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Risk of hospital patient mortality increases with nurse staffing shortfalls, study finds

Date:

March 17, 2011

Source:

University of California - Los Angeles

Summary:

A new study shows that patient mortality increases with hospital nurse staffing shortfalls, and with
higher patient turnover.

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FULL STORY

Nurses are the front-line caregivers to hospital patients, coordinating and providing direct care and
delivering it safely and reliably. The goal for any hospital is to ensure that each of its patient-care units
has an adequate number of nurses during every shift.

Ideally, the proper number of hours nurses work -- known as the "target level" -- should be adjusted
each shift, depending on the ebb and flow of patients and their need for care. Too many nurses can be
costly for hospitals; too few can put patients' health in danger.

In a new study, a team of researchers from the UCLA School of Public Health, Mayo Clinic and Vanderbilt
University has determined that patients' mortality risk rises as the number of below-target nursing shifts
they are exposed to increases. The study also found that when nurses' workloads increase during shifts
because of high patient turnover, mortality risk also increases.

The findings appear in the March 17 edition of the New England Journal of Medicine.

For the study, first author Jack Needleman, a professor of health services at UCLA's School of Public
Health, and his colleagues analyzed the records of nearly 198,000 admitted patients and 177,000 eight-
hour nursing shifts across 43 patient-care units at a large tertiary academic medical center in the U.S.

As part of their comprehensive analysis, the researchers calculated the difference between the target
nurse-staffing level and the actual nurse-staffing level for each shift they examined.
The researchers found that for each shift patients were exposed to that was substantially understaffed --
falling eight or more hours below the target level -- patients' overall mortality risk increased by 2
percent. Because the average patient in the study was exposed to three nursing shifts that fell below
target levels, the mortality risk for these patients was about 6 percent higher than for patients on units
that were always fully staffed.

The study also found that when nurses' workloads increase because of high patient turnover in
individual units, mortality risk also increases. For each shift a patient experienced in which turnover --
due to admissions, discharges and transfers -- was substantially higher than usual, the risk of mortality
was 4 percent higher. The average patient in the study was exposed to one high-turnover shift.

Study closes door on controversy

Nearly a decade ago, research published by Needleman and his colleagues in the New England Journal of
Medicine provided important early evidence that nurse staffing in hospitals was associated with patients'
clinical outcomes. This was followed by additional research that reported similar findings using different
analytic methods, different data and different measures of patient outcomes associated with hospital
nurse staffing.

Despite agreement that nurse staffing does indeed matter to the well-being of patients, earlier findings
were challenged because the data used did not allow researchers to directly link staffing to the precise
hospital units on which patients stayed or to the nursing shifts to which they were exposed. Nor did
earlier studies include information on how staffing decisions were made. In addition, because the earlier
studies compared hospitals with high average nurse staffing to hospitals with low staffing, researchers
could not control for all the variations across hospitals that might contribute to differences in mortality.

This time, however, by examining a single hospital rather than comparing hospitals, these challenges
have been addressed, thus "closing the door on the controversy," said Marcelline Harris, a senior
associate consultant in biomedical informatics at the Mayo Clinic and principal investigator of the current
study.

"This study, conducted a decade later than our original analysis, addresses the challenges to prior studies
and finds that, indeed, nurse staffing is hugely important," Needleman said. "Since the hospital we
studied delivers high-quality care, has low mortality rates, has high nurse-staffing targets and meets its
targets over 85 percent of the time, it's unlikely the increased mortality we observe is due to general
quality problems.

"We believe that these findings apply to all hospitals -- those like the one we studied, where staffing is
generally high and targets are usually met, and hospitals that are less successful in achieving staffing
levels needed to meet patient needs and keep them safe," he said.

"I believe this study sets a new standard for rigor," said study author Peter Buerhaus, a professor of
nursing at Vanderbilt University. "The results reinforce the importance of hospital management,
physicians and nurses working closer together to examine all the elements that contribute to providing
patient care, including nurse staffing, to be sure that each patient's welfare is assured throughout their
entire hospital stay."
"These results can be used to shift the national dialogue," Harris said. "It moves it away from questioning
whether nurse staffing impacts patient outcomes, to focusing on the most effective ways to deliver
nursing care and how current and emerging payment systems can reward hospitals' efforts to ensure
adequate staffing."

Other authors of the study included V. Shane Pankratz and Cynthia L. Leibson, of the Mayo Clinic, and
Susanna R. Stevens, of Duke University Medical Center.

Funding for the study was provided by the Agency for Health Research and Quality, part of the U.S.
Department of Health and Human Services.

make a difference: sponsored opportunity

Story Source:

Materials provided by University of California - Los Angeles. Original written by Sarah Anderson. Note:
Content may be edited for style and length.

Journal Reference:

1. Jack Needleman, Peter Buerhaus, V. Shane Pankratz, Cynthia L. Leibson, Susanna R. Stevens,
Marcelline Harris. Nurse Staffing and Inpatient Hospital Mortality. New England Journal of
Medicine, 2011; 364 (11): 1037 DOI: 10.1056/NEJMsa1001025

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University of California - Los Angeles. "Risk of hospital patient mortality increases with nurse staffing
shortfalls, study finds." ScienceDaily. ScienceDaily, 17 March 2011.
<www.sciencedaily.com/releases/2011/03/110317093109.htm>.

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