Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions

Lasater, Karen B.; McHugh, Matthew D.; Rosenbaum, Paul R.; Aiken, Linda H.; Smith, Herbert L.; Reiter, Joseph G; Niknam, Bijan A.; Hill, Alexander S.; Hochman, Lauren L.; Jain, Siddharth; Silber, Jeffrey H.

doi:10.1007/s11606-020-06151-z

Cited by 35 publications

(39 citation statements)

References 36 publications

(43 reference statements)

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“…We report LOS results only for surgical patients because previous work revealed that LOS for medical patients was not associated with either staffing or the work environment. 22 Additional outcomes were derived from the patient survey and dichotomised to facilitate their presentation and interpretation: patient ratings of their hospitals on a 10-point scale (contrasting patients rating their hospital lower than 7 with patients rating it 7 or higher) and whether patients would (or would not) definitely recommend their hospital.…”

Section: Patient and Nurse Outcome Measuresmentioning

confidence: 99%

Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional study

Aiken

Simonetti

Sloane

et al. 2021

The Lancet Global Health

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Background Unrest in Chile over inequalities has underscored the need to improve public hospitals. Nursing has been overlooked as a solution to quality and access concerns, and nurse staffing is poor by international standards. Using Chile's new diagnosis-related groups system and surveys of nurses and patients, we provide information to policy makers on feasibility, net costs, and estimated improved outcomes associated with increasing nursing resources in public hospitals.Methods For this multilevel cross-sectional study, we used data from surveys of hospital nurses to measure staffing and work environments in public and private Chilean adult high-complexity hospitals, which were linked with patient satisfaction survey and discharge data from the national diagnosis-related groups database for inpatients. All adult patients on medical and surgical units whose conditions permitted and who had been hospitalised for more than 48 h were invited to participate in the patient experience survey until 50 responses were obtained in each hospital. We estimated associations between nurse staffing and work environment quality with inpatient 30-day mortality, 30-day readmission, length of stay (LOS), patient experience, and care quality using multilevel random-effects logistic regression models and zero-truncated negative binomial regression models, with clustering of patients within hospitals.Findings We collected and analysed surveys of 1652 hospital nurses from 40 hospitals (34 public and six private), satisfaction surveys of 2013 patients, and discharge data for 761 948 inpatients. Nurse staffing was significantly related to all outcomes, including mortality, after adjusting for patient characteristics, and the work environment was related to patient experience and nurses' quality assessments. Each patient added to nurses' workloads increased mortality (odds ratio 1•04, 95% CI 1•01-1•07, p<0•01), readmissions (1•02, 1•01-1•03, p<0•01), and LOS (incident rate ratio 1•04, 95% CI 1•01-1•06, p<0•05). Nurse workloads across hospitals varied from six to 24 patients per nurse. Patients in hospitals with 18 patients per nurse, compared with those in hospitals with eight patients per nurse, had 41% higher odds of dying, 20% higher odds of being readmitted, 41% higher odds of staying longer, and 68% lower odds of rating their hospital highly. We estimated that savings from reduced readmissions and shorter stays would exceed the costs of adding nurses by US$1•2 million and $5•4 million if the additional nurses resulted in average workloads of 12 or ten patients per nurse, respectively.Interpretation Improved hospital nurse staffing in Chile was associated with lower inpatient mortality, higher patient satisfaction, fewer readmissions, and shorter hospital stays, suggesting that greater investments in nurses could return higher quality of care and greater value.

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Section: Patient and Nurse Outcome Measuresmentioning

confidence: 99%

Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional study

Aiken

Simonetti

Sloane

et al. 2021

The Lancet Global Health

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“…A study of adult medical patients showed that patients in hospitals with better nurse resources had better outcomes including less mortality, fewer readmissions and shorter lengths of stay—at no difference in cost, when compared with similar patients in hospitals with poorer resources. 23 These study findings have been corroborated in surgical patients; 24 25 and find that improving nurse staffing would avoid adverse outcomes with sizeable cost savings to hospitals. 26 …”

Section: Introductionmentioning

confidence: 64%

Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study

et al. 2021

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ObjectiveTo evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals.DesignCross-sectional analysis of multiple data sources including a 2020 survey of nurses linked to patient outcomes data.Setting: 87 acute care hospitals in Illinois.Participants210 493 Medicare patients, 65 years and older, who were hospitalised in a study hospital. 1391 registered nurses employed in direct patient care on a medical–surgical unit in a study hospital.Main outcome measuresPrimary outcomes were 30-day mortality and length of stay. Deaths avoided and cost savings to hospitals were predicted based on results from regression estimates if hospitals were to have staffed at a 4:1 ratio during the study period. Cost savings were computed from reductions in lengths of stay using cost-to-charge ratios.ResultsPatient-to-nurse staffing ratios on medical-surgical units ranged from 4.2 to 7.6 (mean=5.4; SD=0.7). After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by 16% for each additional patient in the average nurse’s workload (95% CI 1.04 to 1.28; p=0.006). The odds of staying in the hospital a day longer at all intervals increased by 5% for each additional patient in the nurse’s workload (95% CI 1.00 to 1.09, p=0.041). If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million.ConclusionsPatient-to-nurse staffing ratios vary considerably across Illinois hospitals. If nurses in Illinois hospital medical–surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.

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“…Improving the nurse work environment is a solution that can be employed in these hospitals in order to combat chronic and acute threats to hospital care delivery. We know that there continues to be significant variation in quality of care and nurse outcomes across hospitals (Lasater et al, 2020). An important next step would be to evaluate the relationships we examined herein in more current data to determine whether the findings are stable or whether there have been changes relative to the baseline we establish in this study, perhaps induced by the COVID-19 pandemic.…”

Section: Discussionmentioning

confidence: 93%

Care Quality, Patient Safety, and Nurse Outcomes at Hospitals Serving Economically Disadvantaged Patients: A Case for Investment in Nursing

Viscardi¹,

French

Brom

et al. 2022

Policy, Politics, & Nursing Practice

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We sought to evaluate if better work environments or staffing were associated with improvements in care quality, patient safety, and nurse outcomes across hospitals caring for different proportions of patients who are economically disadvantaged. Few actionable approaches for hospitals with quality and resource deficits exist. One solution may be to invest in the nurse work environment and staffing. This cross-sectional study utilized secondary data from 23,629 registered nurses in 503 hospitals from a four-state survey collected in 2005–2008. Each 10% increase in the proportion of patients who are economically disadvantaged was associated with 27% and 22% decreased odds of rating unit-level care quality as excellent and giving an “A” safety grade, respectively. Each 10% increase was also associated with 9%, 25%, and 11% increased odds of job dissatisfaction, intent to leave, and burnout, respectively. The work environment had the largest association with each outcome. Accounting for the nurse work environment lessened or eliminated the negative outcomes experienced at hospitals serving high proportions of patients who are economically disadvantaged. Leaders at hospitals serving high proportions of patients who are economically disadvantaged, as well as state and federal policymakers, should work to improve quality, safety, and nurse outcomes by strengthening nurse work environments. Improving work environments highlights the role of nursing in the health care system, and policies focused on work environments are needed to improve the experiences of patients and nurses, especially at hospitals that care for many patients who are economically disadvantaged.

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Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions

Cited by 35 publications

References 36 publications

Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional study

Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional study

Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study

Care Quality, Patient Safety, and Nurse Outcomes at Hospitals Serving Economically Disadvantaged Patients: A Case for Investment in Nursing

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