), whereas the prevalence of PEA was 24% (213) in children and 32% (11,963) in adults (OR, 0.67; 95% CI, 0.57-0.78; P<.001). After adjustment for differences in preexisting conditions, interventions in place at time of arrest, witnessed and/or monitored status, time to defibrillation of VF or pulseless VT, intensive care unit location of arrest, and duration of cardiopulmonary resuscitation, only first documented pulseless arrest rhythm remained significantly associated with differential survival to discharge (24% [135/563] in children vs 11% [2719/24,987] in adults with asystole and PEA; adjusted OR, 2.73; 95% CI, 2.23-3.32).
In this multicenter registry of in-hospital cardiac arrest, the first documented pulseless arrest rhythm was typically asystole or PEA in both children and adults. Because of better survival after asystole and PEA, children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT.
Context The worsening hospital nurse shortage and recent California legislation
mandating minimum hospital patient-to-nurse ratios demand an understanding
of how nurse staffing levels affect patient outcomes and nurse retention in
hospital practice.Objective To determine the association between the patient-to-nurse ratio and
patient mortality, failure-to-rescue (deaths following complications) among
surgical patients, and factors related to nurse retention.Design, Setting, and Participants Cross-sectional analyses of linked data from 10 184 staff nurses
surveyed, 232 342 general, orthopedic, and vascular surgery patients
discharged from the hospital between April 1, 1998, and November 30, 1999,
and administrative data from 168 nonfederal adult general hospitals in Pennsylvania.Main Outcome Measures Risk-adjusted patient mortality and failure-to-rescue within 30 days
of admission, and nurse-reported job dissatisfaction and job-related burnout.Results After adjusting for patient and hospital characteristics (size, teaching
status, and technology), each additional patient per nurse was associated
with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12)
increase in the likelihood of dying within 30 days of admission and a 7% (OR,
1.07; 95% CI, 1.02-1.11) increase in the odds of failure-to-rescue. After
adjusting for nurse and hospital characteristics, each additional patient
per nurse was associated with a 23% (OR, 1.23; 95% CI, 1.13-1.34) increase
in the odds of burnout and a 15% (OR, 1.15; 95% CI, 1.07-1.25) increase in
the odds of job dissatisfaction.Conclusions In hospitals with high patient-to-nurse ratios, surgical patients experience
higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses
are more likely to experience burnout and job dissatisfaction.
Importance
National efforts to measure hospital performance in treating cardiac arrest have focused on case survival, with the hope of improving survival after cardiac arrest. However, it is plausible that hospitals with high case-survival rates do a poor job of preventing cardiac arrests in the first place.Objective
To describe the association between inpatient cardiac arrest incidence and survival rates.Design
Within a large, national registry, we identified hospitals with at least 50 adult in-hospital cardiac arrest cases between January 1, 2000, and November 30, 2009. We used multivariable hierarchical regression to evaluate the correlation between a hospital’s cardiac arrest incidence rate and its case-survival rate after adjusting for patient and hospital characteristics.Main Outcomes and Measures
The correlation between a hospital’s incidence rate and case-survival rate for cardiac arrest.Results
Of 102 153 cases at 358 hospitals, the median hospital cardiac arrest incidence rate was 4.02 per 1000 admissions (interquartile range, 2.95-5.65 per 1000 admissions), and the median hospital case-survival rate was 18.8% (interquartile range, 14.5%-22.6%). In crude analyses, hospitals with higher case-survival rates also had lower cardiac arrest incidence (r, −0.16; P = .003). This relationship persisted after adjusting for patient characteristics (r, −0.15; P = .004). After adjusting for potential mediators of this relationship (ie, hospital characteristics), the relationship between incidence and case survival was attenuated (r, −0.07; P = .18). The one modifiable hospital factor that most attenuated this relationship was a hospital’s nurse-to-bed ratio (r, −0.12; P = .03).Conclusions and Relevance
Hospitals with exceptional rates of survival for in-hospital cardiac arrest are also better at preventing cardiac arrests, even after adjusting for patient case mix. This relationship is partially mediated by measured hospital attributes. Performance measures focused on case-survival rates seem an appropriate first step in quality measurement for in-hospital cardiac arrest.
[Utstein Style Writing Group: Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: The in-hospital “Utstein style.” Ann Emerg Med May 1997;29:650-679.]
Objectives:
The purpose of this study is to develop a method for risk-standardizing hospital survival after cardiac arrest.
Background:
A foundation with which hospitals can improve quality is to be able to benchmark their risk-adjusted performance against other hospitals, something that cannot currently be done for survival after in-hospital cardiac arrest.
Methods:
Within the Get With The Guidelines (GWTG)-Resuscitation registry, we identified 48,841 patients admitted between 2007 and 2010 with an in-hospital cardiac arrest. Using hierarchical logistic regression, we derived and validated a model for survival to hospital discharge and calculated risk-standardized survival rates (RSSRs) for 272 hospitals with at least 10 cardiac arrest cases.
Results:
The survival rate was 21.0% and 21.2% for the derivation and validation cohorts, respectively. The model had good discrimination (C-statistic 0.74) and excellent calibration. Eighteen variables were associated with survival to discharge, and a parsimonious model contained 9 variables with minimal change in model discrimination. Before risk adjustment, the median hospital survival rate was 20% (interquartile range: 14% to 26%), with a wide range (0% to 85%). After adjustment, the distribution of RSSRs was substantially narrower: median of 21% (interquartile range: 19% to 23%; range 11% to 35%). More than half (143 [52.6%]) of hospitals had at least a 10% positive or negative absolute change in percentile rank after risk standardization, and 50 (23.2%) had a ≥20% absolute change in percentile rank.
Conclusions:
We have derived and validated a model to risk-standardize hospital rates of survival for in-hospital cardiac arrest. Use of this model can support efforts to compare hospitals in resuscitation outcomes as a foundation for quality assessment and improvement.
Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a critical resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best available national data on heart disease, stroke, and other cardiovascular disease-related morbidity and mortality and the risks, quality of care, use of medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited >10 500 times in the literature, based on citations of all annual versions. In 2012 alone, the various Statistical Updates were cited ≈3500 times (data from Google Scholar). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas, as well as increasing the number of ways to access and use the information assembled. For this year's edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year. This year's edition includes a new chapter on peripheral artery disease, as well as new data on the monitoring and benefits of cardiovascular health in the population, with additional new focus on evidence-based approaches to changing behaviors, implementation strategies, and implications of the AHA's 2020 Impact Goals. Below are a few highlights from this year's Update.
Aim This study examines the relationship between nurse/physician collaboration and patient length of stay (LOS).
Background The quality of nurse/physician relationships has been shown to have an impact on patient outcomes. As the acuity level of patients admitted to hospitals continue to rise, the need for collaboratively determined care is essential for avoiding errors and promoting quality.
Methods Data were collected on four units located in two Midwest hospitals. Nurses (n = 135) were asked to complete a survey seeking perceptions of nurse/physician collaboration. The survey data were then linked with patient (n = 310) data, including LOS, diagnostic-related groups (DRG) category and other patient-specific characteristics.
Results Perceptions of nurse/physician collaboration were positively linked with actual LOS (P < 0.001) and inversely related to deviation from expected LOS (i.e. patient stay longer than expected) (P < 0.01). Patients receiving care from nurses who perceived greater collaboration were elderly and had higher levels of acuity. Longer LOS for these patients may be a result of their higher acuity level.
Conclusions and implications for Nursing Management This study found that collaboratively determined care may result in longer LOS, but could prevent complications that may otherwise go untreated. Nurse administrators must implement strategies that foster the development of nurse/physician collaboration.
To determine the association between nurse staffing and postsurgical outcomes for older black adults, including 30-day mortality and failure to rescue.
A cross-sectional study of University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey data, linked to 2006-2007 administrative patient discharge data from four states (CA, PA, NJ, FL), American Hospital Association Annual Survey data, and a U.S. Census-derived measure of socioeconomic status (SES). Risk-adjusted logistic regression models with correction for clustering were used for the analysis.
Five hundred ninety-nine adult nonfederal acute care hospitals in California, Pennsylvania, New Jersey, and Florida
Five hundred forty-eight thousand three hundred ninety-seven individuals ages 65 and older undergoing general, orthopedic, or vascular surgery (94% white, 6% black).
Thirty-day mortality and failure to rescue (death after a complication).
In models adjusting for sex and age, 30-day mortality was significantly higher for black than white participants (odds ratio (OR) = 1.42, 95% confidence interval (CI) = 1.32-1.52). In fully adjusted models that accounted for SES, surgery type, and comorbidities, as well as hospital characteristics, including nurse staffing, the odds of 30-day mortality were not significantly different for black and white participants. In the fully adjusted models, one additional patient in the average nurse's workload was associated with higher odds of 30-day mortality for all patients (OR = 1.03, 95% CI = 1.01-1.05). A significant interaction was found between race and nurse staffing for 30-day mortality, such that blacks experienced higher odds of death with each additional patient per nurse (OR = 1.10, 95% CI = 1.03-1.18) compared to whites (OR = 1.03, 95% CI = 1.01-1.06). Similar patterns were detected in failure-to-rescue models.
Older surgical patients experience poorer postsurgical outcomes, including mortality and failure to rescue, when cared for by nurses with higher workloads. The effect of nurse staffing inadequacies is more significant in older black individuals.
It is unknown how in-hospital cardiac arrest (IHCA) rates vary across hospitals and predictors of variability.
Measure variability in IHCA across hospitals and determine if hospital-level factors predict differences in case-mix adjusted event rates.
Get with the Guidelines Resuscitation (GWTG-R) (n=433 hospitals) was used to identify IHCA events between 2003 and 2007. The American Hospital Association survey, Medicare, and US Census were used to obtain detailed information about GWTG-R hospitals.
Adult patients with IHCA.
Case-mix-adjusted predicted IHCA rates were calculated for each hospital and variability across hospitals was compared. A regression model was used to predict case-mix adjusted event rates using hospital measures of volume, nurse-to-bed ratio, percent intensive care unit beds, palliative care services, urban designation, volume of black patients, income, trauma designation, academic designation, cardiac surgery capability, and a patient risk score.
We evaluated 103,117 adult IHCAs at 433 US hospitals. The case-mix adjusted IHCA event rate was highly variable across hospitals, median 1/1000 bed days (interquartile range: 0.7 to 1.3 events/1000 bed days). In a multivariable regression model, case-mix adjusted IHCA event rates were highest in urban hospitals [rate ratio (RR), 1.1; 95% confidence interval (CI), 1.0-1.3; P=0.03] and hospitals with higher proportions of black patients (RR, 1.2; 95% CI, 1.0-1.3; P=0.01) and lower in larger hospitals (RR, 0.54; 95% CI, 0.45-0.66; P<0.0001).
Case-mix adjusted IHCA event rates varied considerably across hospitals. Several hospital factors associated with higher IHCA event rates were consistent with factors often linked with lower hospital quality of care.
Better hospital nurse staffing, more educated nurses, and improved nurse work environments have been shown to be associated with lower hospital mortality. Little is known about whether and under what conditions each type of investment works better to improve outcomes.
To determine the conditions under which the impact of hospital nurse staffing, nurse education, and work environment are associated with patient outcomes.
Outcomes of 665 hospitals in 4 large states were studied through linked data from hospital discharge abstracts for 1,262,120 general, orthopedic, and vascular surgery patients, a random sample of 39,038 hospital staff nurses, and American Hospital Association data.
A 30-day inpatient mortality and failure-to-rescue.
The effect of decreasing workloads by 1 patient/nurse on deaths and failure-to-rescue is virtually nil in hospitals with poor work environments, but decreases the odds on both deaths and failures in hospitals with average environments by 4%, and in hospitals with the best environments by 9% and 10%, respectively. The effect of 10% more Bachelors of Science in Nursing Degree nurses decreases the odds on both outcomes in all hospitals, regardless of their work environment, by roughly 4%.
Although the positive effect of increasing percentages of Bachelors of Science in Nursing Degree nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environments.
Greater amounts of nursing surveillance is thought to decrease failure to rescue but studies to date have used nurse staffing levels as a proxy for nursing surveillance. The purpose of this nursing effectiveness study was to examine the unique treatment effect of nursing surveillance on failure to rescue. Data were abstracted from 9 electronic clinical data repositories including the nursing documentation system that used the Nursing Interventions Classification (NIC) to record nursing care. Nursing surveillance was quantified as "high use" when the subjects received it an average of 12 times per day or more. Propensity scores were used to match subjects who had received high-dose nursing surveillance with subjects who received low-dose nursing surveillance (average of less than 12 times a day). The results indicate that when nursing surveillance is performed an average of 12 times a day or greater, there is a significant (p = .0058) decrease in the odds of experiencing failure to rescue (odds ratio [OR] = 0.52) compared to when surveillance was delivered an average of less than 12 times a day. Additional unique variables included in this study are robust levels of nurse staffing based on hourly data, medical treatments, pharmaceutical treatments, and nursing treatments. The use of propensity scores helped determine the unique contribution of nursing surveillance on failure to rescue in this observational study.
Although the Practice Environment Scale of the Nursing Work Index has been endorsed as a gauge of the quality of the nursing practice environment by several organizations in the United States promoting healthcare quality, there is no literature describing its use in different practice settings and countries.
The purpose of this study was to inform research by describing the modifications and use of the scale in a variety of practice settings and countries.
The Cumulative Index to Nursing and Allied Health Literature and the PubMed databases were searched for the years 2002-2010 to identify 37 research reports published since 2002 describing use, modification, and scoring variations in different practice settings and countries.
The scale was modified for 10 practice settings in five countries and translated into three languages. Composite scores ranged from 2.48 to 3.17 (on a 1-4 scale). The Staffing and Resource Adequacy subscale most often scored lowest. A new Nursing Information Technology subscale has been developed. New scoring methods to identify the favorability of practice environments are described. Over time, the nature of the research conducted using the measure has changed. Overall, most publications report significant associations between scale scores and multiple nurse, patient, and organizational outcomes.
Scale use is growing across different clinical settings and countries. Recommendations for future research use include reducing scale length, using consistent scoring methods, considering the impact of various modifications on the basis of cultural and clinical setting nuances, and using the measure in longitudinal and intervention research designs.
Delays to defibrillation are associated with worse survival after in-hospital cardiac arrest, but the degree to which hospitals vary in defibrillation response times and hospital predictors of delays remain unknown.
Using hierarchical models, we evaluated hospital variation in rates of delayed defibrillation (>2 minutes) and its impact on survival among 7479 adult inpatients with cardiac arrests at 200 hospitals within the National Registry of Cardiopulmonary Resuscitation.
Adjusted rates of delayed defibrillation varied substantially among hospitals (range, 2.4%-50.9%), with hospital-level effects accounting for a significant amount of the total variation in defibrillation delays after adjusting for patient factors. We found a 46% greater odds of patients with identical covariates getting delayed defibrillation at one randomly selected hospital compared with another. Among traditional hospital factors evaluated, however, only bed volume (reference category: <200 beds; 200-499 beds: odds ratio [OR], 0.62 [95% confidence interval {CI}, 0.48-0.80]; >or=500 beds: OR, 0.74 [95% CI, 0.53-1.04]) and arrest location (reference category: intensive care unit; telemetry unit: OR, 1.92 [95% CI, 1.65-2.22]; nonmonitored unit: OR, 1.90 [95% CI, 1.61-2.24]) were associated with differences in rates of delayed defibrillation. Wide variation also existed in adjusted hospital rates of survival to discharge (range, 5.3%-49.6%), with higher survival among hospitals in the top-performing quartile for defibrillation time (compared with the bottom quartile: OR for top quartile, 1.41 [95% CI, 1.11-1.77]).
Rates of delayed defibrillation vary widely among hospitals but are largely unexplained by traditional hospital factors. Given its association with improved survival, future research is needed to better understand best practices in the delivery of defibrillation at top-performing hospitals.
Better patient outcomes are often achieved through effective surveillance, a primary function of nurses. The purpose of this article is to define, operationalize, measure, and evaluate the nurse surveillance capacity of hospitals. Nurse surveillance capacity is defined as the organizational features that enhance or weaken nurse surveillance. It includes a set of registered nurse (staffing, education, expertise, experience) and nurse practice environment characteristics. Empirical referents were extracted from existing survey data from 9,232 nurses in 174 hospitals. Using a ranking methodology, a Hospital Nurse Surveillance Capacity Profile was created for each hospital. Greater nurse surveillance capacity was significantly associated with better quality of care and fewer adverse events. The profile may assist administrators to improve nurse surveillance and patient outcomes.
The AHA Committee on Emergency Cardiac Care recommends that all communities strengthen the four links in the chain of survival: Early Access: Install an enhanced 911 emergency dispatch system. Provide certification training to all emergency medical dispatchers. Develop community-wide education and publicity programs that focus on cardiac emergencies and a proper response by citizens. Early CPR: Implement and support community CPR training programs. In these programs emphasize early recognition, early telephone contact with the EMS system, and early defibrillation. Use training methods that will increase the likelihood that citizens will start CPR. Adopt targeted CPR programs. Implement programs for dispatcher-assisted CPR. Early Defibrillation: Adopt the principle of early defibrillation. Train all emergency personnel who perform basic CPR to operate an automated external defibrillator. Implement more widespread use of automated external defibrillators by community responders and allied health responders. Early Advanced Life Support: Coordinate advanced life support units with first-response units that provide early defibrillation. Develop procedures that combine rapid defibrillation by first-response units with rapid intubation and intravenous medications by the advanced life support units.
To investigate the association of collaboration between intensive care unit (ICU) physicians and nurses and patient outcome.
Prospective, descriptive, correlational study using self-report instruments.
A community teaching hospital medical ICU, a university teaching hospital surgical ICU, and a community non-teaching hospital mixed ICU, all in upstate New York.
Ninety-seven attending physicians, 63 resident physicians, and 162 staff nurses.
When patients were ready for transfer from the ICU to an area of less intensive care, questionnaires were used to assess care providers' reports of collaboration in making the transfer decision. After controlling for severity of illness, the association between interprofessional collaboration and patient outcome was assessed. Unit-level organizational collaboration and patient outcomes were ranked.
Healthcare providers' reported levels of collaboration, patient severity of illness and individual risk, patient outcomes of death or readmission to the ICU, unit-level collaboration, and unit patient risk of negative outcome.
Medical ICU nurses' reports of collaboration were associated positively with patient outcomes. No other associations between individual reports of collaboration and patient outcome were found. There was a perfect rank order correlation between unit-level organizational collaboration and patient outcomes across the three units.
The study offered some support for the importance of physician-nurse collaboration in ICU care delivery, a variable susceptible to intervention and further study.
To report the outcomes from and the impact of the chain of survival in 'in-hospital' cardiac arrest where the presenting rhythm was VF/VT, the arrest was witnessed, defibrillation was conducted rapidly and no other resuscitation interventions were required. Outcome measures: Any return of spontaneous circulation and discharge from hospital.
A 2-year prospective resuscitation audit using the Utstein style was conducted within a major London NHS Hospital Group.
There were 124 patients who had primary VF/VT arrest. Eight were excluded from the study and 14 had non-witnessed cardiac arrest. Twenty one patients had witnessed VF/VT arrest but with delayed defibrillation, 81 patients had witnessed VF/VT arrest with rapid defibrillation, 69 patients had witnessed VF/VT arrest with rapid defibrillation, CPR and other additional interventions. There were 15 patients that had witnessed cardiac arrest with a presenting rhythm of VF/VT, who received rapid defibrillation and had no ventilation or chest compression prior to or following defibrillation. All 15 patients achieved a return of spontaneous circulation, and 12 were discharged alive.
Rapid defibrillation prior to any other resuscitation intervention is associated with increased survival from witnessed VF/VT arrest in in-hospital cardiac arrest victims, and that the time to first shock is critical in enhancing the prospects of long-term survival in these patients.
Five subscales were derived from the Nursing Work Index (NWI) to measure the hospital nursing practice environment, using 1985-1986 nurse data from 16 magnet hospitals. The NWI comprises organizational characteristics of the original magnet hospitals. The psychometric properties of the subscales and a composite measure were established. All measures were highly reliable at the nurse and hospital levels. Construct validity was supported by higher scores of nurses in magnet versus nonmagnet hospitals. Confirmatory analyses of contemporary data from 11,636 Pennsylvania nurses supported the subscales. The soundness of the new measures is supported by their theoretical and empirical foundations, conceptual integrity, psychometric strength, and generalizability. The measures could be used to study how the practice environment influences nurse and patient outcomes.
It is uncertain whether lower levels of staffing by nurses at hospitals are associated with an increased risk that patients will have complications or die.
We used administrative data from 1997 for 799 hospitals in 11 states (covering 5,075,969 discharges of medical patients and 1,104,659 discharges of surgical patients) to examine the relation between the amount of care provided by nurses at the hospital and patients' outcomes. We conducted regression analyses in which we controlled for patients' risk of adverse outcomes, differences in the nursing care needed for each hospital's patients, and other variables.
The mean number of hours of nursing care per patient-day was 11.4, of which 7.8 hours were provided by registered nurses, 1.2 hours by licensed practical nurses, and 2.4 hours by nurses' aides. Among medical patients, a higher proportion of hours of care per day provided by registered nurses and a greater absolute number of hours of care per day provided by registered nurses were associated with a shorter length of stay (P=0.01 and P<0.001, respectively) and lower rates of both urinary tract infections (P<0.001 and P=0.003, respectively) and upper gastrointestinal bleeding (P=0.03 and P=0.007, respectively). A higher proportion of hours of care provided by registered nurses was also associated with lower rates of pneumonia (P=0.001), shock or cardiac arrest (P=0.007), and "failure to rescue," which was defined as death from pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis, or deep venous thrombosis (P=0.05). Among surgical patients, a higher proportion of care provided by registered nurses was associated with lower rates of urinary tract infections (P=0.04), and a greater number of hours of care per day provided by registered nurses was associated with lower rates of "failure to rescue" (P=0.008). We found no associations between increased levels of staffing by registered nurses and the rate of in-hospital death or between increased staffing by licensed practical nurses or nurses' aides and the rate of adverse outcomes.
A higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day are associated with better care for hospitalized patients.
The National Registry of Cardiopulmonary Resuscitation (NRCPR) is an American Heart Association (AHA)-sponsored, prospective, multisite, observational study of in-hospital resuscitation. The NRCPR is currently the largest registry of its kind. The purpose of this article is to describe the NRCPR and to provide the first comprehensive, Utstein-based, standardized characterization of in-hospital resuscitation in the United States. All adult (>/=18 years of age) and pediatric (<18 years of age) patients, visitors, employees, and staff within a facility (including ambulatory care areas) who experience a resuscitation event are eligible for inclusion in the NRCPR database. Between January 1, 2000, and June 30, 2002, 14720 cardiac arrests that met inclusion criteria occurred in adults at the 207 participating hospitals. An organized emergency team is available 24 h a day, 7 days a week in 86% of participating institutions. The three most common reasons for cardiac arrest in adults were (1) cardiac arrhythmia, (2) acute respiratory insufficiency, and (3) hypotension. Overall, 44% of adult in-hospital cardiac arrest victims had a return of spontaneous circulation (ROSC); 17% survived to hospital discharge. Despite the fact that a primary arrhythmia was one of the precipitating events in nearly one half of adult cardiac arrests, ventricular fibrillation (VF) was the initial pulseless rhythm in only 16% of in-hospital cardiac arrest victims. ROSC occurred in 58% of VF cases, yielding a survival-to-hospital discharge rate of 34% in this subset of patients. An automated external defibrillator was used to provide initial defibrillation in only 1.4% of patients whose initial cardiac arrest rhythm was VF. Neurological outcome in discharged survivors was generally good. Eighty-six percent of patients with Cerebral Performance Category-1 (CPC-1) at the time of hospital admission had a postarrest CPC-1 at the time of hospital discharge.
In this exploratory cross-sectional study, nursing unit organizational characteristics and how they influenced patient outcomes in the form of nurse-sensitive adverse events and failure to rescue were examined. Results showed significant associations between characteristics and adverse events at the unit level. Autonomy/collaboration was associated with pressure ulcer and failure to rescue, practice control with urinary tract infection, and continuity/specialization with death. Unit-level study provided a better understanding of the effect of unit work environment upon nursing practice and outcomes.
Outcome following cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002 a task force of ILCOR met in Melbourne. Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (i.e., essential and desirable) data elements recommended by previous Utstein consensus conference. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (C) 2004 Published by Elsevier Ireland Ltd.
While improvements in nursing practice environments are considered essential to address the nursing shortage, relatively little is known about the nursing practice environments in most hospitals.
The objectives of this study are to describe variations in nursing practice environments across hospitals and to examine their associations to hospital bed size, community size, teaching intensity, and nurse staffing levels.
The research design was cross-sectional analyses of nurse survey and administrative data for 156 Pennsylvania hospitals from 1999. For comparative reference, nurse survey data from earlier years from two small samples of nursing magnet hospitals were analyzed. The nursing practice environment was measured by the Practice Environment Scale of the Nursing Work Index (PES-NWI).
Nursing practice environments varied greatly among the hospitals studied. The nursing practice environments of the small samples of magnet hospitals were superior to those of the Pennsylvania sample. About 17% of the hospitals in the Pennsylvania sample had favorable practice environments. Pennsylvania hospitals with better practice environments had higher RN-to-bed ratios. Practice environment differences were not associated with hospital bed size or community size. Hospitals with a modest teaching level had less favorable environments.
Considerable variation exists in the quality of hospital nursing practice environments. Five out of six hospitals are targets for improvement. Favorable nursing practice environments can be achieved in a wide variety of hospital settings.
Improvements in nurses' practice environments are essential to retain nurses and keep patients safe. The pace of improvements can accelerate if evidence is translated clearly for researchers, managers, and policymakers. This article evaluates the utility of published multidimensional instruments to measure the nursing practice environment. The assessment criteria are theoretical relevance, ease of use, and dissemination. This article also synthesizes the research that has used these instruments. Seven instruments and 54 studies are evaluated. The Practice Environment Scale of the Nursing Work Index (PES-NWI) is proposed as the most useful instrument. Its content, length, and dissemination best satisfy the set of criteria. Researchers should use the PES-NWI to generate consistent and comparable evidence; expand the content to reflect all conceptual domains; develop a short form; test the instrument in different care settings; expand the evidence of the practice environment's influence on patient outcomes; and test interventions for practice environment improvements.
Use of failure-to-rescue (FTR) as an indicator of hospital quality has increased over the past decade, but recent authors have used different sets of complications and deaths to define this measure. This study examines the reliability and validity of different FTR measures currently in use.
We studied 3 definitions: (1) "original" FTR (using all deaths); (2) FTR-N, a "nursing sensitive" definition that uses only specific complications and deaths; and (3) FTR-A [another restricted definition of FTR used by Agency for Healthcare Research and Quality (AHRQ) for analyzing Healthcare Cost and Utilization Project (HCUP) data]. Each FTR measure was applied to 403,679 general surgical patients across 1567 hospitals reported in 1999-2000 Medicare MEDPAR data.
Although FTR used all deaths, FTR-N and FTR-A definitions omitted 49% and 42% of deaths, respectively. Reliability was better for FTR than FTR-A or FTR-N (rho = 0.32 vs. 0.18 vs. 0.18, respectively).
Hospitals ranked by adjusted mortality were highly correlated with FTR (Kendall's tau = 0.83) and less correlated with FTR-A (tau = 0.43) and FTR-N (tau = 0.41). Adjusting for patient characteristics, all FTR measures showed strong associations with bed-to-nurse ratio, nursing mix, teaching status, and hospital size; however, hospital "high technology" was not as well associated with FTR-N.
For general surgery, more limited definitions used by FTR-N and FTR-A omit over 40% of deaths, display less reliability, and may have more questionable validity than the original FTR measure. We encourage analysts to use the original FTR definition that uses all deaths when analyzing hospital quality of care.
To examine the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery.
Secondary analysis of cancer registry, inpatient claims, administrative and nurse survey data collected in Pennsylvania for 1998-1999.
Nurse staffing (patient to nurse ratio), educational preparation (proportion of nurses holding at least a bachelor's degree), and the practice environment (Practice Environment Scale of the Nursing Work Index) were calculated from a survey of nurses and aggregated to the hospital level. Logistic regression models predicted the odds of 30-day mortality, complications, and failure to rescue (death following a complication).
Unadjusted death, complication, and failure to rescue rates were 3.4, 35.7, and 9.3 percent, respectively. Nurse staffing and educational preparation of registered nurses were significantly associated with patient outcomes. After adjusting for patient and hospital characteristics, patients in hospitals with poor nurse practice environments had significantly increased odds of death (odds ratio, 1.37; 95 percent confidence interval, 1.07-1.76) and of failure to rescue (odds ratio, 1.48; 95 percent confidence interval, 1.07-2.03). Receipt of care in National Cancer Institute-designated cancer centers significantly decreased the odds of death, which can be explained partly by better nurse practice environments.
This study is one of the first to examine the predictive validity of the National Quality Forum's endorsed measure of the nurse practice environment. Improvements in the quality of nurse practice environments could reduce adverse outcomes for hospitalized surgical oncology patients.
Objective:
To compare alternative measures of nurse staffing and assess the relative strengths and limitations of each measure.
Data sources/study setting:
Primary and secondary data from 2000 and 2002 on hospital nurse staffing from the American Hospital Association, California Office of Statewide Health Planning and Development, California Nursing Outcomes Coalition, and the California Workforce Initiative Survey.
Study design:
Hospital-level and unit-level data were compared using summary statistics, t-tests, and correlations.
Data collection/extraction methods:
Data sources were matched for each hospital. When possible, hospital units or types of units were matched within each hospital. Productive nursing hours and direct patient care hours were converted to full-time equivalent employment and to nurse-to-patient ratios to compare nurse staffing as measured by different surveys.
Principal findings:
The greatest differences in staffing measurement arise when unit-level data are compared with hospital-level aggregated data reported in large administrative databases. There is greater dispersion in the data obtained from publicly available, administrative data sources than in unit-level data; however, the unit-level data sources are limited to a select set of hospitals and are not available to many researchers.
Conclusions:
Unit-level data collection may be more precise. Differences between databases may account for differences in research findings.
. Effects of hospital care environment on patient mortality and nurse outcomes.
- Aiken
. American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Hospital variation in time to defibrillation after in-hospital cardiac arrest.
- Chan