‘‘A SAFE PATIENT’’

1. ‘‘A SAFE PATIENT’’ Dr J Edem-Hotah Dean – Faculty of Nursing' College of Medicine and Allied Health Sciences University of Sierra Leone

2. What do RNs do? • What you see • Health teaching • Integration • Supervision • Emotional support • Physiologic therapy • Compensate for loss of function

3. What do RNs do? / 2 • What you don’t see • Surveillance • Assessment • Nursing diagnosis • Planning interventions • Identifying desired outcomes

4. Quantifying Nursing Value • Research and quantification: late 1980s • Prompted by changes in the health care environment • Downsizing • Decreased reimbursement • Decreased length of stay • Emergence of managed care

5. Quantifying Nursing Value / 2 • In 1994, Aitken et al, notes 4.6 lower mortality rates in Magnet Hospital vs Non-Magnet Hospitals • ANA requested the study of the impact of restructuring on patient care (1994)

6. Quantifying Nursing Value / 3 • In 1995, ‘‘Nursing Care Report for Acute Care’’ is published by ANA • 21 nursing sensitive indicators identified • National Database of Nursing Quality Indicators (NDNQI) is born • National Centre for Nursing Quality and University of Kansas School of Nursing

7. Nursing Indicators • Defined as variable patient, family or caregiver state, condition, or perception responsive to nursing intervention • Indicators capture health care or outcomes most affected by nursing

8. Nursing Indicators / 2 • Patient-focused outcome indicators: • Mortality rate • Length of stay • Adverse events: falls*, medication errors • Complications: UTI, decubitus, pneumonia • Patient satisfaction • Readmission rates

9. Nursing Indicators / 3 • Process of care indicators: • Nurse satisfaction • Pain management • Patient education • Discharge planning • Appropriate use of restraints • Assessment and implementation of patient care requirements

10. Nursing Indicators / 4 • Structure of care indicators: • Ratio of nursing staff to patients • Staff education and experience • Total nursing hour per patient • Staff continuity • Overtime • Staff injury rates

11. What the Research Shows • RN staffing and mortality, length of stay • High nurse ratios in ICU (1:3 or more), increased ICU days by 49%: similar high nurse patient ratios on the evening shift resulted in 20% increase in length of stay

12. What the Research Shows / 2 • RN staffing and mortality / failure to rescue: • Each additional patient per nurse results in 7% increase in the likelihood of dying within 30 of admission • Each additional patient per nurse results in a 7% increase in the odds of failure to rescue

13. What the Research Shows / 3 • RN staffing and health care costs: • Hepatic resection patients in ICU’s with nurse/patient ratio of 1:3 or more incurred a 14% increase in hospital costs • The same patients were a increase risk of re-intubation

14. What the Research Shows / 4 • Staffing levels and sentinel events: • Staffing levels have been a factor in 24% of the 1609 sentinel events-unanticipated events that result in death, injury or permanent loss of function-that have been reported to the Joint Commission as of March 2002

15. What the Research Shows / 5 • RN staffing and patient outcomes: • Hours of care delivered by RN’s was inversely related to unit rates of medication errors, decubitis, and patient complaints • Among medical patients, more RNs hours of care result in decreased LOS, UTI, and GI bleeds • Among surgical patients, more RNs hours of care result in decreased rates of pneumonia, Shocks or cardiac arrest, failure to rescue

16. What the Research Shows / 6 • RN staffing and patient outcomes: • Higher rates of RN staffing associated with a 3-12% reduction on adverse outcomes • Higher staffing at all levels associated with a 2-25% reduction on adverse outcomes • RN hours of care, not skill mix, impact level of adverse patient events • There is a greater incidence of nearly all adverse events in hospitals with fewer licensed nurses

17. What the Research Shows / 7 • Nursing staffing and hepatitis C transmission • Higher nurse/patient ratios resulted in significantly higher HCV prevalence and seroconversion rates per year • 2:1 (26.8%, 5.3%), 3:1 (43.6%, 8.6%), 4:1 (71.8%, 14.4%)

18. What the Research Shows / 8 • RN staffing and operational costs: • A 1% increase in RN FTEs increased operating expenses by 0.25% but had no effect on profit margins • Higher levels of non-nurse staffing resulted in both higher operating expenses and lower profits

19. Additional Research • Positive nurse-physician communication related to improved patient outcomes and decreased incidents of failure to rescue • Educational levels of nurses may have some impact on patient outcomes

20. ‘‘A safe patient’’ • RNs are the essential part of the safety equation

21. THANK YOU

22. Bibliography • Aitken et al (2002) Hospital Nurse-Staffing and Patient Mortality, Nurse Burnout and Job Dissatisfaction • Blegen et al (1998) Nurse Staffing and Patient Outcomes • Dimick et al (2001) Effects of Nurse-Patient Ratios in ICU on Pulmonary Complications and Resource Use After Hepatectomy • JCAHO (2002) Health Care at the Cross-roads: Strategies for addressing the Evolving Nursing Crisis • JCAHO (2002) Patient Safety Goal , 2005: reduce the Risk of Patient Harm Resulting from Falls • IOM (2004) Keeping Patients Safe: Transforming the Work Environment of Nurses • McCue et al (2003) Nurse Staffing, Quality and Financial Performance • Needleman et al (2002) Nurse Staffing Levels and Quality of Care in Hospitals • Pronovost et al (1999) Organisational Characteristics of Intensive Care Units Related to Outcomes of Abdominal Aortic Surgery • Saxena et al (2004) The Impact of Nurse Understanding on the Transmission of Hepatitis C Virus in a Hospital-Based Haemodialysis Unit • Unruh (2003) Licensed Nurse Staffing and Adverse Events in Hospitals