Effect of Discharge Readiness on 30-Day Readmissions Among Older Adults Living With Multiple Chronic Conditions.

BACKGROUND: Despite decreases in readmissions among Medicare beneficiaries after the implementation of the Hospital Readmissions Reduction Program, older adults living with multiple chronic conditions (MCCs) continue to experience higher readmission rates. Few strategies leverage nursing to identify patients at risk for readmission. OBJECTIVES: Examine the effect of nurse assessments of discharge readiness on 30-day readmissions. RESEARCH DESIGN: Cross-sectional study linking 3 secondary data sources (ie, nurse survey, hospital survey, and Medicare claims data) representing 424 hospitals. SUBJECTS: A total of 188,806 Medicare surgical patients with MCCs. MEASURES: Discharge readiness was derived from the 2016 RN4CAST-US survey. Medicare claims data was used to determine the MCC count. The outcome was 30-day readmissions across the MCC count. RESULTS: The average discharge readiness score was 0.45 (range=0-0.86) indicating that, in the average hospital, <50% of nurses were confident their patient or caregiver could manage their care after discharge. Nearly 8% of patients were readmitted within 30 days of discharge; the highest rates of readmissions were among individuals with ≥5 MCCs (4293, 13.50%). For each 10% increase in the proportion of nurses in a hospital who were confident in their patients' discharge readiness, the odds of 30-day readmission decreased by 2% (95% CI: 0.96-1.00; P =0.028) for patients with 2-4 MCCs and 3% (95% CI: 0.94-0.99; P =0.015) for patients with ≥5 MCCs, relative to patients with 0-1 MCCs. CONCLUSIONS: Nurse assessments of discharge readiness may be a useful signal for hospitals to reduce readmissions and examine factors interfering with discharge processes.

Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care.

BACKGROUND: Hospitals are resurrecting the outdated "team nursing" model of staffing that substitutes lower-wage staff for registered nurses (RNs). OBJECTIVES: To evaluate whether reducing the proportion of RNs to total nursing staff in hospitals is in the best interest of patients, hospitals, and payers. RESEARCH DESIGN: Cross-sectional, retrospective. SUBJECTS: In all, 6,559,704 Medicare patients in 2676 general acute-care US hospitals in 2019. MEASURES: Patient outcomes: in-hospital and 30-day mortality, 30-day readmission, length of stay, and patient satisfaction. Avoidable Medicare costs associated with readmissions and cost savings to hospitals associated with shorter stays are projected. RESULTS: A 10 percentage-point reduction in RNs was associated with 7% higher odds of in-hospital death, 1% higher odds of readmission, 2% increase in expected days, and lower patient satisfaction. We estimate a 10 percentage-point reduction in RNs would result in 10,947 avoidable deaths annually and 5207 avoidable readmissions, which translates into roughly $68.5 million in additional Medicare costs. Hospitals would forgo nearly $3 billion in cost savings annually because of patients requiring longer stays. CONCLUSIONS: Reducing the proportion of RNs in hospitals, even when total nursing personnel hours are kept the same, is likely to result in significant avoidable patient deaths, readmissions, longer lengths of stay, and decreased patient satisfaction, in addition to excess Medicare costs and forgone cost savings to hospitals. Estimates represent only a 10 percentage-point dilution in skill mix; however, the team nursing model includes much larger reductions of 40-50 percentage-points-the human and economic consequences of which could be substantial.

Effect of the Nurse Work Environment on Older Hispanic Surgical Patient Readmissions.

BACKGROUND: Readmissions following hospitalization for common surgical procedures are prevalent among older adults and are disproportionally experienced by Hispanic patients. One potential explanation for these disparities is that Hispanic patients may receive care in hospitals with lower-quality nursing care. OBJECTIVES: The objective of this study was to evaluate the relationship between the hospital-level work environment of nurses and hospital readmissions among older Hispanic patients. METHODS: Using linked data sources from 2014 to 2016, we conducted a cross-sectional analysis of 522 hospitals and 732,035 general, orthopedic, and vascular surgical patients (80,978 Hispanic patients and 651,057 non-Hispanic White patients) in four states. Multivariable logistic regression models were employed to determine the relationship between the work environment and older Hispanic patient readmissions at multiple time periods (7, 30, and 90 days). RESULTS: In final adjusted models that included an interaction between work environment and ethnicity, an increase in the quality of the work environment resulted in a decrease in the odds of readmission that was greater for older Hispanic surgical patients at all time periods. Specifically, an increase in three of the five work environment subscales (Nurse Participation in Hospital Affairs, Nursing Foundations for Quality of Care, and Staffing and Resource Adequacy) was associated with a reduction in the odds of readmission that was greater for Hispanic patients than their non-Hispanic White counterparts. DISCUSSION: System-level investments in the work environment may reduce Hispanic patient readmission disparities. This study's findings may be used to inform the development of targeted interventions to prevent hospital readmissions for Hispanic patients.

Validation of a short form of the practice environment scale of the nursing work index: The PES-5.

The Practice Environment Scale of the Nursing Work Index (PES-NWI) has been utilized for two decades globally to measure nurse work environments. Its 31 items in five domains present a substantial respondent burden, threatening survey response rates. The purpose of this study was to derive and validate a short form: the PES-5. We conducted a cross-sectional, secondary analysis of survey data from nurses in 760 hospitals in six U.S. states in 2016 or 2019. One representative item per subscale was selected by highest item-to-subscale R2 from the original PES-NWI publication. Five psychometric properties of the PES-5 were evaluated. The reproduced structure of the full form was confirmed in the 2016 data by the highest R2 for the selected items. The unidimensional structure of the PES-5 was confirmed through confirmatory factor analysis. The correlation between the composite values of the 28-item and 5-item versions was 0.94. The Cronbach's alpha reliability of the PES-5 was >0.80. The intraclass correlation coefficient (ICC 1, k), which evaluates the stability of aggregated values when data are clustered, i.e., nurses are nested within hospitals, was >0.80 in both datasets, demonstrating satisfactory aggregate properties. Construct validity was supported by the selected items being ranked highly in their respective subscales by an expert panel. Criterion validity was supported by an analysis of variance of the PES-5 mean value across responses to a single-item work environment measure. Similar patterns of relationships with other key variables were identified by statistically significant odds ratios in regression models predicting patient mortality from the PES-5. The classification accuracy of the PES-5 was high, with 88% of hospitals classified identically by both versions. The PES-5 shows promise for measurement of nurses' work environments while maximizing response rate by reducing participant burden.

Mortality Among the Dementia Population in Not-For-Profit Hospitals with Better Nursing Resources.

The dementia population has higher rates of mortality during hospital stays than those without dementia. The aim of this study is to examine the relationship between ownership status (i.e. for-profit vs. not-for-profit) and nursing resources (i.e. nurse work environment, nurse-to-patient staffing, and nurse education) on 30-day mortality among post-surgical older adults with dementia. A cross-sectional analysis of linked American Hospital Association, Medicare claims, and nurse survey data was conducted using multi-level logistic regression models. We examined these models to assess the relationship between ownership status and 30-day mortality after adjusting patient and hospital characteristics. We also analyzed the relationship between the hospital ownership status and the 30-day mortality, after considering the three nursing resources. Older adults with dementia who received care in hospitals with not-for-profit status were less likely to die within 30 days of admission following surgery compared to those treated in hospitals with for-profit hospital status (i.e. odds ratio 0.82, 95% confidence interval 0.73-0.92, p = <.001). In addition, the odds ratios estimating the association between ownership and mortality were similar across the different models of the three nursing resources with and without those controls (i.e. 0.88 vs. 0.83 vs. 0.82). Surgical patients with dementia had better outcomes when cared for in not-for-profit hospitals, particularly with greater levels of nurse education and nurse staffing. The relationship between profit status and mortality was partly explained by the lower levels of nurse staffing and education in for-profit vs. not-for-profit hospitals.

Operative and Nonoperative Outcomes of Emergency General Surgery Conditions: An Observational Study Using a Novel Instrumental Variable.

OBJECTIVE: To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes. BACKGROUND: Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce. METHODS: We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions. RESULTS: For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter. CONCLUSIONS: The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.

Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions.

INTRODUCTION: Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially. METHODS: We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients. RESULTS: A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes. CONCLUSIONS: The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.

Electronic Health Record Usability and Postsurgical Outcomes Among Older Adults With Dementia.

INTRODUCTION: Electronic health record (EHR) usability, defined as the extent to which the system can be used to complete tasks, can influence patient outcomes. The aim of this study is to assess the relationship between EHR usability and postsurgical outcomes of older adults with dementia including 30-day readmission, 30-day mortality, and length of stay (LOS). METHODS: A cross-sectional analysis of linked American Hospital Association, Medicare claims data, and nurse survey data was conducted using logistic regression and negative binominal models. RESULTS: The dementia population who received care in hospitals with better EHR usability were less likely to die within 30 days of their admission following surgery compared to hospitals with poorer EHR usability (OR: 0.79, 95% CI: 0.68-0.91, p = 0.001). EHR usability was not associated with readmission or LOS. DISCUSSION: Better nurse reported EHR usability has the potential to reduce mortality rates among older adults with dementia in hospitals.

Work Environment and Operational Failures Associated With Nurse Outcomes, Patient Safety, and Patient Satisfaction.

BACKGROUND: Operational failures, defined as the inability of the work system to reliably provide information, services, and supplies needed when, where, and to who, are a pervasive problem in U.S. hospitals that disrupt nurses' ability to provide safe and effective care. OBJECTIVES: We examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes (e.g., burnout and job satisfaction) and whether differences in hospital work environments explained the relationship. METHODS: We conducted a cross-sectional analysis using population-based survey data from 11,709 registered nurses in 415 hospitals who participated in the RN4CAST-US nurse survey (2015-2016) and the 2016 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The RN4CAST-US nurse survey focused on hospital quality and safety, job outcomes, and hospital work environments. The HCAHPS survey collected publicly reported patient data on their satisfaction with their care. Operational failures were evaluated using an eight-item composite measure that assessed missing supplies, orders, medication, missing/wrong patient diet, electronic documentation problems, insufficient staff, and time spent on workarounds and nonnursing tasks. Multilevel regression models were used to test the hypothesized relationships. RESULTS: Operational failures were associated with low patient satisfaction scores, poor quality and safety outcomes, and poor nurse job outcomes, and those associations were partly accounted for by hospital work environments. DISCUSSION: Operational failures prevent high-quality care and positive patient and nurse outcomes. Operational failures and the hospital work environment should be targeted simultaneously to maximize quality improvement efforts. Hospital leadership should work with frontline staff to identify and target the sources of operational failures in nursing units. Improvements to hospital work environments may reduce the occurrence of operational failures.

A repeated cross-sectional study of nurses immediately before and during the COVID-19 pandemic: Implications for action.

BACKGROUND: The shortage of nursing care in US hospitals has become a national concern. PURPOSE: The purpose of this manuscript was to determine whether hospital nursing care shortages are primarily due to the pandemic and thus likely to subside or due to hospital nurse understaffing and poor working conditions that predated it. METHODS: This study used a repeated cross-sectional design before and during the pandemic of 151,335 registered nurses in New York and Illinois, and a subset of 40,674 staff nurses employed in 357 hospitals. FINDINGS: No evidence was found that large numbers of nurses left health care or hospital practice in the first 18 months of the pandemic. Nurses working in hospitals with better nurse staffing and more favorable work environments prior to the pandemic reported significantly better outcomes during the pandemic. DISCUSSION: Policies that prevent chronic hospital nurse understaffing have the greatest potential to stabilize the hospital nurse workforce at levels supporting good care and clinician wellbeing.

Left Without Being Seen: Nurse Work Environment and Timely Outcomes in New York and Illinois Emergency Departments.

INTRODUCTION: This study determined the relationship between the emergency nurse work environment and emergency department patient left without being seen rates and lengths of stay. METHODS: Cross-sectional analysis of 215 New York and Illinois emergency departments. The work environment (abbreviated Practice Environment Scale of the Nursing Work Index) was measured by emergency nurses in the 2021 RN4CAST-NY/IL survey and linked with outcomes from Hospital Compare. Regression models estimated the relationship between the nurse work environment and emergency department patient left without being seen rates, median length of stay (in minutes), and median behavioral health patient length of stay. Model coefficients were used to estimate expected additional care minutes gained if emergency department work environments improved. RESULTS: "Mixed" work environments had the longest median overall length of stay (3.4 hours) and the highest median left without being seen rates (2.2%), while "poor" work environments had the longest median length of stay for behavioral health patients (6 hours). Improving the emergency department work environment from poor to mixed (and mixed to better) was associated with a 13-minute reduction in overall length of stay (P ≤ .05), a 33-minute reduction in behavioral health length of stay (P ≤ .01), and a 19% reduction in left without being seen rates (P ≤ .01). We estimated 11,824 to 41,071 additional patients could be seen in emergency departments associated with work environment improvements from "poor" to "better," depending on annual patient volumes. DISCUSSION: Hospital administrators should consider investing in nurse work environments as a foundation to improve timely outcomes.

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals.

BACKGROUND: Substantial evidence indicates that patient outcomes are more favourable in hospitals with better nurse staffing. One policy designed to achieve better staffing is minimum nurse-to-patient ratio mandates, but such policies have rarely been implemented or evaluated. In 2016, Queensland (Australia) implemented minimum nurse-to-patient ratios in selected hospitals. We aimed to assess the effects of this policy on staffing levels and patient outcomes and whether both were associated. METHODS: For this prospective panel study, we compared Queensland hospitals subject to the ratio policy (27 intervention hospitals) and those that discharged similar patients but were not subject to ratios (28 comparison hospitals) at two timepoints: before implementation of ratios (baseline) and 2 years after implementation (post-implementation). We used standardised Queensland Hospital Admitted Patient Data, linked with death records, to obtain data on patient characteristics and outcomes (30-day mortality, 7-day readmissions, and length of stay [LOS]) for medical-surgical patients and survey data from 17 010 medical-surgical nurses in the study hospitals before and after policy implementation. Survey data from nurses were used to measure nurse staffing and, after linking with standardised patient data, to estimate the differential change in outcomes between patients in intervention and comparison hospitals, and determine whether nurse staffing changes were related to it. FINDINGS: We included 231 902 patients (142 986 in intervention hospitals and 88 916 in comparison hospitals) assessed at baseline (2016) and 257 253 patients (160 167 in intervention hospitals and 97 086 in comparison hospitals) assessed in the post-implementation period (2018). After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio [OR] 1·07, 95% CI 0·97-1·17, p=0·18), but were significantly lower than at baseline in intervention hospitals (0·89, 0·84-0·95, p=0·0003). From baseline to post-implementation, readmissions increased in comparison hospitals (1·06, 1·01-1·12, p=0·015), but not in intervention hospitals (1·00, 0·95-1·04, p=0·92). Although LOS decreased in both groups post-implementation, the reduction was more pronounced in intervention hospitals than in comparison hospitals (adjusted incident rate ratio [IRR] 0·95, 95% CI 0·92-0·99, p=0·010). Staffing changed in hospitals from baseline to post-implementation: of the 36 hospitals with reliable staffing measures, 30 (83%) had more than 4·5 patients per nurse at baseline, with the number decreasing to 21 (58%) post-implementation. The majority of change was at intervention hospitals, and staffing improvements by one patient per nurse produced reductions in mortality (OR 0·93, 95% CI 0·86-0·99, p=0·045), readmissions (0·93, 0·89-0·97, p<0·0001), and LOS (IRR 0·97, 0·94-0·99, p=0·035). In addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing. INTERPRETATION: Minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment. FUNDING: Queensland Health, National Institutes of Health, National Institute of Nursing Research.

Association between physician practice Medicaid acceptance and employing nurse practitioners and physician assistants: A longitudinal analysis.

BACKGROUND: Access to care is often a challenge for Medicaid beneficiaries due to low practice participation. As demand increases, practices will likely look for ways to see Medicaid patients while keeping costs low. Employing nurse practitioners (NPs) and physician assistants (PAs) is one low-cost and effective means to achieve this. However, there are no longitudinal studies examining the relationship between practice Medicaid acceptance and NP/PA employment. PURPOSE: The purpose of this study was to examine the association of practice Medicaid acceptance with NP/PA employment over time. METHODS: Using SK&A data (2009-2015), we constructed a panel of 102,453 unique physician practices to assess for changes in Medicaid acceptance after newly employing NPs and PAs. We employed practice-level fixed effects linear regressions. RESULTS: Our results showed that, among practices employing both NPs and PAs, there was a roughly 2% increase in the likelihood of Medicaid participation over time. When stratifying our sample by practice size and specialty, the positive correlation localized to small primary care and medical practices. When both NPs and PAs were present, small primary care practices had a 3.3% increase and small medical practices had a 6.9% increase in the likelihood of accepting Medicaid. CONCLUSION: NP and PA employment was positively associated with increases in Medicaid participation. PRACTICE IMPLICATIONS: As more individuals gain coverage under Medicaid, organizations will need to decide how to adapt to greater patient demand. Our results suggest that hiring NPs and PAs may be a potential lower cost strategy to accommodate new Medicaid patients.

Variations in nursing baccalaureate education and 30-day inpatient surgical mortality.

BACKGROUND: In 2010, the IOM recommended an increase in the proportion of bachelor's-prepared (BSN) nurses to 80% by 2020. This goal was largely based on evidence linking hospitals with higher proportions of BSN nurses to better patient outcomes. Though, evidence is lacking on whether outcomes differ by a hospital's composition of initial BSN and transitional RN-to-BSN nurses. PURPOSE: The purpose of this study is to determine whether risk-adjusted odds of surgical mortality are associated with a hospital's proportion of initial BSN and transitional RN-to-BSN nurses. METHODS: Logistic regression models were used to analyze cross-sectional data of general surgical patients, nurses, and hospitals in four large states in 2015 to 2016. FINDINGS: Higher hospital proportions of BSN nurses, regardless of educational pathway, are associated with lower odds of 30-day inpatient surgical mortality. DISCUSSION: Findings support promoting multiple BSN educational pathways to reach the IOM's recommendation of at least an 80% BSN workforce.

Care Quality, Patient Safety, and Nurse Outcomes at Hospitals Serving Economically Disadvantaged Patients: A Case for Investment in Nursing.

We sought to evaluate if better work environments or staffing were associated with improvements in care quality, patient safety, and nurse outcomes across hospitals caring for different proportions of patients who are economically disadvantaged. Few actionable approaches for hospitals with quality and resource deficits exist. One solution may be to invest in the nurse work environment and staffing. This cross-sectional study utilized secondary data from 23,629 registered nurses in 503 hospitals from a four-state survey collected in 2005-2008. Each 10% increase in the proportion of patients who are economically disadvantaged was associated with 27% and 22% decreased odds of rating unit-level care quality as excellent and giving an "A" safety grade, respectively. Each 10% increase was also associated with 9%, 25%, and 11% increased odds of job dissatisfaction, intent to leave, and burnout, respectively. The work environment had the largest association with each outcome. Accounting for the nurse work environment lessened or eliminated the negative outcomes experienced at hospitals serving high proportions of patients who are economically disadvantaged. Leaders at hospitals serving high proportions of patients who are economically disadvantaged, as well as state and federal policymakers, should work to improve quality, safety, and nurse outcomes by strengthening nurse work environments. Improving work environments highlights the role of nursing in the health care system, and policies focused on work environments are needed to improve the experiences of patients and nurses, especially at hospitals that care for many patients who are economically disadvantaged.

An Assessment of Patient, Caregiver, and Clinician Perspectives on the Post-discharge Phase of Care.

OBJECTIVE: We sought to elicit patients', caregivers', and health care providers' perceptions of home recovery to inform care personalization in the learning health system. SUMMARY BACKGROUND DATA: Postsurgical care has shifted from the hospital into the home. Daily care responsibilities fall to patients and their caregivers, yet stakeholder concerns in these heterogeneous environments, especially as they relate to racial inequities, are poorly understood. METHODS: Surgical oncology patients, caregivers, and clinicians participated in freelisting; an open-ended interviewing technique used to identify essential elements of a domain. Within 2 weeks after discharge, participants were queried on 5 domains: home independence, social support, pain control, immediate, and overall surgical impact. Salience indices, measures of the most important words of interest, were calculated using Anthropac by domain and group. RESULTS: Forty patients [20 whites and 20 African-Americans (AAs)], 30 caregivers (17 whites and 13 AAs), and 20 providers (8 residents, 4 nurses, 4 nurse practitioners, and 4 attending surgeons) were interviewed. Patients and caregivers attended to the personal recovery experience, whereas providers described activities and individuals associated with recovery. All groups defined surgery as life-changing, with providers and caregivers discussing financial and mortality concerns. Patients shared similar thoughts about social support and self-care ability by race, whereas AA patients described heterogeneous pain management and more hopeful recovery perceptions. AA caregivers expressed more positive responses than white caregivers. CONCLUSIONS: Patients live the day-to-day of recovery, whereas caregivers and clinicians also contemplate more expansive concerns. Incorporating relevant perceptions into traditional clinical outcomes and concepts could enhance the surgical experience for all stakeholders.

Electronic Health Record Usability: Associations With Nurse and Patient Outcomes in Hospitals.

BACKGROUND: Electronic health record (EHR) usability issues represent an emerging threat to the wellbeing of nurses and patients; however, few large studies have examined these relationships. OBJECTIVE: To examine associations between EHR usability and nurse job (burnout, job dissatisfaction, and intention to leave) and surgical patient (inpatient mortality and 30-day readmission) outcomes. METHODS: A cross-sectional analysis of linked American Hospital Association, state patient discharge, and nurse survey data was conducted. The sample included 343 hospitals, 1,281,848 surgical patients, and 12,004 nurses. Logistic regression models were used to assess relationships between EHR usability and outcomes, before and after accounting for EHR adoption level (comprehensive vs. basic or less) and other confounders. RESULTS: In fully adjusted models, nurses who worked in hospitals with poorer EHR usability had significantly higher odds of burnout [odds ratio (OR), 1.41; 95% confidence interval (CI), 1.21-1.64], job dissatisfaction (OR, 1.61; 95% CI, 1.37-1.90) and intention to leave (OR, 1.31; 95% CI, 1.09-1.58) compared with nurses working in hospitals with better usability. Surgical patients treated in hospitals with poorer EHR usability had significantly higher odds of inpatient mortality (OR, 1.21; 95% CI, 1.09-1.35) and 30-day readmission (OR, 1.06; 95% CI, 1.01-1.12) compared with patients in hospitals with better usability. Comprehensive EHR adoption was associated with higher odds of nurse burnout (OR, 1.14; 95% CI, 1.01-1.28). CONCLUSION: Employing EHR systems with suboptimal usability was associated with higher odds of adverse nurse job outcomes and surgical patient mortality and readmission. EHR usability may be more important to nurse job and patient outcomes than comprehensive EHR adoption.

Value of Nurse Practitioner Inpatient Hospital Staffing.

BACKGROUND: Evidence indicates hospitals with better registered nurse (RN) staffing have better patient outcomes. Whether involving more nurse practitioners (NPs) in inpatient care produces better outcomes is largely unknown. OBJECTIVE: The objective of this study was to determine whether the presence of more NPs produces better inpatient outcomes net of RN staffing. RESEARCH DESIGN: This was a 2015-2016 cross-sectional data on 579 hospitals linked from: (1) RN4CAST-US nurse surveys; (2) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient surveys; (3) surgical patient discharge abstracts; (4) Medicare Spending per Beneficiary (MSPB) reports; (5) American Hospital Association (AHA) Annual Survey. Hospitals were grouped according to their NP/beds ratios [<1 NP/100 beds (N=132), 1-2.99 NPs/100 beds (N=279), and 3+ NPs/100 beds (N=168)]. SUBJECTS: RNs randomly sampled nurses from licensure lists yielded 22,273 RNs in study hospitals; discharge data for 1.4 million surgical patients; HCAHPS data for 86% of study hospitals. MEASURES: Mortality, readmissions, lengths of stay, MSPB, patient experience, and quality reported by patients and nurses. RESULTS: After adjustments, patients in hospitals with 3+ NPs/100 beds had lower odds than patients in hospitals with <1 NP/100 beds of 30-day mortality [odds ratio (OR)2=0.76; 95% confidence interval (CI)=0.67-0.82; P<0.001] and 7-day readmissions (OR2=0.90; 95% CI=0.86-0.96; P<0.001), shorter average length of stay (incident rate ratio2=0.92; 95% CI=0.88-0.96; P<0.001) and 5.4% lower average MSPB (95% CI=3.8%-7.1%). Patients and nurses in the hospitals with higher NP/bed ratios were significantly more likely to report better care quality and safety, and nurses reported lower burnout, higher job satisfaction, greater intentions of staying in their jobs. CONCLUSIONS: Having more NPs in hospitals has favorable effects on patients, staff nurse satisfaction, and efficiency. NPs add value to existing labor resources.

Is Hospital Nurse Staffing Legislation in the Public's Interest?: An Observational Study in New York State.

BACKGROUND: The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown. OBJECTIVES: To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs). RESEARCH DESIGN: Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data. SUBJECTS: A total of 417,861 Medicare medical and surgical patients. MEASURES: Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios. RESULTS: Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions. CONCLUSIONS: Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.

Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions.

BACKGROUND: Nursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear. OBJECTIVE: To determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources. DESIGN: Matched cohort study of patients in 306 acute care hospitals. PATIENTS: A total of 74,045 matched pairs of fee-for-service Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status. MAIN MEASURES: Better (n = 76) and worse (n = 230) nursing resourced hospitals were defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs. KEY RESULTS: Patients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%, p < 0.0001) and fewer readmissions (32.3% vs 33.6%, p < 0.0001) yet costs were not significantly different ($18,848 vs 18,671, p = 0.133). The greatest outcomes and cost advantage of better nursing resourced hospitals were in patients with sepsis who had lower mortality (25.3% vs 27.6%, p < 0.0001). Overall, patients with the highest risk of mortality on admission experienced the greatest reductions in mortality and readmission from better nursing at no difference in cost. CONCLUSIONS: Medicare beneficiaries with common medical conditions admitted to hospitals with better nursing resources experienced more favorable outcomes at almost no difference in cost.