A recent publication in The New England Journal of Medicine (NEJM) rejuvenated discussion on quality of care and its major determinant—patient-per-nurse ratios (PNRs).1 This study settled debates on whether PNRs have any significant impact on quality of care. The answer is an unequivocal yes: The authors demonstrated that PNRs have a noticeable effect on patient mortality. Given that the study was performed at a facility with rather low PNRs, its results are even more striking. The authors clearly state that during peaks in hospital census or admissions, patient lives are subjected to an additional mortality risk.
So, what's the underlying cause of the problem? Opinions differ and often reflect a "silo" mentality as opposed to system thinking. Myths and legends abound:
- "Of course it's the ED—the doctors there admit far too many people. That's their solution to manage ED overcrowding–it's an abuse of the system!"
- "It's the lack of appropriate staffing! If hospital administration would hire enough nurses, safety would definitely improve...but all they think about is the bottom line."
- "Sure, census peaks are a problem, but that means business is good. Mondays are especially heavy for some reason. Yes, event reports increase—but we've created several new forms and checklists to assure compliance with key standards and regulations."
- "Nurses have to work harder and faster to manage the demands. This new generation just doesn't seem to have the same work ethic."
Beyond the myths and legends, the real solution to the real problem is to effectively manage patient flow and alleviate the census peaks. That requires changing the status quo. The dilemma is how. Let's consider possible strategies and potential outcomes:
1. Staff hospitals 24/7 according to the peaks in both bed occupancy and admissions. This solution would definitely improve PNRs and eliminate many quality-of-care concerns. The one "small" problem is that it's obviously not feasible given the current economy, skyrocketing healthcare costs, and a looming nursing shortage.
2. Be "creative" by introducing dynamic PNRs that will fluctuate in a synchronous manner with census and admissions. Unfortunately, hospital attempts to adjust PNR to the census are rarely successful given that census fluctuations occur with a very high frequency (every half an hour or hour during peak times), as was demonstrated in a 4-hospital study.2
3. Legislate PNRs. This solution is a survival strategy and represents a bold response to multiple failed attempts to change the status quo in PNRs when no other viable options are available. It's a variation of the strategy that demands hospitals either staff to peak census 24/7 or (given resource limitations) cut off the peaks. The unintended consequence is that census can be artificially reduced by erecting barriers to patient flow (for example, by diverting ambulances from the EDs, holding admitted patients in the EDs, and closing available beds if the required PNR can't be maintained), leading to excessive wait times for services.
4. Preserve the status quo and do nothing. Unfortunately, this approach is prevalent. It occurs when hospitals are caught in an unsolvable dilemma between the inability to staff to peaks in census and the inability to be "creative" by providing flexible staffing. It leads some hospitals to choose the "ostrich solution" and do nothing. This generates three threats to quality of care. The primary threat is the incremental mortality imposed on patients; "patient centeredness" isn't achievable with any level of integrity. Healthcare reform could exacerbate this situation when newly insured patients contribute to demand. Second, more litigation could be an unintended consequence of the NEJM study—now that the relationship between PNR and mortality has been established, hospitals could be blamed for knowingly increasing patient mortality if they fail to take action. Finally, the simple decision to do nothing could serve as a catalyst for PNR legislation, which is a flawed solution for reasons discussed above.
There's no sense in telling nurses: "Yes, we know that you're stressed at work by periodic overloading. Yes, we know patient lives are endangered. However, we aren't going to change anything except to form more quality-of-care committees. Just be creative." Doing nothing is no solution.
5. Change hospital patient flow management. When staffing to peaks in patient demand isn't feasible and staffing below these peaks is dangerous for patients and stressful for nurses, the only option left is to question if peaks are even necessary. Fortunately, evidence exists in numerous publications, as well as the multiyear work of the Institute for Healthcare Optimization, that the vast majority of peaks in patient census and admissions are artificial; they result from mismanaged elective patient admissions and patient flow.3–6 Optimizing the scheduling of elective admissions coupled with lean design principles to improve patient flow can result in a significant reduction in nursing workload and, in turn, improve care quality and access, increase patient case volume, enhance staff satisfaction, and dramatically reduce healthcare costs.6,7 It could also substantially reduce readmissions.8
Implementing #5, the last solution, requires strong hospital commitment to scientifically manage variability in patient flow. Success relies on changing hospital operations and culture. These changes aren't easy but they're absolutely necessary for patients and clinicians, particularly in light of healthcare reform. We can no longer afford to maintain the status quo and risk avoidable patient deaths, dissatisfied nurses, mandated PNRs, and increased litigation. The science of managing patient flow can transform our journey. This path is well worth the effort, even though it's still the road less traveled.
1. Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med
2. Robert Wood Johnson Foundation. How the number of surgical patients affects nursing care; 2007
3. Litvak E, Buerhaus PI, Davidoff F, Long MC, McManus ML, Berwick DM. Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety. Jt Comm J Qual Patient Saf
5. Litvak E, Bisognano M. More patients, less payment: increasing hospital efficiency in the aftermath of health reform. Health Affairs
(Millwood). 2011;30(1):76–80. http://content.healthaffairs.org/content/30/1/76.abstract
8. Baker DR, Pronovost PJ, Morlock LL, Geocadin RG, Holmueller CG. Patient flow variability and unplanned readmissions to an intensive care unit. Crit Care Med
Editor's note: In June 2011, I wrote an editorial entitled "In Support of Safe Staffing" that highlighted research linking nurse staffing levels with patient mortality. This month, I'm joined by Dr. Eugene Litvak as my guest co-author in a special editorial that explores ways that the healthcare industry can address staffing challenges imposed by demand for nursing services.