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New Study Finds ICU Nurse Staffing and Working Conditions Linked to Increase in Infections and Deaths Among Elderly Patients

Study Bolsters Case for Increasing RN Staffing in Hospitals

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CANTON, Mass. — A new study to be published in the June issue of the journal Medical Care finds that hospitals that have better staffing and less overtime for registered nurses are safer for elderly intensive care unit (ICU) patients. The study is yet another piece of scientific evidence that bolsters the case for increasing RN staffing in hospitals, prohibiting mandatory overtime and limiting the number of patients assigned to a nurse, as proposed in the Patient Safety Act (H.2059), legislation currently before the Massachusetts legislature.

This report, which was led by Columbia University School of Nursing researchers, measured rates of hospital-associated infections; the sixth-highest cause of death in the United States (CDC, March 2007). Findings suggest that nurses, as the largest workforce in the nation’s hospitals, are in a unique position to positively affect the safety of ICUs if systematic improvements to their working conditions are made.

A review of outcomes data for more than 15,000 patients in 51 U.S. hospital ICUs showed that those with higher nurse staffing levels had a lower incidence of infections such as central-line associated bloodstream infections (CLSBI), a common cause of mortality in intensive-care settings. The study found that patients cared for in hospitals with higher staffing levels are 68 percent less likely to acquire such an infection.

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. Higher levels of overtime hours were associated with increased rates of infection, including catheter-associated urinary tract infections as well as skin ulcers. On average, the ICU nurses worked overtime 5.6 percent of the time.

"Nurses are the hospitals’ safety officers," said Patricia W. Stone, Ph.D., M.P.H., RN, 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."

"This is yet another in a long line of published studies that clearly demonstrate that improving RN staffing ratios has enormous 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 that only nurses can provide if they are allowed to care for a safe number of patients at any given moment."

The study on ICU staffing comes on the heels of a study published in the May issue of the same publication. That study reported that a 10 percent increase in the number of patients assigned to a nurse leads to a 28 percent increase in adverse events such as infections, medication errors, and other injuries. A 2003 report by the prestigious Institute of Medicine (IOM) regarding the impact on patient safety of nurses’ working conditions found that poor RN staffing and excessive overtime increase the likelihood of preventable patient injuries and deaths. The IOM report recommended that a strict limit of no more than two patients per nurse in ICUs be established and that overtime for nurses be limited.

Massachusetts nurses 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 Massachusetts Nurses Association 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.

A case in point is Lawrence General Hospital where the nurses are locked in a protracted struggle to improve unsafe staffing conditions, and where the administration has recently informed its ICU nurses that they will be assigned up to three patients at a time, a practice that is patently dangerous and unacceptable by any standard of nursing practice.

"This and countless other studies confirm that the case for better RN staffing has been made and the time has come to act to ensure that a safe limit is put on the number of patients a nurse is assigned," said Beth Piknick, RN, president of the Massachusetts Nurses Association. "Patients are suffering and dying routinely because hospitals continue to understaff, while they reap mounting profits year after year. The hospital industry has proved that it will not staff safely until it is required by law to do so. Hospitals must be held accountable for investing in a safe standard of care."

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 Senator 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 has been scheduled before the Joint Committee on Public Health on Oct. 24, 2007.