Vincent S. Staggs

Effect of Medicare’s Nonpayment for Hospital-Acquired Conditions: Lessons for Future Policy

IMPORTANCE In 2008, Medicare implemented the Hospital-Acquired Conditions (HACs) Initiative, a policy denying incremental payment for 8 complications of hospital care, also known as never events. The regulations effect on these events has not been well studied. OBJECTIVE To measure the association between Medicares nonpayment policy and 4 outcomes addressed by the HACs Initiative: central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure ulcers (HAPUs), and injurious inpatient falls. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental study of adult nursing units from 1381 US hospitals participating in the National Database of Nursing Quality Indicators (NDNQI), a program of the American Nurses Association. The NDNQI data were combined with American Hospital Association, Medicare Cost Report, and local market data to examine adjusted outcomes. Multilevel models were used to evaluate the effect of Medicares nonpayment policy on never events. EXPOSURES United States hospitals providing treatment for Medicare patients were subject to the new payment policy beginning in October 2008. MAIN OUTCOMES AND MEASURES Changes in unit-level rates of HAPUs, injurious falls, CLABSIs, and CAUTIs after initiation of the policy. RESULTS Medicares nonpayment policy was associated with an 11% reduction in the rate of change in CLABSIs (incidence rate ratio [IRR], 0.89; 95% CI, 0.83-0.95) and a 10% reduction in the rate of change in CAUTIs (IRR, 0.90; 95% CI, 0.85-0.95), but was not associated with a significant change in injurious falls (IRR, 0.99; 95% CI, 0.99-1.00) or HAPUs (odds ratio, 0.98; 95% CI, 0.96-1.01). Consideration of unit-, hospital-, and market-level factors did not significantly alter our findings. CONCLUSIONS AND RELEVANCE The HACs Initiative was associated with improvements in CLABSI and CAUTI trends, conditions for which there is strong evidence that better hospital processes yield better outcomes. However, the HACs Initiative was not associated with improvements in HAPU or injurious fall trends, conditions for which there is less evidence that changing hospital processes leads to significantly better outcomes.

Unit-level time trends in inpatient fall rates of US hospitals.

Background:Little is known about the recent development of the quality of nursing care. Objective:To examine trends in the rate of total inpatient falls, one of the nursing-sensitive quality indicators, in US hospitals. Research Design:A longitudinal study of unit-level data collected during 2004–2009 by the National Database of Nursing Quality Indicators. Hierarchical Poisson regression models were used for the analysis of the unit-level fall rate. Subjects:Approximately 37,000 observations from 8915 nursing units (1994 critical care, 1328 step-down, 1663 medical, 1279 surgical, 2217 medical-surgical, and 434 rehabilitation units) in 1171 hospitals were examined. Measures:The outcome measure was the annual count of unit-level inpatient falls with the annual count of unit-level patient days taken as the exposure variable. Independent variables included hospital size (≥300 or <300 beds), teaching status, and Magnet status and unit-level total nursing hours per patient day and proportion of total nursing hours supplied by RNs (skill-mix) at baseline. Results:The mean fall rates for most unit types remained stable or decreased, whereas those for surgical units increased over time. A higher register nurses skill-mix and the total nursing hours per patient day were both associated with lower fall rates (P<0.001); hospitals with more beds tended to have lower fall rates (P=0.001). Hospital Magnet and teaching status were not associated with the fall rate. Conclusions:Overall, the fall rate in the United States hospitals decreased over time, but the large variation in the fall rate at both the hospital and the unit level indicates much room for improvement in the quality of nursing care related to fall prevention.

Hospital and unit characteristics associated with nursing turnover include skill mix but not staffing level: An observational cross-sectional study

BACKGROUND Nursing turnover is expensive and may have adverse effects on patient care. Little is known about turnovers association with most hospital and nursing unit characteristics, including nurse staffing level and registered nurse skill mix. OBJECTIVE To explore associations between nursing unit turnover rates and several hospital- and unit-level variables, including staffing level and skill mix. DESIGN Observational cross-sectional study of longitudinal data. SETTINGS 1884 nursing units in 306 U.S. acute care hospitals. METHODS During a 2-year period units reported monthly data on staffing and turnover. Total nursing staff turnover and registered nurse turnover rates were modeled as dependent variables in hierarchical Poisson regression models. The following hospital characteristics were considered as predictors: Magnet(®) status, ownership (government or non-government), teaching status, locale (metropolitan, micropolitan, or rural), and size (average daily census). The U.S. state in which the hospital was located was included as a covariate. Unit-level variables included total nursing hours per patient day, size of nursing staff, registered nurse skill mix, population age group (neonatal, pediatric, or adult), and service line (critical care, step-down, medical, surgical, medical/surgical, psychiatric, or rehabilitation). RESULTS Government ownership, Magnet designation, and higher skill mix were associated with lower total turnover and registered nurse turnover. Neonatal units had lower total and registered nurse turnover than pediatric units, which had lower total and registered nurse turnover than adult units. Unit service line was associated only with total turnover. Psychiatric, critical care, and rehabilitation units had the lowest mean turnover rates, but most differences between service lines were not significant. The other explanatory variables considered were not significant. CONCLUSIONS Several hospital and unit characteristic variables have significant associations with nursing turnover; these associations should be taken into account in nursing turnover research and need to be explored further. Controlling for hospital ownership, Magnet status, unit service line, and unit population age group, registered nurse skill mix is apparently more important than total nurse staffing level in predicting nursing turnover.

Associations between rates of unassisted inpatient falls and levels of registered and non-registered nurse staffing

Objective To enhance understanding of how nurse staffing relates to unassisted falls by exploring non-linear associations between unassisted fall rates and levels of registered nurse (RN) and non-RN staffing on 5 nursing unit types, thereby enabling managers to improve patient safety by making better-informed decisions about staffing. Design Cross-sectional analysis of routinely collected data using hierarchical negative binomial regression. Settings 8069 nursing units in 1361 U.S. hospitals participating in the National Database of Nursing Quality Indicators®. Main outcome measure Rate of unassisted falls per inpatient day. Results Associations between unassisted fall rates and nurse staffing varied by unit type. For medical–surgical units, higher RN staffing was weakly associated with lower fall rates. On step-down and medical units, the association between RN staffing and fall rates depended on the level of staffing: At lower staffing levels, the fall rate increased as staffing increased, but at moderate and high staffing levels, the fall rate decreased as staffing increased. Higher levels of non-RN staffing were generally associated with higher fall rates.. Conclusions Increasing non-RN staffing seems ineffective at preventing unassisted falls. Increasing RN staffing may be effective, depending on the unit type and the current level of staffing.

Unit‐level time trends and seasonality in the rate of hospital‐acquired pressure ulcers in US acute care hospitals

This is a longitudinal study of the trend and seasonality in unit-level hospital-acquired pressure ulcer (HAPU) rates from 2004 to 2011, for 5447 acute care nursing units in 733 US hospitals. Unit-level HAPU rates decreased significantly during 2004-2007 (OR = 0.91, 95% CI [0.90, 0.91]) and the decreasing trend was much stronger during 2008-2011 (OR = 0.84 [0.83, 0.85]). Seasonal variations in HAPU rates were strong and consistent during 2004-2008, with the highest HAPU rate in Quarter 1 (Jan-Mar) and the lowest rate in Quarter 3 (Jul-Sep). During 2009-2011, the magnitude of this seasonality was greatly reduced, and only HAPU rate in Quarter 1 remained significantly higher than HAPU rates in other quarters.

Concurrent and lagged effects of registered nurse turnover and staffing on unit-acquired pressure ulcers.

OBJECTIVE We examined the concurrent and lagged effects of registered nurse (RN) turnover on unit-acquired pressure ulcer rates and whether RN staffing mediated the effects. DATA SOURCES/SETTING Quarterly unit-level data were obtained from the National Database of Nursing Quality Indicators for 2008 to 2010. A total of 10,935 unit-quarter observations (2,294 units, 465 hospitals) were analyzed. METHODS This longitudinal study used multilevel regressions and tested time-lagged effects of study variables on outcomes. FINDINGS The lagged effect of RN turnover on unit-acquired pressure ulcers was significant, while there was no concurrent effect. For every 10 percentage-point increase in RN turnover in a quarter, the odds of a patient having a pressure ulcer increased by 4 percent in the next quarter. Higher RN turnover in a quarter was associated with lower RN staffing in the current and subsequent quarters. Higher RN staffing was associated with lower pressure ulcer rates, but it did not mediate the relationship between turnover and pressure ulcers. CONCLUSIONS We suggest that RN turnover is an important factor that affects pressure ulcer rates and RN staffing needed for high-quality patient care. Given the high RN turnover rates, hospital and nursing administrators should prepare for its negative effect on patient outcomes.

Linking RN workgroup job satisfaction to pressure ulcers among older adults on acute care hospital units

We examined the relationship between registered nurse (RN) workgroup job satisfaction and hospital-acquired pressure ulcers (HAPUs) among older adults on six types of acute care units. Random-intercept logistic regression analyses were performed using 2009 unit-level data from the National Database of Nursing Quality Indicators® (NDNQI®) and the NDNQI RN Survey. Overall, RN workgroup job satisfaction was negatively associated with HAPU rates, although the relationship varied by unit type. RN workgroup satisfaction was significantly associated with HAPU rates on critical care, medical, and rehabilitation units. No significant association was found on step-down, surgical, and medical-surgical units. Findings provide evidence that higher RN workgroup job satisfaction is related to lower HAPU rates among older adult patients in acute care hospitals.

Nurse staffing, RN mix, and assault rates on psychiatric units.

The association between nurse staffing and patient violence on psychiatric units is unclear, and the association between nursing skill mix and violence has not been studied. Monthly data on physical/sexual assaults by patients against others were obtained for 351 adult psychiatric units. Total and injury assault rates were modeled as dependent variables using hierarchical Poisson regression, with total staffing and registered nurse (RN) mix as predictors. Assault rates were 12% higher per additional nursing hour per patient day but 6% lower per 5-point increase in percent of hours provided by RNs. In cubic spline models fit to explore nonlinear staffing-violence associations, assault rates increased with staffing through most of its range but began to decline at very high levels.

Comparability of nurse staffing measures in examining the relationship between RN staffing and unit-acquired pressure ulcers: A unit-level descriptive, correlational study

BACKGROUND Various staffing measures have been used in examining the relationship between nurse staffing and patient outcomes. Little research has been conducted to compare these measures based on their explanatory power as predictors of nursing-sensitive outcomes. In this study, both administrative and nurse-reported measures were examined. Administrative measures included registered nurse (RN) skill mix and three versions of nursing hours per patient day (HPPD); nurse-reported measures included RN-reported number of assigned patients and RN-perceived staffing adequacy. OBJECTIVES To examine correlations among six nurse staffing measures and to compare their explanatory power in relation to unit-acquired pressure ulcers (UAPUs). DESIGN Descriptive, correlational study. SETTINGS 2397 nursing units in 409 U.S. acute care hospitals. METHODS Random-intercept logistic regression analyses were performed using 2011 data from a national database. Relationships between nurse staffing measures and UAPU occurrences were examined in eight models, each with one or more staffing measures as predictors. Characteristics of nursing units (RN workgroup education level and RN workgroup unit tenure) and hospitals (size, teaching status, and Magnet status) were included as control variables. RESULTS Two versions of HPPD (total nursing HPPD and RN HPPD) and RN skill mix were significantly correlated with RN-reported number of assigned patients (r range=-0.87 to -0.75). These staffing measures had weaker correlations with RN-perceived staffing adequacy (r range=0.16 to 0.23). Of the six staffing variables, only RN-perceived staffing adequacy and RN skill mix were significantly associated with UAPU odds, the former being the better predictor. CONCLUSIONS Although RN-perceived staffing adequacy was not highly correlated with administrative measures of HPPD and RN skill mix, it was the strongest predictor of UAPU occurrences. RN-perceived staffing adequacy can serve as a more appropriate measure of staffing for nursing-sensitive outcomes research than administrative measures, as it reflects relevant aspects of staffing and involves an implicit adjustment for patient acuity.

Understanding unassisted falls: effects of nurse staffing level and nursing staff characteristics.

Hierarchical Poisson modeling was used to explore hospital and nursing unit characteristics as predictors of the unassisted fall rate. Longitudinal data were collected from 1502 units in 248 US hospitals. The relation between the fall rate and total nurse staffing was positive at lower staffing levels and negative for levels around and above the median. The fall rate was negatively associated with registered nurse skill mix and average registered nurse tenure on the unit.