Nursing Team Composition and Mortality Following Acute Hospital Admission.

Importance: Many studies show the adverse consequences of insufficient nurse staffing in hospitals, but safe and effective staffing is unlikely to be just about staff numbers. There are considerable areas of uncertainty, including whether temporary staff can safely make up shortfalls in permanent staff and whether using experienced staff can mitigate the effect of staff shortages. Objective: To explore the association of the composition of the nursing team with the risk of patient deaths. Design, Setting, and Participants: This patient-level longitudinal observational study was conducted in 185 wards in 4 acute hospital trusts in England between April 2015 and March 2020. Eligible participants were patients with an overnight stay and nursing staff on adult inpatient wards. Data analysis was conducted from month April 2022 to June 2023. Exposure: Naturally occurring variation during the first 5 days of hospital admission in exposure to days of low staffing from registered nurses (RNs) and nursing support (NS) staff, the proportion of RNs, proportion of senior staff, and proportion of hospital-employed (bank) and agency temporary staff. Main Outcomes and Measures: The primary outcome was death within 30 days of admission. Mixed-effect Cox proportional hazards survival models were used. Results: Data from 626 313 admissions (319 518 aged ≥65 years [51.0%]; 348 464 female [55.6%]) were included. Risk of death was increased when patients were exposed to low staffing from RNs (adjusted hazard ratio [aHR], 1.08; 95% CI 1.07-1.09) and NS staff (aHR, 1.07; 95% CI, 1.06-1.08). A 10% increase in the proportion of temporary RNs was associated with a 2.3% increase in the risk of death, with no difference between agency (aHR, 1.023; 95% CI, 1.01-1.04) and bank staff (aHR, 1.02; 95% CI, 1.01-1.04). A 10% increase in the proportion of agency NS was associated with a 4% increase in risk of death (aHR, 1.04; 95% CI, 1.02-1.06). Evidence on the seniority of staff was mixed. Model coefficients were used to estimate the association of using temporary staff to avoid low staffing and found that risk was reduced but remained elevated compared with baseline. Conclusions and Relevance: This cohort study found that having senior nurses in the nursing team did not mitigate the adverse outcomes associated with low nurse staffing. These findings indicate that while the benefits of avoiding low staffing may be greater than the harms associated with using temporary staff, particularly for RNs, risk remains elevated if temporary staff are used to fill staffing shortages, which challenges the assumption that temporary staff are a cost-effective long-term solution to maintaining patient safety.

Inpatient midwifery staffing levels and postpartum readmissions: a retrospective multicentre longitudinal study.

BACKGROUND: Preventing readmission to hospital after giving birth is a key priority, as rates have been rising along with associated costs. There are many contributing factors to readmission, and some are thought to be preventable. Nurse and midwife understaffing has been linked to deficits in care quality. This study explores the relationship between staffing levels and readmission rates in maternity settings. METHODS: We conducted a retrospective longitudinal study using routinely collected individual patient data in three maternity services in England from 2015 to 2020. Data on admissions, discharges and case-mix were extracted from hospital administration systems. Staffing and workload were calculated in Hours Per Patient day per shift in the first two 12-hour shifts of the index (birth) admission. Postpartum readmissions and staffing exposures for all birthing admissions were entered into a hierarchical multivariable logistic regression model to estimate the odds of readmission when staffing was below the mean level for the maternity service. RESULTS: 64 250 maternal admissions resulted in birth and 2903 mothers were readmitted within 30 days of discharge (4.5%). Absolute levels of staffing ranged between 2.3 and 4.1 individuals per midwife in the three services. Below average midwifery staffing was associated with higher rates of postpartum readmissions within 7 days of discharge (adjusted OR (aOR) 1.108, 95% CI 1.003 to 1.223). The effect was smaller and not statistically significant for readmissions within 30 days of discharge (aOR 1.080, 95% CI 0.994 to 1.174). Below average maternity assistant staffing was associated with lower rates of postpartum readmissions (7 days, aOR 0.957, 95% CI 0.867 to 1.057; 30 days aOR 0.965, 95% CI 0.887 to 1.049, both not statistically significant). CONCLUSION: We found evidence that lower than expected midwifery staffing levels is associated with more postpartum readmissions. The nature of the relationship requires further investigation including examining potential mediating factors and reasons for readmission in maternity populations.

Opioid use, postoperative complications, and implant survival after unicompartmental versus total knee replacement: a population-based network study.

BACKGROUND: There is uncertainty around whether to use unicompartmental knee replacement (UKR) or total knee replacement (TKR) for individuals with osteoarthritis confined to a single compartment of the knee. We aimed to emulate the design of the Total or Partial Knee Arthroplasty Trial (TOPKAT) using routinely collected data to assess whether the efficacy results reported in the trial translate into effectiveness in routine practice, and to assess comparative safety. METHODS: We did a population-based network study using data from four US and one UK health-care database, part of the Observational Health Data Sciences and Informatics network. The inclusion criteria were the same as those for TOPKAT; briefly, we identified patients aged at least 40 years with osteoarthritis who had undergone UKR or TKR and who had available data for at least one year prior to surgery. Patients were excluded if they had evidence of previous knee arthroplasty, knee fracture, knee surgery (except diagnostic), rheumatoid arthritis, infammatory arthropathies, or septic arthritis. Opioid use from 91-365 days after surgery, as a proxy for persistent pain, was assessed for all participants in all databases. Postoperative complications (ie, venous thromboembolism, infection, readmission, and mortality) were assessed over the 60 days after surgery and implant survival (as measured by revision procedures) was assessed over the 5 years after surgery. Outcomes were assessed in all databases, except for readmission, which was assessed in three of the databases, and mortality, which was assessed in two of the databases. Propensity score matched Cox proportional hazards models were fitted for each outcome. Calibrated hazard ratios (cHRs) were generated for each database to account for observed differences in control outcomes, and cHRs were then combined using meta-analysis. FINDINGS: 33 867 individuals who received UKR and 557 831 individuals who received TKR between Jan 1, 2005, and April 30, 2018, were eligible for matching. 32 379 with UKR and 250 377 with TKR were propensity score matched and informed the analyses. UKR was associated with a reduced risk of postoperative opioid use (cHR from meta-analysis 0·81, 95% CI 0·73-0·90) and a reduced risk of venous thromboembolism (0·62, 0·36-0·95), whereas no difference was seen for infection (0·85, 0·51-1·37) and readmission (0·79, 0·47-1·25). Evidence was insufficient to conclude whether there was a reduction in risk of mortality. UKR was also associated with an increased risk of revision (1·64, 1·40-1·94). INTERPRETATION: UKR was associated with a reduced risk of postoperative opioid use compared with TKR, which might indicate a reduced risk of persistent pain after surgery. UKR was associated with a lower risk of venous thromboembolism but an increased risk of revision compared with TKR. These findings can help to inform shared decision making for individuals eligible for knee replacement surgery. FUNDING: EU/European Federation of Pharmaceutical Industries and Associations Innovative Medicines Initiative (2) Joint Undertaking (EHDEN).