What’s New in the Patient Safety World

May  2011

More on Nursing Workload and Patient Outcomes



Last month, in our April 2011 What’s New in the Patient Safety World column “Nursing Staffing and Mortality”, we highlighted a study (Needleman 2011) using an improved methodology which confirmed that both low nursing staffing levels and higher than normal nursing workloads correlate with increased patient mortality rates. That study, in conjunction with the numerous prior studies, should leave little doubt about the importance of matching nursing staffing levels to the needs of patients (both census and acuity).


This month another study (Trinkoff 2011) found that pneumonia deaths were significantly more likely in hospitals where nurses reported increased psychological demands and more adverse work schedules. Postoperative pulmonary embolism/deep vein thrombosis was also more likely. They also correlated more post-op hemorrhages in cases where nurses were frequently interrupted, more CHF deaths when nurses worked long shifts, and several other adverse patient outcomes associated with various stresses on nurses.


And another interesting study (Weiss 2011) correlates nursing overtime with both hospital readmissions and increased ER visits. The study was done at 4 acute care hospitals and found that hospitals having higher nursing staffing levels (not relying on overtime) had reduced readmission levels (odds ratio = 0.56), whereas staffing utilizing increased overtime resulted in increased ER visits (odds ratio = 1.70). The implication is that nurses are less effective at certain processes when working overtime. Interestingly, to perform better a hospital would have to pay more for higher staffing and then see fewer visits! So in today’s reimbursement world you won’t find many hospitals wanting to do that. However, in the reimbursement world of the future (ACO’s, global budgets, etc.) doing better staffing and not relying on overtime will make great sense. Hmm…if you are a payor today, why wouldn’t you incentivize hospitals to ensure adequate (or even “luxury” nursing staffing)!


There are lots of other examples of where investing more in certain areas creates savings much greater than your extra investment (see our November 10, 2009 Patient Safety Tip of the Week “Conserving Resources…But Maintaining Patient Safety”). In that Tip we noted  examples where you do not want to cut and where investment in resources may save money in the long run. Housekeeping is one of those areas. We have seen hospitals faced with budget deficits cut housekeeping staff, only to encounter increased nosocomial infection rates. We also noted a study from the UK (Dancer et al 2009) which found that hiring an additional cleaner who focuses near-patient high-touch sites has the potential to save a hospital $50,000 to $116,000 annually even after accounting for the salary for the extra cleaner.


Sometimes spending a little extra in some areas can improve both patient safety and your budget.






Needleman J, Buerhaus P,  Pankratz VS, et al. Nurse Staffing and Inpatient Hospital Mortality. N Engl J Med 2011; 364:1037-104




Trinkoff A, Johantgen M, Storr CL, et al. Linking Nursing Work Environment and Patient Outcomes. J Nursing Regulation 2011; 2(1): 10-16




Weiss ME, Yakusheva O, Bobay KL. Quality and Cost Analysis of Nurse Staffing, Discharge Preparation, and Postdischarge Utilization. Health Services Research 2011; Article first published online: 21 APR 2011




Dancer SJ, White LF, Lamb J, Girvan EK, Robertson C. Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study. BMC Medicine 2009, 7:28  doi:10.1186/1741-7015-7-28














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