Kane_2007 - REVIEW ARTICLE The Association of Registered...

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R EVIEW A RTICLE The Association of Registered Nurse Staffing Levels and Patient Outcomes Systematic Review and Meta-Analysis Robert L. Kane, MD,* Tatyana A. Shamliyan, MD, MS,* Christine Mueller, PhD, RN,† Sue Duval, PhD,* and Timothy J. Wilt, MD, MPH‡ Objective: To examine the association between registered nurse (RN) stafFng and patient outcomes in acute care hospitals. Study Selection: Twenty-eight studies reported adjusted odds ratios of patient outcomes in categories of RN-to-patient ratio, and met inclusion criteria. Information was abstracted using a standardized protocol. Data Synthesis: Random effects models assessed heterogeneity and pooled data from individual studies. Increased RN stafFng was associated with lower hospital related mortality in intensive care units (ICUs) @ odds ratios (OR), 0.91; 95% conFdence interval (CI), 0.86–0.96 # , in surgical (OR, 0.84; 95% CI, 0.80–0.89), and in medical patients (OR, 0.94; 95% CI, 0.94–0.95) per additional full time equivalent per patient day. An increase by 1 RN per patient day was associated with a decreased odds ratio of hospital acquired pneumonia (OR, 0.70; 95% CI, 0.56–0.88), unplanned extubation (OR, 0.49; 95% CI, 0.36–0.67), respiratory failure (OR, 0.40; 95% CI, 0.27–0.59), and cardiac arrest (OR, 0.72; 95% CI, 0.62–0.84) in ICUs, with a lower risk of failure to rescue (OR, 0.84; 95% CI, 0.79–0.90) in surgical patients. Length of stay was shorter by 24% in ICUs (OR, 0.76; 95% CI, 0.62–0.94) and by 31% in surgical patients (OR, 0.69; 95% CI, 0.55–0.86). Conclusions: Studies with different design show associations be- tween increased RN stafFng and lower odds of hospital related mortality and adverse patient events. Patient and hospital character- istics, including hospitals’ commitment to quality of medical care, likely contribute to the actual causal pathway. Key Words: nursing staff, hospital, quality, length of stay, mortality, safety, failure to rescue ( Med Care 2007;45: 1195–1204) N urses are crucial to providing high-quality care. 1–3 Hos- pital restructuring in the last 2 decades, in response to the advent of managed care and diagnosis-related groups, shortened hospitalizations of acutely ill patients and placed new stresses on nurses to provide safe patient care. 4–6 In- creasing the nurse-to-patient ratios has been recommended as a means to improve patient safety. 7–9 California is the only state that has mandatory nurse-to-patient ratios, although man- datory nurse stafFng legislation has been proposed in several other states 10,11 as well as all Medicare participating hospitals. 12 However, these mandatory stafFng regulations are not supported by evidence-based optimal nurse-to-patient ratios. 13 We undertook a systematic review of the extant literature on the association between registered nurse (RN)-to-patient ratios, and outcomes. These ratios have been expressed in 2 different ways. 14 One method uses a ratio of full time equiva- lents (±TEs) of RNs per patient day, whereas the second uses the number of patients assigned to 1 RN per shift in the unit (see Appendix A which can be found on the Medical Care website, www.lww-medicalcare.com). This study is part of a larger
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This note was uploaded on 05/30/2010 for the course GE DZMBGS0100 taught by Professor Sofieverhaeghe during the Spring '10 term at Ghent University.

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Kane_2007 - REVIEW ARTICLE The Association of Registered...

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