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Comprehensive study, JCAHO panel say lives may be in danger
Ever since the nursing shortage came to the fore in health care circles, concerns have been raised about its possible impact on patient safety. But even experts have not been able to agree as to whether the evidence of such a linkage was conclusive. However, the most comprehensive scientific look at the subject to date and a white paper from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), in Oakbrook Terrace, IL, have drawn a direct link between the nursing shortage and serious complications — even death.
A study by the Harvard School of Public Health in Boston and Vanderbilt University’s School of Nursing in Nashville, TN, has shown that the size and mix of nursing staffing at U.S. hospitals has a direct impact on the outcome of patient health. The Harvard/Vanderbilt study, published in the May 30, 2002, issue of the New England Journal of Medicine, represents a re-examination and refinement of the co-authors’ previous analysis released last year by the Health Resources and Services Administration in cooperation with the Department of Health and Human Services, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare & Medicare Services, and the National Institute for Nursing Research.
Specifically, the researchers confirmed their initial findings that low levels of RNs among a hospital’s nurses were associated with rates of serious complications such as pneumonia, upper gastrointestinal bleeding, shock, and cardiac arrest, including deaths among patients with these three complications, as well as sepsis or deep vein thrombosis. These complications occurred 3% to 9% more often than in hospitals with higher RN staffing.
"In some subtle ways this article is different, but the fundamental conclusions hold up," says Jack Needleman, PhD, assistant professor at the Harvard School of Public Health, a co-author of the article with Peter Buerhaus, PhD, RN, FAAN, of Vanderbilt. Needleman noted that the sample size (his study used data from 799 hospitals in 11 states, and 6 million patients discharged) helped underscore the validity of his findings.
The main difference, says Needleman, is that in the original HRSA presentation "we were some-what equivocal — there was no consistent evidence of an association between [licensed practical nurses] and aide staffing and these outcomes, but some evidence of a total effect. When we looked more and harder, we determined that all we really see on these data is a registered nurse effect."
The growing shortage of nurses in America’s hospitals is putting patient lives in danger and requires immediate attention, according to an expert panel put together by JCAHO. The panel was convened to discuss a recent white paper report by JCAHO, via expert roundtable, designed to address the growing nursing shortage crisis. Failure to address this problem aggressively, the panel members warned, is likely to result in increased patient complications and deaths, greater lengths of stay and other undesirable outcomes.
According to JCAHO, more than 126,000 nursing positions are unfilled today, and that number is expected to skyrocket just as 78 million baby boomers begin placing greater demands on America’s health care system. Today, this nurse-staffing problem is a major factor in emergency department overcrowding, cancellation of elective surgeries, discontinuation of clinical services, and the limited ability of the health system to respond to any mass casualty incident, it said.
According to Dennis O’Leary, MD, president of JCAHO, the organization found that almost 25% of all medical error reports can be traced to inadequate staffing, and clear evidence suggests that high nursing turnover is associated with increased patient mortality. "The need for solutions to this problem is particularly urgent," O’Leary says. "We must, as a country, understand not simply what needs to be done but who specifically is responsible for getting each task done. Otherwise, we face a future in which patient safety and health care quality will be significantly compromised." He termed nurses "the frontline of health care."
Perfect storm’ brewing
Current forces in place spell bad news down the road for patient safety unless something is done; all the elements are in place for "a perfect storm brewing," warned Marilyn Chow, RN, vice president of patient care services at Kaiser Permanente in Oakland, CA, and a JCAHO roundtable panelist. She said an aging nursing population — average age just over 43 — and fewer coming into the profession, along with the rapid increase in aging baby boomers needing increased health care, all contribute to darkening clouds hanging over not just nursing but the entire health care sector.
Chow said that the proposals set forth in the JCAHO white paper will spur action on the issue, but that it will require effort from all parties involved. "We believe there are solutions, but making these solutions happen will require a commitment from leaders across the industry and government and for all those who care about how America’s patients are cared for," she said.
Sally Sample, RN, termed the current situation "untenable." As moderator of JCAHO’s national nursing shortage roundtable, which also compiled the report, Sample cited a recent poll indicating that 40% of nurses are dissatisfied with their jobs. "And many are planning to leave nursing within the next year."
Nurses, she noted, are being described as the "canaries in the coal mine," this particular coal mine being the hospital workplace, "which needs immediate improvement." Cost-cutting, lack of adequate training, and a variety of workplace stresses are adding up to create high levels of job dissatisfaction among nurses, she said. As a result, nurses are not encouraging others to follow in their footsteps.
"What I hear from nurses, on a regular basis, is that they are struggling to do the best that they can, and some of the situations in which they are working are presenting barriers to them feeling satisfied in their ability to give good nursing care," observed Mary Foley, RN, immediate past president of the American Nurses Association, Washington, DC. She said nurses "don’t feel valued" and they "don’t want to work in an unsatisfactory environment," often featuring excessive levels of mandatory overtime hours.
O’Leary elaborated: "When nurses who work in hospital settings feel stressed, overworked, [and] undervalued, and they go home and tell their children and they tell their friends and neighbors — that’s discouraging people from going into nursing as a career." And he noted the impact of increased competition for women professionals from other job sectors.
Nurses save money
Solving the problem will be much more difficult than identifying it, Needleman concedes. "Fixing that problem is going to require bringing more nurses into the hospital. There may be ways to restructure work, but efforts in the 90s [to do that] do not seem to have been very successful."
To some degree, he says, the idea that using fewer nurses will save hospitals money can be misleading. "There is some reason to believe that the cost of bringing in more nurses will be associated with savings, in terms of shorter lengths of stay, a reduction in the need to treat complications, and so forth," he notes. "I can’t tell you whether there will be a full offset, but to the extent it isn’t, in this climate it seems to me that the patient may not be prepared to play roulette with his health. Given that, patients will be willing to pay some of the increased costs through higher premiums and Medicare."
O’Leary in particular underlined the link between additional funding and patient safety. "We need to put new federal money into nurse staffing, and that should be driven off of the patient safety platform," he said, noting that in the past 25 years, public policy-makers have been subtracting resources from hospitals "and it’s starting to have its effect."
But he said that any money put back into hospital health care should be done in a targeted fashion, "so that hospitals are [incentivized] to achieve quantifiable goals that are very much along the lines of patient safety, which is very closely related to nurse staffing."
Foley concurred that safety initiatives attached to nursing investment are very valid. "There is a direct correlation between safety, quality, and nurse staffing and the adequacy of preparation and the continuity of practice," she concluded.
Joint Commission issues patient safety goals
Goals will show up in surveys
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, has for the first time issued a set of national patient safety goals, for the year 2003. The goals will be incorporated into JCAHO’s survey and scoring process.
"The background for these goals was laid by the publication of our Sentinel Event Alert over the last four years," notes Richard J. Croteau, MD, JCAHO’s executive director for strategic initiatives. Each issue contains several recommendations about improving patient safety, Croteau points out. "Last year, we decided to survey compliance with these recommendations, because they have been seen by subscribers as good, sound advice," he explains. "Everyone agreed, until we said we would survey organizations and score them if they did not comply."
The feeling was there were simply too many recommendations, Croteau says. "Accredited organizations wanted us to get a little more focused and prioritize the recommendations so they’d be in a more manageable package, at least for the purposes of surveys and scoring and impacting accreditation."
Health care organizations also wanted to know where the evidence was behind the recommendations, Croteau says. "We had provided it in most cases in the background information, but decided we would take all the recommendations, which totaled about 70, and convene an expert panel representing the full scope of health care, and then base the recommendations on evidence and/or expertise, and practicality," he relates.
The advisory group was composed of physicians, nurses, risk managers, and other professionals. They identified a total of 44 expert- and evidence-based recommendations from the 25 Sentinel Event Alerts that include the 11 associated with the 2003 Goals. The remaining recommendations constitute an initial pool upon which future National Patient Safety Goals may be based. "We prioritized them and then grouped them by the goals," Croteau explains.
Beginning Jan. 1, 2003, the more than 17,000 JCAHO-accredited health care organizations that provide care relevant to the goals will be evaluated for compliance with the recommendations or implementation of acceptable alternatives. On what basis might an alternative be considered acceptable? "We ask the organization to submit the alternative on a simple form we are developing that tells what it is, why they want to use it, and what they have from the literature or other sources to support its efficacy," Croteau says. "We will ask our advisory panel to make a recommendation and then the Joint Commission will decide. The organizations will then know ahead of time if the alternative is acceptable; they won’t have to wait until they are surveyed," he says.
Goal is 100% compliance
The Joint Commission’s goals for this new initiative are anything but modest. "We are looking for 100% compliance," Croteau says. "The expectation is that the organizations will implement all of the goals that apply to them or they will get a Type I and have to do it to keep their accreditation."
Compliance may not be as difficult as it first appears. "The goals and recommendations selected by the advisory group are all high-impact, low- cost targets," says Henri R. Manasse Jr., PhD, chair of the Sentinel Event Advisory Group, executive vice president and CEO of the American Society of Health-System Pharmacists, and past chair of the National Patient Safety Foundation. "This initiative should really make a difference in improving patient safety," he says.
Interestingly, five of the six National Patient Safety Goals correlate with early drafts of the core safe practices being identified by the National Quality Forum (NQF), a Washington, DC-based not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. The public/private sector-based NQF is expected to finalize its list of safe practices by the end of 2002.
"The work they do is good work, and we collaborate with them," Croteau says. "What we are doing with respect to patient safety goals is to try to align what we’re doing with what they’re doing, so as to eliminate redundancy." The Joint Commission’s intentions are to keep the number of goals at six, with no more than two recommendations per goal. "Each year we will review the goals, and keep or replace each one," Croteau says. The decisions, he says, will be based on what is learned from the surveys, and what the national focus is.
Aggregate data on the achievement of the goals will be made public each year, and individual organization compliance information will be disclosed when the reformatting of Joint Commission organization performance reports is completed in mid-2004.
It may never be possible to prove a direct correlation between these goals and improved patient safety, Croteau concedes. "What the organizations can do, and what we can do through our surveys is determine the degree to which these goals are implemented," he says. "We may never know the total impact on patient outcomes; we don’t know about all adverse outcomes. There is no 100% capture."
Clearly, he says, "We absolutely hope we will have a significant impact on patient safety, and that is part of the reason these specific goals were selected. They are effective, and yet they will still be practical for a broad range of organizations. You can’t require them to do something they simply can’t do."
[For more information, contact: The Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. Web site: www.jcaho.org.]
2003 National Patient Safety Goals and Recommendations
Improve the accuracy of patient identification.
• Use at least two patient identifiers (not the patient’s room number) whenever taking blood samples or administering medications or blood products.
• Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "timeout," to confirm the correct patient, procedure, and site, using active — not passive — communication techniques.
Improve the effectiveness of communication among caregivers.
• Implement a process for taking verbal or phone orders that requires a verification "read-back" of the complete order by the person receiving the order.
• Standardize the abbreviations, acronyms, and symbols used throughout the organization, including a list of abbreviations, acronyms, and symbols not to use.
Improve the safety of using high-alert medications.
• Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride > 0.9%) from patient care units.
• Standardize and limit the number of drug concentrations available in the organization.
Eliminate wrong-site, wrong-patient, and wrong-procedure surgery.
• Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
• Implement a process to mark the surgical site and involve the patient in the marking process.
Improve the safety of using infusion pumps.
• Ensure free-flow protection on all general-use and patient-controlled analgesia intravenous infusion pumps used in the organization.
Improve the effectiveness of clinical alarm systems.
• Implement regular preventive maintenance and testing of alarm systems.
• Ensure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
Source: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL.