# Presentation: 341633

## Nurse Working Conditions and Patient Safety:The Outcomes of ICU Working Conditions Study

- Investigators: Pat Stone, Andy Dick, Teresa Horan, Elaine Larson, Cathy Mooney-Kane, and Jack Zwanziger
- ps2024@columbia.edu

- Funded by AHRQ R01 HS013114
- Supported by the CDC

## Working Conditions and Patient Safety

- Growing concern that poor working conditions in the health care sector is contributing to decreasing patient safety (IOM, 2004).
- An acute nursing shortage that will not be as cyclic as past shortages due to
- Aging workforce
- Aging population and increased demand for nursing services
- Poor working conditions resulting in difficulty recruiting and retaining qualified nursing personnel

## Healthcare Associated Infections (HAI):Important Patient Safety Issue

- HAI rates have risen over the last 30 years
- 2 million cases annually
- 500,000 occur in ICU
- Commonly associated with insertion of a device
- 6th leading cause of death
- Estimated to cost hospitals $5.9 billion per year
- Increasing numbers of HAI are resistant to one or more antibiotics

## Purpose

- Examine the factors related to ICU nurse working conditions and
**Patient safety outcomes**

## Conceptual Framework

**Nurse Working Conditions **
- Organizational Climate
- Staffing
- Overtime
- Wages

**Patient Characteristics**Severity of Illness
- Comorbidities
- Demographics
- Socio-economics

**Patient Outcomes**
- CLBSI
- VAP
- CAUTI
- Decubitus Ulcer
- 30-day Mortality

**Structures of Care**Hospital Size
- Teaching Status
- ICU Type
- Nursing Case-mix

**Structures of Care**Profit Margin
- Magnet Status

**Covariates**

**Independent**
**Variables**

**Dependent**
**Variables**

## Recruitment

- Through infection control professionals
- Invitations sent to CDC NNIS hospitals
- APIC listserve
- Eligibility
- ICU must have conducted device related HAI surveillance for part of 2002 according to NNIS definitions

## Data Collection Procedures

- Patient characteristics
- Medicare files
- Structure of Care
- AHA data
- Public files
- Administrative Processes related to Nurse Working Conditions
- Nurse survey
- Payroll
- Patient census
-  Patient Outcomes
- CDC infection data
- AHRQ PSI

## Design/Statistical Analysis 

- Cross sectional analysis
- All data provided for 2002
- Variables computed on a monthly basis
- Except organizational climate
- If patient’s stay covered more than 1 month, patient assigned to period with the longest stay
- Multivariate logistic regressions for each safety outcome

## Sample

- 15,846 patients
- 51 ICUs
- 31 hospitals
- 1,095 RNs

## Summary of Results

- Increased staffing significantly (p <0.05) related to safety outcomes
- CLBSI (OR=.32), VAP (OR=.21), 30-day mortality (OR=. 81) and decubitus ulcer (OR=.69)
- Patients in ICUs staffed with higher proportions had a 3 to 5 fold increase in CAUTI and 2 fold increase in decubiti

## Summary of Results (cont)

- Organizational climate related to CLBSI and CAUTI
- Patients in ICUs with positive organizational climate 39% decreased odds of CAUTI
- OR=0.61, CI95% 0.44-0.83
- Conflicting results with CLBSI
- OR=1.19, CI95% 1.05-1.36
- Mixed results with profit margin
- No independent effect of Magnet status

## Discussion

- First study to link nurse working conditions with CDC infection surveillance data.
- Comprehensive examination with unique data sources.
- The administrative processes related to nurse working conditions were associated with patient safety outcomes.

## Strengths and Limitations

- Unique data set
- Large national sample
- Generalizability?
- ICU specific
- Over represented by large teaching hospitals
- Hospitals were part of the CDC network

## Clinical Application

- A systems approach, including improving nurse working conditions, can improve patient safety.
- Substitutes for overtime and a flexible, qualified workforce is needed.

## Other Analyses, Nurse and System Outcomes

- Organizational climate related to
- Occupational injuries
- Stone & Gershon (2007).

- Organizational climate related to
- Nurses’ intention to leave position
- Increasing wages alone, without attention to organizational climate insufficient
- Stone et al., (2007).

## That’s it, time to go...

- Special thanks to all the infection control professionals, staff nurses and hospitals that participated in this project

## Next Research Steps

- Prevention of Nosocomial Infections and Cost-Effectiveness Analysis (P-NICE)
- Describe and determine effectiveness of infection control staffing and interventions
- Estimate long term outcomes of HAI
- Estimate cost-effectiveness of infection control staffing and interventions
- Funded by NIH
- Exploratory Study Using Queueing Theory to Improve Nurse Staffing Effectiveness
- Can queueing theory be used to inform nurse staffing decisions?
- Funded by AHRQ