MASSACHUSETTS NURSE NEWSLETTER :: September 2007

Another study links RN staffing to increased infection rates

2,000 state residents die annually from hospital infections

A new study published in the July edition of the open access journal Critical Care finds that understaffing of registered nurses in hospital intensive care units increases the risk of serious infections for patients; specifically pneumonia, a preventable and potential deadly complication that can add thousands of dollars to the cost of care for hospital patients.

Meanwhile, the Massachusetts Department of Public Health released a similar report (“State targets killer hospital infections,” Boston Herald; Aug. 8, 2007) announcing that as many as 2,000 Bay State patients a year are dying needlessly from hospital-acquired infections.

“These reports are shocking, but not surprising,” said Beth Piknick, RN and MNA president. “Any nurse who has been forced to practice under the current conditions in our state’s hospitals could have predicted these types of statistics.” These studies represent the second and third such studies in as many months to link poor ICU staffing to hospital infections, and the Critical Care study was the fourth this year to link poor RN-to-patient ratios to poor outcomes for hospitalized patients.

The new research bolsters the case for increasing RN staffing in hospitals and limiting the number of patients assigned to a nurse as proposed in pending legislation, the Patient Safety Act (H.2059), currently before the Massachusetts Legislature.

In the case of the Critical Care study, Stéphane Hugonnet and colleagues from the University of Geneva Hospitals, Switzerland, investigated the number of patients admitted to the ICU who developed ventilator-associated pneumonia (VAP), over a four-year period. They then compared this to the number of nurses on duty for each patient in the preceding days. VAP affected over a fifth of the 936 patients who received mechanical ventilation during the study.

The team found that when there were lower numbers of nurses, patients were more likely to catch pneumonia six days or more after being placed on a ventilator. This could be due to short-staffed nurses having less time to follow hand hygiene recommendations and proper isolation procedures or being unable to provide adequate care to the ventilated patient. The nurses’ training levels had no effect on infection rates.

“This study shows that a low nurse-to-patient ratio increases the risk of late-onset VAP,” said Hugonnet. “It also adds to the growing body of evidence demonstrating that adequate staffing is a key determinant and a prerequisite for adequate care and patient safety.” VAP is caused by bacteria entering the lungs as a consequence of the ventilator tubing and is one of the most common preventable problems affecting critically ill hospital patients. It can cause a stay of about an average of 10 extra days in the hospital at a cost of $10,000 to $40,000.

“This is yet another in a long line of recently published studies that clearly demonstrate that improving RN staffing ratios has enormous societal benefits in terms of lives saved and reduced complications, while also being highly cost effective,” said Karen Higgins, RN, an ICU nurse at Boston Medical Center and co-chair of the Coalition to Protect Massachusetts Patients—an alliance of 107 leading health care, civic and consumer groups promoting passage of the Patient Safety Act. “There is no longer any rationale for allowing hospitals to deprive patients of the lifesaving care nurses are capable of providing if and when nurses have a safe number of patients to care for at one time.”

A 2003 report by the prestigious Institute of Medicine on the impact of nurses’ working conditions on patient safety found that poor RN staffing and excessive overtime increased the likelihood of preventable patient injuries and deaths. One of the recommendations of the IOM report was for a strict limit of no more than two patients for nurses in ICUs as well as to provide limits on overtime for nurses.

Nurses in Massachusetts hospitals, including those working in ICUs, are regularly forced to accept unsafe patient assignments as identified in the new study. A study of actual RN staffing levels in the state’s hospitals conducted by the MNA and Andover Economic Evaluation in 2006 found that in a shocking 36 percent of observations hospitals failed to meet the accepted minimum standard of no more than two patients per nurse in the intensive care unit.

The Patient Safety Act (H.2059) would dramatically improve care by setting a safe limit on the number of patients assigned to a nurse. The measure, which is co-sponsored by state Rep. Christine Canavan (D-Brockton) and Sen. Marc Pacheco (D-Taunton), calls upon the Department of Public Health to set a safe limit on the number of patients a nurse is assigned at one time. In addition, the bill calls for staffing ratios to be adjusted based on patient needs. It also bans mandatory overtime and includes initiatives to increase nursing faculty and nurse recruitment. During the last legislative session, the Massachusetts House of Representatives passed a similar bill by a vote of 133-20. A hearing on the bill before the Joint Committee on Public Health has been scheduled for Oct. 24.