Identifying optimal labor and delivery nurse staffing: The case of cesarean births and nursing hours.

BACKGROUND: Numerous studies have identified a relationship between nurse staffing and adverse patient outcomes in medical / surgical patient populations. However, little is known about the impact of labor and delivery (L&D) nurse staffing and adverse birth outcomes, such as unintended cesarean delivery, in low-risk term-gestation women. PURPOSE: We examined nurse staffing patterns on the likelihood of cesarean sections (C-sections) among low- risk, full gestation births and provided a testing framework to distinguish optimal from ineffective levels of nurse staffing. METHODS: This retrospective descriptive study used hours of productive nursing time per delivery as the treatment variable to determine direct nursing time per delivery and its impact on the likelihood of a C-section. For comparisons, we also assessed the likelihood of augmentations and of inductions, as well as the number of neonatal intensive care unit (NICU) hours per birth. We limited our sample to those births between 37 and 42 weeks of gestation. Two complimentary models (the quadratic and piecewise regressions) distinguishing optimal staffing patterns from ineffective staffing patterns were developed. The study was implemented in eleven hospitals that are part of a large, integrated healthcare system in the Southwest. DISCUSSION: While a simple linear regression of the likelihood of a C-section on nursing hours per delivery indicated no statistically distinguishable effect, our 'optimal staffing' model indicated that nurse staffing hours employed by using a large sample of hospitals were actually minimizing C-sections (robustness checks are provided using similar model comparisons for the likelihood of augmentation and induction, and NICU hours). Where the optimal staffing models did not appear to be effective for augmentations, inductions, and NICU hours, we found significant differences between facilities (i.e., significant fixed effects for hospitals). In all specifications, we also controlled for weeks of gestation, race, sex of the child, and mother's age.

Staffing needs for unscheduled activity in obstetrics and gynecology.

INTRODUCTION: To determine a minimum threshold of medical staffing needs (obstetricians-gynecologists, anesthesiologists-resuscitation specialists, nurse-anesthetists, pediatricians, and midwives) to ensure the safety and quality of care for unscheduled obstetrics-gynecology activity. MATERIALS AND METHODS: Face to face meetings of French healthcare professionals involved in perinatal care in different types of practices (academic hospital, community hospital or private practice) who belong to French perinatal societies: French National College of Gynecologists-Obstetricians (CNGOF), the French Society of Anesthesia and Resuscitation Specialists (SFAR), the French Society of Neonatology (SFN), the French Society of Perinatal Medicine (SFMP), the National College of French Midwives (CNSF), and the French Federation of Perinatal Care Networks (FFRSP). RESULTS: Different minimum thresholds for each category of care provider were proposed according to the number of births/year in the facility. These minimum thresholds can be modulated upwards as a function of the level of care (Level 1, 2 or 3 for perinatal centers), existence of an emergency department, and responsibilities as a referral center for maternal-fetal and/or surgical care. For example, an obstetrics-gynecology department handling 3000-4500 births per year without serving as a referral center must have an obstetrician-gynecologist, an anesthesiologist-resuscitation specialist, a nurse-anesthetist, and a pediatrician onsite specifically to provide care for unscheduled obstetrics-gynecology needs and a second obstetrician-gynecologist available within a time compatible with security requirements 24/7; the number of midwives always present (24/7) onsite and dedicated to unscheduled care is 5.1 for 3000 births and 7.2 for 4500 births. A maternity unit's occupancy rate must not exceed 85 %. CONCLUSION: The minimum thresholds proposed here are intended to improve the safety and quality of care of women who require unscheduled care in obstetrics-gynecology or during the perinatal period.

Cardiac Intensive Care Units: What Should Be the Standard of Care?

Since the creation of intensive care units (ICU) in the early 1960s, the central question of how to operate and staff them has continued to be an ongoing discussion. Early studies demonstrated decreased morality when staffing was altered from remote providers to full-time on-site providers. In addition to the shift towards full-time onsite providers, the structure of daily care has also undergone significant paradigm changes. Several studies have revealed the importance and benefit of multidisciplinary rounds with direct and open communication of daily goals. Particularly for cardiac patients in shock, two recent studies have provided hard data demonstrating a significant decrease in mortality in ICUs with full-time onsite providers. This benefit was even more pronounced for patients supported with extracorporeal membrane oxygenation. These data support the practice of intensive care with (1) full-time onsite provider staffing, (2) multidisciplinary rounds, and (3) a safe environment with open communication between team members.

Sleep and Lifestyle Habits of Osteopathic Emergency Medicine Residents During Training.

CONTEXT: Duty hours were enacted in 2003 with the intent to improve patient safety and resident well-being. However, limited data exist regarding improvements in residents' well-being since the implementation of these restrictions. OBJECTIVE: To examine osteopathic emergency medicine (EM) resident characteristics regarding sleep and lifestyle habits and duty hour reporting. METHOD: A convenience sample of osteopathic EM residents was surveyed at a statewide conference in May 2014. The conference included 177 residents from 15 osteopathic EM residencies. Data regarding demographics, sleep and lifestyle habits (including work-related motor vehicle incidents [MVIs] and chemical aid use for sleep/wakefulness), and duty hour reporting were collected. The Epworth Sleepiness Scale (ESS) score was calculated, with a score greater than 10 indicating sleep disturbance. RESULTS: Of the 128 residents (72%) who returned the survey, approximately two-thirds were female, were currently on an EM rotation, and were training in suburban emergency departments with more than 60,000 annual visits. Only 35% of respondents slept 8 or more hours per night during an EM rotation, and 63% admitted to weight change during residency. Forty-two percent of respondents had a work-related MVI, which was more likely to occur if their ESS score was greater than 11 (P<.03). Mean (SD) ESS score was 9.9 (4.8; range, 0-24). Respondents reported using chemical aids for staying awake or going to sleep on a mean (SD) of 6.9 (9.3) days per month (range, 0-30). The majority of respondents (84%) reported strict duty hour enforcement policies, few (17%) had ever been asked to falsify reports, and more than half (56%) had ever voluntarily reported false hours. CONCLUSION: Most residents surveyed slept fewer than 8 hours per night and had a weight change during EM residency training. The majority of residents used a chemical aid for sleep or wakefulness. Nearly half of residents surveyed met criteria for disordered sleep, which was associated with a higher occurrence of MVIs.

Midwifery one-to-one support in labour: More than a ratio.

OBJECTIVE: To explore midwifery one-to-one support in labour in a real world context of midwife-led birth environments. DESIGN: Ethnographic study. Data was collected from 30 observations inside and outside the birth environments in three different birth settings. Semi-structured interviews were completed following the births with 29 low-risk women and 30 midwives with at least one year labour support experience to gain their perspectives. Twenty-seven maternity records were also analysed. SETTING: An alongside midwife-led unit, freestanding midwife-led unit and women's homes in England. FINDINGS: Six components of care were identified that required balance inside midwife-led birth environments: (1) presence, (2) midwife-woman relationships, (3) coping strategies, (4) labour progress, (5) birthing partners and (6) midwifery support. Midwives used their knowledge, experience and intuitive skills to synchronise their care for the six components to work in balance. Balancing of the six components have been translated into continuums representing the labour care and requirements. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Midwifery one-to-one support in labour is more than a ratio when translated into clinical practice. When the balance of the six components were tuned into the needs of women, women were satisfied with their labour and birth experience, even when it did not go to plan. A one midwife to one woman ratio should be available for all women in labour.

The Impact of the Veteran's Affairs Medical System on an Otolaryngology Residency Training Program.

Introduction: The field of otolaryngology has become the leading specialty in the management of head and neck pathology and trauma. Graduate medical education programs tasked to train military head and neck surgeons within the Department of Defense (DoD) maintain certification by ensuring adequate surgical case volume and training. In recent years, surgical case numbers have declined due to an overall healthy active duty patient population and deployments of residency faculty. As such, a novel initiative between the San Antonio Military Medical Center and the South Texas Veteran's Healthcare system was developed to provide seamless care among active duty service members, dependents, retirees, and veterans. The goal of this study is to review the impact on Otolaryngology Key Indicator Procedures (KIP), as defined by the Accreditation Council for Graduate Medical Education (ACGME), following integration of a Veterans Affairs health care population into a military otolaryngology residency program. Further, we aim to assess the potential secondary benefits of an integrated health care initiative between the DoD and the Veteran's Affairs (VA) systems. Materials and Methods: Otolaryngology key indicator procedures, as defined by the ACGME, were reviewed at an academic military medical center before and after implementation of an ENT Federal Healthcare Consortium integrating care of VA patients at a military hospital. The surgical scheduling system at our institution was queried for cases within the KIP categories of "Head & Neck" and "Otology" from 2011 to 2015. Results: Case data was reviewed from the San Antonio Military Medical Center before (2011-2012) and following integration of VA patient care (2013-2015). A total of 520 "Head & Neck" and 532 "Otology" KIP were performed following development of an ENT Federal Consortium. One hundred and sixty-five KIPs were performed on patients referred from the VA. The range of VA-generated cases contributing to total KIPs for "Head & Neck" and "Otology" ranged from 6.8% to 59.5% and 0% to 18.9% per year. Conclusions: The establishment of a Federal Healthcare Consortium and integration of VA patient population provided a tangible and quantifiable increase in otolaryngology KIPs. Development of a training relationship with VA patients is beneficial in reaching outcome-oriented goals for otolaryngology residents.

Severity and workload related to adverse events in the ICU.

OBJECTIVE:: To analyze whether an increase in patient severity and nursing workload are correlated to a greater incidence of adverse events (AEs) in critical patients. METHOD:: A prospective single cohort study was performed on a sample of 138 patients hospitalized in an intensive care unit (ICU). RESULTS:: A total of 166 AEs, occurred, affecting 50.7% of the patients. Increased patient severity presented a direct relationship to the probability of AEs occurring. However, nursing workload did not present a statistically significant relationship with the occurrence of AEs. CONCLUSION:: The results cast light on the importance of using evaluation tools by the nursing personnel in order to optimize their daily activities and focus on patient safety. OBJETIVO:: Analisar se o aumento da gravidade do paciente e a carga de trabalho de enfermagem está relacionado à maior incidência de Eventos Adversos (EAs) em pacientes críticos. MÉTODO:: Estudo de coorte única, prospectivo, com amostra de 138 pacientes internados em uma Unidade de Terapia Intensiva (UTI). RESULTADOS:: Ao todo, foram evidenciados 166 EAs, que acometeram 50,7% dos pacientes. O aumento da gravidade do paciente apresentou relação direta com a chance de ocorrência de EAs. Entretanto, a carga de trabalho de enfermagem não apresentou relação estatisticamente significativa, na ocorrência de EAs. CONCLUSÃO:: Os resultados permitem refletir acerca da importância da equipe de enfermagem, em utilizar instrumentos de avaliação, com o objetivo de melhorar e planejar suas ações diárias, com foco na segurança do paciente.

Severity and workload related to adverse events in the ICU / Gravedad y carga de trabajo relacionadas a eventos adversos en UTI / Gravidade e carga de trabalho relacionadas a eventos adversos em UTI

ABSTRACT Objective: To analyze whether an increase in patient severity and nursing workload are correlated to a greater incidence of adverse events (AEs) in critical patients. Method: A prospective single cohort study was performed on a sample of 138 patients hospitalized in an intensive care unit (ICU). Results: A total of 166 AEs, occurred, affecting 50.7% of the patients. Increased patient severity presented a direct relationship to the probability of AEs occurring. However, nursing workload did not present a statistically significant relationship with the occurrence of AEs. Conclusion: The results cast light on the importance of using evaluation tools by the nursing personnel in order to optimize their daily activities and focus on patient safety.

RESUMEN Objetivo: Analizar si el aumento de la gravedad del paciente y la carga de trabajo de enfermería está relacionada con mayor incidencia de Eventos Adversos (EAs) en pacientes críticos. Método: Estudio de cohorte única, prospectivo, con muestra de 138 pacientes internados en una Unidad de Terapia Intensiva (UTI). Resultados: En total, fueron evidenciados 166 EAs, incidiendo sobre 50,7% de los pacientes. El aumento de la gravedad del paciente mostró relación directa con la posibilidad de ocurrencia de EAs. Sin embargo, la carga de trabajo de enfermería no demostró relación estadísticamente significativa en la ocurrencia de EAs. Conclusión: Los resultados permiten reflexionar sobre la importancia del equipo de enfermería, en utilizar instrumentos de evaluación, con el objeto de mejorar y planificar sus acciones diarias, enfocándose en la seguridad del paciente.

RESUMO Objetivo: Analisar se o aumento da gravidade do paciente e a carga de trabalho de enfermagem está relacionado à maior incidência de Eventos Adversos (EAs) em pacientes críticos. Método: Estudo de coorte única, prospectivo, com amostra de 138 pacientes internados em uma Unidade de Terapia Intensiva (UTI). Resultados: Ao todo, foram evidenciados 166 EAs, que acometeram 50,7% dos pacientes. O aumento da gravidade do paciente apresentou relação direta com a chance de ocorrência de EAs. Entretanto, a carga de trabalho de enfermagem não apresentou relação estatisticamente significativa, na ocorrência de EAs. Conclusão: Os resultados permitem refletir acerca da importância da equipe de enfermagem, em utilizar instrumentos de avaliação, com o objetivo de melhorar e planejar suas ações diárias, com foco na segurança do paciente.

Are stipulated requirements for the quality of maternity care complied with? / Følges fastsatte kvalitetskrav i fødselsomsorgen?

BACKGROUND: The Directorate of Health's national guide Et trygt fødetilbud ­ kvalitetskrav til fødselsomsorgen [A safe maternity service ­ requirements regarding the quality of maternity care] was published in December 2010 and was intended to provide a basis for an improved and more predictable maternity service. This article presents data from the maternity institutions on compliance with the quality requirements, including information on selection, fetal monitoring, organisation, staffing and competencies. MATERIAL AND METHOD: The information was acquired with the aid of an electronic questionnaire in the period January­May 2015. The form was sent by e-mail to the medical officer in charge at all maternity units in Norway as at 1 January 2015 (n=47). RESULTS: There was a 100 % response to the questionnaire. The criteria for selecting where pregnant women should give birth were stated to be in conformity with the quality requirements. Some maternity institutions failed to describe the areas of responsibilities of doctors and midwives (38.5 % and 15.4 %, respectively). Few institutions recorded whether the midwife was present with the patient during the active phase. Half of the maternity departments (level 2 birth units) reported unfilled doctors' posts, and a third of the university hospitals/central hospitals (level 1 birth units) reported a severe shortage of locum midwives. Half of the level 2 birth units believed that the quality requirements had resulted in improved training, but reported only a limited degree of interdisciplinary or mandatory instruction. INTERPRETATION: The study reveals that there are several areas in which the health enterprises have procedures that conform to national quality requirements, but where it is still unclear whether they are observed in practice. Areas for improvement relate to routines describing areas of responsibility, availability of personnel resources and staff training.

[Guideline-adherent inpatient psychiatric psychotherapeutic treatment of obsessive-compulsive disorder : Normative definition of personnel requirements]. / Leitliniengerechte stationäre psychiatrisch-psychotherapeutische Behandlung der Zwangsstörung : Normative Personalbedarfsermittlung.

BACKGROUND: Guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with obsessive-compulsive disorder (OCD) is an important part of the care available for these patients. It may not be adequately reflected in the current personnel resources available according to the German psychiatry personnel regulation (Psych-PV). OBJECTIVES: The goal of this work was to assess the personnel resources necessary for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD and compare the necessary resources with the resources available according to Psych-PV. METHODS: Based on the German national guidelines for OCD and a meta-analysis on treatment intensity, we formulated a normative weekly treatment plan. Based on this plan we calculated the necessary personnel resources and compared these with the resources available according to Psych-PV category A1 (standard care). RESULTS: The weekly treatment time for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is 23.5 h per week. This corresponds to a weekly personnel requirement of 20.9 h. This requirement is only partly reflected in the Psych-PV (17.3 h, 82.8 %). The coverage of personnel resources by Psych-PV is even lower for psychotherapy provided by psychiatrist and psychologists (38.3 %, i. e. 183 min in the normative plan versus 70 min in Psych-PV). CONCLUSIONS: The current paper shows that the personal resources required for a guideline-oriented inpatient psychiatric and psychotherapeutic treatment of patients with OCD is not adequately reflected in the German psychiatry personnel regulation (Psych-PV). The actual shortage may be underestimated in our paper.

Evaluating palliative care ward staffing using bed occupancy, patient dependency, staff activity, service quality and cost data.

BACKGROUND: Palliative care staffing has remained unchallenged for decades while service provision has changed markedly, bringing new workforce demands. There is little evidence to inform hospice workforce structures, which strive to deliver the highest-quality holistic care. AIM: The study had three main aims, to: (i) adapt the acuity-quality workforce planning method used extensively in the UK National Health Service (NHS) for use in hospices; (ii) compare hospice and NHS palliative care staffing establishments and their implications; and (iii) create ward staffing benchmarks and formulae for hospice managers. DESIGN: A method adapted from a widely used nursing workforce planning and development (WP&D) study was used to collect data in hospice and palliative care wards. SETTING: Twenty-three palliative care and hospice wards, geographically representing England, were studied. RESULTS: A dataset, which profiles and benchmarks hospice and NHS palliative care ward occupancy, patient dependency, staff activity, ward establishments, quality and costs in 23 palliative care and hospice wards has been created. The database reveals large differences between hospice and palliative care wards. For example, hospice wards are better staffed and more expensive to run but staff deliver higher-quality care (measured using an established service quality audit) despite facing heavier workloads. Consequently, staffing multipliers are created to help managers estimate workload-based ward staffing. CONCLUSIONS: This dataset provides evidence-based recommendations to inform palliative care nursing workforce modelling, including deciding future nursing workforce size and mix based on rising workloads. The new dataset is suitable for use in UK hospice wards and may be appropriate for future international use.

Healthcare team members' perception of staffing adequacy in a comprehensive cancer center.

PURPOSE/OBJECTIVES: to describe the perceptions of staffing adequacy of healthcare team members working together on units in a comprehensive cancer center. RESEARCH APPROACH: a descriptive, phenomenologic design was used. Semistructured interviews were conducted with participants. SETTING: an urban, Magnet-designated comprehensive cancer center in the southwestern United States. PARTICIPANTS: a purposive sample of 10 RNs, 5 nursing assistants, and 5 associate directors. METHODOLOGIC APPROACH: data analysis was guided by Streubert's procedural interpretation of the phenomenologic method. FINDINGS: themes emerged, including alterations to care; challenges to an already challenging shift; the right mix; effects on patients, safety, and quality; mitigating factors; and the aftermath. CONCLUSIONS: perceived inadequate staffing affects healthcare staff both personally and professionally, triggering responses that influence approaches to patient care, unit operations, and relationships. INTERPRETATION: the unique and sometimes varied perspectives and experiences of frontline staff are critical to understanding factors that influence and affect willingness to work and remain in hospital settings, and may serve as a basis for shaping interventions and strategies to ensure adequate numbers of caregivers at the bedside.

Looking inside the black box of community rehabilitation and intermediate care teams in the United Kingdom: an audit of service and staffing.

OBJECTIVE: To generate a picture of the range, configuration and staffing of community and intermediate care services in the United Kingdom (UK) and to ascertain whether any relationships exist between service configuration and staffing models. METHOD: A service audit tool was sent to members of the Community Therapist's Network (CTN) and to chief executives of primary care and National Health Service trusts in the UK. Data were collected from the CTN and chief executives of primary care trusts (PCTs) and NHS trusts between late 2005 and early 2006. RESULTS: The overall response rate to the two audits was 37% (n = 243), with 77% of these responses (n = 186) useable. Services varied greatly in terms of their organisation and staffing configurations. Skill mix varied according to the location of service delivery, with home-based services utilising more therapy and support staff than inpatient services. Two clusters of service emerged, based on the number of referrals per year, support staff in the team and the level of care provided by the service. CONCLUSION: There are no clear patterns to the structure and organisation of community and intermediate care services in relation to their purpose, and it remains unclear how different staffing configurations impact on service costs and patient outcomes. The amount of variation observed indicates that there is likely to be considerable variability in service costs and outcomes for the teams. Further evidence is required to determine the impact of different staffing models, and to identify approaches that optimise both effectiveness and efficiency.

Evaluating nursing staff mix in long-term care: a comprehensive framework for decision-makers.

The connection between care-provider type and patient outcomes is well established. Less well understood, however, is how to evaluate staff mix decision-making aimed at maximizing quality outcomes for care recipients, nursing staff and healthcare systems. From May through November 2008, Eastern Health, the largest regional integrated health authority in Newfoundland and Labrador, conducted a Staff Mix Intervention Project designed, in part, to gauge the effectiveness of the Evaluation Framework to Determine the Impact of Nursing Staff Mix Decisions in assessing the impact of nursing staff mix changes in long-term care. Results reveal that the Evaluation Framework is a useful tool for managers and other decision-makers to use when measuring the comprehensive effects of staff mix changes and planning further human resources modifications.