Inadequate staffing in surgical wards linked to adverse outcomes

A new paper in the British Journal of Surgery, published by Oxford University Press, shows that nursing shortages result in longer hospital stays and worse patient outcomes, including higher mortality.

Doctors perform over 300 million surgeries each year worldwide. Observers have expressed concern about the quality of care for adult patients undergoing surgery and the rising cost of avoidable complications, extended hospitalizations, and readmissions. Some 55% of surgical site infections are preventable.

Until now safety interventions to address this have focused mostly on implementing checklists, staff training and improving teamwork. But staff shortages alone may be an important reason for infections and other adverse outcomes after surgery. Nurses play an important role in keeping surgical patients safe and healthy. Understaffing by both registered nurses and nurse assistants is associated with increased risks of a range of adverse events.

One recent review of 44 studies found that higher nurse staffing levels were associated with lower 30-day mortality among surgical patients. However, most studies have focused on staffing at the hospital level, rather than in actual surgical wards. In this new paper researchers from the University of Southampton, using surgical patient and staffing data from 213,910 hospital admissions from four medical institutions in the English National Health Service, explored outcomes between April 2015 and February 2020.

In situations where staffing levels were below the mean for the ward, researchers found that such understaffing increases the relative risk of readmission by 2.3% for nursing shortages (and by 1.4% for nursing assistant shortages). The study indicated that nursing shortages were associated with 4.8% increases in deep vein thrombosis, 5.7% increases in pneumonia, and 6.4% increases in pressure ulcers.

The relative risk of mortality increased by 9.2% with each day of low registered nurse staffing and by 10.3% for each day of low nursing assistant staffing.

The safety of patients undergoing surgery is paramount and there is rightly a considerable emphasis on appropriate systems, policies, and procedures."

Paul Meredith, University of Southampton

"This research is a timely reminder that workload is also a major driver of risk and that risks to surgical patients persist beyond the immediate operative period. Adequate nurse staffing on wards is vital to ensure the safety of patients undergoing and recovering from surgery."