The impact of nurse staffing on hospital costs and patient length of stay: a systematic review

Research examining the relationships between nurse staffing, hospital costs, and length of stay is varied using a range of methods and definitions. This lack of coherence in definitions and measurement tools for cost and length of stay makes it difficult to conclude with certainty the results of nurse staffing on hospital cost and length of stay. However, the evidence reflected that significant reductions in cost and length of stay may be possible with higher ratios of nursing personnel in hospital settings. Sufficient numbers of RNs may prevent patient adverse events that cause patients to stay longer than necessary. Patient costs were also reduced with greater RN staffing as RNs have higher knowledge and skill levels to provide more effective nursing care as well as reduce patient resource consumption. Hospital administrators are encouraged to use higher ratios of RNs to non-licensed personnel to achieve their objectives of quality patient outcomes and cost containment.     

The community impact of school-shootings on stress-related emergency department visits

School-shootings can enormously impact U.S. gun policy, but very little is known about the community mental health impact of school-shootings. We used difference-in-differences and event study analyses to compare stress-related ED visits in zip-codes within 5 miles (exposed) and in zip-codes 10–15 miles from (control) school-shootings before and after school-shootings using data from California, 2005–2011. School-shootings and fatal school-shootings were associated with annual increases of 0.7 and 1.5 stress-related ED visits per 1000 people, increases of 7% and 14%, respectively, compared to pre-shooting utilization. These previously unmeasured costs of school-shootings reinforce calls to prevent gun violence, especially in schools.     

Analysis of chronic emergency department use

This retrospective emergency department (ED) chart review study examined the relationship between acuity level and the type of insurance in a patient population who used the ED on a chronic basis (seven or more times in the calendar year 1996). Of 1,185 patients seen in the ED in 1996, 122 had between 7 and 29 visits. In the study population: 62.5% of their visits were classified as nonurgent; 42.6% of the nonurgent visits were made by those with insurance; the highest frequency of visits took place between 8:00 am and 4:00 pm when most alternative nonemergency facilities are open. Some of the factors seen as influencing overuse of the ED include: the fact that some chronic use appeared to be associated with psychiatric conditions including substance abuse and patients with recurrent chest pain; and patient's perceptions that access to lab and X-ray facilities are readily available within the ED.     

Improving retention, confidence, and competence of new graduate nurses: results from a 10-year longitudinal database

Developing competent and confident new graduate nurses who remain with their hospitals is a major challenge. A structured evidence-based RN residency was developed and implemented in hospitals across the United States. Outcomes data were collected from over 6000 new graduate nurses who completed the RN residency over a 10-year period. The results indicate an accelerated increase in competence and self-confidence and a significant decrease in turnover intent and actual turnover. This study provides persuasive evidence that both new graduate nurses and their organizations benefit from the implementation of a structured, clinical immersion RN residency.     

Nurse staffing decisions: an integrative review of the literature

The author exhaustively explores the current literature and attempts to summarize the current thinking on how to best decide on the most cost-effective nurse staffing requirements. Between 1984 and 1994 FTE nursing employees decreased by 7.3%, causing some researchers to seek ways to explore the relationship between staffing levels, staff and patient satisfaction and outcomes of care. Satisfaction among staff nurses working in a self-scheduling environment was determined largely by the individual's ability to negotiate for the desired days and shifts and by the nurse manager's ability to stand back from the process and let the staff collaboratively work it out. Work structure related studies seemed to find that 12-hour shifts were reported to be "less fatiguing" than traditional 8-hour shifts. Staffing studies found that rural hospitals still used 0.27 more RNs per occupied bed than urban hospitals and that the presence of a unit secretary was associated with a decreased use of RNs.     

Impact of apixaban vs low molecular weight heparin/vitamin k antagonist on hospital resource use in patients with venous thromboembolism

Background: The clinical and economic benefits associated with apixaban treatment have been established in clinical trials and published economic evaluations. The benefits associated with apixaban could extend to improving hospital efficiencies, potentially influencing hospital resource use, and bed days. The objective of this study is to estimate the impact of 6-month treatment with apixaban vs low molecular weight heparin/vitamin k antagonist (LMWH/VKA) on hospital resource use among patients with venous thromboembolism (VTE).

Methods: A model was developed to assess the impact of apixaban vs LMWH/VKA for treatment of VTE and prevention of recurrences on hospital resource use and costs. Resource use items included total hospitalizations, length of stay (LOS), and emergency department (ED) visits, estimated for all incident VTE patients in the UK over a 5-year time horizon. Rates of hospitalizations, ED visits, and LOS associated with recurrent VTE, major, and clinically relevant non-major bleeding were obtained from the AMPLIFY trial; costs were obtained from UK published sources.

Results: Over a 5-year time horizon, the model predicted that, compared to 6 months of LMWH/VKA, 6 months of apixaban led to 3,954 fewer hospitalizations (consisting of 2,341 fewer new admissions and 1,613 fewer re-admissions) and 32,214 fewer bed days, among 332,607 incident VTE patients. ED visits were reduced by 1,582. The reduction in hospital resource use led to a cost saving of ～£4.5 million in a market of patients treated with apixaban as compared to a market treated with LMWH/VKA. Sensitivity analysis indicated these findings were robust over a wide range of inputs.

Conclusions: 6-month treatment with apixaban for treatment of VTE and prevention of recurrences on hospital resource use led to a reduction in hospitalizations and LOS in comparison to LMWH/VKA. These findings can help the efforts in reducing the growing burden of preventable re-admissions to hospitals.     

Why are shortages of hospital RNs concentrated in specialty care units?

This article is the first in a series examining the interplay between the aging of the nurse workforce and other factors driving the growing nursing shortage that are already affecting some specialty areas. Nearly 60% of the current RN workforce is over 40 years of age; and the percentage of RNs under age 30 has fallen by nearly 40% since 1980. The total number of FTE RNs is projected to shrink after 2010, likely resulting in shortages of RNs "when the large baby-boom generation of RNs starts to retire." Because ICUs have historically attracted younger RNs, the rapid decline in the number of RNs in the workforce under age 30 plays a large role in explaining the development of shortages in the ICU. The growing difficulties staffing operating rooms and other peri-operative services is seen as related to the aging work force as more diploma prepared nurses have been attracted to this specialty because they had educational exposure to this area.     

A panel data analysis of productive efficiency in freestanding health clinics

By using a panel data on a number of freestanding health clinics in New York State over 1984–1987, we have estimated the production function for ambulatory care after controlling for unmeasured clinic-specific managerial efficiency. We found significant differences in management efficiency, which peaks around 50500 visits per year. The optimal staffing ratio between doctors, extenders and nurses was found to be around 1∶1/3∶1, in order for a clinic to be on the efficiency frontier.     

资源控制视角下人员任用与绩效的关系——华南地区IJV的实证研究

对东道国母公司来说,组织学习是建立国际合资公司(IJV)的重要原因之一。与外方母公司相比,东道国母公司在技术实力和管理经验方面都处于劣势,然而由于地缘的优势,东道国母公司能够为IJV的运作提供必须的物质和人力资源,并依靠这些资源与外方母公司展开谈判,对IJV实施必要的控制,从而促成学习目标的达成。从这个角度出发,本文研究了东道国母公司对IJV所采取的资源控制、人员任用控制以及IJV学习绩效之间的相互关系,并选取我国华南地区的96家合资企业作为实证研究对象,对资源控制、人员任用和IJV学习绩效的关系进行了实证研究。结果表明东道国母公司采取的资源控制并不直接影响IJV的学习绩效;但是通过东道国母公司对IJV的人员任用控制、资源控制会对IJV的学习绩效产生间接的影响。     

What every nurse executive should know about staffing and scheduling technology initiatives

Staffing in hospitals has a history of being based in opinion and tradition, not evidence. In recent years, for many, staffing practices have spun out of control creating chaos in overtime, the use of incentives, entitlement behaviors, dissatisfaction and frustration among nurses, and has opened doors for such things as staffing ratio legislation. Unprecedented pressures around budgets and financial performance have no doubt compounded this situation. We are in a new day, where technology can help us more than ever in a move towards staffing excellence and staffing practices based on evidence. Highly successful implementations of new technologies are the result of good leadership. The effectiveness of staffing and scheduling has significant business, safety, and quality implications that sit at the heart of the nurse executive's role.     

Impact of hospitalist care on hospital malpractice premiums using California hospital data

This study assessed the impact of hospitalist care on hospital malpractice premiums. The retrospective cohort study used hospital financial data from the California Office of Statewide Health Planning and Development and the annual hospital survey conducted by the American Hospital Association. The sample included 1000 California hospitals from 2006 to 2010. The effect of hospitalist care on hospital malpractice premiums was evaluated using generalized estimation equation models with log link normal distribution after controlling for hospital and market characteristics, patient utilization and staffing patterns. In multivariable analyses, hospitals with more full-time hospitalists per average daily census were associated with lower malpractice insurance premiums. For example, a one-hospitalist increase per 100 daily censuses resulted in a 5.1% reduction in malpractice insurance premiums. Hospitalist care was associated with a reduction in malpractice insurance expenses. The data reveal that hospitalist care is more efficient and effective in patient treatment and preventing complications. The improved efficiency may reduce malpractice insurance expenses.     

The impact of nursing on patient and organizational outcomes

The impact of nursing on patient and organizational outcomes has received significant attention from researchers in the past 10 years. Although some research has been based on a theoretical framework, to date, there has not been one, consistent framework that can guide this research. In addition, the frameworks that have been used do not identify nursing as the pivotal concept in the model. The purpose of this article is to identify a framework to guide such research with an emphasis on nursing as the essential concept. Unit culture, nurse staffing, staffing mix, and other variables do not have a direct effect on outcomes. It is only through these variables' influence on the delivery of nursing care that outcomes are affected.     

Enculturation of professional contract nurses: a concept analysis

The concept enculturation, an essential component of integration into the work arrangement of professional contract nurses, also known as travel nurses, is analyzed. These registered nurses are contracted by hospitals through health care staffing service firms, for temporary work assignments. The work of travel RNs involves frequent recurring episodes of integration to health care teams at hospitals throughout the nation. Rodgers Evolutionary Method (Rodgers & Knafl, 2000) is applied to analyze the concept of enculturation, leading to a pragmatic perspective on its meaning and utility. This work may contribute new knowledge applicable to future nursing research.     

Factors influencing work productivity and intent to stay in nursing

The researchers document the individual and workplace characteristics associated with decreased work productivity and intent to stay in nursing for nurses employed in direct patient care in the hospital setting. Factors associated with decreased work productivity were age, total years worked as a RN, quality of care provided, job stress score, having had a job injury, and having a health problem. Nurse leaders must place additional efforts on changes needed to improve the hospital workplace environment to decrease job stress, improve RNs' ability to provide quality care, and to assure the health and safety of nurses. Reducing job stress and providing adequate staffing so quality of care can be provided will enhance job satisfaction which will also encourage RNs to stay at the bedside. Improved work environments may delay older RNs' retirement from the workforce.     

Using intervention analysis to assess catastrophic events on business environment

This article describes the use of Autoregressive Interactive Moving Average with impact assessment (intervention analysis) on a time series. In this case, a search was made for sudden changes in the business environment when a natural disaster struck a community. The catastrophic event was hurricane Hugo. Data were obtained from a public hospital. Admissions, outpatient visits, and emergency room visits were examined. All showed a significant increase in activity, not only for the period immediately following the event, but also for at least two years following the storm. Studies indicate that the long-term clean-up and reconstruction activities may have increased this public facility's case load in a manner somewhat different from other community hospitals.     

Costs of inpatient and emergency department care for chronic obstructive pulmonary disease in an elderly Medicare population

Objective:

Treatment in the hospital setting accounts for the largest portion of healthcare costs for COPD, but there is little information about components of hospital care that contribute most to these costs. The authors determined the costs and characteristics of COPD-related hospital-based healthcare in a Medicare population.

Methods

Using administrative data from 602 hospitals, 2008 costs of COPD-related care among Medicare beneficiaries age ≥65 years were calculated for emergency department (ED) visits, simple inpatient admissions and complex admissions (categorized as intubation/no intensive care, intensive care/no intubation, and intensive care/intubation) in a cross-sectional study. Rates of death at discharge and trends in costs, length of stay and readmission rates from 2005 to 2008 also were examined.

Main results:

There were 45,421 eligible healthcare encounters in 2008. Mean costs were $679 (SD, $399) for ED visits (n = 10,322), $7,544 ($8,049) for simple inpatient admissions (n = 25,560), and $21,098 ($46,160) for complex admissions (n = 2,441). Intensive care/intubation admissions (n = 460) had the highest costs ($45,607, SD $94,794) and greatest length of stay (16.3 days, SD 13.7); intubation/no ICU admissions had the highest inpatient mortality (42.1%). In 2008, 15.4% of patients with a COPD-related ED visit had a repeat ED visit and 15.5–16.5% of those with a COPD-related admission had a readmission within 60 days. From 2005 to 2008, costs of admissions involving intubation increased 10.4–23.5%. Study limitations include the absence of objective clinical data, including spirometry and smoking history, to validate administrative data and permit identification of disease severity.

Conclusions:

In this Medicare population, COPD exacerbations and related inpatient and emergency department care represented a substantial cost burden. Admissions involving intubation were associated with the highest costs, lengths of stay and inpatient mortality. This population needs to be managed and treated adequately in order to prevent these severe events.     

Violence against nurses and its impact on stress and productivity

The purpose of this study was to examine how violence from patients and visitors is related to emergency department (ED) nurses' work productivity and symptoms of post-traumatic stress disorder (PTSD). Researchers have found ED nurses experience a high prevalence of physical assaults from patients and visitors. Yet, there is little research which examines the effect violent events have on nurses' productivity, particularly their ability to provide safe and compassionate patient care. A cross-sectional design was used to gather data from ED nurses who are members of the Emergency Nurses Association in the United States. Participants were asked to complete the Impact of Events Scale-Revised and Healthcare Productivity Survey in relation to a stressful violent event. Ninety-four percent of nurses experienced at least one posttraumatic stress disorder symptom after a violent event, with 17% having scores high enough to be considered probable for PTSD. In addition, there were significant indirect relationships between stress symptoms and work productivity. Workplace violence is a significant stressor for ED nurses. Results also indicate violence has an impact on the care ED nurses provide. Interventions are needed to prevent the violence and to provide care to the ED nurse after an event.     

The recession's effect on hospital registered nurse employment growth

Recessions are not uncommon in the United States, but the most recent recession is arguably the most severe economic downturn since the Great Depression of the 1930s. Although recessions result in increases in national unemployment in most sectors of the economy, they have resulted in increases in registered nurse (RN) employment as many non-working married RNs re-enter the workforce when their spouses lose their jobs. Over the past decade, hospital RN employment increased by more than 400,000 with virtually all of this growth associated with the two recessions that occurred during this period. The most recent recession led to an increase in hospital RN employment that was not only unprecedented in size, estimated at nearly 250,000, but was marked by the employment of large numbers of RNs over 50 years of age. While national unemployment rates remain high, hospitals should prepare for an eventual jobs recovery when many RNs are likely to leave the workforce.