Revisiting Nursing's Effect on Surgical Quality and Cost.

Improvements in surgical safety remain an important focus of hospitals and clinicians. With nearly 100 000 patients dying per year in the United States after undergoing elective surgery and mortality rates varying from 2-fold to 10fold across hospitals,1-3 excess surgical mortality qualifies as a significant public health problem. Unfortunately, the precise means to improve surgical safety remain elusive. While several hypotheses have been proposed to explain the variation in postoperative mortality, failure to rescue— death following a major complication—ranks among them as the most popular, intuitive, and actionable theory.4 Yet rescuing patients from surgical complications requires substantial human and financial resources. Increased cost pressures places “rescue” at odds with current hospital priorities. In this issueof JAMASurgery, Silber andcolleagues5 evaluate the “value” of improved nursing environments in surgicalpatients.Theyevaluatedifferences inpatientoutcomesand cost between hospitals with better nursing work environments, determined by Magnet status and higher nurse-tobedratios,andmatchedcontrols.Thisstudyusesa largesample ofMedicare patientswith exquisite attentionpaid to comparing similar populations using rigorous statistical matching methods. Twokey findingsemerge.First, hospitalswithbetternursing environments (termed focal hospitals) have a nearly 20% lower failure-to-rescue rate than control hospitals. Interestingly, even larger benefits were observed in the sickest patient group. While causation cannot be assumed, the quality and quantity of nursing care likely enables early recognition and management of these complex patients. Further, the intensive care unit length of stay wasmarkedly lower in the focal hospitals, anotherpotential signal of successful rescues associated with better nursing environments. Second, the overall value of care delivered at focal hospitals was superior to that of control hospitals. Specifically, focal hospitals achieved similar costswith decreasedmortality, thereby tipping thevalue scale.However, care associatedwith the sickest patients in focal hospitals was not consistently associatedwith lower cost. The survival benefitwasoffset by increased spending in this highest risk cohort. Whilewedonot fullyunderstandhowhospitals rescuesurgicalpatients,6successful rescuelikelyrequiresteamwork,communication, and leadership skills from front-line nurses. Yet these attributes are hard to measure, and researchers continue to work toward gathering pertinent and reliable data in these importantdomains.Executivesmayalsowonderwhether they should improve nurse staffing, improve working conditions, or both. Despite Silber and colleagues’ evidence of the valueofbetternurse staffingandhospital recognition fornursing excellence, safety cultures cannot be changed quickly. For example, our group has shown that hospitals transitioning to Magnetstatusdonot improvetheiroutcomesafter recognition.7 Committedefforts tounderstand thecontext inwhich rescue occurs successfully are needed to provide clinicians and executives with actionable targets. Armed with such data, implementationsciencecanhelpusdisseminatepromisingorganizational strategies to improve patient outcomes while spending resources judiciously. Surgery is a teamsport and the thoughtful coordination of all the “players”will no doubt improve patient safety.