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IOM links staffing, patient infections
You have to be willing to invest something now’
Infection control is one of the key areas cited in a recent national report warning that nursing staffing problems pose a grave threat to patient safety. Overall, the Washington, DC-based Institute of Medicine (IOM) panel recommends the working environment of nurses be transformed substantially to better protect patients from health care errors.1
"We saw infection control as one of the major patient safety issues," says Donald Steinwachs, PhD, chair of the IOM committee and head of the department of health policy and management at Johns Hopkins University in Baltimore.
"We said the priority areas to initiate were in medications, safety, and infection control — with hand washing as a specific intervention. Another thing we talk about is establishing a culture of safety where everyone in the organization from top to bottom [views patient safety] as equally important, if not more so, than efficiency and costs," he explains.
In that regard, the report includes a "true" account of a system breakdown and an overwhelmed nurse resulting in a noscomial infection. Staffing woes and infection rates are linked fairly well in the infection control literature.
Investigators repeatedly have traced nosocomial infections to staff problems caused by department mergers or addition of new services, spikes in census, cutbacks in nursing, or increased use of pool and agency nurses.
Though it can be difficult to establish a clear epidemiological link between such conditions and subsequent infections, the general consensus is that staffing problems — particularly if they occur in conjunction with an increase in patient acuity — may undermine aseptic technique, catheter care, and hand-washing compliance by harried health care workers.2-4
Despite the strong and accumulating evidence that higher nurse staffing levels in hospitals and nursing homes result in safer patient care, there is wide variation in nurse staffing levels across hospitals and nursing homes, the IOM reported.
Data from 135 hospitals in 2002 show a nurse working in a medical-surgical unit on the day shift typically is assigned six patients. Some are assigned several more. "Fully 23% of hospitals reported that nurses in their medical-surgical units on the day shift were each responsible for caring for seven to 12 patients," the IOM report stated.
Changes in how to establish staffing levels
The report calls for changes in how nurse staffing levels are established and mandatory limits on nurses’ work hours as part of a comprehensive plan to reduce problems that threaten patient safety by strengthening the work environment in four areas: management, work force deployment, work design, and organizational culture.
Moreover, staffing shortcuts to save money may backfire and fuel greater costs, Steinwachs says.
"When safety conditions are not as good as they could be, those incidents that adversely affect patients increase length of stay and increase use of resources," he says. "Under the payment systems of most hospitals, it means that you actually are absorbing a lot those costs. Adequate staffing to achieve safety goals can save resources, but you have to be willing to invest something now to get this process started. In the future, we’ll find that improving patient safety really has a positive impact on the bottom line of organizations."
The nation’s 2.2 million registered nurses, 700,000 licensed practical and vocational nurses, and 2.3 million nursing assistants constitute 54% of all health care providers. "Studies show that increased infections, bleeding, and cardiac and respiratory failure are associated with inadequate numbers of nurses," the report states.
"Available methods for achieving safer staffing levels, such as authorizing nursing staff to halt admissions to their units when staffing is inadequate for safe patient care, are not employed uniformly at hospitals," it adds.
The IOM recommends national health officials specify that staffing levels increase as the number of patients increases. "Hospital intensive care units [ICU} should increase internal oversight when staffing falls below one nurse for every two ICU patients," the report states. "Federal and state report cards on nursing homes should include information on nursing staff levels, and measures of staffing levels should be developed for hospital report cards. Whenever possible, health care facilities should avoid using nurses from temporary agencies to fill staffing shortages."
Long work hours pose one of the most serious threats to patient safety, because fatigue slows reaction time, decreases energy, diminishes attention to detail, and otherwise contributes to errors, the IOM finds. While most nurses typically work eight- to 12-hour shifts, some work even longer hours. At the same time, patients admitted to hospitals typically are more acutely ill and require technologically more complicated care than in the past. State regulatory bodies should prohibit nursing staff from working longer than 12 hours a day and more than 60 hours per week, the committee says.
Increasing nursing home staff oversight
In addition, the committee recommends that nursing homes increase internal oversight of their staffing practices and effects on patient safety whenever staffing falls below one RN for every 32 residents, one licensed nurse per 18 residents, and one nurse assistant per 8.5 residents per day.
The committee’s recommendations are made in a climate of high rates of turnover among nursing staff, as well as a nursing shortage that is predicted to worsen in the future. Implementation of the recommended changes in nurses’ work environments likely would help health care organizations recruit and retain nurses, the report says.
"It may be tempting to think that these recommendations can wait for increases in the supply of nurses, but evidence on nursing retention indicates just the reverse is true," Steinwachs says. "Nurses will be more likely to stay in health care organizations that implement the management and work-design practices recommended in this report."
(Editor’s note: To see the IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses , go to: www.nap.edu.)
1. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC; 2003.
2. Fridkin SK, Pear SM, Williamson TH, et al. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996; 17:150-158.
3. Kidd F, Heitkemper P, Kressel A. A neonatal intensive care unit outbreak of S. aureus associated with inadequate staffing. Abstract S74. Presented at the Conference of the Society for Healthcare Epidemiology of America. San Francisco; April 1999.
4. Duncan RA, Levine A, Willey S, et al. Nursing staffing and central venous catheter-related bloodstream infections (CVC-BSIs) in a changing surgical intensive care unit (SICU). Revised Abstract. Presented at the Conference of the Society for Healthcare Epidemiology of America. San Francisco; April 1999.