Abstract
Background: The impact of nursing care on patient outcomes is not well understood. The objective of this study is to assess the effects of nursing care hours per patient day, nursing skill mix, and nurse turnover on central line-associated bloodstream infection (CLABSI) rates, length of stay (LOS), and mortality in the context of intensive care units (ICUs) using interventions to reduce bloodstream infections and improve patient safety, teamwork and interdisciplinary communication. Methods: This study uses longitudinal data from 45 ICUs from 35 hospitals in two faith-based health systems across12 states. The 45 ICUs were divided into two groups. We analyzed 19 months of experience for the first group and a year of experience for the second group. We collected hours worked by all bedside nurses to calculate National Quality Forum (NQF) nursing measures. We used a two-level random-intercept model to account for the correlations among repeated measures for the same ICU. Regressions accounted for the influences of number of Intensivists, type of ICUs, ICU bed size, which health system the unit belonged to, nursing practice environment (PES-NWI) and project phase. Models also adjusted for average patient charges, to partially account for ICU casemix. Results: Nursing care hours per patient day greater than 20 hours was associated with lower CLABSI rates. Increasing nursing hours per patient day was also associated with shorter LOS, with the strongest relationship where nursing hours per patient day was lower (< 20 hours compared to ≥ 20 hours). A Higher skill mix was associated with shorter LOS but higher CLABSI rates. We found no significant relationships of nursing turnover with any outcome, or between any nursing variables and mortality. Conclusions: Our findings suggest that nursing care hours per patient day and nursing skill mix significantly contribute to CLABSI prevention and LOS in the ICU setting.
Highlights
The landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century highlighted the difference between the quality of care that is, and the quality of care that should be, provided in the United States [1]
Highlighting the importance of the nurse role in health care delivery, in 2009 the National Quality Forum (NQF) endorsed several nurse-staffing related quality indicators developed by the American Nurses Association [5]
Based on a framework adapted from Donabedian’s structureprocess-outcome approach [29], we hypothesized that nursing skill mix, nursing hours per patient care, and nurse turnoverwould be associated with patient outcomes in the intensive care units (ICUs) (Figure 1)
Summary
The landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century highlighted the difference between the quality of care that is, and the quality of care that should be, provided in the United States [1]. There is much that we still do not fully understand about optimizing patient care and patient outcomes. One of these important areas is the impact of nurses on patient outcomes. Nurses make up one of the largest clinician populations, nurses have said for years that there are not enough of them to provide quality patient care [2,3]. Highlighting the importance of the nurse role in health care delivery, in 2009 the National Quality Forum (NQF) endorsed several nurse-staffing related quality indicators developed by the American Nurses Association [5]. The impact of nursing care on patient outcomes is not well understood. The objective of this study is to assess the effects of nursing care hours per patient day, nursing skill mix, and nurse turnover on central line-associated bloodstream infection (CLABSI) rates, length of stay (LOS), and mortality in the context of intensive care units (ICUs) using interventions to reduce bloodstream infections and improve patient safety, teamwork and interdisciplinary communication
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