RESUMEN
BACKGROUND: Unrest in Chile over inequalities has underscored the need to improve public hospitals. Nursing has been overlooked as a solution to quality and access concerns, and nurse staffing is poor by international standards. Using Chile's new diagnosis-related groups system and surveys of nurses and patients, we provide information to policy makers on feasibility, net costs, and estimated improved outcomes associated with increasing nursing resources in public hospitals. METHODS: For this multilevel cross-sectional study, we used data from surveys of hospital nurses to measure staffing and work environments in public and private Chilean adult high-complexity hospitals, which were linked with patient satisfaction survey and discharge data from the national diagnosis-related groups database for inpatients. All adult patients on medical and surgical units whose conditions permitted and who had been hospitalised for more than 48 h were invited to participate in the patient experience survey until 50 responses were obtained in each hospital. We estimated associations between nurse staffing and work environment quality with inpatient 30-day mortality, 30-day readmission, length of stay (LOS), patient experience, and care quality using multilevel random-effects logistic regression models and zero-truncated negative binomial regression models, with clustering of patients within hospitals. FINDINGS: We collected and analysed surveys of 1652 hospital nurses from 40 hospitals (34 public and six private), satisfaction surveys of 2013 patients, and discharge data for 761 948 inpatients. Nurse staffing was significantly related to all outcomes, including mortality, after adjusting for patient characteristics, and the work environment was related to patient experience and nurses' quality assessments. Each patient added to nurses' workloads increased mortality (odds ratio 1·04, 95% CI 1·01-1·07, p<0·01), readmissions (1·02, 1·01-1·03, p<0·01), and LOS (incident rate ratio 1·04, 95% CI 1·01-1·06, p<0·05). Nurse workloads across hospitals varied from six to 24 patients per nurse. Patients in hospitals with 18 patients per nurse, compared with those in hospitals with eight patients per nurse, had 41% higher odds of dying, 20% higher odds of being readmitted, 41% higher odds of staying longer, and 68% lower odds of rating their hospital highly. We estimated that savings from reduced readmissions and shorter stays would exceed the costs of adding nurses by US$1·2 million and $5·4 million if the additional nurses resulted in average workloads of 12 or ten patients per nurse, respectively. INTERPRETATION: Improved hospital nurse staffing in Chile was associated with lower inpatient mortality, higher patient satisfaction, fewer readmissions, and shorter hospital stays, suggesting that greater investments in nurses could return higher quality of care and greater value. FUNDING: Sigma Theta Tau International, University of Pennsylvania Global Engagement Fund, University of Pennsylvania School of Nursing's Center for Health Outcomes, and Policy Research and Population Research Center. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.
Asunto(s)
Personal de Enfermería en Hospital/organización & administración , Evaluación del Resultado de la Atención al Paciente , Admisión y Programación de Personal/estadística & datos numéricos , Adulto , Chile , Estudios Transversales , Femenino , Hospitales Privados , Hospitales Públicos , Humanos , Masculino , Análisis Multinivel , Personal de Enfermería en Hospital/estadística & datos numéricos , Encuestas y CuestionariosRESUMEN
BACKGROUND: Rigorous measurement of organizational performance requires large, unbiased samples to allow inferences to the population. Studies of organizations, including hospitals, often rely on voluntary surveys subject to nonresponse bias. For example, hospital administrators with concerns about performance are more likely to opt-out of surveys about organizational quality and safety, which is problematic for generating inferences. OBJECTIVE: The objective of this study was to describe a novel approach to obtaining a representative sample of organizations using individuals nested within organizations, and demonstrate how resurveying nonrespondents can allay concerns about bias from low response rates at the individual-level. METHODS: We review and analyze common ways of surveying hospitals. We describe the approach and results of a double-sampling technique of surveying nurses as informants about hospital quality and performance. Finally, we provide recommendations for sampling and survey methods to increase response rates and evaluate whether and to what extent bias exists. RESULTS: The survey of nurses yielded data on over 95% of hospitals in the sampling frame. Although the nurse response rate was 26%, comparisons of nurses' responses in the main survey and those of resurveyed nonrespondents, which yielded nearly a 90% response rate, revealed no statistically significant differences at the nurse-level, suggesting no evidence of nonresponse bias. CONCLUSIONS: Surveying organizations via random sampling of front-line providers can avoid the self-selection issues caused by directly sampling organizations. Response rates are commonly misinterpreted as a measure of representativeness; however, findings from the double-sampling approach show how low response rates merely increase the potential for nonresponse bias but do not confirm it.
Asunto(s)
Administración Hospitalaria/normas , Hospitales/normas , Garantía de la Calidad de Atención de Salud/métodos , Proyectos de Investigación , Encuestas y Cuestionarios/normas , Sesgo , Humanos , Sesgo de SelecciónRESUMEN
BACKGROUND: Recent studies suggest that nurses may be unable to complete all aspects of necessary care due to a lack of time. Research is needed to determine whether unmet nursing care contributes to disparities in readmissions for vulnerable populations. OBJECTIVES: To examine differences in the relationship between nursing care left undone and acute myocardial infarction readmissions among older black patients compared with older white patients. RESEARCH DESIGN: Cross-sectional analysis of multiple datasets, including: 2006 to 2007 administrative discharge data, a survey of registered nurses, and the American Hospital Association Annual Survey. Risk-adjusted logistic regression models were used to estimate the association between care left undone and 30-day readmission. Interactions were used to examine the moderating effect of care left undone on readmission by race. RESULTS: The sample included 69,065 patients in 253 hospitals in California, New Jersey, and Pennsylvania. Older black patients were 18% more likely to experience a readmission after adjusting for patient and hospital characteristics and more likely to be in hospitals where nursing care was often left undone. Black patients were more likely to be readmitted when nurses were unable to talk/comfort patients [odds ratio (OR), 1.09; 95% confidence interval (CI), 1.01-1.19], complete documentation (OR, 1.16; 95% CI, 1.01-1.32), or administer medications in a timely manner (OR, 1.26; 95% CI, 1.09-1.46). CONCLUSIONS: Unmet nursing care is associated with readmissions for older black patients following acute myocardial infarction. Investment in nursing resources to improve the delivery of nursing care may decrease disparities in readmission.
Asunto(s)
Negro o Afroamericano , Infarto del Miocardio/terapia , Personal de Enfermería en Hospital/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Calidad de la Atención de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Comorbilidad , Estudios Transversales , Femenino , Humanos , Modelos Logísticos , Masculino , Oportunidad Relativa , Alta del Paciente/estadística & datos numéricos , Admisión y Programación de Personal/estadística & datos numéricos , Factores de Tiempo , Estados Unidos , Población Blanca/estadística & datos numéricos , Carga de TrabajoRESUMEN
OBJECTIVES: The mortality rate for mechanically ventilated older adults in ICUs is high. A robust research literature shows a significant association between nurse staffing, nurses' education, and the quality of nurse work environments and mortality following common surgical procedures. A distinguishing feature of ICUs is greater investment in nursing care. The objective of this study is to determine the extent to which variation in ICU nursing characteristics-staffing, work environment, education, and experience-is associated with mortality, thus potentially illuminating strategies for improving patient outcomes. DESIGN: Multistate, cross-sectional study of hospitals linking nurse survey data from 2006 to 2008 with hospital administrative data and Medicare claims data from the same period. Logistic regression models with robust estimation procedures to account for clustering were used to assess the effect of critical care nursing on 30-day mortality before and after adjusting for patient, hospital, and physician characteristics. SETTING: Three hundred and three adult acute care hospitals in California, Florida, New Jersey, and Pennsylvania. PATIENTS: The patient sample included 55,159 older adults on mechanical ventilation admitted to a study hospital. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients in critical care units with better nurse work environments experienced 11% lower odds of 30-day mortality than those in worse nurse work environments. Additionally, each 10% point increase in the proportion of ICU nurses with a bachelor's degree in nursing was associated with a 2% reduction in the odds of 30-day mortality, which implies that the odds on patient deaths in hospitals with 75% nurses with a bachelor's degree in nursing would be 10% lower than in hospitals with 25% nurses with a bachelor's degree in nursing. Critical care nurse staffing did not vary substantially across hospitals. Staffing and nurse experience were not associated with mortality after accounting for these other nurse characteristics. CONCLUSIONS: Patients in hospitals with better critical care nurse work environments and higher proportions of critical care nurses with a bachelor's degree in nursing experienced significantly lower odds of death.