Jeannie P. Cimiotti

Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments.

Context:Better hospital nurse staffing, more educated nurses, and improved nurse work environments have been shown to be associated with lower hospital mortality. Little is known about whether and under what conditions each type of investment works better to improve outcomes. Objective:To determine the conditions under which the impact of hospital nurse staffing, nurse education, and work environment are associated with patient outcomes. Design, Setting, and Participants:Outcomes of 665 hospitals in 4 large states were studied through linked data from hospital discharge abstracts for 1,262,120 general, orthopedic, and vascular surgery patients, a random sample of 39,038 hospital staff nurses, and American Hospital Association data. Main Outcome Measures:A 30-day inpatient mortality and failure-to-rescue. Results:The effect of decreasing workloads by 1 patient/nurse on deaths and failure-to-rescue is virtually nil in hospitals with poor work environments, but decreases the odds on both deaths and failures in hospitals with average environments by 4%, and in hospitals with the best environments by 9% and 10%, respectively. The effect of 10% more Bachelors of Science in Nursing Degree nurses decreases the odds on both outcomes in all hospitals, regardless of their work environment, by roughly 4%. Conclusions:Although the positive effect of increasing percentages of Bachelors of Science in Nursing Degree nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improves patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environments.

Nurse staffing, burnout, and health care–associated infection

BACKGROUND Each year, nearly 7 million hospitalized patients acquire infections while being treated for other conditions. Nurse staffing has been implicated in the spread of infection within hospitals, yet little evidence is available to explain this association. METHODS We linked nurse survey data to the Pennsylvania Health Care Cost Containment Council report on hospital infections and the American Hospital Association Annual Survey. We examined urinary tract and surgical site infection, the most prevalent infections reported and those likely to be acquired on any unit within a hospital. Linear regression was used to estimate the effect of nurse and hospital characteristics on health care-associated infections. RESULTS There was a significant association between patient-to-nurse ratio and urinary tract infection (0.86; P = .02) and surgical site infection (0.93; P = .04). In a multivariate model controlling for patient severity and nurse and hospital characteristics, only nurse burnout remained significantly associated with urinary tract infection (0.82; P = .03) and surgical site infection (1.56; P < .01) infection. Hospitals in which burnout was reduced by 30% had a total of 6,239 fewer infections, for an annual cost saving of up to

Nurse Specialty Certification, Inpatient Mortality, and Failure to Rescue

68 million. CONCLUSIONS We provide a plausible explanation for the association between nurse staffing and health care-associated infections. Reducing burnout in registered nurses is a promising strategy to help control infections in acute care facilities.

Factors associated with hand hygiene practices in two neonatal intensive care units

PURPOSE To determine if hospital proportion of staff nurses with specialty certification is associated with risk-adjusted inpatient 30-day mortality and failure to rescue (deaths in surgical inpatients following a major complication). DESIGN Secondary analysis of risk-adjusted adult general, orthopedic, and vascular surgical inpatients discharged during 2005-2006 (n= 1,283,241) from 652 nonfederal hospitals controlling for state, hospital, patient, and nursing characteristics by linking outcomes, administrative, and nurse survey data (n= 28,598). METHOD Nurse data, categorized by education and certification status, were aggregated to the hospital level. Logistic regression models were used to estimate effects of specialty certification and other nursing characteristics on mortality and failure to rescue. FINDINGS Hospital proportion of baccalaureate and certified baccalaureate staff nurses were associated with mortality and failure to rescue; no effect of specialization was seen in the absence of baccalaureate education. A 10% increase in hospital proportion of baccalaureate and certified baccalaureate staff nurses, respectively, decreased the odds of adjusted inpatient 30-day mortality by 6% and 2%; results for failure to rescue were identical. CONCLUSIONS Nurse specialty certification is associated with better patient outcomes; effect on mortality and failure to rescue in general surgery patients is contingent upon baccalaureate education. CLINICAL RELEVANCE Investment in a baccalaureate-educated workforce and specialty certification has the potential to improve the quality of care.

Attributable costs and length of stay of an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae outbreak in a neonatal intensive care unit.

Objective. To determine whether hand hygiene practices differ between levels of contact with neonates; to characterize the hand hygiene practices of different types of personnel; and to compare hand hygiene practices in neonatal intensive care units (NICUs) using different products. Methods. Research assistants observed staff hand hygiene practices during 38 sessions in two NICUs. Patient touches were categorized as touching within the neonates’ environment but only outside the Isolette (Level 1), touching within the Isolette but not the neonate directly (Level 2) or directly touching the neonate (Level 3). Hand hygiene practices for each touch were categorized into five groups: cleaned hands and new gloves; uncleaned hands and new gloves; used gloves; clean hands and no gloves; uncleaned hands and no gloves. Results. Research assistants observed 1472 touches. On average each neonate or his or her immediate environment was touched 78 times per shift. Nurses (P = 0.001), attending physicians (P = 0.02) and physicians-in-training (P = 0.03) were more likely to use appropriate practices during Level 3 touches, but only 22.8% of all touches were with cleaned and/or newly gloved hands. The mean number of direct touches by staff members with cleaned hands was greater in the NICU using an alcohol-based hand rub than in the NICU using antimicrobial soap (P < 0.01). Conclusions. Hand hygiene was suboptimal in this high risk setting; administrative action and improved products may be needed to assure acceptable practice. In this study use of an alcohol-based product was associated with significantly improved hand hygiene and should be encouraged, as recommended in the new CDC hand hygiene guideline.

Highlights of the National Workforce Survey of Registered Nurses

OBJECTIVES To determine the costs of the interventions aimed at controlling the 4-month outbreak and to determine the attributable length of stay (LOS) associated with infection and colonization with extended-spectrum beta-lactamase-producing Klebsiella pneumoniae. DESIGN A retrospective cost analysis was conducted from the hospital perspective. A micro-costing approach was employed. The LOS of four groups of hospitalized patients were compared with each other. National Perinatal Information Center criteria were used to stratify infants for severity of risk. The LOS of each group was compared with that of a national sample of similarly stratified infants. SETTING A level III-IV, 45-bed neonatal intensive care unit. PATIENTS Infant groups were infected (n = 8), colonized (n = 14), concurrent cohort (n = 54), and prior cohort (n = 486). RESULTS The cost of the outbreak totaled 341,751 dollars. The largest proportion of costs was related to healthcare worker time providing direct patient care (2,489 hours at a cost of 146,331 dollars). Infected and colonized neonates had longer LOS than either the concurrent cohort or the prior cohort (P < .001). Compared with the national sample, infected infants had a 48.5-day longer mean LOS (95% confidence interval [CI95], 1.7 to 95.2), whereas the prior cohorts mean LOS was 6 days shorter (CI95, -9.4 to -2.9). CONCLUSIONS This study increases the understanding of the burden of these multidrug-resistant organisms. Further research is needed to estimate the societal costs of these infections and the cost-effectiveness of preventive interventions.

Nurses' Working Conditions: Implications for Infectious Disease

Over the past 3 decades the Health Resources and Services Administration has reported on the supply of registered nurses (RNs) through the National Sample Survey of Registered Nurses (NSSRN). Data collection from the most recent, and final, NSSRN was completed in 2008; hence, there is no current data on the nationwide supply of RNs. This current project was conducted by the National Council of State Boards of Nursing and the Forum of State Nursing Workforce Centers to fill this ongoing need and is titled, The National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers 2013 National Workforce Survey of RNs. This article presents the highlights of the study and its results.

Gram-negative bacilli associated with catheter-associated and non-catheter-associated bloodstream infections and hand carriage by healthcare workers in neonatal intensive care units.

Poor working conditions are associated with risk for occupational infections.

Changes in patient and nurse outcomes associated with magnet hospital recognition

Objective: Bloodstream infections caused by Gram-negative bacilli are a substantial cause of morbidity and mortality in infants in neonatal intensive care units. This study describes the species of Gram-negative bacilli causing bloodstream infections in two neonatal intensive care units, compares characteristics of catheter-related and non-catheter-related bloodstream infections, and compares species and antibiotic resistance patterns of these organisms with those isolated from the hands of nurses working in the same neonatal intensive care units. Design: Interventional study. Setting: Two high-risk neonatal intensive care units. Patients: Neonates hospitalized for ≥24 hrs. Interventions: Prospective surveillance for bloodstream infections was performed in two neonatal intensive care units from March 2001 to January 2003. Hand cultures were obtained quarterly from participating nurses immediately after they performed hand hygiene. Measurements and Main Results: There were 298 episodes of bloodstream infections among 2,935 admissions (5.75 episodes per 1,000 patient-days); 77 of 298 (26%) episodes were caused by Gram-negative bacilli. Among these, 47 (61.0%) were catheter-related bloodstream infections (2.61 episodes per 1,000 catheter-days). Eleven and 24 Gram-negative bacilli species were isolated from neonates and nurses, respectively. The most common Gram-negative bacilli causing bloodstream infections were Klebsiella pneumoniae (38.7%), Escherichia coli (21.2%), Enterobacter cloacae (11.2%), and Serratia marcescens (11.2%). In contrast, Acinetobacter lwoffi (18.1%), K. pneumoniae (11.7%), E. cloacae (10.6%), K. oxytoca (10.6%), and Pseudomonas spp. (7.4%) were most commonly isolated from hands of nurses. E. coli, P. aeruginosa, E. cloacae, and E. aerogenes were significantly more likely to cause bloodstream infections than to be isolated from nurses’ hands (all p < .001). Although 39% of bloodstream infections were non-catheter-related, there were no significant differences in types of organisms or antimicrobial resistance patterns between catheter-related bloodstream infections and non-catheter-related bloodstream infections (all p ≥ .35). Resistance patterns were similar between Gram-negative bacilli isolates from neonates and nurses’ hands except for a significantly higher proportion of resistance to cefotaxime and gentamicin among neonatal isolates of K. pneumoniae (p < .05). Conclusions: Gram-negative bacilli species isolated from neonatal bloodstream infections and nurses’ hands varied significantly. Clean hands of providers are an unlikely source of endemic Gram-negative bacilli, suggesting that prevention strategies should focus more on control of endogenous neonatal flora or environmental sources.

Assessing nurses' hand hygiene practices by direct observation or self-report

Background:Research has documented an association between Magnet hospitals and better outcomes for nurses and patients. However, little longitudinal evidence exists to support a causal link between Magnet recognition and outcomes. Objective:To compare changes over time in surgical patient outcomes, nurse-reported quality, and nurse outcomes in a sample of hospitals that attained Magnet recognition between 1999 and 2007 with hospitals that remained non-Magnet. Research Design:Retrospective, 2-stage panel design using 4 secondary data sources. Subjects:One hundred thirty-six Pennsylvania hospitals (11 emerging Magnets and 125 non-Magnets). Measures:American Nurses Credentialing Center Magnet recognition; risk-adjusted rates of surgical 30-day mortality and failure-to-rescue, nurse-reported quality measures, and nurse outcomes; the Practice Environment Scale of the Nursing Work Index. Methods:Fixed-effects difference models were used to compare changes in outcomes between emerging Magnet hospitals and hospitals that remained non-Magnet. Results:Emerging Magnet hospitals demonstrated markedly greater improvements in their work environments than other hospitals. On average, the changes in 30-day surgical mortality and failure-to-rescue rates over the study period were more pronounced in emerging Magnet hospitals than in non-Magnet hospitals, by 2.4 fewer deaths per 1000 patients (P<0.01) and 6.1 fewer deaths per 1000 patients (P=0.02), respectively. Similar differences in the changes for emerging Magnet hospitals and non-Magnet hospitals were observed in nurse-reported quality of care and nurse outcomes. Conclusions:In general, Magnet recognition is associated with significant improvements over time in the quality of the work environment, and in patient and nurse outcomes that exceed those of non-Magnet hospitals.