Hospitals that have better working conditions for nurses are safer for elderly intensive care unit patients

May 28 2007

Hospitals that have better working conditions for nurses are safer for elderly intensive care unit (ICU) patients, according to a recent report, led by Columbia University School of Nursing researchers that measured rates of hospital-associated infections.

Hospital associated infections are the number six cause of death in the United States (CDC March 2007). Nurses, as the largest workforce in the nation's hospitals, are in a unique position to positively impact the safety of ICUs if systematic improvements to their working conditions can be made.

A review of outcomes data for more than 15,000 patients in 51 U.S. hospital ICUs showed that those with high nurse staffing levels (the average was 17 registered nurse hours per patient day) had a lower incidence of infections. Higher levels of overtime hours were associated with increased rates of infection and skin ulcers. On average nurses worked overtime 5.6 percent of the time. These findings, reported in the June issue of Medical Care, one of the leading health care administration journals, support the notion that a systematic approach aimed at improving nurse working conditions will improve patient safety.

"Nurses are the hospitals' safety officers," said Patricia W. Stone, Ph.D., M.P.H., R.N., assistant professor of nursing at Columbia University Medical Center and the study's first author. "However, nursing units that are understaffed and that have overworked nurses are shown to have poor patient outcomes. Improvements in nurse working conditions are necessary for the safety of our nation's sickest patients. With the looming nursing shortage, hospitals direly need to address working conditions in order to help retain current staff now and recruit people into nursing in the future."

Researchers evaluated several measures of working conditions to assess their effect on hospital-associated infections. They analyzed the organizational climate as measured by nurse surveys, and reviewed objective measures of staffing, overtime and wages with payroll data. They also looked at hospital profitability and magnet accreditation (a national recognition program for nursing excellence in hospitals). Patient outcome data came from the Centers for Disease Control and Prevention (CDC) National Nosocomial Infection Surveillance system and Medicare files.

After careful review, findings revealed that ICUs with higher staffing had lower incidence of central line associated bloodstream infections (CLSBI), a common cause of mortality in intensive care settings. Other measures such as ventilator-associated pneumonia and skin ulcers, which are common among hospitalized patients who cannot move regularly, were also reduced in units with high staffing levels. Patients were also less likely to die within 30 days in these higher-staffed units.

Increased overtime hours in ICUs were associated with increased rates of another common hospital-associated infection, catheter-associated urinary tract infection, as well as increased rates of skin ulcers on patients.

"Our careful analysis found that decisions related to staffing, overtime, and overall work environment directly affected patient safety outcomes," said Andrew W. Dick, Ph.D., a senior health economist at the RAND Corporation and a co-author of this study. "Involvement from hospital administrators, staffing professionals, legislators and consumers is needed in order to address problems in the ICU work environment. Our hope is that with concentrated efforts, we can prevent hospital infections and improve patient safety in ICUs."

One possible solution presented in the study suggests increasing the availability of highly-qualified float nurses through cross training. This would allow hospitals to more appropriately staff their ICUs and further develop the skills of nursing staff based on other units.

The sample comprised 15,846 patients in 51 adult intensive care units in 31 hospitals; 1095 nurses were surveyed. Severity of patient illness was controlled for in this study.

The results measuring the effects of organization climate and hospital profitability were not consistent. Magnet status and wages also were not significant predictors for poor patient outcomes.