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The Nursing Activities Score per Nurse Ratio Is Associated With In-Hospital Mortality, Whereas the Patients Per Nurse Ratio Is Not

Margadant, Charlotte MSc1,2; Wortel, Safira MSc1,2; Hoogendoorn, Marga MSc2,3; Bosman, Rob MD2,4; Spijkstra, Jan Jaap MD2,5; Brinkman, Sylvia PhD1,2; de Keizer, Nicolette PhD1,2

doi: 10.1097/CCM.0000000000004005
Clinical Investigation: PDF Only
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Objectives: Studies have shown contradicting results on the association of nursing workload and mortality. Most of these studies expressed workload as patients per nurse ratios; however, this does not take into account that some patients require more nursing time than others. Nursing time can be quantified by tools like the Nursing Activities Score. We investigated the association of the Nursing Activities Score per nurse ratio, respectively, the patients per nurse ratio with in-hospital mortality in ICUs.

Design: Retrospective analysis of the National Intensive Care Evaluation database.

Setting: Fifteen Dutch ICUs.

Patients: All ICU patients admitted to and registered ICU nurses working at 15 Dutch ICUs between January 1, 2016, and January 1, 2018, were included. The association of mean or day 1 patients per nurse ratio and Nursing Activities Score per nurse ratio with in-hospital mortality was analyzed using logistic regression models.

Interventions: None.

Measurements and Main Results: Nursing Activities Score per nurse ratio greater than 41 for both mean Nursing Activities Score per nurse ratio as well as Nursing Activities Score per nurse ratio on day 1 were associated with a higher in-hospital mortality (odds ratios, 1.19 and 1.17, respectively). After case-mix adjustment the association between a Nursing Activities Score per nurse ratio greater than 61 for both mean Nursing Activities Score per nurse ratio as well as Nursing Activities Score per nurse ratio on day 1 and in-hospital mortality remained significant (odds ratios, 1.29 and 1.26, respectively). Patients per nurse ratio was not associated with in-hospital mortality.

Conclusions: A higher Nursing Activities Score per nurse ratio was associated with higher in-hospital mortality. In contrast, no association was found between patients per nurse ratios and in-hospital mortality in the Netherlands. Therefore, we conclude that it is more important to focus on the nursing workload that the patients generate rather than on the number of patients the nurse has to take care of in the ICU.

1Department of Medical Informatics, Amsterdam UMC, Location AMC, Amsterdam Public Health research institute, Amsterdam, The Netherlands.

2National Intensive Care Evaluation (NICE) Foundation, Department of Medical Informatics, Amsterdam UMC, Amsterdam, The Netherlands.

3Department Anesthesiology and Intensive Care, Isala, Zwolle, The Netherlands.

4Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

5Department of Intensive Care, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

The funding by the National Intensive Care Evaluation foundation does not alter the authors’ adherence to all Intensive Care Medicine policies on sharing data and materials.

Prof. Dr. de Keizer, Dr. Brinkman and Drs. Margadant’s department of Medical Informatics received funding from the National Intensive Care Evaluation (NICE) foundation to process and analyse data for the registry. Drs. Hoogendoorn, Bosman, and Spijkstra, and Prof. Dr. de Keizer are members of the board of NICE. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: c.c.margadant@amc.uva.nl

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