Bed-to-nurse ratios, provision of basic nursing care, and in-hospital and 30-day mortality among acute stroke patients admitted to an intensive care unit: Cross-sectional analysis of survey and administrative data Sung-Hyun Cho a,*, Sung-Cheol Yun b a Department of Nursing, Hanyang University, Seoul, Republic of Korea b Department of Preventive Medicine, College of Medicine, University of Ulsan, Seoul, Republic of Korea A B S T R A C T Background: The literature reports inconsistent evidence of the effects of nurse staffing on mortality despite continuing examination of this association.Objective: To examine differences in provision of basic nursing care and in-hospital and 30-day mortality by nurse staffing of ICUs and general wards among acute stroke patients admitted to ICUs during hospitalization. Design: A cross-sectional design that included survey and administrative data. Settings and participants: The study included 6957 patients with hemorrhagic and ischemic stroke who were admitted to ICUs of 185 Korean hospitals. Methods: Nurse staffing of ICUs and general wards was graded based on the bed-to-nurse ratios of each hospital.Provision of basic care was measured by whether five activities, such as bathing and feeding assistance, were fully provided by ICU nursing staff without delegation to patient families.
Hospitals were categorized into low, middle, and high mortality groups for in-hospital and 30-day mortality based on z-scores that indicated standardized difference between observed and expected mortality after controlling for patient characteristics. Results: In 83. 8% of hospitals, basic care was provided fully by ICU nursing staff. The overall in-hospital and 30-day mortality rates were 21. and 25. 4%, respectively.
Hospitals with higher ICU staffing weremore likely to fully provide basic care. Better ICU and general staffing tended to be associated with lower in-hospital and 30-day mortality. Compared with in-hospital mortality, 30-daymortality had a more distinct increase as nurse staffing became worse. Conclusion: The findings provide evidence that nurse staffing may impact provision of basic care and patient mortality and suggest the need for policies for providing adequate nurse staffing. References Agency for Healthcare Research and Quality, 2007.
Guide to Inpatient Quality Indicators: Quality of Care in Hospitals—Volume, Mortality, and Utilization (Version 3. 1). [Online]. Agency for Healthcare Research and Quality.
Available at: http://www. qualityindicators. ahrq. gov/downloads/iqi/iqi_guide_v31. pdf. [accessed 5 June 2007]. Agency for Healthcare Research and Quality, 2008.
Inpatient Quality Indicators: Technical Specifications (Version 3. 2). [Online]. Agency for Healthcare Research and Quality. Available at: http://www.
qualityindicators. ahrq. gov/downloads/iqi/iqi_technical_specs_v32a. df. [accessed 1 July 2008]. Armesto, S. G.
, Lapetra, M. L. G. , Wei, L. , Kelley, E. , the Members of the HCQI Expert Group, 2007. Health Care Quality Indicators Project 2006 Data Collection Update Report.
[Online]. Organisation for Economic Cooperation and Development. Available at: http://www. oecd. org/ dataoecd/57/22/39447928.
pdf. [accessed 11 August 2008]. Burton, C.
R. , Fisher, A. , Green, T.
L. , 2009. The organisational context of nursing care in stroke units: a case study approach.
International Journal of Nursing Studies 46, 86–95.Candelise, L. , Gattinoni, M. , Bersano, A. , Micieli, G. , Sterzi, R.
, Morabito, A. , on the behalf of the PROSIT Study Group, 2007. Stroke-unit care for acute stroke patients: an observational follow-up study. Lancet 369, 299–305. Carmel, S. , Rowan, K.
, 2001. Variation in intensive care unit outcomes: a search for the evidence on organizational factors. Current Opinion in Critical Care 7, 284–296. Cho, S. H. , Hwang, J. H.
, Kim, J. , 2008. Nurse staffing and patient mortality in intensive care units.
Nursing Research 57, 322–330. Cho, S.H.
, Kim, H. R. , 2006.
Family and paid caregivers of hospitalized patients in Korea. Journal of Clinical Nursing 15, 946–953. Clarke, S.
P. , 2007. Registered nurse staffing and patient outcomes in acute care: looking back, pushing forward.
Medical Care 45, 1126–1128. Clarke, S. P. , Donaldson, N. E.
, 2008. Nurse staffing and patient care quality and safety. In: Hughes, R. G. (Ed. ), Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality, Rockville, pp.
1–25. Donabedian, A. , 2003.An Introduction to Quality Assurance in Health Care. Oxford University Press, New York. Duncan, P.
W. , Jorgensen, H. S.
, Wade, D. T. , 2000. Outcome measures in acute stroke trials: a systematic review and some recommendations to improve practice. Stroke 31, 1429–1438. Evans, A. , Perez, I.
, Harraf, F. , Melbourn, A. , Steadman, J. , Donaldson, N. , Kalra, L.
, 2001. Can differences in management processes explain different outcomes between stroke unit and stroke-team care? Lancet 358, 1586–1592. Feigin, V. L. , Lawes, C. M. M. , Bennett, D.
A. , Anderson, C.S. , 2003. Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurology 2, 43–53. Health Insurance Review & Assessment Service, 2007.
Evaluation of Appropriateness of Stroke Care. Health Insurance Review & Assessment Service, Seoul. Jones, S. P. , Leathley, M.
J. , McAdam, J. J. , Watkins, C. L. , 2007.
Physiological monitoring in acute stroke: a literature review. Journal of Advanced Nursing 60, 577–594. Kalisch, B. J. , 2006. Missed nursing care: a qualitative study.
Journal of Nursing Care Quality 21, 306–313. Kalra, L. , Evans, A. , Perez, I. , Knapp, M. , Donaldson, N. , Swift, C.
G. , 2000. Alternative strategies for stroke care: a prospective randomized controlled trial. Lancet 356, 894–899. Kane, R. L.
, Shamliyan, T. A. , Mueller, C.
, Duval, S. , Wilt, T. J. , 2007. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Medical Care 45, 1195– 1204. Kitamura, A.
, Nakagawa, Y. , Sato, M. , Iso, H. , Sato, S. , Imano, H. , Kiyama, M. , Okada, T.
, Okada, H. Iida, M. , Shimamoto, T.
, 2006. Proportions of stroke subtypes among men and women 40 years of age in an urban Japanese city in 1992, 1997, and 2002. Stroke 37, 1374–1378. Korea National Statistical Office, 2007. 2006 Annual Report on the Cause of Death Statistics.
Korea National Statistical Office, Daejeon. Lang, T. A. , Hodge, M. , Olson, V. , Romano, P. S.
, Kravitz, R. L. , 2004. Nursepatient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration 34, 326–337.