Christine Mueller

The Association of Registered Nurse Staffing Levels and Patient Outcomes Systematic Review and Meta-Analysis

Objective:To examine the association between registered nurse (RN) staffing and patient outcomes in acute care hospitals. Study Selection:Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol. Data Synthesis:Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN staffing was associated with lower hospital related mortality in intensive care units (ICUs) [odds ratios (OR), 0.91; 95% confidence interval (CI), 0.86–0.96], in surgical (OR, 0.84; 95% CI, 0.80–0.89), and in medical patients (OR, 0.94; 95% CI, 0.94–0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56–0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36–0.67), respiratory failure (OR, 0.40; 95% CI, 0.27–0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62–0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79–0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62–0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55–0.86). Conclusions:Studies with different design show associations between increased RN staffing and lower odds of hospital related mortality and adverse patient events. Patient and hospital characteristics, including hospitals’ commitment to quality of medical care, likely contribute to the actual causal pathway.

Improving resident outcomes with GAPN organization level interventions

This research tested the effectiveness of the second tier of interventions in a two-tiered nursing intervention model designed to improve quality of care for residents in long-term care facilities (LTCFs). The first tier of the model called for gerontological advanced practice nurses (GAPNs) to provide direct care and to teach staff to implement care protocols for residents with incontinence, pressure ulcers, depression, and aggression. Results of the first-tier study indicated significant improvement in resident outcomes in incontinence, pressure ulcers, and aggression. In the second tier, GAPNs added a set of organization-level (OL) interventions including membership on the LTCF quality assurance committee and collaborating with staff on problem-solving teams. Analysis following the addition of OL interventions revealed significant improvement in both depression scores and in the trajectory of depression in residents of the LTCF where OL interventions were used.

Falls and Nursing Home Residents With Cognitive Impairment: New Insights into Quality Measures and Interventions

OBJECTIVES Prevention and public reporting of falls have suffered due to inadequate attention given to the association of falls and cognitive impairment (CI) among nursing home (NH) residents. This study examines the relationship between CI, residence on dementia special care units (SCUs) and other resident characteristics and likelihood of residents experiencing new falls in NHs. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS A total of 21,587 residents from 381 Minnesota NHs. MEASUREMENTS The NH Minimum Data Set (MDS) for 21,587 residents from 381 Minnesota NHs in the first calendar quarter of 2008 were analyzed. New falls, (fall noted on a current MDS assessment but not on a prior assessment); cognitive status, (as defined by Cognitive Performance Scale); residence on an SCU, and health and functional status covariates were recorded. A random effects logistic regression model was used to examine relationships between new falls and the residents cognitive status, type of unit, and covariates. RESULTS The likelihood of a new fall had a nonlinear association with CI. Compared with residents with normal or mild CI, the likelihood of a new fall was significantly higher among residents with moderate CI (OR= 1.43). The risk decreased slightly (OR= 1.34) for residents with more advanced CI, whereas the presence of severe CI was not significantly associated with new falls. Overall the likelihood of new falls was significantly higher for residents on SCUs compared with those on conventional units (OR= 1.27). CONCLUSIONS Severity of CI and residence on SCU impact fall incidence and should be accounted for in future fall- prevention interventions and quality-reporting indicators and measures.

ANA nurse sensitive quality indicators for long-term care facilities.

Nurse sensitive quality indicators, developed through the American Nurses Associations (ANA) Safety and Quality Initiative, are key to evaluating the quality of patient care in acute care settings. This study found that the ANA quality indicators were also relevant for long-term care facilities. Long-term care facilities can be part of the ANA Safety and Quality Initiative by collecting and reporting nurse sensitive quality indicators and submitting data to the National Database of Nursing Quality Indicators.

Prevalence of Incontinence by Race and Ethnicity of Older People Admitted to Nursing Homes

OBJECTIVE While admissions of minorities to nursing homes (NHs) are increasing and prevalence of incontinence in NHs remains high, little is known about incontinence among racial-ethnic groups of NH admissions other than blacks. The purpose of this study was to describe the prevalence of incontinence among older adults admitted to NHs by race/ethnicity at three levels of measurement: individual resident, NH, and Census division. DESIGN Cross-sectional and descriptive. PARTICIPANTS AND SETTING Admissions of persons age 65 or older to 1 of 457 NHs of a national, for-profit chain over 3 years 2000-2002 (n = 111,640 residents). METHODS Data sources were the Minimum Data Set v. 2.0 and 2000 US Census. Prevalence of the following definitions of incontinence was analyzed: Only Urinary Incontinence (UI), Only Fecal Incontinence (FI), Dual Incontinence (DI; UI and FI), Any UI (UI with or without FI), Any FI (FI with or without UI), and Any Incontinence (UI and/or FI and/or DI). RESULTS Asian patients, black patients, and Hispanic patients had a higher prevalence of Any Incontinence (67%, 66%, and 58%, respectively) compared to white patients (48%) and American Indian patients (46%). At the NH level, all prevalence measures of incontinence (except Only UI) appear to trend in the opposite direction from the percentage of NH admissions who were white. Among Asian and white patients, there was a higher prevalence of all types of incontinence in men compared with women except for Only UI. Among Census divisions, the prevalence of all types of incontinence, except Only UI, was lowest in the 2 divisions with the highest percentage of white admissions to their NHs. CONCLUSIONS NHs admitting more racial/ethnic minorities may be faced with managing more incontinence and needing additional staffing resources. The association of the prevalence of most types of incontinence with the race/ethnicity of NH admissions at all levels of measurement lend support to the growing evidence that contextual factors beyond individual resident characteristics may contribute to NH differences.

Medication regimens in older home care patients.

Medication regimens in older patients have been strongly associated with adverse events leading to hospitalization in ambulatory care settings. Despite a 29% hospitalization rate, to date, no research regarding medication regimens and readmission to the hospital has been completed in the home care setting. As part of a larger study evaluating predictors of readmission to the hospital from home care, descriptive analyses, chi-square tests, and t tests for independent samples were used in this secondary analysis to evaluate the Outcome and Assessment Information Set and medication records from 911 older patients admitted from the hospital to 15 home care agencies. Patients readmitted back to the hospital were older, sicker, and more cognitively impaired, and had complex medication regimens that included significant polypharmacy and inappropriate medication use. Nurses working with older adults need to be especially vigilant in monitoring medication regimens of patients to reduce opportunities for adverse drug events and subsequent hospitalization.

Translating research on incontinence into practice

Background: Translating research evidence into clinical practice (TRIP) is an important initiative for health services so that care delivered is cost-effective, is efficient, and improves patient outcomes. Most TRIP studies have reported on disseminating and implementing clinical practice guidelines, protocols, or care pathways and have been undertaken in acute rather than community settings. Objectives: To identify the factors that influence incontinence TRIP and to present key international studies on incontinence TRIP. Methods: Existing literature on TRIP was analyzed to generate a plan for future research. Results: Several methods to effect incontinence TRIP are described, including clinical practice guidelines and protocols, clinical pathways, partnerships between organizations, a model for incorporating UI research based on generic questions, and implementation strategies that incorporate change theory and consideration of barriers. Conclusions: Future research is needed on incontinence TRIP in the following areas: barriers, the best theoretical approaches, the effectiveness of empowerment approaches, the value of mentors, effective strategies for nurses and unlicensed personnel, the impact of international collaboration, and regulations across settings.

The pivotal role of the director of nursing in nursing homes

The impending wave of aging boomers heightens long-standing concerns for the quality and cost of nursing home care. As industry and policy leaders continue efforts to remedy substandard nursing home care delivery practices, development of a well-prepared and adequately supported workforce of directors of nursing (DONs) is essential to ensuring the industrys readiness for the aging wave population. Directors of nursing are in pivotal positions to influence nursing home quality and costs; however, research demonstrating the extent of this influence—actual and potential—is lacking, and industry leaders have collectively failed to address the current or future capacity of this workforce. A long history of inattention to the DON position, coupled with low expectations for the competencies and requisite educational preparation, has potentially compromised the capacity of DONs to promote and sustain high-quality, cost-effective nursing home care. The purpose of this article is to provide a comprehensive overview and discussion of the current and potential capacity of DONs to lead the delivery of high-quality, cost-effective nursing home care from industry, educational and professional development, healthcare policy, and organizational contexts. Proposed strategies and recommendations to enhance and promote the future capacity of DONs are also presented.

Minnesota's Nursing Facility Performance-Based Incentive Payment Program: An Innovative Model for Promoting Care Quality

PURPOSE Minnesotas Nursing Facility Performance-Based Incentive Payment Program (PIPP) supports provider-initiated projects aimed at improving care quality and efficiency. PIPP moves beyond conventional pay for performance. It seeks to promote implementation of evidence-based practices, encourage innovation and risk taking, foster collaboration and shared learning, and establish a solid case for investing in better quality from the perspective of the state, providers, and consumers. We explain PIPP rationale and design, describe projects and participating facilities, and present findings from interviews with project leaders. DESIGN AND METHODS Provider-initiated projects lasting from 1 to 3 years are selected through a competitive process and are funded for up to 5% of the daily operating per diem rate. Providers are at risk of losing up to 20% of their project funding if they fail to achieve targets on state nursing facility performance measures. RESULTS Minnesota has made a major investment in the PIPP by supporting 45 individual or collaborative projects, representing approximately 160 facilities and annual funding of approximately

The RUG-III case mix classification system for long-term care nursing facilities: is it adequate for nurse staffing?

18 million. Projects involve a wide range of interventions, such as fall reduction, wound prevention, exercise, improved continence, pain management, resident-centered care and culture change, and transitions to the community. IMPLICATIONS The PIPP can serve as a model for other states seeking to promote nursing facility quality either in combination or in place of conventional pay-for-performance efforts.