Yet these studies have been criticized on several grounds. First, they examined staffing levels for hospitals as a whole, not at the level of individual units. Secondly, they compared well-staffed hospitals against poorly staffed ones, raising the possibility that staffing levels were a mere marker for other aspects of quality such as leadership commitment or funding. Finally, they based their findings on average patient load, failing to take into account patient turnover.
Last week’s NEJM contains the best study to date on this crucial issue. It examined nearly 200,000 admissions to 43 units in a “high quality hospital.” While the authors don’t name the hospital, they do tell us that the institution is a US News top rated medical center, has achieved nursing “Magnet” status, and, during the study period, had a mortality rate nearly 40 percent below that predicted for its case-mix. In other words, it was no laggard.
As one could guess from its pedigree and outcomes, the hospital’s approach to nurse staffing was not stingy. Of 176,000 nursing shifts during the study period, only 16 percent were significantly below the established target (the targets are presumably based on patient volume and acuity, but are not well described in the paper). The authors found that patients who experienced a single understaffed shift had a 2 percent higher mortality rate than ones who didn’t. Each additional understaffed shift carried a similar, and additive, risk. This means that the one-in-three patients who experienced three such shifts during their hospital stay had a 6 percent higher mortality than the few patients who didn’t experience any. If the FDA discovered that a new medication was associated with a 2 percent excess mortality rate, you can bet that the agency would withdraw it from the market faster than you could say “Sidney Wolfe.”
The effects of high patient turnover were even more striking. Exposure to a shift with unusually high turnover (7 percent of all shifts met this definition) was associated with a 4 percent increased odds of death. Apparently, patient turnover – admissions, discharges, and transfers – is to hospital units and nurses as takeoffs and landings are to airplanes and flight crews: a single 5-hour flight (one takeoff/landing) is far less stressful, and much safer, than five hour-long flights (5 takeoffs/landings).
As the authors note, this study should end the debate about the impact of nurse staffing on patient outcomes. The senior author, Mayo’s Marcelline Harris, said of the study: “It moves it away from questioning whether nurse staffing impacts patient outcomes, to focusing on the most effective ways to deliver nursing care and how current and emerging payment systems can reward hospitals’ efforts to ensure adequate staffing.” I agree.
As I discussed recently, virtually all research on the relationship between hospital staffing and outcomes comes from the field of nursing. This is because hospitals hire nurses, whereas physicians have traditionally been free to determine their own workloads and staffing ratios. But this is changing: since nearly half of American hospitalists are now employed by their hospitals, the field’s unprecedented growth has begun to catalyze a parallel debate: how many patients should a hospitalist care for? And a similar discussion, with an educational twist, has been a subtext in the controversy over the ACGME’s duty hours regulations. Though most of the attention has been on the work-hour rules, the regulations also set new limits on patients- and admissions-per-resident. And, with more and more physicians becoming hospital employees, expect the staffing ratio debate – for both nurses and doctors – to grow increasingly contentious, particularly as hospital profit margins evaporate. After all, labor costs represent hospitals’ largest expense.
Even today, nurse staffing is the subject of fierce negotiations between hospital management and nurses (or their unions) in many states, but not so much in California. In 2004, the California legislature bowed to pressure from the California Nurses Association to mandate nurse-to-patient ratios: 1:2 in ICUs and 1:5 on med-surg units. Although the law was controversial, it has probably saved lives – a 2006 survey found that a hospital nurse in California cared for one fewer patient per shift than a comparable nurse in New Jersey or Pennsylvania. The companion study estimated that raising those states’ staffing levels to match California’s would have saved nearly 500 lives over a two-year period. Since California’s law went into effect, 14 other states have followed suit.
While having adequate nurse staffing is a lifesaver, we can’t ignore its costs. With the average nurse’s salary topping $100,000 at hospitals like mine, bumping the ratio can easily take a multi-million dollar bite out of the budget. One wonders whether there is another way.
Which brings me to Louise.
Several years ago, investigators at Boston University, led by Dr. Brian Jack, launched a comprehensive program to improve hospital discharges and decrease readmission rates. Dubbed Project RED (“Re-Engineered Discharge”), the protocol involved giving patients intensive pre-discharge counseling, a customized discharge document, an early post-discharge phone call, and a rapid follow-up appointment. The investigators demonstrated a 30 percent decrease in readmissions and – even before the upcoming Medicare payment changes that will penalize hospitals for excess readmissions – modest cost-savings, $412 per patient. One of the most expensive parts of the intervention was the discharge counseling: an RN spent, on average, nearly 90 minutes with each patient and family, a significant cost.
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