Staffing Patterns Research Articles

Impact of board-certified intensive care training facilities on choice of adjunctive therapies and prognosis of severe respiratory failure: a nationwide cohort study

BackgroundPatients with severe respiratory failure have high mortality and need various interventions. However, the impact of intensivists on treatment choices, patient outcomes, and optimal intensivist staffing patterns is unknown. In this study, we aimed to evaluate treatments and clinical outcomes for patients at board-certified intensive care training facilities compared with those at non-certified facilities.MethodsThis retrospective cohort study used Japan’s nationwide in-patient database from 2016 to 2019 and included patients with non-operative severe respiratory failure who required mechanical ventilation for over 4 days. Treatments and in-hospital mortality were compared between board-certified intensive care facilities requiring at least one intensivist and non-certified facilities using propensity score matching.ResultsOf the 66,905 patients in this study, 30,588 were treated at board-certified facilities, and 36,317 were not. The following differed between board-certified and non-certified facilities: propofol (35% vs. 18%), dexmedetomidine (37% vs. 19%), fentanyl (50% vs. 20%), rocuronium (8.5% vs. 2.6%), vecuronium (1.9% vs. 0.6%), noradrenaline (35% vs. 19%), arginine vasopressin (8.1% vs. 2.0%), adrenaline (2.3% vs. 1.0%), dobutamine (8.7% vs. 4.8%), phosphodiesterase inhibitors (1.0% vs. 0.3%), early enteral nutrition (29% vs. 14%), early rehabilitation (34% vs. 30%), renal replace therapy (15% vs. 6.7%), extracorporeal membrane oxygenation (1.6% vs. 0.3%), critical care unit admission (74% vs. 30%), dopamine (9.0% vs. 15%), sivelestat (4.1% vs. 7.0%), and high-dose methylprednisolone (13% vs. 15%). After 1:1 propensity score matching, the board-certified group had lower in-hospital mortality than the non-certified group (31% vs. 38%; odds ratio, 0.75; 95% confidence interval, 0.72–0.77; P < 0.001). Subgroup analyses showed greater benefits in the board-certified group for older patients, those who required vasopressors on the first day of mechanical ventilation, and those treated in critical care units.ConclusionsBoard-certified intensive care training facilities implemented several different adjunctive treatments for severe respiratory failure compared to non-board-certified facilities, and board-certified facilities were associated with lower in-hospital mortality. Because various factors may contribute to the outcome, the causal relationship remains uncertain. Further research is warranted to determine how best to strengthen patient outcomes in the critical care system through the certification of intensive care training facilities.

Methadone clinic staff perceptions of trauma-informed and patient-centered care: the role of individual staff characteristics

BackgroundU.S. policy intervention to increase methadone treatment accommodations during COVID did not result in national adoption of the new patient-centered treatment practices. Staff-level interventions may facilitate adoption of these treatment practices, but this will depend upon knowledge about staff level characteristics and beliefs. Currently, the role of clinic staff characteristics, beliefs about patient-centeredness, and perceptions about the need for treatment practice change is unknown. This study explored the relationship between opioid treatment program staff characteristics, work roles and staff beliefs to identify opportunities for future staff-level treatment practice change interventions.MethodsStaff of three Arizona opioid treatment programs were surveyed (n = 40) from April 11–22, 2023 using a hybrid online survey method. The 161 survey items required less than 30 min to complete. Pearson point biserial correlation coefficients assessed the covariation between staff beliefs, staff characteristics and staff work roles. Perception of the clinic as person-centered was a potential proxy indicator for staff awareness of discontinuity between the clinic’s person-centeredness and person-centered approaches to methadone treatment.ResultsAmong staff, 47.5% reported lived substance use disorder experience and 27.5% reported lived opioid use disorder experience. Most staff (70%) held at least 1 prior clinic role at the current clinic and 5% had had more than 4 prior roles. Rotation was observed with roles that did not require licensure or degrees. Staff with lived experience with substance use disorder or opioid use disorder treatment reported having more prior roles at the clinic than those without such experience. Abstinence-oriented views were significantly associated with reporting vicarious (work related) trauma symptoms. Those who rated the clinic as significantly more person-centered were staff with lived substance use disorder experience who also held abstinence-oriented views, staff with trauma exposure, and staff with lived opioid use disorder treatment experience who held harm reduction beliefs. In contrast, staff without substance use disorder experience who held harm reduction beliefs perceived the clinic as less person-centered.ConclusionsStaff beliefs, personal and work characteristics are likely factors in the recognition of need for clinic practice change. How these characteristics function in a clinic culture may also be influenced by clinic staffing patterns. A patient-to-provider pipeline with role cycling was observed and this staffing pattern may also influence shared beliefs of trauma-informed care or clinic person-centeredness. Vicarious trauma may also be an important factor. Larger studies should examine these relationships further to understand mechanisms associated with recognition of need for clinic practice change in order to inform staff-level interventions to increase opioid treatment program patient-centeredness.

Clinician Staffing and Quality of Care in US Health Centers

Health centers are vital primary care safety nets for underserved populations, but optimal clinician staffing associated with quality care is unclear. Understanding the association of clinician staffing patterns with quality of care may inform care delivery, scope-of-practice policy, and resource allocation. To describe the association of clinician staffing models and ratios with quality-of-care metrics in health centers. This cross-sectional study of US health centers used data from the 2022 Health Resources and Services Administration Uniform Data System (UDS). Clinician staffing ratios, expressed as the fraction of full-time equivalents (FTEs) per 1000 visits of physicians, advanced practice registered nurses (APRNs), and physician associates (PAs) to total clinician FTEs at each health center. Percentage of eligible patients receiving the corresponding service or outcome for 14 individual clinical quality metrics collected by the UDS, including infant immunizations; screening for cancer, depression, tobacco use, hypertension, HIV, and glycated hemoglobin levels; weight and body mass index (BMI) assessment; and appropriate statin, aspirin, and/or antiplatelet therapy. This analysis of 791 health centers serving 16 114 842 patients (56.6% female) identified 5 clinician staffing models: balanced (similar FTEs of physicians, APRNs, and PAs; 152 [19.2%] of health centers), higher FTEs of APRNs than physicians (174 [22.0%]), higher FTEs of physicians than APRNs (160 [20.2%]), approximately equal FTEs of physicians and APRNs (263 [33.2%]), and large scale (42 [5.3%]). Adjusted linear models showed positive associations between physician FTEs per 1000 visits and cervical (β, 14.9; 95% CI, 3.1-26.7), breast (β, 15.7; 95% CI, 3.2-28.1), and colorectal (β, 18.3; 95% CI, 6.0-30.6) cancer screening. Generalized additive models showed nonlinear positive associations beginning at a physician FTE ratio of 0.45 (95% CI, 0.02-6.22) for infant vaccinations, 0.39 (95% CI, 0.05-2.21) for cervical cancer screening, 0.39 (95% CI, 0.02-1.67) for breast cancer screening, 0.47 (95% CI, 0.00-5.76) for HIV testing, and 0.70 (95% CI, 0.18-19.96) for depression in remission; APRN FTE ratio of 0.45 (95% CI, 0.17-7.46) for adult BMI assessment; and PA FTE ratio of 0.16 (95% CI, 0.11-3.88) for infant vaccinations. Staffing models were not associated with 7 of the 14 metrics analyzed. In this cross-sectional study of health centers, physician FTE ratio was associated with higher performance in cancer screening, infant vaccinations, and HIV testing; APRN FTE ratio was associated with higher performance in preventative health assessments; and PA FTE ratio was associated with higher performance in infant vaccination. These findings suggest that targeted staffing strategies may be associated with quality of care in certain domains and that tailored approaches to health center staffing based on community-specific needs are warranted.

Snapshot of Academic Libraries in North Carolina in 2024

Since 2020, the higher education landscape has been in a drastic state of flux. From ramping up efforts around diversity, equity, inclusion to scaling back these same efforts due to new policies and laws, from implementing health and safety measures in the wake of a pandemic to again rolling the measures back, and from shifting teaching and learning into an online setting to bringing it back in-person to varying degrees, academic libraries have been in a constant state of change. In addition to the aforementioned shifts occurring, other new and significant issues are facing colleges in North Carolina. This article will examine some of them through the lens of some of our institutions. In particular, the examples will focus on the rise of AI, construction, and renovation, changing staffing patterns, and a look to the future.

Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation Across Shifts

ObjectivesTo assess the staffing patterns of direct care nursing staff by shift in nursing homes (NHs), assisted living communities (ALCs), and their corresponding memory care units (MCUs). DesignObservational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021. Setting and ParticipantsNHs (n = 678) and ALCs (n = 542) that reported staffing by shift in Ohio. MethodsResident-to-staff ratios in Ohio were calculated from staffing data. The proportion of daily nursing staff assigned to each shift was based on staffing data from the Biennial Survey for NHs and ALCs. Outcomes were calculated for aides and licensed nursing staff. ResultsOhio's NHs and ALCs had lower resident-to-staff ratios on the day shift. Lower resident-to-staff ratios mean there were more staff per resident (ie, better staffed). For both types of staff and all shifts, overall resident-to-staff ratios were lower in NHs than ALCs. However, resident-to-staff ratios for ALC MCUs were on par with NH MCUs. This was consistent with ALC and NH MCUs staffing in a more similar manner. Across all settings, the day shift had the most staff members present, while a number of ALCs had no licensed nurses on duty during the overnight shift. Conclusions and ImplicationsNHs and ALCs have different staffing patterns due to differences in resident needs. However, as ALCs provide for more residents that need NH level of care, ALCs may require additional staffing, especially on the overnight shift where some ALCs have no licensed nurses on duty. The evidence here can be used for decision making about future staffing policies, whether facility-wide policies that encompass MCUs or state-wide policies, so that care delivery aligns with care needs.

Beyond numbers: a holistic exploration of nursing home staffing patterns and financial performance in the Patient-Driven Payment Model landscape

Beyond numbers: a holistic exploration of nursing home staffing patterns and financial performance in the Patient-Driven Payment Model landscape

Interprofessional Staffing Pattern Clusters in U.S. ICUs.

To identify interprofessional staffing pattern clusters used in U.S. ICUs. Latent class analysis. Adult U.S. ICUs. None. None. We used data from a staffing survey that queried respondents (n = 596 ICUs) on provider (intensivist and nonintensivist), nursing, respiratory therapist, and clinical pharmacist availability and roles. We used latent class analysis to identify clusters describing interprofessional staffing patterns and then compared ICU and hospital characteristics across clusters. We identified three clusters as optimal. Most ICUs (54.2%) were in cluster 1 ("higher overall staffing") characterized by a higher likelihood of good provider coverage (both intensivist [onsite 24 hr/d] and nonintensivist [orders placed by ICU team exclusively, presence of advanced practice providers, and physicians-in-training]), nursing leadership (presence of charge nurse, nurse educators, and managers), and bedside nursing support (nurses with registered nursing degrees, fewer patients per nurse, and nursing aide availability). One-third (33.7%) were in cluster 2 ("lower intensivist coverage & nursing leadership, higher bedside nursing support") and 12.1% were in cluster 3 ("higher provider coverage & nursing leadership, lower bedside nursing support"). Clinical pharmacists were more common in cluster 1 (99.4%), but present in greater than 85% of all ICUs; respiratory therapists were nearly universal. Cluster 1 ICUs were larger (median 20 beds vs. 15 and 17 in clusters 2 and 3, respectively; p < 0.001), and in larger (> 250 beds: 80.6% vs. 66.1% and 48.5%; p < 0.001), not-for-profit (75.9% vs. 69.4% and 60.3%; p < 0.001) hospitals. Telemedicine use 24 hr/d was more common in cluster 3 units (71.8% vs. 11.7% and 14.1%; p < 0.001). More than half of U.S. ICUs had higher staffing overall. Others tended to have either higher provider presence and nursing leadership or higher bedside nursing support, but not both.

Emergency Department Provider Staffing among Critical Access Hospitals in Minnesota

Background: Access to healthcare remains a challenge in many rural regions. Rural critical access hospitals (CAHs) remain essential access points. Providing 24-hour access, CAH emergency departments (EDs) rely on medical staff who can treat a wide range of problems. Family physicians/general practitioners have traditionally staffed rural EDs. However, this staffing model may be changing. This study aims to characterize the current medical staffing profiles of Minnesota’s CAH EDs. Methods: From January to February 2021, the executive leaders of all of Minnesota’s 77 CAHs were invited to complete a voluntary online survey about ED staffing patterns at their facility. Results: 37/77 of MN’s CAHs responded to the survey (48% response rate). Just over half (51.4%) of the respondents reported ED physician staffing practices that included multiple physician specialties (family medicine, internal medicine, emergency medicine) while 32.4% reported staffing exclusively with family medicine physicians. A majority, 27/37 (73%), reported including non-physicians on their ED medical staff, especially at CAHs that were part of a larger healthcare system. Discussion: CAHs often operate with limited workforce and resource options. This study demonstrates that MN’s CAHs exhibit a variety of ED staffing patterns with staffing decisions driven by multiple factors. Family medicine physicians contribute to CAH ED coverage. Future studies may expand our understanding of how ED staffing models impact community health, disease outcomes, and CAH financial viability. Conclusion: ED staffing patterns across Minnesota’s CAHs vary significantly with variable use of physicians and non-physician providers. Family physicians remain an important specialty for CAH ED coverage

Administration’s Share of Personnel in Veterans Health Administration and Private Sector Care

Health care administrative overhead is greater in the US than some other nations but has not been assessed in the Veterans Health Administration (VHA). To compare administrative staffing patterns in the VHA and private (non-VHA) sectors. This cross-sectional study was conducted using US employment data from 2019, prior to pandemic-related disruptions in health care staffing, and was carried out between January 14 and August 10, 2023. A nationally representative sample of federal and nonfederal personnel in hospitals and ambulatory care settings from the American Community Survey (ACS), all employees reported in VHA personnel records, and personnel in health insurance carriers and brokers tabulated by the Bureau of Labor Statistics (BLS) were analyzed. VHA vs private sector health care employment, including 397 occupations grouped into 18 categories. The proportion of staff working in administrative occupations. Among 3 239 553 persons surveyed in the ACS, 122 315 individuals (weighted population, 12 501 185 individuals) were civilians working in hospitals or ambulatory care; of the weighted population, 12 156 988 individuals (mean age, 42.6 years [95% CI, 42.5-42.7 years]; 76.2% [95% CI, 75.9%-76.5%] females) were private sector personnel and 344 197 individuals (mean age, 46.2 years [95% CI, 45.7-46.7 years]; 63.8% [95% CI, 61.8%-65.8%] females) were federal employees. In clinical settings, administrative occupations accounted for 23.4% (95% CI, 23.1%-23.8%) of private sector vs 19.8% (95% CI, 18.1%-21.4%) of VHA personnel. After including 1 000 800 employees at private sector health insurers and brokers and 13 956 VHA Central Office personnel with administrative occupations, administration accounted for 3 851 374 of 13 157 788 private sector employees (29.3%) vs 77 500 of 343 721 VHA employees (22.5%). Physicians represented approximately 7% of personnel in the VHA (7.2% [95% CI, 6.1%-8.2%]) and private sector (6.5% [95% CI, 6.3%-6.7%]), while the VHA deployed more registered nurses (23.7% [95% CI, 21.6%-25.8%] vs 21.2% [95% CI, 20.9%-21.5%]) and social service personnel (6.3% [95% CI, 5.4%-7.1%] vs 4.9% [95% CI, 4.7%-5.0%]) than the private sector. In this study, administrative occupations accounted for a smaller share of personnel in the VHA compared with private sector care, a difference possibly attributable to the VHA's simpler financing system. These findings suggest that if staffing patterns in the private sector mirrored those of the VHA, nearly 900 000 fewer administrative staff might be needed.

EXAMINING THE USE AND IMPACT OF CONTRACT CERTIFIED NURSING ASSISTANT STAFFING IN NURSING HOMES

Abstract Certified nursing assistants (CNAs) provide the majority of hands-on care in nursing homes, and adequate CNA staffing is associated with better resident and staff outcomes. However, low wages and overall poor job quality make adequate CNA staffing particularly challenging. There is evidence that nursing homes have increased reliance on contract staffing to fill staffing shortages, though the full scope of this trend for CNAs remains unclear and the impacts on care quality are still unknown. This study addresses this gap by examining staffing levels and patterns for fully employed versus contract CNAs in nursing homes over the past five years and assessing how these staffing trends are associated with quality outcomes for nursing home residents. Specifically, this session will present analysis of data from the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal daily nurse staffing files, CMS nursing homes data archive, LTCFocus data, community transmission of COVID-19 data, and unemployment data to demonstrate how staffing patterns among fully employed versus contract CNAs varied from 2017 to 2022 according to facility-level characteristics, local market conditions, and pandemic-related factors. We also examine how CNA staffing levels and patterns affected care quality for nursing home residents. These findings will be presented with policy and practice recommendations for strengthening and stabilizing CNA nursing home staffing.

THE EFFECT OF PATIENT-DRIVEN PAYMENT MODEL REIMBURSEMENT POLICY CHANGE ON NURSING HOMES

Abstract To promote more value in skilled nursing facility spending in the US, CMS modified the way it pays for nursing homes (NH) services on October 1, 2019. The new Medicare reimbursement methodology, the Patient Driven Payment Model (PDPM), moves away from the traditional system focused on therapist minutes to a value-based focused on resident clinical characteristics. Using contingency theory, this study explores NH responses to PDPM by: 1) examining whether NH’s therapist and nursing staffing patterns are aligning with the policy incentives; and 2) whether the adjustments are resulting in improved financial performance. Seven different datasets were merged for 2017– 2021: Medicare cost reports, Payroll Based Journal, NH Compare, Area Health Resource File, HHS Provider Relief Fund, CDC NH COVID-19 public file, and CDC COVID-19 Data Tracker. The data was modelled using random-effects regression, and we tested for potential moderation effect of staffing on the relationship between PDPM and financial performance. Dependent variables were nursing and therapy staffing intensity, while the independent variable was PDPM for model 1. Dependent variable was operating margin, moderator variable was staffing intensity, and independent variable was PDPM for model 2. Organizational, community level, and COVID-19 related variables were used as controls. Results suggest that PDPM was associated with an increase in RN and LPN staffing intensity, but a decrease in Physical Therapist, Physical Therapist Assistant, and Occupational Therapist Assistant staffing intensity (p&amp;lt; 0.05). PDPM had a positive impact on financial performance moderated by RN and PT staffing intensity (p&amp;lt; 0.05). Policy and managerial implications are discussed.

Patient Care Technician Staffing in US Hemodialysis Facilities: An Ecological Study

Technicians caring for patients receiving dialysis play a critical, frontline role in the care of patients receiving dialysis in the United States. We sought to provide a comprehensive description and identify correlates of US in-center hemodialysis facility patient care technician staffing patterns. This was an ecological study. US facilities providing hemodialysis and reporting patient care technician staffing, identified using the US Renal Data System. Geography, year, and facility characteristics, including aggregated patient characteristics. The study outcome was facility-reported patient-to-patient care technician ratio. We examined patient-to-patient care technician ratios by US state and over time and also estimated the differences in patient-to-patient care technician ratios associated with facility characteristics, using robust regression with adjustment for facility-level covariates. The median patient-to-patient care technician ratio among 6,862 US facilities in 2019 was 9.9 (25th-75th percentiles, 8.2-12.0). Median 2019 patient-to-patient care technician ratios varied substantially by US state and region. There was an overall decline (from 10.6 to 9.9) in median patient-to-patient care technician ratios from 2004 to 2019, whereas the percentage of positions that were unfilled increased (from 2.8% to 3.5%). After adjustment, large dialysis organization status (β,-0.42; 95% CI,-0.61 to-0.23) and larger facility size (β,-0.51; 95% CI,-0.68 to-0.33) were associated with lower patient-to-patient care technician ratios. Higher patient-to-registered nurse (β, 0.80; 95% CI, 0.65-0.94) and patient-to-social worker (β, 0.53; 95% CI, 0.37-0.70) ratios, presence of licensed vocational nurses or licensed practical nurses at the clinic (β, 0.83; 95% CI, 0.53-1.12), and location in a poverty area (β, 0.29; 95% CI, 0.13-0.44) were all associated with higher patient-to-patient care technician ratios. Aggregated patient characteristics of patients treated at the facilities were generally not associated with patient-to-patient care technician ratio after adjustment. Limited causal inference and potential shifts in staffing after2019. US dialysis facilities vary considerably in their patient care technician staffing by geography, over time, and by various facility characteristics. Further investigation of US patient care technician staffing is warranted and could lead to better, more stable dialysis staffing, improved staff and patient satisfaction, and higher quality of care.

Workforce Monitoring: Staffing Patterns in the Public Mental Health Workforce in New York State, 2009-2021.

Workforce Monitoring: Staffing Patterns in the Public Mental Health Workforce in New York State, 2009-2021.

The Effects of Organizational Characteristics, Individual Nurse Characteristics, and Occupational Fatigue on Missed Care at Night.

Missed care is defined as the omission or delay of necessary patient care and is internationally reported by nurses as a significant safety risk. Nurses working at night also report high levels of occupational fatigue that, coupled with inadequate staffing and practice environment support, may impede a nurse's ability to carry out the nursing process and lead to more missed care. The study's objective was to examine the interrelationships among organizational and nurse characteristics, occupational fatigue, and missed care among nurses working at night. A cross-sectional design was used. Participants included registered nurses (RNs) who worked at night in New Jersey acute care hospitals. Multiple linear regression and simple moderation analyses were performed to examine the associations. Nurses reported missing necessary care at night. Unsupportive practice environments, high RN workloads, high patient-RN ratios, high chronic fatigue levels, and low intershift recovery were individually associated with missed care at night. High patient-to-RN ratios and chronic fatigue were independently associated with missed care. However, patient-to-registered-staffing levels had the most considerable effect on missed care at night. Nurses' years of experience and the number of hours of sleep between shifts were significant moderators of the relationship between occupational fatigue states and missed care. This study is the first to examine the interrelationship between occupational fatigue levels, organizational and nurse characteristics, and missed care at night. There is an urgent need to implement strategies in hospital organizations that foster work schedules and adequate staffing patterns that lessen nurses' occupational fatigue levels to ensure our workforce's and patients' safety.

126 National Survey of Staffing Patterns of Non-ACGME Fellowships at 4-Year Residency Programs

126 National Survey of Staffing Patterns of Non-ACGME Fellowships at 4-Year Residency Programs

New Dimensions of Staffing Patterns in Nursing Homes and Nursing Home Quality: Comparing Staffing Instability to Staffing Turnover.

This study examines how measures of staffing-turnover and instability-are associated with one another and how they independently contribute to quality of care in nursing homes. Cross-sectional analysis of 2021-2022 administrative data. Data included the Payroll Based Journal for daily staffing information, merged with Nursing Home Care Compare (NHCC) data for nursing home characteristics, total staffing turnover, and nursing home quality. A total of 11,840 nursing homes nationally reporting data on daily staffing and staffing turnover. We explored correlations between measures of staffing and estimated facility-level regression models with robust standard errors. The dependent variables were indicators of nursing home quality included in the NHCC 5-star ratings. The independent variables of interest were average total staffing hours per resident-day, total staffing turnover, and total staffing instability. For the 11,840 nursing homes in the study, there was a weak positive correlation between turnover and instability, with some overlap between nursing homes with high instability and high turnover. Regression analysis revealed that staffing instability and turnover contributed independently to nursing home quality, with instability having a stronger association with some measures of quality and turnover with others. Staffing instability was positively and more strongly associated with long-stay residents' decline in activities of daily living levels and receipt of antipsychotic drugs and short-stay residents' functioning at discharge. Turnover was positively and more strongly associated with long-stay residents' prevalence of pressure ulcers and worsening mobility, and short-stay residents' hospitalizations. Instability and turnover in total nursing home staffing independently contribute to nursing home quality. This suggests that adding measures of staffing instability to the existing measures of average staffing and staff turnover in NHCC may enhance the report card's value for providers engaged in quality improvement and consumers searching for high-quality nursing homes.

Association of Receipt of Paycheck Protection Program Loans With Staffing Patterns Among US Nursing Homes

Staffing shortages in nursing homes (NHs) threaten the quality of resident care, and the COVID-19 pandemic magnified critical staffing shortages within NHs. During the pandemic, the US Congress enacted the Paycheck Protection Program (PPP), a forgivable loan program that required eligible recipients to appropriate 60% to 75% of the loan toward staffing to qualify for loan forgiveness. To evaluate characteristics of PPP loan recipient NHs vs nonloan recipient NHs and whether there were changes in staffing hours at NHs that received a loan compared with those that did not. This economic evaluation used national data on US nursing homes that were aggregated from the Small Business Administration, Nursing Home Compare, LTCFocus, the Centers for Medicare & Medicaid Services Payroll Based Journal, the Minimum Data Set, the Area Deprivation Index, the Healthcare Cost Report Information System, and the US Department of Agriculture Rural-Urban Continuum Codes from January 1 to December 23, 2020. Paycheck Protection Program loan receipt status. Staffing variables included registered nurse, licensed practical nurse (LPN), and certified nursing assistant (CNA) total hours per week. Staffing hours were examined on a weekly basis before and after loan receipt during the study period. An event-study approach was used to estimate the staffing total weekly hours at NHs that received PPP loans compared with NHs that did not receive a PPP loan. Among 6008 US NHs, 1807 (30.1%) received a PPP loan and 4201 (69.9%) did not. The median loan amount was $664 349 (IQR, $407 000-$1 058 300). Loan recipients were less likely to be part of a chain (733 [40.6%] vs 2592 [61.7%]) and more likely to be for profit (1342 [74.3%] vs 2877 [68.5%]), be located in nonurban settings (159 [8.8%] vs 183 [4.4%]), have a greater proportion of Medicaid-funded residents (mean [SD], 60.92% [21.58%] vs 56.78% [25.57%]), and have lower staffing quality ratings (mean [SD], 2.88 [1.20] vs 3.03 [1.22]) and overall quality star ratings (mean [SD], 3.08 [1.44] vs 3.22 [1.44]) (P < .001 for all). Twelve weeks after PPP loan receipt, NHs that received a PPP loan experienced a mean difference of 26.19 more CNA hours per week (95% CI, 14.50-37.87 hours per week) and a mean difference of 6.67 more LPN hours per week (95% CI, 1.21-12.12 hours per week) compared with nursing homes that did not receive a PPP loan. No associations were found between PPP loan receipt and weekly RN staffing hours (12 weeks: mean difference, 1.99 hours per week; 95% CI, -2.38 to 6.36 hours per week). In this economic evaluation, a forgivable loan program that required funding to be appropriated toward staffing was associated with a significant increase in CNA and LPN staffing hours among NH PPP loan recipients. Because the PPP loans are temporary, federal and state entities may need to institute sufficient and sustainable support to mitigate NH staffing shortages.

Initial observations on the impact of implementation of a seven-day clinical pharmacy service on dispensary activity and performance

Abstract Introduction The need for seven-day clinical pharmacy services is widely acknowledged, although limited, in the acute sector of the National Health Service.1,2 Timely medicine supply is integral to provision of improved clinical pharmacy services to patients across seven-days, and is essential in effective discharge planning. There is a paucity of evidence for implementation of seven-day clinical pharmacy services, including the impact of service transformation on dispensary activity and performance. This limits planning and development of seven-day pharmacy services. Aim To assess the impact of a seven-day clinical pharmacy service on dispensary activity and performance, at the main site of a tertiary-referral teaching hospital. Methods A seven-day clinical pharmacy service was implemented in October 2021. Prior to this, pharmacy services were largely dispensary-based with clinical pharmacy services for acute and neurosciences admission and limited ward-based services in other specialities. At implementation, clinical pharmacy technicians and pharmacists (n=16) provided patient-facing pharmaceutical care for 7.5-hours/day across all specialities over the weekend; this included medicines reconciliation, preparation of discharge-medication lists, independent prescribing, counselling and clinical review of prioritised patients. The weekend dispensary staffing, skill-mix and shift patterns were redesigned to facilitate staff release from the dispensary rota. Dispensing activity data were obtained from Ascribe for six months pre- and post-implementation (April 2021-March 2022). Data were categorised as inpatient/discharge and the mean number of items dispensed per month analysed using Microsoft Excel. Discharge turnaround performance was calculated as percentage of discharge prescriptions dispensed within two-hours of dispensary receipt and obtained from the Prescription Tracking System. Verbal staff feedback was sought 4-months post-implementation. The study was deemed a service evaluation by the Pharmacy Research and Audit Group and so ethical approval was not required. Results Twelve dispensing staff and one pharmacist were rostered to one of three daily 3.75-hour dispensary shift patterns. Following implementation, mean total inpatient dispensing activity increased from 12799 to 13250 items/month (3.5% increase) and mean weekend activity from 2184 to 2677 items/month (22.6% increase). Mean weekday inpatient activity was stable at 10615 to 10573 items/month. The mean discharge dispensing activity increased from 9065 to 9837 items/month (8.5% increase): mean weekday discharge from 8498 to 8622 items/month (1.5% increase); mean weekend activity from 569 to 1215 items/month (114% increase). Discharge turnaround performance remained stable with 85% discharge prescriptions dispensed within 2-hours, versus 84% pre-implementation. Weekday performance also remained stable - from 84% to 83% and the weekend performance increased from 85% to 92%. Dispensary staff fed-back that weekend shift patterns were effective, activity was manageable and shifts usually ran smoothly and finished on time. Discussion/Conclusion Introduction of a seven-day clinical pharmacy service led to an increase in weekend dispensary activity, which was not offset by decrease in weekday activity. Importantly, the dispensary performance was not negatively impacted and weekend discharge performance improved. Increases could be because of weekend medicines reconciliation, pro-active medication ordering and pharmacist-led preparation of discharge-medicine lists. Dispensary activity in Winter 2020 was atypical because of COVID-19, thus it was not feasible to compare data. Further review, including 12 months data would reduce impact of seasonal variations in NHS activity. Limitations include that patient data including length of stay and time to discharge were not within scope.

Associations Between Daily Nurse Staffing Levels and Daily Hospitalizations and ED Visits in Nursing Homes.

Although many prior studies have shown that high average levels of nurse staffing in nursing homes are associated with fewer hospitalizations, some studies have not, suggesting that the average nursing level may mask a more complex relationship. This study examines this issue by investigating the associations of daily staffing patterns and daily hospitalizations and emergency department (ED) visits. Retrospective analyses of national Payroll Based Journal (PBJ) staffing data merged with the Minimum Data Set. A total of 15,718 nursing homes nationally reporting PBJ data during 2017-2019, their staff, and residents. We estimated facility-day-level models as conditional facility fixed-effect Poisson regressions with robust standard errors. The dependent variables were daily numbers of hospitalization and ED visits and the independent variables of interest were the number of registered nurse (RN), licensed practical nurse (LPN), and certified nurse assistant (CNA) hours on the same and prior days. The daily number of hospital transfers averaged 0.28 (SD 0.21). Daily total direct-care staffing hours averaged 288.7 (SD 188.2), with RNs accounting for 35.0, LPNs for 68.7, and CNAs for 185.0. Higher staffing was associated with more hospitalizations on the concurrent day. Higher staffing on the day prior was associated with fewer hospitalizations. The effect size was larger for RNs and LPNs (same day= ∼2%; prior day= approximately-0.7% to-0.9%) than for CNAs (same day &lt;1%; prior day &lt;-0.5%). ED visits not leading to hospitalizations, and analyses for subsamples exhibited similar findings. Our findings suggest that staff can address developing problems and prevent admissions the next day and identify emergent problems and hospitalize the same day. They also underscore the complex array of nursing home factors involved in hospitalization and ED visits, including the influence of daily staffing variation, suggesting the need for further research to better understand the associations between staffing and appropriate resident transfers to the hospital or the ED, and the potential implications for quality metrics in these domains.

Prudence in end-of-life decision making: A virtue-based analysis of physician communication with patients and surrogates

Despite significant improvements in end-of-life care over several decades, belated hospice referrals and hospital staffing patterns make challenging end-of-life conversations between strangers unsurprising, especially when the interaction is time-sensitive. Understanding how physicians perform under these circumstances is relevant to patient quality and medical education. This study is a secondary analysis of transcripts from a simulation that placed 88 intensivists, hospitalists, and ED physicians in the setting of responding to a nurse's call to evaluate a floor patient for impending respiratory collapse. A philosophical account of prudence guided the analytical approach and was operationalized through behavior-based and exemplar-based qualitative coding strategies. Exemplary performances and specific behaviors were then compared with preferred outcomes. Results indicate that exemplary performance correlated with a cluster of 3 behaviors that predicted the desired outcomes, but did not determine them: (1) directly affirming the likelihood that the patient will die in the near term; (2) explicitly soliciting the patient's preferences for care; and (3) asking what other family and friends should be involved. The current study implies that educational initiatives aimed at improving end-of-life conversations should expose clinicians both to technical competencies and to the virtues required to employ these competencies well.