Massachusetts Study Examines Relationships Between Staffing, Sepsis Rates

Sepsis rates at a sample of Massachusetts hospitals were significantly lower with increased nurse staffing and intensivist hours, according to new research published in the October issue of Critical Care Nurse (CCN).

Factors Associated with the Rate of Sepsis After Surgery” examined data related to hospital characteristics, staffing levels and healthcare-acquired conditions to explore the relationships between nurse and physician staffing levels and postoperative sepsis rates.

According to the analysis, adding one more patient to a nurse’s care in a stepdown unit increased the risk that more patients would become septic. The sepsis rate ranged from nine or fewer cases per 1,000 discharges when nurses on stepdown units cared for an average of 2.29 patients but increased to 11 or more cases per 1,000 discharges when they each cared for an average of 3.61 patients.

Sepsis rates were significantly lower when nurses cared for fewer patients and when intensivist hours were greater. In addition, a higher ratio of patients to nurses was associated with a higher rate of catheter-associated urinary tract infections (CAUTIs), which is a common contributor to sepsis.

Co-author Jane Flanagan, PhD, RN, ANP-BC, AHN-BC, is an associate professor at Boston College, Chestnut Hill, Massachusetts.

“Our findings indicated that staffing influences sepsis rates, but not causally or solely,” she said. “Beyond staffing numbers, different roles may contribute to better collaboration and communication between nurses and the providers to whom they would report their concerns for early signs of sepsis.”

For example, intensivists may be assigned to a single unit and work with the nursing staff on a regular basis. Alternatively, physicians and hospitalists often rotate from unit to unit, which may be less conducive to developing collaborative relationships.

Sepsis checklists and treatment guidelines are primarily aimed at early intervention, but a growing body of evidence points to the value of nurses’ worry and intuition as early indicators prior to diagnostic evidence of a patient’s deteriorating condition. Recognition of sepsis often requires not only awareness of the signs and symptoms but knowing the patient well enough to be able to detect subtle changes in behavior or pain, or discomfort threshold.

According to the researchers, it is clear that nurses must be vigilant and sensitive to early symptoms in order to reduce the incidence of critical events, yet such vigilance requires adequate staffing. Their findings further highlight the relationship between nurse staffing levels and failure to rescue.

For the analysis, the researchers used publicly available data from the Massachusetts Hospital Association. The sample used to examine the relationship between nurse staffing and sepsis rates consisted of 53 hospitals with intensive or critical care units and medical-surgical units, and 25 hospitals with stepdown units, often called progressive care or telemetry units. The sample used to examine the relationship between physician staffing and sepsis rates consisted of 54 hospitals with physicians and medical residents, 42 with hospitalists and 33 with intensivists.

Their analysis focused on two healthcare-acquired infection measures – CAUTI and surgical site infection after colon surgery – as standardized infection rates as measured by the Centers for Medicare & Medicaid Services. It also included wound dehiscence after surgery, poor glycemic control and iatrogenic pneumothorax rates.

Separately from nurse staffing and physician staffing, CAUTI was the healthcare-acquired condition most strongly associated with sepsis.

Higher rates of CAUTI and greater numbers of stepdown patients assigned to nurses explained 54% of the variance in sepsis rates, out of seven factors examining the impact of nurse staffing.

A separate analysis of physician staffing found that five of seven factors were associated with sepsis rates, explaining 78% of the variance. Greater intensivist hours were associated with a significantly lower rate of sepsis, while CAUTI, wound dehiscence after surgery, greater hospitalist hours and greater physician hours were associated with higher rates of sepsis.

The authors call for further research related to the roles of intensivists, hospitalists and physicians and the reasons for their varying effects on sepsis rates.   

As the American Association of Critical-Care Nurses’ (AACN’s) bimonthly clinical practice journal for acute and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org.

About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients. The award-winning journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in acute, progressive and critical care settings. CCN enjoys a circulation of more than 120,000 and can be accessed at http://ccn.aacnjournals.org/.

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