Unit-level variation in bed alarm use in US hospitals.

Bed and chair alarms are widely used in hospitals, despite lack of effectiveness and unintended negative consequences. In this cross-sectional, observational study, we examined alarm prevalence and contributions of patient- and unit-level factors to alarm use on 59 acute care nursing units in 57 US hospitals participating in the National Database of Nursing Quality Indicators®. Nursing unit staff reported data on patient-level fall risk and fall prevention measures for 1,489 patients. Patient-level propensity scores for alarm use were estimated using logistic regression. Expected alarm use on each unit, defined as the mean patient propensity-for-alarm score, was compared with the observed rate of alarm use. Over one-third of patients assessed had an alarm in the "on" position. Patient characteristics associated with higher odds of alarm use included recent fall, need for ambulation assistance, poor mobility judgment, and altered mental status. Observed rates of unit alarm use ranged from 0% to 100% (median 33%, 10th percentile 5%, 90th percentile 67%). Expected alarm use varied less (median 31%, 10th percentile 27%, and 90th percentile 45%). Only 29% of variability in observed alarm use was accounted for by expected alarm use. Unit assignment was a stronger predictor of alarm use than patient-level fall risk variables. Alarm use is common, varies widely across hospitals, and cannot be fully explained by patient fall risk factors; alarm use is driven largely by unit practices. Alarms are used too frequently and too indiscriminately, and guidance is needed for optimizing alarm use to reduce noise and encourage mobility in appropriate patients.

Dissemination and Implementation of Patient-centered Indicators of Pain Care Quality and Outcomes.

BACKGROUND: Previous approaches to measuring and improving nursing-sensitive, patient-centered metrics of pain quality and outcomes in hospitalized patients have been limited. METHODS: In this translational research study, we disseminated and implemented pain quality indicators in 1611 medical and/or surgical, step-down, rehabilitation, critical access, and obstetrical (postpartum) units from 326 US hospitals participating in the National Database of Nursing Quality Indicators. Eligible patients were English-speaking adults in pain. Trained nurses collected patients' perceptions via structured interview including 9 pain quality indicators, demographic, and clinical variables; these patient experience data were merged with unit and hospital level data. Analyses included geographic mapping; summary statistics and 3-level mixed effects modeling. RESULTS: Hospitals in 45 states and District of Columbia participated. Of 22,293 screened patients, 15,012 were eligible; 82% verbally consented and participated. Pain prevalence was 72%. Participants were 59.4% female; ages ranged from 19 to 90+ (median: 59 y); 27.3% were nonwhite and 6.5% were Hispanic. Pain intensity on average over the past 24 hours was 6.03 (SD=2.45) on a 0-10 scale. 28.5% of patients were in severe pain frequently or constantly. Race (nonwhite), younger age, being female and nonsurgical were associated (P<0.001) with greater pain. Care quality indicators ranking lowest related to discussion of analgesic side effects and use of nonpharmacologic approaches. CONCLUSIONS: Unrelieved pain remains a high-volume problem. Individual factors and unit type were significantly associated with pain outcomes. Hospitals can employ these quality indicators to direct continuous quality improvement targeting pain care quality.

Evidence on Fall and Injurious Fall Prevention Interventions in Acute Care Hospitals.

Falls and injurious falls are a major safety concern for patient care in acute care hospitals. Inpatient falls and injurious falls can cause extra financial burden to patients, families, and healthcare facilities. This article provides clinical implications and recommendations for adult inpatient fall and injurious fall prevention through a brief review of factors associated with falls and injurious falls and current fall prevention practices in acute care hospitals.

Quality Measures: A Stakeholder Analysis.

For quality measures, confusion and discontentment have increased, as availability of electronic data and data collection tools has expanded. We examined current issues with quality measures across 4 stakeholder groups: developers, regulators/endorsers, data collectors, and consumer advocates. There are missing quality measures, issues with data quality and purpose, questionable usability of electronic health records, and an increased measurement burden and cost. Policymakers, administrators, health care professionals, and consumers need to collaborate on measure development and selection.

Fall Rates in Urban and Rural Nursing Units: Does Location Matter?

Patient falls remain a leading adverse event in hospitals. In a study of 65 rural hospitals with 222 nursing units and 560 urban hospitals with 4274 nursing units, we found that geographic region, unit type, and nurse staffing, education, experience, and outcomes were associated with fall rates. Implications include specific attention to fall prevention in rehabilitation units, creating better work environments that promote nurse retention, and provide RN-BSN educational opportunities.

Multilevel Factors Associated With Injurious Falls in Acute Care Hospitals.

Using National Database of Nursing Quality Indicators data from July 2013 to June 2014, this correlational study examined the associations of injurious falls among all patient falls with multilevel factors in hospitals. The sample included all falls recorded in adult medical, surgical, combined medical-surgical, and step-down units (N = 2299) in participating hospitals (N = 488). Hierarchical negative binominal regression analyses were performed. Results revealed hospital and unit organizational factors associated with inpatient injurious falls.

Comparison of Unit-Level Patient Turnover Measures in Acute Care Hospital Settings.

High patient turnover is a critical factor increasing nursing workload. Despite the growing number of studies on patient turnover, no consensus about how to measure turnover has been achieved. This study was designed to assess the correlation among patient turnover measures commonly used in recent studies and to examine the degree of agreement among the measures for classifying units with different levels of patient turnover. Using unit-level data collected for this study from 292 units in 88 hospitals participating in the National Database of Nursing Quality Indicators®, we compared four patient turnover measures: the inverse of length of stay (1/LOS), admissions, discharges, and transfers per daily census (ADTC), ADTC with short-stay adjustment, and the number of ADTs and short-stay patients divided by the total number of treated patients, or Unit Activity Index (UAI). We assessed the measures' agreement on turnover quartile classifications, using percent agreement and Cohen's kappa statistic (weighted and unweighted). Pearson correlation coefficients also were calculated. ADTC with or without adjustment for short-stay patients had high correlations and substantial agreement with the measure of 1/LOS (κ = .62 to .91; r = .90 to .95). The UAI measure required data less commonly collected by participating hospital units and showed only moderate correlations and fair agreement with the other measures (κ = .23 to .39; r = .41 to .45). The UAI may not be comparable and interchangeable with other patient turnover measures when data are obtained from multiple units and hospitals. © 2016 Wiley Periodicals, Inc.

Nurse staffing and patient outcomes: a longitudinal study on trend and seasonality.

BACKGROUND: Time trends and seasonal patterns have been observed in nurse staffing and nursing-sensitive patient outcomes in recent years. It is unknown whether these changes were associated. METHODS: Quarterly unit-level nursing data in 2004-2012 were extracted from the National Database of Nursing Quality Indicators® (NDNQI®). Units were divided into groups based on patterns of missing data. All variables were aggregated across units within these groups and analyses were conducted at the group level. Patient outcomes included rates of inpatient falls and hospital-acquired pressure ulcers. Staffing variables included total nursing hours per patient days (HPPD) and percent of nursing hours provided by registered nurses (RN skill-mix). Weighted linear mixed models were used to examine the associations between nurse staffing and patient outcomes at trend and seasonal levels. RESULTS: At trend level, both staffing variables were inversely associated with all outcomes (p < 0.001); at seasonal level, total HPPD was inversely associated (higher staffing related to lower event rate) with all outcomes (p < 0.001) while RN skill-mix was positively associated (higher staffing related to higher event rate) with fall rate (p < 0.001) and pressure ulcer rate (p = 0.03). It was found that total HPPD tended to be lower and RN skill-mix tended to be higher in Quarter 1 (January-March) when falls and pressure ulcers were more likely to happen. CONCLUSIONS: By aggregating data across units we were able to detect associations between nurse staffing and patient outcomes at both trend and seasonal levels. More rigorous research is needed to study the underlying mechanism of these associations.

Trends in Nursing Care Efficiency From 2007 to 2011 on Acute Nursing Units.

Improving the efficiency of health care is a national priority. The purpose of this study was to estimate trends in the efficiency of nursing care. Specifically, the baseline and rate of change in efficiency in the association between select hospital and nursing unit characteristics (e.g., nurse staffing levels) and indicators of patient safety (e.g., fall rates and hospital-acquired pressure ulcer rates) was investigated. A small but significant improvement in efficiency for non-Magnet® hospitals and units with increased RN hours per patient day was found. Trends in efficiency varied by unit type, with medical units showing the greatest improvement. In general, efficiency improved most in health care settings having the greatest opportunity for improvement.

Challenges in defining and categorizing falls on diverse unit types: lessons from expansion of the NDNQI Falls Indicator.

In 2012, the National Database of Nursing Quality Indicators launched a project to expand its falls indicator for use on pediatric, neonatal, and psychiatric units. We discuss challenges encountered, argue that schemes for categorizing falls by cause or supposed preventability are not suitable for large-scale efforts to track and prevent falls, express concern about the growing burden of collecting increasingly granular quality data, and discuss limitations of total and injurious fall rates as quality measures.

Associations between rates of unassisted inpatient falls and levels of registered and non-registered nurse staffing.

OBJECTIVE: To enhance understanding of how nurse staffing relates to unassisted falls by exploring non-linear associations between unassisted fall rates and levels of registered nurse (RN) and non-RN staffing on 5 nursing unit types, thereby enabling managers to improve patient safety by making better-informed decisions about staffing. DESIGN: Cross-sectional analysis of routinely collected data using hierarchical negative binomial regression. SETTING: 8069 nursing units in 1361 U.S. hospitals participating in the National Database of Nursing Quality Indicators(®). Main outcome measure Rate of unassisted falls per inpatient day. RESULTS: Associations between unassisted fall rates and nurse staffing varied by unit type. For medical-surgical units, higher RN staffing was weakly associated with lower fall rates. On step-down and medical units, the association between RN staffing and fall rates depended on the level of staffing: At lower staffing levels, the fall rate increased as staffing increased, but at moderate and high staffing levels, the fall rate decreased as staffing increased. Higher levels of non-RN staffing were generally associated with higher fall rates.. CONCLUSIONS: Increasing non-RN staffing seems ineffective at preventing unassisted falls. Increasing RN staffing may be effective, depending on the unit type and the current level of staffing.

Agreement of fall classifications among staff in U.S. hospitals.

BACKGROUND: Patient falls in hospitals are a performance measure endorsed by the National Quality Forum. Agreement of staff classifications of fall situations is not documented. OBJECTIVES: The aims of this study were to (a) investigate how experts classify fall scenarios according to the fall definition of the National Quality Forum; (b) investigate how nursing staff classifies the same fall scenarios; and (c) assess the extent to which fall classifications differ among units, hospitals, and individuals. METHODS: Twenty video scenarios of falls were embedded in an online video survey. A panel of 24 experts and 6,342 hospital staff members from 362 units in 170 U.S. hospitals were asked to classify fall and nonfall scenarios. Experts consisted of nurses, physicians, physical therapists, and statisticians. Hospital staff were registered nurses (78%), unlicensed staff (15%), and other staff (7%). RESULTS: Experts unambiguously classified 14 out of 20 scenarios according to the National Quality Forum fall definition, whereas hospital staff clearly classified 12 scenarios. Experts and hospital staff did not agree on 4 out of 20 scenarios. The sensitivity was 0.90, the specificity was 0.88, and the mean probability for classifying a scenario as a fall was 0.60. DISCUSSION: Results indicate that the National Quality Forum fall definition needs further refinement to classify all scenarios properly. Although variability between individuals indicates some potential for fall reporting training, variability between units and hospitals does not seem to affect fall reporting.

Pressure ulcers and prevention among acute care hospitals in the United States.

BACKGROUND: Most pressure ulcers can be prevented with evidence-based practice. Many studies describe the implementation of a pressure ulcer prevention program but few report the effect on outcomes across acute care facilities. METHODS: Data on hospital-acquired pressure ulcers and prevention from the National Database of Nursing Quality Indicators 2010 Pressure Ulcer Surveys were linked to hospital characteristics and nurse staffing measures within the data set. The sample consisted of 1,419 hospitals from across the United States and 710,626 patients who had been surveyed for pressure ulcers in adult critical care, step-down, medical, surgical, and medical/surgical units. Hierarchical logistic regression analysis was performed to identify study variables associated with hospital-acquired pressure ulcers among patients at risk for these ulcers. RESULTS: The rate of hospital-acquired pressure ulcers was 3.6% across all surveyed patients and 7.9% among those at risk. Patients who received a skin and pressure ulcer risk assessment on admission were less likely to develop a pressure ulcer. Additional study variables associated with lower hospital-acquired pressure ulcer rates included a recent reassessment of pressure ulcer risk, higher Braden Scale scores, a recent skin assessment, routine repositioning, and Magnet or Magnet-applicant designation. Variables associated with a higher likelihood of hospital-acquired pressure ulcers included nutritional support, moisture management, larger hospital size, and academic medical center status. CONCLUSIONS: Results provide empirical support for pressure ulcer prevention guideline recommendations on skin assessment, pressure ulcer risk assessment, and routine repositioning, but the 7.9% rate of hospital-acquired pressure ulcers among at-risk patients suggests room for improvement in pressure ulcer prevention practice.

Unit-level time trends and seasonality in the rate of hospital-acquired pressure ulcers in US acute care hospitals.

This is a longitudinal study of the trend and seasonality in unit-level hospital-acquired pressure ulcer (HAPU) rates from 2004 to 2011, for 5447 acute care nursing units in 733 US hospitals. Unit-level HAPU rates decreased significantly during 2004-2007 (OR = 0.91, 95% CI [0.90, 0.91]) and the decreasing trend was much stronger during 2008-2011 (OR = 0.84 [0.83, 0.85]). Seasonal variations in HAPU rates were strong and consistent during 2004-2008, with the highest HAPU rate in Quarter 1 (Jan-Mar) and the lowest rate in Quarter 3 (Jul-Sep). During 2009-2011, the magnitude of this seasonality was greatly reduced, and only HAPU rate in Quarter 1 remained significantly higher than HAPU rates in other quarters.

Unit-level time trends in inpatient fall rates of US hospitals.

BACKGROUND: Little is known about the recent development of the quality of nursing care. OBJECTIVE: To examine trends in the rate of total inpatient falls, one of the nursing-sensitive quality indicators, in US hospitals. RESEARCH DESIGN: A longitudinal study of unit-level data collected during 2004-2009 by the National Database of Nursing Quality Indicators. Hierarchical Poisson regression models were used for the analysis of the unit-level fall rate. SUBJECTS: Approximately 37,000 observations from 8915 nursing units (1994 critical care, 1328 step-down, 1663 medical, 1279 surgical, 2217 medical-surgical, and 434 rehabilitation units) in 1171 hospitals were examined. MEASURES: The outcome measure was the annual count of unit-level inpatient falls with the annual count of unit-level patient days taken as the exposure variable. Independent variables included hospital size (≥300 or <300 beds), teaching status, and Magnet status and unit-level total nursing hours per patient day and proportion of total nursing hours supplied by RNs (skill-mix) at baseline. RESULTS: The mean fall rates for most unit types remained stable or decreased, whereas those for surgical units increased over time. A higher register nurses skill-mix and the total nursing hours per patient day were both associated with lower fall rates (P<0.001); hospitals with more beds tended to have lower fall rates (P=0.001). Hospital Magnet and teaching status were not associated with the fall rate. CONCLUSIONS: Overall, the fall rate in the United States hospitals decreased over time, but the large variation in the fall rate at both the hospital and the unit level indicates much room for improvement in the quality of nursing care related to fall prevention.

Application of bayesian methodology to measure equivalence between two rating scales.

BACKGROUND: Little is known about measuring equivalence between two rating scales. Measuring the equivalence between two rating scales requires a study design and analysis conducive to clear interpretation of actual equivalence with simple inferences. OBJECTIVE: The aim of this study was to show the use of bayesian methodology in determining equivalence within a simulated content validity study (to establish equivalence, not content validity). METHODS: Participants were randomized into two groups and responded to the items' perceived relevance or perceived correlation to a construct, job enjoyment. Items from the National Database of Nursing Quality Indicators were used. RESULTS: Eighty-seven nursing faculty members from various schools of nursing participated. Findings revealed in all items having a posterior probability of >95% that rating scales are equivalent using an informative prior whereas using a weak or flat prior led to a minimal decrease in posterior probability results. DISCUSSION: Prior and new information collected from this study was used to determine a posterior probability that a mean difference (±0.5 points) between the relevance and correlation group exists, thereby demonstrating equivalence between two rating scales.

Understanding unassisted falls: effects of nurse staffing level and nursing staff characteristics.

Hierarchical Poisson modeling was used to explore hospital and nursing unit characteristics as predictors of the unassisted fall rate. Longitudinal data were collected from 1502 units in 248 US hospitals. The relation between the fall rate and total nurse staffing was positive at lower staffing levels and negative for levels around and above the median. The fall rate was negatively associated with registered nurse skill mix and average registered nurse tenure on the unit.

Support from Work and Intent to Stay Among Nurses During COVID-19: An Academic-Practice Collaboration.

The COVID-19 pandemic created stressful working conditions for nurses and challenges for leaders. A survey was conducted among 399 acute and ambulatory care nurses measuring availability of calming and safety resources, perceptions of support from work, and intent to stay. Most nurses reported intent to stay with their employer, despite inadequate safety and calming resources. High levels of support from work were significantly influenced nurses' intent to stay. Leadership actions at the study site to provide support are described, providing context for results. Nurse leaders can positively influence intent to stay through consistent implementation of supportive measures.

The Box-Cox power transformation on nursing sensitive indicators: does it matter if structural effects are omitted during the estimation of the transformation parameter?

BACKGROUND: Many nursing and health related research studies have continuous outcome measures that are inherently non-normal in distribution. The Box-Cox transformation provides a powerful tool for developing a parsimonious model for data representation and interpretation when the distribution of the dependent variable, or outcome measure, of interest deviates from the normal distribution. The objectives of this study was to contrast the effect of obtaining the Box-Cox power transformation parameter and subsequent analysis of variance with or without a priori knowledge of predictor variables under the classic linear or linear mixed model settings. METHODS: Simulation data from a 3 × 4 factorial treatments design, along with the Patient Falls and Patient Injury Falls from the National Database of Nursing Quality Indicators (NDNQI® for the 3rd quarter of 2007 from a convenience sample of over one thousand US hospitals were analyzed. The effect of the nonlinear monotonic transformation was contrasted in two ways: a) estimating the transformation parameter along with factors with potential structural effects, and b) estimating the transformation parameter first and then conducting analysis of variance for the structural effect. RESULTS: Linear model ANOVA with Monte Carlo simulation and mixed models with correlated error terms with NDNQI examples showed no substantial differences on statistical tests for structural effects if the factors with structural effects were omitted during the estimation of the transformation parameter. CONCLUSIONS: The Box-Cox power transformation can still be an effective tool for validating statistical inferences with large observational, cross-sectional, and hierarchical or repeated measure studies under the linear or the mixed model settings without prior knowledge of all the factors with potential structural effects.

The reliability of the National Database of Nursing Quality Indicators pressure ulcer indicator: a triangulation approach.

A triangulation approach was used to examine the reliability of the National Database of Nursing Quality Indicators pressure ulcer indicator that included direct observation of these wounds in hospitalized patients and web-based testing with and without accompanying wound descriptions. Overall κ coefficients for pressure ulcer identification, staging, and origin indicate moderate to near perfect reliability and suggest that web-based testing can estimate the reliability of pressure ulcer staging from direct observation. Nurse certification in wound care and wound descriptors improved reliability levels.