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Our June 6, 2017 Patient Safety Tip of the Week NYS Mandate for Sepsis Protocol Works reported on the successful reduction in sepsis mortality in New York State after the New York State Department of Health mandated that hospitals begin using protocols to help with early identification and treatment of sepsis. Hospitals began implementing these protocols in 2014. By the third quarter of 2016, 84.7% of adult patients and 85.3% of pediatric patients with severe sepsis or septic shock were treated using protocols (NYSDOH 2017). Adult in-hospital mortality fell from 30.2% in early 2014 to 25.4% by late 2016. Pediatric mortality rates were more variable without a clearcut trend. After adjusting for patient factors, the NYSDOH analysis of the data showed that the odds of dying were 21% less for adult patients who received protocol-driven treatments compared to patients who do not receive protocol-driven treatments. The time frame for management was also critical. After adjustment, the NYSDOH analysis showed that the odds of dying were 27% less for adult patients who received all of the recommended treatments within three hours compared to patients who did not receive all of the recommended treatments.
Seymour et al. dove deeper into the data (Seymour 2017). Supporting the importance of early treatment, they found that each hour of time to the completion of the 3-hour bundle was associated with higher mortality (odds ratio of death until completion of 3-hour bundle, 1.04 per hour). Patients who had the bundle completed during hours 3 through 12 had 14% higher odds of dying in the hospital than those whose bundle was completed by 3 hours. Those same odds (1.04 per hour) were seen for time to administration of antibiotics and in-hospital mortality and patients who received first dose of antibiotics during hours 3 through 12 had 14% higher odds of dying in the hospital than those receiving antibiotics by 3 hours.
But there may be more to the story of the New York State experience. Lasater et al. (Lasater 2020) looked at New York State hospital data from 2017 and found a significant relationship between sepsis mortality and hospital nurse-to-patient staffing ratios. They found that each additional patient per nurse was associated with 12% higher odds of in-hospital mortality, 7% higher odds of 60-day mortality, 7% higher odds of 60-day readmission, and longer lengths of stay, even after accounting for patient and hospital covariates including hospital adherence to SEP-1 bundles. And, while adherence to SEP-1 bundles was associated with lower in-hospital mortality and shorter lengths of stay, the effects were markedly smaller than those observed for nursing staffing. Each additional patient per nurse is associated with 12% higher odds of in-hospital mortality compared with a 10% change in SEP-1 adherence associated with only a 5% change in in-hospital mortality. Higher SEP-1 scores were also associated with shorter lengths of stay, but staffing had more than twice as large an effect on shorter lengths of stay, even when accounting for hospitals SEP-1 scores. Moreover, the effect of staffing was large and significant in terms of 60-day mortality and readmissions, while the SEP-1 scores revealed no association.
So, how does this relate to the prior NYS studies? They emphasized that adherence to the sepsis protocols in the first 3 hours was important. So how does that relate to nursing staffing? Our June 6, 2017 Patient Safety Tip of the Week NYS Mandate for Sepsis Protocol Works also noted a study (Peltan 2017) that showed a relationship between adherence to protocols and how busy the emergency departments are. They found that patients received antibiotics within three hours in 83 percent of cases in uncrowded ERs, but only 72 percent of the time when the ER was crowded (exceeded the ERs licensed beds). Such might reflect nursing staffing ratios in the ER.
But the Lasater study used nursing staffing ratios on med/surg units, not the ER. Nurses on the med/surg units would be more likely to be involved in the 6-hour bundle, which included fluid administration, vasopressors for refractory hypotension, and reassessment of serum lactate levels. But there is another important consideration. The original New York State studies reported only the relationship of mortality to the timing of the first dose of antibiotics. But it turns out that the subsequent administration of antibiotics may also be important. Another study (Leisman 2017) found that major second antibiotic dose delays were common. They observed an association between major second dose delay and increased mortality, length of stay, and mechanical ventilation requirement. In fact, in their multivariable analysis, major delay was associated with a 61% increased odds of hospital mortality. Interestingly, they found that major delays in second doses were paradoxically more frequent for patients receiving compliant initial care. Its quite conceivable that better nurse:patient ratios on the med/surg units might reduce such delays in administration of the second antibiotic dose.
Whatever the actual reasons, the Lasater study suggests that better nurse:patient ratios are beneficial for outcomes in patients with sepsis. That shouldnt be surprising, since there have been a number of studies showing reduced patient mortality, in general, when there are fewer patients per nurse (see the list of our prior columns on nursing staffing below). However, well reiterate a point we make in almost each of those columns the nurse:patient ratio is likely less important that the actual nurse workload, which is more difficult to quantitate.
The Lasater study is a valuable addition to the growing body of evidence linking patient outcomes to nursing staffing.
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 HAIs and Nurse Staffing
September 1, 2020 NY State and Nurse Staffing Issues
February 9, 2021 Nursing Burnout
Our other columns on sepsis:
NYSDOH (New York State Department of Health). New York State report on sepsis care improvement initiative: hospital quality performance. March 2017 https://www.health.ny.gov/press/reports/docs/2015_sepsis_care_improvement_initiative.pdf
Seymour CW, Gesten F, Prescott HC, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. NEJM 2017; Online First May 23, 2017
Lasater KB, Sloane DM, McHughMD, et al. Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes. American Journal of Infection Control 2020; Published online December 10, 2020
Peltan ID, Bledsoe JR, Oniki TA, et al. Increasing ED Workload Is Associated with Delayed Antibiotic Initiation for Sepsis. Abstract 5505. 2017 American Thoracic Society International Conference. Presented May 21, 2017
Leisman D, Huang V, Zhou Q, et al. Delayed Second Dose Antibiotics for Patients Admitted From the Emergency Department With Sepsis: Prevalence, Risk Factors, and Outcomes. Critical Care Medicine 2017; 45(6): 956-965, June 2017
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