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We’ve often cited the work of Linda Aiken and colleagues, who have demonstrated that patient outcomes are better with stronger nurse:patient ratios and higher educational levels of nursing staffing. They found that each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure-to-rescue (Aiken 2002), and a 10% increase in the proportion of nurses holding a bachelor's degree was associated with a 5% decrease in the likelihood of patients dying within 30 days of admission and the odds of failure to rescue for surgical patients (Aiken 2003).
A study in the UK (Griffiths 2018) looked at in-hospital mortality in relation to nursing staffing, comparing those with staffing levels above to those below the mean staffing level. They found the hazard of death was increased by 3% for every day a patient experienced RN staffing below the ward mean. Each additional hour of RN care available over the first 5 days of a patient’s stay was associated with 3% reduction in the hazard of death. And days where admissions per RN exceeded 125% of the ward mean were associated with an increased hazard of death (aHR 1.05). Although low nursing assistant staffing was associated with increases in mortality, high nursing assistant staffing was also associated with increased mortality.
Once again, Aiken and her colleagues from the University of Pennsylvania recently analyzed nursing staffing patterns in 87 acute care hospitals in the state of Illinois (Lasater 2021). They assessed patient:nurse ratios via nurse responses to a survey and correlated those with mortality and length-of-stay (LOS) data on Medicare patients.
They found that patient-to-nurse staffing ratios on medical-surgical units varied substantially (from 4.2 to 7.6). 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 nurse’s average workload. In addition, 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.
Illinois is one of the several states in which legislation to mandate patient-to-nurse staffing ratios is actively being debated. Apparently, a 4:1 patient per nurse ratio is being proposed in the legislation. The authors calculate that, 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.
Nurses responding to the survey in the current study also reported safety concerns related to the number of patients they cared for during their last shift. Over half (51.2%) of nurses reported that their patient assignment during their last shift exceeded the number they assessed they could safely care for. Two-thirds of nurses (67.0%) who were assigned 6 or more patients assessed that workload was unsafe. On the other hand, 82.7% of nurses who were assigned four or fewer patients assessed that patient assignment constituted a safe workload.
We’ve long been supporters of legislation that improves nursing staffing. But the issue is more complex than simple patient:nurse ratios. Those ratios do not take into account actual nurse workload nor do they take into account the fatigue factor that may accompany long work shifts or forced overtime. Even a 4:1 patient:nurse ratio may be too high if the intensity of patient care needed is excessive or the nurses are too fatigued to deliver all necessary care. One factor that comes into play in those conditions is the concept of “missed nursing care” or “care left undone” (see our Patient Safety Tips of the Week for November 26, 2013 “Missed Care: New Opportunities?” and May 9, 2017 “Missed Nursing Care and Mortality Risk”). We discussed the issue of nursing workload in detail in our Patient Safety Tips of the Week for March 6, 2018 “Nurse Workload and Mortality” and May 29, 2018 “More on Nursing Workload and Patient Safety”. In those columns we discussed the issue of how to best measure workload and match nursing staffing levels to that workload.
But, for the time being, the patient:nurse ratio is probably a reasonable focus. There are now multiple studies linking high patient:nurse ratios to increased mortality and other adverse patient outcomes. The studies suggest that not only are better nurse staffing ratios better for our patients, but they would likely improve hospital bottom lines as well.
Unfortunately, the near future does not bode well for improving patient:nurse ratios. The COVID-19 pandemic has taken its toll on the nursing profession in addition to virtually all other healthcare worker categories. Burnout, retirements, and shifts to other venues has already impacted hospital nursing staffing and the shortage is likely to worsen soon.
In our September 1, 2020 Patient Safety Tip of the Week “NY State and Nurse Staffing Issues” we noted another article by Lasatar et al. (Lasater 2020). They were actually collecting survey data in New York and Illinois just prior to the first COVID-19 wave. They found that over half the nurses in both states experienced high burnout. Half gave their hospitals unfavorable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent and would not definitely recommend it to others. After adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavorable reports; odds ratio’s ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units. Their conclusion was that hospital nurses were already burned out and already working in understaffed conditions in the weeks prior to the first wave of COVID-19.
Co-author of the current study Linda Aiken seems to be more optimistic, stating “This independent scientific study shows that setting a quality standard for nurse staffing in hospitals is in the public’s interest. And there are plenty of nurses to take good jobs in hospitals with the nation’s nursing schools producing an all-time high of over 180,000 new nurses every year.” (UPenn 2021). Indeed, the American Association of Colleges of Nursing reported that student enrollment in baccalaureate, master’s, and doctoral nursing programs increased in 2020 despite concerns that the pandemic might diminish interest in nursing careers (AACN 2021). In programs designed to prepare new registered nurses (RNs) at the baccalaureate level, enrollment increased by 5.6% with 251,145 students now studying in these programs nationwide.
Some of our other columns on nursing workload and missed nursing care/care left undone:
November 26, 2013 “Missed Care: New Opportunities?”
May 9, 2017 “Missed Nursing Care and Mortality Risk”
March 6, 2018 “Nurse Workload and Mortality”
May 29, 2018 “More on Nursing Workload and Patient Safety”
October 2018 “Nurse Staffing Legislative Efforts”
February 2019 “Nurse Staffing, Workload, Missed Care, Mortality”
July 2019 “HAI’s and Nurse Staffing”
September 1, 2020 “NY State and Nurse Staffing Issues”
February 9, 2021 “Nursing Burnout”
August 2021 “The New NY State Law on Nursing Staffing”
Aiken LH, Clarke SP, Sloane DM, et al. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA 2002; 288(16): 1987-1993
Aiken LH, Clarke SP, Cheung RB, et al. Educational levels of hospital nurses and surgical patient mortality. JAMA 2003; 290(12): 1617-1623
Griffiths P, Maruotti A, Recio Saucedo A, et al. on behalf of the Missed Care Study Group. Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study. BMJ Qual Saf 2018; Published Online First: 04 December 2018
Lasater KB, Aiken LH, Sloane D, et al. Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study. BMJ Open 2021; 11: e052899
Lasater KB, Aiken LH, Sloane DM, et al. Chronic hospital nurse understaffing meets COVID-19: an observational study. BMJ Quality & Safety 2020; Published Online First: 18 August 2020
University of Pennsylvania School of Nursing. News Release “Illinois nurse staffing legislation predicted to reduce hospital deaths and improve care“; EurekAlert 2021’ News Release 8-Dec-2021
AACN (American Association of Colleges of Nursing). Student Enrollment Surged in U.S. Schools of Nursing in 2020 Despite Challenges Presented by the Pandemic. AACN News Release 2021; Published April 01, 2021
The AuntMinnie.com website is a very valuable site for information on safety in a variety of imaging venues. Over the past several months there have been a number of MRI-related safety events reported on that website.
Perhaps the most bothersome report was another fatal incident involving an oxygen cylinder in an MRI unit (Yee 2021a). Projectile accidents in MRI suites are, of course, the most feared events. The recent event occurred in a South Korean hospital, where a 60-year-old man was killed when an oxygen cylinder was carried into the MRI scanning suite during his exam. The oxygen cylinder was apparently already on the pallet on which the patient was brought into the suite. During the scan, it was shifted about two meters and was sucked into the device, killing the patient.
Yee points out that it has been almost 20 years since 6-year old Michael Colombini was killed when a hospital staff member brought a portable oxygen tank into the MRI room. That tank was sucked into the MRI and struck the child in the head. Colombini's death kicked off what has now been a decades-long effort to prevent these kinds of events. We discussed that incident in our October 25, 2011 Patient Safety Tip of the Week “Renewed Focus on MRI Safety”, including the outstanding root cause analysis done by Tobias Gilk and Robert Latino published in Patient Safety and Quality Healthcare ( ). The incident, like almost all other incidents we see with bad patient outcomes, was the result of a cascade of events, not a single error or event. And many (in fact most) of the contributory events were not temporally related to the accident but rather were related to the design, planning, and oversight of the MRI unit.
Tobias Gilk actually discussed both the recent South Korean incident and the Columbini incident in a video at the RSNA 2021 conference (RSNA 2021). He notes that we often put too much of the burden on accident prevention on the MRI technologist rather than changing the structure of MRI safety. He stresses we need more “built-in” preventions to stop such accidents from occurring. He points out the striking lack of regulatory oversight of MRI facilities in the US. He points out that newer technologies, like different strength magnets and point-of-care MRI, raise new safety issues. A big problem in recent years is that the COVID-19 pandemic has led to lesser availability of MRI technicians and that remaining MRI technicians may be less experienced. That is a challenge as the pent-up demand for MRI imaging now stresses the system.
We discussed another death related to an oxygen cylinder acting as a projectile in an MRI suite in our March 2018 What's New in the Patient Safety World column “MRI Death a Reminder of Dangers”. Projectile incidents, in addition to other safety issues, were also discussed in our January 7, 2020 Patient Safety Tip of the Week “Even More Concerns About MRI Safety”. And, though it was not technically a “projectile” incident, our November 5, 2019 Patient Safety Tip of the Week “A Near-Fatal MRI Incident” discussed an incident in Sweden in which a nurse wearing some sort of “weight belt” was sucked up against the MRI unit and rendered unconscious by the strap of that belt wrapping around his neck.
And as many hospitals and other facilities are installing newer MRI scanners, another recent accident raises a different issue. A worker was killed in Utah has an MRI scanner was being moved from the 4th floor of a hospital to the 1st floor (Casey 2021, Yee 2021b). The scanner fell to the ground near the facility's loading dock, killing the worker who apparently fell alongside the scanner. The Yee article also discusses the risk of helium release from such a dropped MRI scanner.
Some of our prior columns on patient safety issues related to MRI:
Yee KM. Oxygen cylinder kills South Korean man in MRI accident. AuntMinnie.com 2021; October 18, 2021
Gilk T, Latino RJ. MRI Safety 10 Years Later. What can we learn from the accident that killed Michael Colombini? Patient Safety and Quality Healthcare 2011; online first Nov-Dec 2011
Video from RSNA 2021: Tobias Gilk on MRI safety. AuntMinnie.com 2021; November 30, 2021
Casey B. Falling MRI scanner kills worker at Utah hospital. AuntMinnie.com 2021; September 15, 2021
Yee KM. Industrial MRI accidents are uncommon, but can be deadly. AuntMinnie.com 2021; October 13, 2021
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AHRQ has just released “Strategies to Improve Patient Safety” (AHRQ 2021). This is the final report required by the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act). We really have mixed feelings about this report.
Perhaps the biggest disappointment we have has to do with PSO’s (Patient Safety Organizations). When these were originally created, we had great expectations that the work of PSO’s would result in dissemination of innumerable lessons learned from analysis of root causes from many sources. But where are those lessons learned! Some obviously would have been shared among members of the individual PSO’s (the confidentiality and privilege protections afforded by the Patient Safety Act only apply when a provider works with a federally listed PSO), but there has been no public release of lessons learned to the greater healthcare community.
To date, PSOs have voluntarily submitted over 2 million records to the NPSD (Network of Patient Safety Databases), which is the data infrastructure aspect of the Patient Safety Act. However, the NPSD’s ability to publicly release data is constrained by limitations in the mechanisms currently available for data collection and the need to accumulate a sufficient volume of data prior to public release in order to protect confidentiality. The report also notes that the voluntary nature of the system and corresponding need to minimize the burden of data submission affects the nature, volume, and quality of the data available to the NPSD
The NPSD needed a critical mass of data before it could become operational. The NPSD achieved this threshold and launched in June 2019. The NPSD has provided various dashboards, but these largely only provide us with a snapshot of the various types and frequency of incidents. Dashboards utilize AHRQ’s Common Formats, Common Formats for Event Reporting (CFER), and Common Formats for Surveillance (CF-S).
The report does list in tabular form strategies and practices to reduce errors. It provides these in 28 categories, providing links to the evidence base for each. Those links come primarily from three “Making Health Care Safer” books (Shojania 2001, AHRQ 2013, Hall 2020).
The report goes on to describe the CUSP (Comprehensive-Unit-based-Safety-Program) program, which we have discussed in multiple columns as being a major reason for success of such collaboratives as the Michigan Keystone Project. It also describes TeamSTEPPS®, which we’ve also discussed in many columns.
The report discusses various other AHRQ grant-supported research projects and learning initiatives, the AHRQ patient safety primers and toolkits, and the CANDOR (Communication and Optimal Resolution) process
And it discusses “Safer Together: A National Action Plan to
Advance Patient Safety” (IHI
2020) put together by the National Steering Committee for Patient Safety
and lists the 17 recommendations to advance patient safety from that action
AHRQ. Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.
AHRQ. NPSD Dashboards.
Shojania KG, Duncan BW, McDonald KM, et al., editors. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Reports/Technology Assessments, No. 43. Rockville (MD): Agency for Healthcare Research and Quality (US); 2001 Jul.
AHRQ. Making Health Care Safer II. An Updated Critical Analysis of the Evidence for Patient Safety Practices. Evidence Reports/Technology Assessments, No. 211; Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Mar.
Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. Rockville (MD): Agency for Healthcare Research and Quality (US); Report No.: 20-0029-EF; 2020 Mar.
National Steering Committee for Patient Safety. Safer Together: A National Action Plan to Advance Patient Safety. Boston, Massachusetts: Institute for Healthcare Improvement. 2020
The COVID-19 pandemic has wreaked havoc on our population and our healthcare system. But it has led to some changes that we consider to be positives. The most obvious one is the emergence of telemedicine, which is likely to be here to stay even after the pandemic has ended (see our November 2020 What's New in the Patient Safety World column “Telemedicine Here to Stay But Use It Safely”). Another useful practice might be virtual medication history interviews and discharge education (see our April 7, 2020 Patient Safety Tip of the Week “Patient Safety Tidbits for the COVID-19 Pandemic”).
1. A centralized monitoring system
2. Daily meetings to pinpoint safety and quality concerns
3. Reducing the number of times workers enter patients' rooms
4. Guides for respiratory treatments to reduce the spread of disease
5. Safety precautions for visitors
The first item uses a central system to remotely monitor patients' vital signs and consult with other hospitals in a hospital’s network, supplementing a labor shortage. Such systems can also be used to virtually supervise bedside nurses to ensure that tasks are completed correctly.
For the second item, front-line staff on each unit would meet in the morning to voice any concerns about safety and quality. Then, managers would report these concerns at a director-level meeting. Issues were handled on the spot and communicated to senior executives. To this, we might also add the “mid-shift” huddle (see our July 2021 What's New in the Patient Safety World column “Mid-Shift Huddles”).
The third item is used to reduce front-line workers' exposure to Covid-19 patients. It involves “clustering” of care so that certain services and actions get bundled together to minimize the number of times a nurse or other healthcare worker has to enter the room. Such systems require good IT systems to promote such clustering. And, while reducing the number of times workers enter patients’ rooms may help protect staff (and some patients), there may also be a downside. See our numerous columns (listed below) on the unintended consequences of contact isolation.
The fourth item includes implementing specific guides for certain respiratory procedures. At one hospital system, staff are now required to wear respirators during these procedures, and signs are posted on doors where these procedures are being done to warn others not to enter until it has been vacant for a certain amount of time.
Regarding the last item (safety precautions for visitors), Leah Binder (President and CEO of the Leapfrog Group) is quoted: "Now, visitors are just expected to wash their hands, wear a mask and they have certain responsibilities to protect against family and other patients from infection".
Interesting list. We suspect there are multiple other practices from the COVID-19 era that will be here for the long run. Let us know which ones you’ve identified.
See also our other columns related to COVID-19:
Some of our prior columns on the unintended consequences of contact isolation:
Gillespie L. Hospital safety practices that will outlive the pandemic. Modern Healthcare 2021; December 14, 2021
Advisory Board. Covid-19 led to new hospital safety measures. These 5 will outlast the pandemic. Advisory Board 2021; December 15, 2021
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