Monthly Archives: February 2014

Nurse workload and education linked to patient survival following surgery


Between administering medications and coordinating care, nurses are some of the busiest health care professionals, often placed as the first point of contact for patients. Perhaps it comes as no surprise, then, that a recent study suggests patients are more likely to die after common surgeries when the nurses who care for them have heavier workloads.

Results of the study are published in The Lancet, where researchers from nine European countries report on data derived from over 420,000 patients in 300 hospitals.

They say that for every extra patient added to a nurse’s average workload, the chance of surgical patients dying within 30 days of admission increases by 7%.

However, they also found that a 10% increase in the ratio of nurses who hold a bachelor degree is linked to a 7% decrease in the risk of death.

To conduct their study, the team evaluated responses from more than 26,500 nurses and reviewed medical records for the hundreds of thousands of patients aged 50 years or older who were discharged after common surgeries, such as hip/knee replacements, appendectomy, gall bladder surgery and vascular procedures.

Their investigation took into account each patient’s risk of death and included age, sex, type of surgery, type of admission and the presence of certain chronic conditions. In addition, the team considered hospital characteristics, such as bed size, teaching status and technology.

Lead researcher Prof. Linda Aiken, from the University of Pennsylvania School of Nursing in the US, says:

“Our findings emphasize the risk to patients that could emerge in response to nurse staffing cuts under recent austerity measures, and suggest that an increased emphasis on bachelor’s education for nurses could reduce hospital deaths.”

‘Evidence may be deemed too expensive to act upon’

In detail, the report shows that the overall percentage of patients who died in the hospital within 30 days of admission was low, between an average of 1.0-1.5%.

But this percentage varied from hospital to hospital and ranged from less than 1% to more than 7%, the researchers say.

Additionally, nurse workload and education levels differ among countries. For example, the average patient-to-nurse ratio in Spain was 12:7, whereas in Norway this was 5:2.

In terms of education, all nurses in Spain and Norway had a bachelor’s degree, compared with an average of only 10% in Switzerland. In England, 28% of nurses had bachelor’s degrees.

The authors write about their findings in detail:

“These associations imply that patients in hospitals in which 60% of nurses had bachelor’s degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients.”

Prof. Aiken says the European findings mirror data from the US suggesting “that a safe level of hospital nursing staff might help to reduce surgical mortality, and challenge the widely held view that nurses’ experience is more important than their education.”

The team says their findings back a European Union (EU) decision last year to approve education for nurses within higher education institutions starting after 12 years of general education.

In a linked comment to the study, Alvisa Palese, from the University of Udine in Italy, and Roger Watson, from the University of Hull in the UK, write that this latest research provides support for appropriate patient-to-nurse ratios.

“Whether these findings are used to inform health care policy or how they are implemented in practice will be interesting to see,” they say.

“We fear that the evidence here will not be tried and found wanting, but will rather be deemed too expensive to act upon.”

Written by Marie Ellis


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Neonatal mortality rates an increasing trend in home birth

NursingIn a study to be presented on Feb. 7 at 2:15 p.m. CST, at the Society for Maternal-Fetal Medicine’s annual meeting, The Pregnancy Meeting ™, in New Orleans, researchers will report that patients delivered at home by midwives had a roughly four times higher risk of neonatal deaths than babies delivered in the hospital by midwives. The increased neonatal mortality risk is associated with the location of a planned birth, rather than the credentials of the person delivering the baby.

The number of homebirths in the United States has grown over the last decade. In the largest study of its kind, using Centers for Disease Control data on nearly 14 million linked infant birth and neonatal death data, term singleton U.S. births, researchers at New York-Presbyterian/Weill Cornell Medical Center found the absolute risk of neonatal mortality was 3.2/10,000 births in midwife hospital births, and 12.6/10,000 births in midwife home births, and it further increased in first-time mothers to 21.9/10,000 births in midwife home deliveries. Neonatal mortality was defined as neonatal deaths up to 28 days after delivery.

“This risk further increased to about seven-fold if this was the mother’s first pregnancy, and to about ten-fold in pregnancies beyond 41 weeks,” said Amos Grunebaum, M.D.

The excess total neonatal mortality for deliveries performed by home midwives was 9.3/10,000 births or about 18-19 excess neonatal deaths a year from midwife homebirths. Based on the most recent 2012 births data, the authors concluded that if home births by midwives continue to grow at the present 10 percent yearly rate, then the excess total neonatal mortality of home births by midwives would nearly double from about 16-17 in 2009 to about 32 in 2016.

Given the study’s findings, Amos Grunebaum, M.D. and Frank Chervenak, M.D., the main authors of the study, said that obstetric practitioners have an ethical obligation to disclose the increased absolute and relative risks associated with planned home birth to expectant parents who express an interest in this delivery setting, and to recommend strongly against it.

The authors also continued to say that hospitals should create a welcoming and comfortable birthing environment, as well as address unnecessary obstetric interventions, both of which are often a primary motivation for planned homebirth.



Patients with learning disabilities become ‘invisible’ in hospitals, says study


Nursing_January1Hospital patients with learning disabilities face longer waits and mismanaged treatment due to a failure to understand them by nursing staff, says a new report.

In one case, a patient who had problems making herself understood was accused of being drunk by hard pressed hospital staff.

It is estimated that one in 50 people in England have some form of learning disabilities such as Down’s syndrome.

Dr Irene Tuffrey-Wijne, senior research fellow in nursing at St George’s, University of London and Kingston University, said: “People with learning disabilities are largely invisible within the hospitals, which meant that their additional needs are not recognised or understood by staff.

“Our study found many examples of good practice, but also many examples where the safety of people with learning disabilities in hospitals was at risk.”

Dr Tuffrey-Wijne, a co-author of the study who works at the Faculty of Health, Social Care and Education, a partnership between the two universities, added: “The most common safety issues were delays and omissions of care and treatment.

“Some examples come down to basic nursing care like providing enough nutrition but other serious consequences were also seen in our study.

“These included delays in clinical investigations and treatment by staff unclear or unaware of what to do in certain situations when patients had trouble expressing their consent or opinions or lacked an understanding about what was required from them.”

The study included questionnaire surveys, interviews and observation with senior hospital managers, clinical staff, patients and carers in all types of areas within hospitals in the NHS.

It found that the main barrier to better and safer care was a lack of effective flagging systems, leading to a failure to identify patients with learning disabilities in the first place.

There was also a lack of understanding by nursing staff about learning disability issues and a lack of clear lines of responsibility and accountability for the care of each patient with learning disabilities.

Specialist nurses such as learning disability liaison nurses and ward managers with specific responsibility to advocate on behalf of patients with learning difficulties were recommended by the report.

The report, Identifying the factors affecting the implementation of strategies to promote a safer environment for patients with learning disabilities in NHS hospitals, published in the Health Services and Delivery Research journal, also recommended that the NHS investigate practical and effective ways of flagging patients with learning disabilities across NHS services and within NHS hospitals while also providing for procedures to ensure that family and other carers are involved in the care of such patients.

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