Journal Reviews

Nurse working conditions affect infection rates

Patients at risk when understaffed, overtime

Stone PW, Mooney-Kane C, Larson E, et al. Nurse working conditions and patient safety outcomes. Medical Care 2007; 45(6):571-578.

Hospitals that have higher staff levels and better working conditions for nurses are safer for elderly intensive care unit patients, according to a recent report, led by Columbia University School of Nursing researchers that measured rates of hospital-associated infections.

A review of outcomes data for more than 15,000 patients in 51 U.S. hospital ICUs showed that those with high nurse staffing levels (the average was 17 registered nurse hours per patient day) had a lower incidence of infections. Higher levels of overtime hours were associated with increased rates of infection and skin ulcers.

Researchers evaluated several measures of working conditions to assess their effect on hospital-associated infections. They analyzed the organizational climate as measured by nurse surveys, and reviewed objective measures of staffing, overtime, and wages with payroll data. They also looked at hospital profitability and magnet accreditation (a national recognition program for nursing excellence in hospitals).

After careful review, findings revealed that ICUs with higher staffing had a lower incidence of central line-associated bloodstream infections, a common cause of mortality in intensive care settings. Other measures such as ventilator-associated pneumonia and skin ulcers, which are common among hospitalized patients who cannot move regularly, also were reduced in units with high staffing levels. Patients also were less likely to die within 30 days in these higher-staffed units.

Increased overtime hours in ICUs were associated with increased rates of another common hospital-associated infection, catheter-associated urinary tract infection, as well as increased rates of skin ulcers on patients. One possible solution presented in the study suggests increasing the availability of highly qualified float nurses through cross training. This would allow hospitals to more appropriately staff their ICUs and further develop the skills of nursing staff based on other units.

CR-BSIs: Studies flawed but some interventions work

Better models of economic benefit needed in future

Halton K, Graves N. Economics of preventing catheter-related bloodstream infections. Emerg Infect Dis [serial on the Internet]. 2007 Jun. Available from www.cdc.gov.

Apparently, infection prevention is no exception to the old saw that if all the economists were lined up end to end, they still would not reach a conclusion.

Catheter-related bloodstream infections (CR-BSIs) are a serious problem, but efforts to prove the economic benefit and cost-effectiveness of spending money to prevent them have been fraught with intrigue. "The cost-effectiveness studies are characterized by a lack of transparency, short time-horizons, and narrow economic perspectives," the authors of a new study report. "Data quality is low for some important model parameters. "

Four interventions were found to be clinically effective and cost-saving: use of antibiotic-coated catheters compared with use of either antiseptic-coated or standard catheters, maximal sterile barrier precautions during catheter insertion compared with less stringent aseptic technique, and use of chlorhexidine gluconate as either a skin preparation or impregnated into the insertion site dressing compared with use of povidone-iodine skin preparation and nonimpregnated dressings. Results of these evaluations are robust to a wide range of parameter estimates and assumptions. Two other interventions showed health benefits and increased costs: use of a three-day or 10-day catheter replacement regimen rather than replacement every five days and use of commercially available plastic bags for delivery of total parenteral nutrition rather than glass bottles, the authors noted.