Essay: Heavy work loads compromise patient health: look at hospital staffing

© The Medical-Legal News 2007

By Rose Clifford, editor

The prudent attorney will take a medical malpractice case from being a simple issue of negligence on the part of one overworked nurse, up the corporate ladder to a hospital’s official policy of staffing ratio.

An article in the Journal of the American Medical Association reports a strong link between the number of patients a nurse has to care for and the rate of patient mortality and failure-to-rescue. Failure-to-rescue is defined as the death rate among patients with sepsis, pneumonia, shock, upper gastrointestinal bleeding or deep vein thrombosis. Also, failure-to-rescue is interpreted to mean complications.

Registered nurses are the eyes and ears of physicians. They are the first line of protection for the hospitalized patient in the form of 24-hour surveillance. The nurse’s role is to ascertain early, and intervene immediately, on a patient’s behalf. A big factor working against the nurse in this role is the number of patients assigned to each nurse, known as the nurse-patient ratio, or staffing ratio. Recommended staffing ratios range anywhere from three to ten patients per nurse. Many hospital specialists favor ten patients to each nurse on medical and surgical floors. Nurses nationwide have consistently reported that hospital nurse staffing levels are inadequate for them to provide safe and effective care. Physicians agree, citing inadequate nurse staffing as a major impediment to the provision of high-quality hospital care.

How a hospital chooses to staff its nursing unit may have a direct correlation on the patient’s ability to survive his hospitalization. The research in the JAMA article indicated that the more patients one nurse cared for, the higher the patient’s risk of dying or suffering a failure-to-rescue event within 30 days of the patient’s admission. The research also suggested that “burnout” of the nurse was a factor.

Decreases in patient mortality could result from simply increasing the number of RNs, especially for patients who develop complications. If the staffing ratio in all study hospitals were six patients per nurse rather than four per nurse, the study revealed 2.3 additional deaths per 1,000 patients, and 8.7 additional deaths per 1,000 patients with complications. If the ratio were raised to eight patients per nurse rather than six per nurse, 2.6 additional deaths per 1,000 patients and 9.5 additional deaths per 1,000 patients with complications was found. The study further indicated that to staff hospitals uniformly at eight vs. four patients per nurse would result in five excess deaths per 1,000 patients and 18.2 excess deaths per 1,000 complicated patients.

Because the study looked at more than 230,000 patients, the authors felt the study represented a conservative estimate of preventable deaths attributable to nurse staffing. •

Rose Clifford is a legal nurse consultant based in Kentucky, rose@medical-legalnews.com.