Olga Yakusheva

Quality and Cost Analysis of Nurse Staffing, Discharge Preparation, and Postdischarge Utilization

OBJECTIVES To determine the impact of unit-level nurse staffing on quality of discharge teaching, patient perception of discharge readiness, and postdischarge readmission and emergency department (ED) visits, and cost-benefit of adjustments to unit nurse staffing. DATA SOURCES Patient questionnaires, electronic medical records, and administrative data for 1,892 medical-surgical patients from 16 nursing units within four acute care hospitals between January and July 2008. DESIGN Nested panel data with hospital and unit-level fixed effects and patient and unit-level control variables. DATA COLLECTION/EXTRACTION Registered nurse (RN) staffing was recorded monthly in hours-per-patient-day. Patient questionnaires were completed before discharge. Thirty-day readmission and ED use with reimbursement data were obtained by cross-hospital electronic searches. PRINCIPAL FINDINGS Higher RN nonovertime staffing decreased odds of readmission (OR=0.56); higher RN overtime staffing increased odds of ED visit (OR=1.70). RN nonovertime staffing reduced ED visits indirectly, via a sequential path through discharge teaching quality and discharge readiness. Cost analysis projected total savings from 1 SD increase in RN nonovertime staffing and decrease in RN overtime of U.S.

Identifying Patients at Increased Risk for Unplanned Readmission

11.64 million and U.S.

Nurse and patient perceptions of discharge readiness in relation to postdischarge utilization.

544,000 annually for the 16 study units. CONCLUSIONS Postdischarge utilization costs could potentially be reduced by investment in nursing care hours to better prepare patients before hospital discharge.

Economic evaluation of the 80% baccalaureate nurse workforce recommendation: A patient-level analysis

Background:Reducing readmissions is a national priority, but many hospitals lack practical tools to identify patients at increased risk of unplanned readmission. Objective:To estimate the association between a composite measure of patient condition at discharge, the Rothman Index (RI), and unplanned readmission within 30 days of discharge. Subjects:Adult medical and surgical patients in a major teaching hospital in 2011. Measures:The RI is a composite measure updated regularly from the electronic medical record based on changes in vital signs, nursing assessments, Braden score, cardiac rhythms, and laboratory test results. We developed 4 categories of RI and tested its association with readmission within 30 days, using logistic regression, adjusted for patient age, sex, insurance status, service assignment (medical or surgical), and primary discharge diagnosis. Results:Sixteen percent of the sample patients (N=2730) had an unplanned readmission within 30 days of discharge. The risk of readmission for a patient in the highest risk category (RI<70) was >1 in 5 while the risk of readmission for patients in the lowest risk category was about 1 in 10. In multivariable analysis, patients with an RI<70 (the highest risk category) or 70–79 (medium risk category) had 2.65 (95% confidence interval, 1.72–4.07) and 2.40 (95% confidence interval, 1.57–3.67) times higher odds of unplanned readmission, respectively, compared with patients in the lowest risk category. Conclusion:Clinicians can use the RI to help target hospital programs and supports to patients at highest risk of readmission.

Age-Related Differences in Perception of Quality of Discharge Teaching and Readiness for Hospital Discharge

Background:Prevention of hospital readmission and emergency department (ED) utilization will be a crucial strategy in reducing health care costs. There has been limited research on nurse assessment and patient perceptions of discharge readiness in relation to postdischarge outcomes. Objectives:To investigate the association of nurse and patient assessments of discharge readiness with postdischarge readmissions and ED visits. Research Design:Hierarchical regression analysis of readmission or ED utilization using independent nurse and patient assessments of discharge readiness and patient characteristics as explanatory variables, with hospital and unit fixed effects. Subjects:A total of 162 adult medical-surgical patients and their discharging nurses from 13 medical-surgical units of 4 Midwestern hospitals. Measures:Readiness for Hospital Discharge Scale completed independently by patients and their discharging nurses within 4 hours before hospital discharge; Postdischarge utilization (unplanned readmission or ED visit within 30 days postdischarge). Results:Correlations between nurse assessment and patient perceptions of discharge readiness were low (r = 0.15–0.32). Nurses rated patient readiness higher than patients themselves. Controlling for patient characteristics, nurse readiness for hospital discharge scale score (odds ratio = 0.57, P = 0.05) but not patient readiness for hospital discharge scale score was associated with postdischarge utilization. Conclusions:Nurse assessment was more strongly associated with postdischarge utilization than patient self-assessment. Formalizing nurse assessment of discharge readiness could facilitate identification of patients at risk for readmission or ED utilization before discharge when anticipatory interventions could prevent avoidable postdischarge utilization.

Clinical effectiveness and cost benefit of universal versus targeted methicillin-resistant Staphylococcus aureus screening upon admission in hospitals

Background:Higher proportions of BSN-educated nurses were associated with improved outcomes in hospital-level studies. A recent Institute of Medicine report calls for increasing the proportion of BSN-educated nurses to 80% by 2020. Patient-level evidence of cost and quality implications of the 80% BSN threshold is needed for a business case to support these efforts. Objectives:To conduct the economic analysis of meeting the 80% BSN threshold on patient outcomes and costs, using linked patient-nurse data. Research Design:Retrospective observational patient-level analysis of electronic data. Linear and logistic regression modeling with patient controls and diagnosis and unit fixed effects. Subjects:A total of 8526 adult medical-surgical patients matched with 1477 direct care nurses from an Eastern US academic medical center, during June 1, 2011–December 31, 2011. Measures:Outcomes include hospital mortality, all-cause same-facility 30-day readmission, length-of-stay, and total hospitalization cost. BSN proportion is a continuous measure for the proportion of nurse assessment inputs into the patient’s electronic medical record made by BSN-educated nurses; a dichotomous indicator for BSN proportion is 0.8–1.0. Results:Continuous BSN proportion was associated with lower mortality (OR=0.891, P<0.01). Compared with patients with <80% BSN care, patients receiving ≥80% of care from BSN nurses had lower odds of readmission (OR=0.813, P=0.04) and 1.9% shorter length-of-stay (P=0.03). Economic simulations support a strong business case for increasing the proportion of BSN-educated nurses to 80%. Conclusions:A combined approach of increasing the hospital-level BSN proportion to 80% and assuring a high BSN dose through individual patient-level staffing assignments is needed to achieve projected quality and costs benefits.

Patient Perceptions of Patient-Empowering Nurse Behaviours, Patient Activation and Functional Health Status in Postsurgical Patients with Life-Threatening Long-Term Illnesses

Adults aged 65 and older account for one third of all hospitalizations in the United States.(1) Almost one fifth (19.6%) of Medicare beneficiaries discharged from an acute care hospital are readmitted within 30 days.(2) High readmission rates have been attributed to inadequate discharge preparation, lack of patient and family caregiver readiness, poor discharge transition coordination, and unsuccessful coping with the demands of daily living.(3-9) Discharge needs may be different for older adults than for the general population because of the increased likelihood of multiple comorbidities, illness-induced limitations, impaired mobility, fatigue, anxiety, cognitive impairment, hearing impairments, health literacy deficits, and living alone.(7,8,10-12) The purpose of this study was to investigate differences in perceptions of the quality of discharge teaching and readiness for hospital discharge and their relationship to postdischarge utilization of emergency department (ED) visits and readmissions across the older adult age spectrum. Of particular interest is the applicability of quality of discharge teaching and discharge readiness assessment tools for the older adult population.

Validation of Patient and Nurse Short Forms of the Readiness for Hospital Discharge Scale and Their Relationship to Return to the Hospital

OBJECTIVE To conduct an exploratory study to evaluate the clinical effectiveness and cost benefit of universal versus targeted screening for methicillin-resistant Staphylococcus aureus (MRSA) to prevent hospital-acquired MRSA infections. DESIGN Prospective, interventional study, using a case-control design, difference-in-differences, and cost-benefit analyses. SETTING Two community hospitals in Wisconsin. PATIENTS Consecutive sample of 15,049 adult admissions from April 2009 to July 2010. INTERVENTIONS MRSA surveillance performed by polymerase chain reaction (PCR) on samples collected from all adult patients (aged over 18 years) within 30 days before or upon an admission to the hospital. During a 9-month baseline period, targeted screening was conducted at both hospitals. During the 5-month intervention period, all patients admitted to the intervention hospital were screened for MRSA. Infection control measures were consistent at both hospitals. RESULTS Universal screening was associated with an increase in admission screening of 43.58 percentage points (P< .01), an increase in MRSA detection of 2.95 percentage points (P< .01), and a small, nonsignificant decline in hospital-acquired MRSA infections of 0.12 percentage points (P< .01). The benefit-to-cost ratio was 0.50, indicating that for every dollar spent on universal versus targeted screening, only

Obesogenic environmental influences on young adults: Evidence from college dormitory assignments

0.50 is recovered in avoided costs of hospital-acquired MRSA infection. CONCLUSION Compared with targeted screening, universal screening increased the rate of detection of MRSA upon hospital admission but did not significantly reduce the rate of hospital-acquired MRSA infection. Universal screening was associated with higher costs of care and was not cost beneficial.

Estimating Heterogeneous and Hierarchical Peer Effects on Body Weight Using Roommate Assignments as a Natural Experiment

AIM To explore the trajectory of associations between the nursing care process of patient empowerment during postsurgical hospitalization and postdischarge patient self-management outcomes, specifically patient activation and functional health status. BACKGROUND Patient-centred care models advocate for patient empowerment in long-term illness care. Postsurgical patients with life-threatening long-term illnesses frequently feel powerless, have unmet needs, decreased functional health status and high readmission rates; however, previous studies of patient empowerment have conceptualized empowerment as an outcome primarily in outpatient settings, with little attention paid to provider processes used to empower patients during hospitalizations. DESIGN A non-experimental, prospective, correlational study. METHODS This sample consisted of 113 postsurgical cancer and cardiac patients enrolled between August 2012–February 2013. Patient perceptions of patient-empowering nurse behaviours and baseline patient activation were measured prior to discharge. Patient activation and functional health status were measured 6 weeks following discharge. Data were analysed with multiple linear regression using a simultaneous equation approach. RESULTS Patients reported high perceptions of patient-empowering nurse behaviours and patient activation levels. Functional health status scores were below population norms. Patient perceptions of empowering nurse behaviours were positively associated with postdischarge patient activation, which was positively associated with mental functional health status. Length of stay was the only significant predictor of physical functional health status. CONCLUSION This study provides further quantitative evidence supporting the relationship between quality nursing care and postdischarge patient outcomes. Intentional use of patient-empowering nurse behaviours could lead to improved patient activation and functional health status in postsurgical patients with life-threatening long-term illnesses.