Short-staff, high hopes: ICPs chart bold new course amid nursing shortage

APIC members sound alarm on staffing problems

Concerned that shrinking nursing staffs may imperil patients, the Centers for Disease Control and Prevention is gathering national experts in Atlanta to address escalating personnel shortages in the health care system, Hospital Infection Control has learned. The move was spurred in part by a CDC survey of members of the Association for Professionals in Infection Control and Epidemiology (APIC), who cited staffing woes as the primary obstacle to preventing infections and other adverse outcomes.

"One of the major [concerns] was the need
and importance of improving staffing," Julie Gerberding, MD, MPH, director of the CDC division of healthcare quality promotion, said in reporting preliminary findings
of the survey recently in Seattle at the annual APIC conference.

In the survey, which netted responses from APIC chapters in 40 states, ICPs were asked to cite obstacles and brainstorm for innovations in order to accomplish seven infection control challenges that have been identified by the CDC. (See related story, p. 91.)

"APIC members recognize that overall health care staffing is the single biggest obstacle that has to be overcome to accomplish many of these challenges," Gerberding told HIC. "In addition to general nurse staffing, infection control staffing was also a very major problem that came up time and time again."

To address such concerns, the CDC is hosting
a working group on nurse staffing in July at its Atlanta headquarters, she said. "We are bringing experts in from the nursing and health services research communities from around the country to present information that documents the relationship between the nursing shortage and health care infections."

The CDC hopes to crystallize the work group discussions into a formal "white paper" that could be used to lobby "decision makers, purchasers, and others who have a stake in health care quality," Gerberding said.

APIC leaders welcomed the opportunity for input on the issue, particularly as the organization reminded safety-come-lately groups that it has been dedicated to protecting patients for almost three decades. (See related story, p. 93.)

"[Staffing] is a huge issue that we can partner with our sister nursing organizations in working toward," Judith English, RN, MSN, CIC, APIC president, told HIC. "It is more likely that health care-acquired infections will happen in an understaffed, overworked [institution]. The average age of an ICU staff nurse is
45 years old. And up to some 30% of RNs in the United States will retire in the next 10 years. There are not that many people in nursing schools now to replace them."

Grim forecasts aside, there is evidence aplenty now that reduced staffing compromises patient safety. The issue has been compounded by other health care delivery changes, as nosocomial infection rates in general have risen with increases in the severity of illness of hospitalized patients. In addition to outright shortages, health care infections have been linked to staff problems caused by department mergers or addition of new services, spikes in census, cutbacks in nursing, or increased use of "pool" and agency nurses.1-6 (See Hospital Infection Control, June 1999 under archives at HIConline.com.)

Though it can be difficult to establish a clear epidemiological link between staffing and adverse outcomes, the mounting evidence suggest that staffing problems undermine aseptic technique, catheter care, and hand-washing compliance.

"It’s a tremendous problem," William Jarvis, MD, associate director for program development at the CDC division of healthcare quality promotion, told HIC. "We have done three or four studies now showing increase in infection rates associated with decreasing nurse-to-patient ratios or decreasing expertise of the nurses — in ICUs particularly. I don’t know that there are very many — if any — hospitals in this country right now that feel like they have adequate nursing personnel levels."

Amid the general loss of nursing staff, there are increasing reports of downsized infection control departments, he noted. Infection control and health care epidemiology are under "constant attack" because they appear as nonrevenue-generating departments on the radar of cost cutters. Yet untold millions are being spent every day in U.S. hospitals overrun with antibiotic resistant pathogens such as vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA).

"How many institutions have not taken those organisms seriously, and now have hordes of patients who are colonized and infected?" Jarvis said. "Those patients are staying longer in the hospital, they have increased morbidity and mortality, and more and more costly antimicrobials are being used [on them]. It’s hard to get [hospital] administration to look at what is the cost to you now for not doing something five years ago. [If] you cut it now, you will probably pay for it the future."

In spite of such trends — or maybe because of them — both the CDC quality division and APIC have decided to chart a bold course rather than cling to the past. For example, the aforementioned CDC infection control challenges — to be accomplished over the next five years — include a dizzying agenda of reducing bloodstream infections, adverse surgical events, and antibiotic-resistant infections and eliminating needlesticks.

"We’re beginning to use the word eliminate,’" Gerberding told APIC attendees. "If we are going to accomplish anything we are going to have to have a vision that is exciting and energizes us. Eliminating these adverse complications of health care is the highest priority."

For the challenge related to needlestick injuries, ICPs suggested an emphasis on safety devices, training, and finding the root cause of injuries. "Again, the staffing issue was identified over and over again as the most likely root cause for many of these injuries," she said.

In responding to the survey, many ICPs told the CDC that collaborative approaches (e.g., IV teams to fight catheter-related problems) are critical to accomplish the goals. ICPs also cited the need for more scientific evidence of impact, so they could show a clear link to their efforts and patient outcomes. (See related story on cost savings, p. 94.)

"We all recognize the reality of the system that we are working in," Gerberding said. "If we don’t have a product that makes good business sense, we don’t have a product that we can sell. That is [an area] that I think we can contribute — with your help and your expertise — in making more cogent arguments."

In releasing preliminary results from the survey, Gerberding said other important themes cited by ICPs were the need for patient and family education, and integrating and standardizing care processes across the health care delivery system.

"I was really struck by this paradox between knowing what to do, but not having the systems in place to make it possible," she said. "We don’t need research here; we need action."

Such "interventional epidemiology" was a key theme of the APIC conference, as discussions centered on multidisciplinary teams, greater use of technology, and striving for quality beyond benchmarks. The new direction, said English, is nothing less than "a sea change. We are going to zero-based tolerance for infection rather than staying within a range or benchmark."

Asked whether such dramatic changes amid a nursing shortage were ill-advised, English said, on the contrary, "The traditional way of looking at is not going to work now."

References

1. Firkin SK, Pear SM, Williamson TH, et al. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996; 17:150-158.

2. Haley RP, Bregman DA. The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis 1982; 145:875-885.

3. McKee KT, Cotton RB, Stratton CW, et al. Nursery
epidemic due to multiple-resistant Klebsiella pneumoniae. Epidemiological setting and impact on prenatal health care delivery. Infect Control 1982; 3:150-156.

4. Kidd F, Heitkemper P, Kressel A. A neonatal intensive care unit outbreak of S. aureus associated with inadequate staffing. Abstract S74. Presented at the Conference of the Society for Healthcare Epidemiology of America. San Francisco; April 1999.

5. Cunney RJ, Thornley D, Bialachowski A, et al. Environmental and nursing staff levels: Relationship to nosocomial acquisition of methicillin-resistant Staphylococcus aureus (MRSA). Abstract M29. Presented at the Conference of the Society for Healthcare Epidemiology of America. San Francisco; April 1999.

6. Duncan RA, Levine A, Willey S, et al. Nursing staffing and central venous catheter-related bloodstream infections (CVC-BSIs) in a changing surgical intensive care unit (SICU). Revised Abstract. Presented at the Conference of the Society for Healthcare Epidemiology of America. San Francisco; April 1999.