Staffing Patterns Research Articles

Evaluating the Role of Patient Sample Definitions for Quality Indicators Sensitive to Nurse Staffing Patterns

Administrative data are an attractive data source for the construction of quality indicators to assess and monitor quality of nursing care in hospitals. Current approaches to constructing measures from discharge abstracts apply substantial restrictions to exclude patients at high risk or with preexisting conditions. This study evaluates whether broader sample definitions combined with risk adjustment would allow for larger samples and increase analytic power. Eight indicators were constructed from discharge abstracts of major surgical and medical patients from 799 hospitals in 11 states using existing definitions: pneumonia, urinary tract infection, decubitus ulcers, central nervous system complications, shock, sepsis, pulmonary failure, and upper gastrointestinal bleeding. We tested the effect of broadening the samples in 4 ways: comparing indicator rates in the broader and restrictive samples; assessing correlations of hospital ranks in the broader and restrictive samples; performing clinical reviews of cases in the added samples; and using different samples in regressions of indicators on nurse staffing variables, adjusting for patient risk. Indicator rates in the broader samples tended to be higher but did not change hospital rankings significantly. Clinical review suggested that many sample restrictions could be dropped. Using indicators based on broader definitions, coefficients on staffing variables increased in magnitude. Less restrictive sample definitions were shown to be feasible and increased the sensitivity of the indicators and thus the power of the analysis. Particularly in surgical patients, the samples could be broadened, although more conservative definitions appeared appropriate for medical patients.

An Integrated Analysis of Nurse Staffing and Related Variables: Effects on Patient Outcomes

The objective of this article is to synthesize much of the research done on nurse staffing and patient outcomes; the impact of organizational characteristics on nurse staffing patterns, patient outcomes, and costs; and the impact of nurses' experience on patient outcomes. The author concludes research indicates that nurse staffing has a definite and measurable impact on patient outcomes, medical errors, length of stay, nurse turnover, and patient mortality. Moreover, the literature reports data that help determine what is, indeed, appropriate staffing. Ratios are important--a consensus seems to be emerging supporting a range of from 4 to 6 patients per nurse in most acute care hospital inpatient settings, with no more than one to two patients per nurse in areas of high patient acuity. However, ratios must be modified by the nurses' level of experience, the organization's characteristics, and the quality of clinical interaction between and among physicians, nurses, and administrators.

Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients: A Systematic Review

Survey of Anesthesiology: August 2003 - Volume 47 - Issue 4 - p 196-197 doi: 10.1097/01.sa.0000087673.65158.1b

Roles and Responsibilities of Attending Physicians in Skilled Nursing Facilities

There is an ongoing public debate on the perceived lack of quality care in many nursing facilities and the best means for improvement. Suggested solutions include improving reimbursement, mandating staffing levels, implementing practice guidelines and other care processes, reducing the regulatory burden, increasing the use of managed care, and much more. Little research has been done on the relationship between physician involvement and quality of care in nursing facilities. Recent literature suggests that quality of care in various settings, including nursing facilities, is related to physician involvement and physician staffing patterns. The Committee on Improving Quality in Long-Term Care of the Institute of Medicine believes that “nursing homes should. . .enable and require a more focused and dedicated medical staff” as part of the solution for improving quality. The American Medical Directors Association (AMDA) has always maintained that physician involvement in long-term care is essential to the delivery of quality care. Beginning with the shift in hospital reimbursement some two decades ago, there has been a shift in the type of population cared for in skilled nursing facilities. With the compression of morbidity, today’s older people have less disability, enabling them to take advantage of new options in community-based and assisted living programs. Today’s nursing facility residents are those for whom no other option exists: they need high acuity postacute or end-of-life care, are increasingly frail and medically complex, and more than half suffer from dementia. But paradigms of care have not shifted significantly in tandem with these changes. The current nursing-dominated process of care, combined with staffing shortage and competency issues, simply does not suffice, as evidenced by reports of inadequate care and the mounting liability crisis. Despite increasing medical complexity and acuity over time, physician involvement in nursing facilities has been inadequate. Physicians are reluctant to get involved for various reasons related to reimbursement, regulations, negative public perception, liability, and the unfamiliar nursing home culture and practice environment. Yet today’s nursing facility population requires much more medical attention than what is generally available. Given the acuity and medical complexity of today’s nursing facility residents, improvement in quality of care and resolution of the liability crisis can be achieved if attending physicians change the way they provide care to their nursing facility residents and treat them in the same manner they treat residents in the office or hospital. For example, physicians should be prepared to be available, personally or via adequate coverage arrangements, to see residents as often as medical conditions require, as well as proactively anticipating and arranging for follow-up visits. The attending physician must also understand that nursing facility residents require an approach to care that combines chronic and acute elements. In addition to attention to apparent and to difficult-to-recognize acute or subacute problems (for example, delirium), attention must be directed to chronic problems, functional impairments and disabilities, palliative care, risks and preventive care, psychosocial and family issues, all in the context of resident choices, preferences or advanced directives and quality of life concerns. In addition, all this needs to be done within a difficult regulatory, institutional, and reimbursement environment requiring team work and specific documentation. It is the medical director’s responsibility to educate attending physicians about these issues as well as to provide them with tools and processes that help them practice quality care. Attending physicians should be educated in geriatric care principles, a process of care that includes recognition of multiple problems, cause assessment, care goals and planning, evidence-based intervention, geriatric prescribing, and care monitoring. They should be vigilant in attempting to obtain clinical information that is often minimal and provide adequate documentation rather than leaving it to others. They should have a working knowledge of available geriatric assessment tools the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), and Resident Assessment Protocols (RAPs) as well as various state-specific assessment and transfer documents. Finally, they should understand and document the basis for billing level decisions as well as their supervision of midlevel practitioners. Medical practice in nursing facilities is different than in other practice locations. Because of the special population served, physicians must work as members of the care team, and must understand regulatory and other requirements that are different than those in other practice settings. A previous review listed regulatory and accreditation requirements related to the role and responsibilities of attending physicians. The majority of recommendations in this review regarding physicians’ roles and responsibilities are driven by regulatory requirements. Few are based on evidence from the Medical Director, Lutheran Augustana Center for Extended Care and Rehabilitation, Director of Geriatrics, Lutheran Medical Center, Brooklyn, New York.

Roles and responsibilities of attending physicians in skilled nursing facilities.

There is an ongoing public debate on the perceived lack of quality care in many nursing facilities and the best means for improvement. Suggested solutions include improving reimbursement, mandating staffing levels, implementing practice guidelines and other care processes, reducing the regulatory burden, increasing the use of managed care, and much more. 1,2 Little research has been done on the relationship between physician involvement and quality of care in nursing facilities. Recent literature suggests that quality of care in various settings, including nursing facilities, is related to physician involvement and physician staffing patterns.

Incidence and Costs of Acute Medical Conditions in Long-Stay Incontinent Nursing Home Residents

Objectives To determine the incidence of acute medical conditions in incontinent nursing home residents, and associated costs of diagnostic testing and treatment Design Prospective, cohort study. Setting Three community nursing homes. Participants 161 long-stay residents with urinary incontinence in (mean age 86 years, 77% female, 92% white). Measurements Acute medical conditions were identified prospectively through medical record review based on standardized criteria. All diagnostic testing and treatment provided for these conditions were recorded, and related costs in the nursing home were assigned based on 1997–1998 Medicare and Medicaid reimbursement. Results The highest incidences of illness were for dermatological conditions (107 episodes per 1000 patient-weeks, involving 70% of subjects), respiratory illnesses (29 per 1000 patient-weeks, 47% of subjects) and gas-trointestinal illnesses (24 per 1000 patient-weeks, 36% of subjects). Among episodes with an incidence of at least 5 per 1000 patient-weeks, the illness events with the highest median diagnostic testing and treatment costs per episode were pneumonia, acute bronchitis, and depression. Only 42 out of the total 1071 episodes identified resulted in a hospitalization. Significant predictors of higher illness incidence included greater baseline comorbidity and higher number of routine medications (model adjusted R-square = 0.319, P = 0.021). Conclusion Acute illness is very common among incontinent nursing home residents, and is generally diagnosed and treated at the nursing home site, with variation among conditions in associated costs. Important policy implications include resource allocation (including appropriate staffing patterns), educational and quality improvement activities, and future research and guideline development for the optimal management of medical conditions in the nursing home setting.

Incidence and costs of acute medical conditions in long-stay incontinent nursing home residents.

To determine the incidence of acute medical conditions in incontinent nursing home residents, and associated costs of diagnostic testing and treatment Prospective, cohort study. Three community nursing homes. 161 long-stay residents with urinary incontinence in (mean age 86 years, 77% female, 92% white). Acute medical conditions were identified prospectively through medical record review based on standardized criteria. All diagnostic testing and treatment provided for these conditions were recorded, and related costs in the nursing home were assigned based on 1997-1998 Medicare and Medicaid reimbursement. The highest incidences of illness were for dermatological conditions (107 episodes per 1000 patient-weeks, involving 70% of subjects), respiratory illnesses (29 per 1000 patient-weeks, 47% of subjects) and gas-trointestinal illnesses (24 per 1000 patient-weeks, 36% of subjects). Among episodes with an incidence of at least 5 per 1000 patient-weeks, the illness events with the highest median diagnostic testing and treatment costs per episode were pneumonia, acute bronchitis, and depression. Only 42 out of the total 1071 episodes identified resulted in a hospitalization. Significant predictors of higher illness incidence included greater baseline comorbidity and higher number of routine medications (model adjusted R-square = 0.319, P = 0.021). Acute illness is very common among incontinent nursing home residents, and is generally diagnosed and treated at the nursing home site, with variation among conditions in associated costs. Important policy implications include resource allocation (including appropriate staffing patterns), educational and quality improvement activities, and future research and guideline development for the optimal management of medical conditions in the nursing home setting.

Responsibilities of attending physicians in long-term care facilities.

Physicians have been reluctant to attend to residents in skilled nursing facilities. However, cooperation of primary care physicians, and physician staffing patterns, are key to providing quality care to residents in skilled nursing facilities as well as maintaining regulatory compliance and Joint Commission for Accreditation of Healthcare Organizations accreditation status. In 1974 federal regulations mandated the position of medical director in skilled nursing facilities, whose function was to coordinate the medical care in the facility. Additional regulations in 1987 further defined the role of the medical director to include implementation of medical care policies in addition to medical care coordination. The same regulations also define multiple responsibilities of the primary care physicians. In order to fulfill their responsibilities, medical directors must secure availability and cooperation of attending physicians by providing physicians with an efficient practice environment and a clear set of expectations. In addition, medical directors must develop and implement general processes of care that assure appropriate care delivery, assess physicians performance, and hold physicians accountable. The delineation of physicians responsibilities described in this article provides medical directors with a minimum set of expectations that ought to be required of physicians practicing in any skilled nursing facility. The responsibilities enumerated in the document are based mostly on regulatory requirements and the Joint Commission 1998 standards. The applicable regulatory section (known as “F” tag), or the Joint Commission specific standard are referenced in the text. (The Joint Commission standards referenced in the text include Leadership LD, Residents Rights and Organizational Ethics RI, Continuum of Care CC, Assessment of Residents PE, and Care and Treatment of Residents TX). In addition, Medicare and Medicaid documentation and medical necessity requirements were considered in developing this document. ETHICAL AND LEGAL RESPONSIBILITIES

Approval Times For New Drugs: Does The Source Of Funding For FDA Staff Matter?

The Food and Drug Administration (FDA) has been criticized for injudicious and excessively rapid approval of new drugs as a result of pharmaceutical industry influence. Many critics focus on the Prescription Drug User Fee Act (PDUFA) of 1992, which augmented the FDA's budget through the charging of user fees. We assess the effect of FDA staffing patterns and attributes of submitting firms on approval times for 843 new drug applications (NDAs) submitted between 1977 and 2000. NDA review times shortened by 3.3 months for every 100 additional FDA staff. The amount of funding for FDA staff appears to be a much more important influence on NDA review time than the source of funding.

Regional after-hours urgent care provided by a tertiary children's hospital.

Ambulatory presentation to a tertiary pediatric emergency department (ED) is not convenient for many families. Yet many primary care pediatricians (PCPs) desire after-hours urgent care for their patients as an alternative to extended office hours or care by general emergency medicine providers at community hospitals. To describe a regional, community-based pediatric urgent care network (PUCN). The PUCN consists of 4 models: 1) pediatric emergency medicine faculty in a community hospital ED; 2) general pediatricians in a community hospital ED; 3) general pediatricians in a freestanding urgent care center; and 4) general pediatricians in a community hospital-based urgent care center. Physician staffing at all 4 sites is managed by our tertiary children's hospital. Billing records were reviewed and a questionnaire was mailed to 55 PCP practices in our metro area. Year 2001 visits totaled 37 143. Minor trauma, ear complaints, and viral illnesses accounted for 70% of visits. Current Procedural Terminology codes for visits, reflecting complexity levels 1, 2, 3, 4, and 5 were billed at the following frequency: 1%, 35%, 44%, 17% and 3%, respectively. A total of 2.2% of visits required admission or transfer. Mean collection rates ranged from 37% to 68% across the 4 sites. Break-even average hourly patient volumes ranged from 1.1 (site 4) to 1.9 (sites 1 and 3). A total of 110 PCPs, representing all 55 practices, responded to the questionnaire: 81% reported their patients used the PUCN often, 85% felt that communication between the PUCN and their practice was good, and 99% reported overall satisfaction with the network. The PUCN effectively addresses the needs of regional PCPs; however, the cost-effectiveness of such a program depends on billing practices, local collection rates, and site-specific staffing patterns.

Does Care by Intensivists Improve Outcomes in the ICU

Study results suggest that physician staffing patterns affect clinical outcomes in intensive care units. In this systematic review, researchers

Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review.

Intensive care unit (ICU) physician staffing varies widely, and its association with patient outcomes remains unclear. To evaluate the association between ICU physician staffing and patient outcomes. We searched MEDLINE (January 1, 1965, through September 30, 2001) for the following medical subject heading (MeSH) terms: intensive care units, ICU, health resources/utilization, hospitalization, medical staff, hospital organization and administration, personnel staffing and scheduling, length of stay, and LOS. We also used the following text words: staffing, intensivist, critical, care, and specialist. To identify observational studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non-English-language citations, we reviewed only English-language articles. We also searched EMBASE, HealthStar (Health Services, Technology, Administration, and Research), and HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful Med and The Cochrane Library and hand searched abstract proceedings from intensive care national scientific meetings (January 1, 1994, through December 31, 2001). We selected randomized and observational controlled trials of critically ill adults or children. Studies examined ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and length of stay (LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590 abstracts and identified 26 relevant observational studies (of which 1 included 2 comparisons), resulting in 27 comparisons of alternative staffing strategies. Twenty studies focused on a single ICU. We grouped ICU physician staffing into low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. High-intensity staffing was associated with lower hospital mortality in 16 of 17 studies (94%) and with a pooled estimate of the relative risk for hospital mortality of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing was associated with a lower ICU mortality in 14 of 15 studies (93%) and with a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI, 0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU LOS in both studies that adjusted for case mix. No study found increased LOS with high-intensity staffing after case-mix adjustment. High-intensity vs low-intensity ICU physician staffing is associated with reduced hospital and ICU mortality and hospital and ICU LOS.

Mental Health Services in Nursing Homes: Introduction to Special Section

Back to table of contents Previous article Next article Special Section on Long-Term CareFull AccessMental Health Services in Nursing Homes: Introduction to Special SectionMarion Zucker Goldstein, M.D.Marion Zucker GoldsteinSearch for more papers by this author, M.D.Published Online:1 Nov 2002https://doi.org/10.1176/appi.ps.53.11.1389AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail A multidisciplinary consensus conference on providing optimal mental health services in long-term care was held June 22 to 24, 2000, in Washington, D.C. The conference, on which this special section is based, was conceived and implemented by a steering committee whose members represented the American Association for Geriatric Psychiatry, the American Psychiatric Association, the American Society for Consultant Pharmacists, the American Psychological Association, the American Geriatrics Society, the American College of Health Care Administrators, and the National Association of Directors of Nursing Administration.Barriers to research and to the implementation of findings that would improve the quality of life of the increasing number of nursing home patients and their families remain most difficult to penetrate (1). Despite these barriers, considerable advances have been made in our knowledge of the assessment, incidence, and prevalence of psychiatric disorders and the inordinate unmet need for mental health services in nursing homes.To overcome barriers to high-quality mental health services in nursing homes, insight into the systems in which they occur is vital (2). An understanding of governmental agencies, oversights, and payment policies as well as clarification of the role and competencies of primary care physicians, psychiatrists, psychologists, pharmacists, social workers, nurses, and administrators is essential. The authors of the five articles in this special section address these issues.Stephen J. Bartels, M.D., M.S., and his coauthors (see page 1390) reviewed the literature on the effectiveness of optimal models of service delivery in nursing homes and on provider surveys. Although they advocate more rigorous outcome studies on the optimal intensity of services, composition of interdisciplinary teams, competencies, and cost-effectiveness, their review confirms that most effective interventions blend consultation with the training and education of primary care physicians and frontline nursing staff.In the second article, Cameron J. Camp, Ph.D., and his colleagues (see page 1397) define the various subtypes of inappropriate behaviors observed among persons with dementia and the unmet needs reflected by such behaviors. This well-referenced analysis of individualized needs assessments is interspersed with an equally well-supported rationale for interventions that are proven to be effective. The authors confirm that much education is necessary to bring the advances made by research into the practice arena and highlight the need for future research.Next, Marisue Cody, Ph.D., R.N., and her colleagues (see page 1402) address barriers that arise from nursing home organization and structure and that are compounded by external barriers from regulatory agencies and legal and economic constraints. The authors give specific recommendations related to communications and environmental adaptations that can overcome internal barriers. The need to overhaul staffing patterns, education, and reimbursements is an ongoing outcry of all who wish to improve conditions in nursing homes. The authors also discuss their recommendation that nursing homes adopt a risk management approach similar to that used by hospitals.In the fourth article J. Michael Ryan, M.D., and his colleagues—a fellow psychiatrist and two pharmacists—address the use of psychotropic, antidepressant, anticonvulsant, and cholinesterase-inhibiting medications from both a historical and a regulatory perspective (see page 1407). They bring readers up-to-date on the outcomes of several randomized, placebo-controlled studies that provide an evidence base for various prescribing decisions. Whether and how this research proceeds will depend on federal, state, and local governments and on the pharmaceutical industry. The lack of interface between pharmacologic and nonpharmacologic treatments is apparent and regrettable.Finally, Joel E. Streim M.D., and his coauthors discuss regulatory oversight, payment policy, and quality improvement in the provision of mental health services in nursing homes (see page 1414). The many acronyms that have been generated by government agencies over the past 15 years are clearly explained within their evolving contexts. The authors clarify the roles of the psychiatrist, the psychologist, and the social worker in budgetary processes, including denial of medically necessary medical mental health services. They explain concisely how assessment, quality measures, and payment policy must be coordinated so that nursing home patients can have access to medical mental health services when "medically necessary." They point out that mental health providers must be offered appropriate financial incentives to work in nursing homes.Dr. Goldstein, guest editor of this special section, is associate professor of psychiatry in the division of geriatric psychiatry at the School of Medicine and Biomedical Sciences at the State University of New York at Buffalo. Send correspondence to her at the Erie County Medical Center, Department of Psychiatry, 462 Grider Street, Buffalo, New York 14215 (e-mail, [email protected]).

An observation unit in a pediatric emergency department: One children's hospital's experience

Introduction: The observation unit at The Children's hospital in Denver is a care delivery system which provides expanded ED services to patients. The purposes of this study of the observation unit included: constructing a demographic profile; determining the distribution of admissions by diagnosis and related disposition; and evaluating staffing patterns and nursing workload. Issues related to safety, length of stay, and appropriate utilization were raised as well as the need to accurately identify the most effective nursing staff requirements to provide safe, quality care. Methods: A sample of all patients admitted to the ED observation unit over a 6-month period (686 patients, 4.8% of ED patients) was studied. Descriptive statistics were used to describe the sample of patients. Nurse-to-patient staff ratios were calculated utilizing the BENCHmarking Effort to Network Children's Hospitals parameters. Results: The average age of patients admitted to the observation unit was 4.36 years, equally distributed between males and females. Diagnostic categories were correlated to length of stay. Patients with respiratory illnesses required the longest observation. The majority of patients were discharged home after an average stay of 8.4 hours. Discussion: Study findings inform clinical staffing and formulate guidelines for the ED observation unit usage.

Awards Honor Psychiatrists Who Confront Obstacles to Patient Care

Awards Honor Psychiatrists Who Confront Obstacles to Patient Care

Responsibilities of Attending Physicians in Long-Term Care Facilities

Physicians have been reluctant to attend to residents in skilled nursing facilities.1–3 However, cooperation of primary care physicians,4 and physician staffing patterns,5 are key to providing quality care to residents in skilled nursing facilities as well as maintaining regulatory compliance6 and Joint Commission for Accreditation of Healthcare Organizations accreditation status.7 In 1974 federal regulations mandated the position of medical director in skilled nursing facilities, whose function was to coordinate the medical care in the facility.

Management of an Inpatient-Outpatient Clinic

Healthcare organizations have historically separated outpatient from inpatient facilities. In order to streamline the continuity of high quality care, an outpatient burn clinic was established on our inpatient burn center in 1991. Management of the outpatient clinic required alternate staffing patterns and supply allocation plus training in managed care and third party payors. Budget decisions and health care trends affected the number of full time equivalents (FTEs). Between 1990 and 1998, a 33% RN FTE reduction occurred with an overall 22% decrease in total inpatient care providers. Clinic positions were allocated as patient volume and workload data could justify additional staff. Enhanced flexibility in assignment and use of personnel with varying skill levels led to efficient integration of inpatient and outpatient care with an overall reduction in RN FTEs. The purpose of this study is to review the changes in nursing management strategies required by this consolidation.

A divided land: Probable impacts of current affirmative action and employment law trends on criminal justice staffing patterns in 2010*

This article describes for us how in the 1950s and 1960s we witnessed the anti‐discrimination movement gain momentum. What has happened since? The current legal and political climate is such that virtually any decision involving hiring, training, or promotion can be challenged when a member of a minority group competes with a member of the majority group. Critics of affirmative action seldom consider that one of the underlying purposes of affirmative action was to overcome the inherent advantage of those who are members of the long standing, ‘informal system’ of privilege and preference. The justice professional of this century will have to be a strategic thinker—a strategic practitioner, to avoid the behavioral implications of the current trends in public sector employment law and most specifically, affirmative action law.

Concentrated Poverty and Nursing Home Bed Supply in Chicago

This study explores whether poverty areas of Chicago have fewer nursing home beds and unique staffing patterns. Using 1990 census data and Illinois's 1994 Long-Term Care Facility Survey, census tracts were compared by need for long-term care, bed supply, and nursing home characteristics. While facilities cluster on the north side, and the number of beds follow the elderly, the supply of beds per elderly is actually greater in tracts with high proportions of poverty, disability, and African American residents due, in part, to the predominance of larger facilities. Ironically, economic segregation may work together with Medicaid's policy of serving the poorest to increase the supply of beds to those who might otherwise remain unserved. Nursing homes in the poorest communities have high percentages of Medicaid residents, are larger, and employ fewer staff per resident; homes with a high Medicaid population are more likely to employ LPNs, which may reflect labor supply differences.

Give emergency medicine true departmental control.

As early as 1958, confronted by a 400% rise in emergency department (ED) visits in 15 years, the medical community called for a modernization of the staffing patterns in emergency rooms.1 This critical mass of need resulted in the establishment of the first “ER” and emergency physician group in 1961. Over the next 2 decades, emergency medical services developed, and emergency medicine became a specialty with its own training and board certification.