Concerns mounting about link between nursing ratios and infections, injuries
Congressional bill would require staffing, infection rate disclosures
Shifts in nurse staffing patterns and greater inpatient acuity are increasing the risk of infections in the nation’s hospitals, studies show. Emerging data from both the Centers for Disease Control and Prevention and the American Nurses Association (ANA) in Washington, DC, suggest that patients as well as staff may be at greater risk as the nation’s health care system continues to experience dramatic economic fluctuations that affect staffing patterns and quality of care.
The latest findings from the CDC the third such study issued this year by the agency link a nosocomial outbreak of Serratia marcescens in a cardiac intensive care unit to fluctuations in nurse-to-patient ratio that created periods of time where too few nurses were treating too many patients. (See related story in Hospital Infection Control, June 1996, pp. 69-72.)
’[Nurses] pointed out that they had been stretched pretty far covering four and five patients at a time,” says William Jarvis, MD, chief of the investigations and prevention branch in the CDC hospital infections program. ’We looked at the nurse-to-patient ratio and found a very good correlation between the reduction of nursing staff and the increase in infection rates.”
In addition, a recent national survey by the ANA reveals widespread concern among the nation’s nurses about both nursing staff cutbacks in hospitals and increased use of unlicensed assistant personnel. Slated for publication in this month’s issue of the American Journal of Nursing, the survey found two-thirds of some 5,000 RNs polled reporting an increase in the numbers of patients assigned to them, and three-fourths citing increased patient acuity as well.
The combination is creating what the ANA calls a ’speed-up” working environment, as nurses deliver care at a pace that increases the risk of nosocomial infections and other adverse events. On average, two out of five nurses reported an increase in patient complications, medication errors, nosocomial infections, skin breakdown, and injuries to patients, the ANA reports.
’The entire survey is pretty jarring,” says Susan Wilburn, RN, MPH, occupational safety and health specialist at the ANA in Washington, DC. ’It’s amazing how significant and widespread the problem is across the country. Both nosocomial infections and [nursing] injury and illness have hidden costs. If the reason why we are downsizing is to cut costs and to respond to the consumer demand for cost-effective care, but one result of downsizing is that we have increased workers’ compensation costs and nosocomial infections, we have just cut off our nose to spite our face.”
As an example of the trend, the ANA gathered data over a four-year period from 86 Minnesota hospitals that were reporting reductions in staffing, changes in the organization of work, decreased lengths of patient stay, and increased acuity of patients. Over the period, the number of nurses at the hospitals declined 9% from 8,951 nurses in 1990 to 8,121 nurses in 1994. There was a corresponding 65% increase in injuries and illness reported by nurses in the hospital 200 log records required by the Occupational Safety and Health Administration, Wilburn notes.
The Minnesota data revealed that in 1990 there were 569 reportable incidents and in 1994 there were 921. Though injury-specific percentage break-outs were not available, she says the two categories of incidents that increased the most over the period were needlesticks and back injuries.
Citing an overall lack of data on the effects of downsizing and changes in skill mix on the quality of care, the ANA is launching state and federal initiatives to try to document the issue. In that regard, Congress may get into the act with a proposed bill that would require hospitals to disclose staffing levels and nosocomial infection rates. Proposed by Rep. Maurice Hinchey (D-NY), The Patient Safety Act of 1996 (H.R. 33355) is the first national legislation to address the staffing/infection link.
’We have concerns about staffing levels insofar as they may affect quality of care,” says Christopher Arthur, PhD, Hinchey’s legislative director. ’People go into a hospital now and think there are going to be just as many nurses as there were 10 years ago, and that’s not true. We introduced it this year to start building attention, attracting interest to the issue. We have gotten a lot of inquires about it and we are encouraged by that.”
Up for re-election this term, Hinchey will reintroduce the bill if he returns to Washington, Arthur says, noting that the political prognosis is probably more favorable for such legislation if the Democrats regain a majority in the House. Regardless, some version of the action may resurface in light of the recent CDC findings and the alarm being sounded by the ANA. There is also the possibility that OSHA may become involved, as the agency already has in the areas of bloodborne pathogens and tuberculosis. In addition, the National Institute of Occupational Safety and Health (NIOSH) which conducts research that often forms the basis for OSHA standards recently added issues of downsizing and work organization to its occupational research agenda, Wilburn notes.
’I certainly think that OSHA should be looking at this data in relation to staffing and skill mix,” she says. ’But I think that the hospitals will be very willing to make the changes that need to be made when we demonstrate to them that is more expensive for them not to staff appropriately.”
Indeed, given the flurry of interest in the issue, the American Hospital Association is advising member institutions to proceed cautiously in making fiscal changes that may affect their ability to prevent nosocomial infections.
’There are some studies going on looking at staffing ratios and things like that, but there hasn’t been anything definitive yet,” says AHA spokesman Rick Wade. ’But this is an area where we have to be very careful in how we handle re-engineering and tightening of operations. It is not only the impact on quality, it is the impact on public perception. There are other things that [hospitals] do that are still largely mysterious to the public but infection control is something they understand very clearly.”
A factor that confounds the trend is that according to the AHA, the overall number of nurses in hospitals is either stable or increasing in almost every region of the country. Yet any gains in numbers of hospital-based RNs have been largely offset by a corresponding increase in patient acuity, argues Lucille Joel, RN, EdD, FAAN, immediate past president of the ANA and professor in the College of Nursing at Rutgers (NJ) University.
’The presence of the registered nurse next to that patient is more important than any time in history,” she emphasizes. ’Patients are more complex, more acutely ill than ever. When you look at length of stay, it’s down. When you look at resource utilization and many other measures of severity and acuity, they’re up. We have a much more demanding patient. So the fact that on paper there is as great a nursing presence as ever is lying with statistics. The nursing resources are not there at the same level given the nature of today’s patient.”
In that regard, data from the CDC’s National Nosocomial Infections Surveillance system indicates that over the last five years total hospital beds have decreased while the number of ICU beds continues to rise, says Lennox Archibald, MD, a medical epidemiologist in the CDC hospital infections program.
’Basically there are more patients who are severely ill coming into hospitals, which is increasing the number of ICU patients,” he says. ’With more severely ill patients you need more intensive nursing care and procedures that require a set amount of time if you want to do them properly dressing changes, changing lines, washing hands between patients, just doing infection control procedures. If you have a large patient load or fewer nurses on a busy unit people have less time to devote to these things, which are the basis for preventing nosocomial infections.”
Such were the contributing factors in the aforementioned CDC investigation of an S. marcens outbreak in a cardiac ICU at the Children’s Hospital in Philadelphia, says Archibald, who presented the CDC’s findings recently in New Orleans at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC).
Following the outbreak, the CDC conducted a study to assess the role of nurse staffing changes on the overall nosocomial infection rate from December 1994 through December 1995. Investigators calculated the monthly nursing hours:patient-days (RN:PT) ratio and the monthly ICU nosocomial infection rate (number infections/1000 patient-days). They found a statistically significant link between the respective monthly ICU nosocomial infection rate and monthly RN:PT ratio, with the data suggesting that periodic staffing fluctuations were associated with an increased nosocomial infection risk.
’As the nurse-to-patient ratio fell as there were less numbers of [nursing] hours devoted per patient day the nosocomial infection rate went up,” Archibald says. ’During the outbreak, nurses said they were taking care of up to five patients on a 12-hour shift, when they shouldn’t have been taking care of more than two.”
Complicating the issue, the situation was apparently not a result of direct staff cuts, but nurse-to-patient ratio ’fluctuations” that can be caused by an influx of patients, staff illness, or reassignment of nurses to other areas.
’But one of the things that is coming up in other hospitals is that they are cutting nursing staff and using nurses from a pool group who work on demand,” Archibald tells Hospital Infection Control. ’A lot of these nurses are RNs, but they are not trained or accustomed to the unit. That’s another factor.”
The CDC findings suggest it is time to consider routinely looking at staffing fluctuations in intensive care units during epidemiological investigations of nosocomial infections. However, ICPs that begin assessing staffing in conjunction with infection rates probably should first rule out more traditional factors, Jarvis notes.
’Probably the best approach is to have an active, good surveillance program in place that would detect an increase in the infection rate, and as you see the infection rate increasing look at the wide variety of factors that might be responsible for it,” Jarvis says. ’There could be a lot of reasons for an increase in infection rates, with the nurse-to-patient ratio just being one of those. But certainly if they see that their infection rate is increasing it’s one of the factors they need to assess.”
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