1. THE IMPACT OF NURSING STAFF LEVELS ON QUALITY INDICATORS MARCIA K. FLESNER, PHD, RN, MHCA SINCLAIR SCHOOL OF NURSING UNIVERSITY OF MISSOURI JUNE 12, 2015

2. WHAT IS BENEFIT OF RN STAFFING? Consistent research findings reveal that increased RN hours per patient day in hospitals results in better outcomes (less mortality, less complications, less infections) Research also revealed better outcomes the more education RN received (ADN [2 years] versus BSN [4 years]) Hospitals have RNs on staff 24 hours a day 7 days a week As patient acuity increased and length of stay decreased, RNs were essential to direct patient care “Every Missouri patient deserves a registered nurse”

3. Nurse Staffing Tied to In-Hospital Cardiac Arrest Survival May 21, 2015 in the United States, of the 200,000 patients who experience in-hospital cardiac arrest annually, the rate of survival is less than 25%. The team analyzed the outcomes for 11,160 patients 18 years and older who were hospitalized from 2005 to 2007 in one of 75 hospitals in California, Florida, New Jersey, and Pennsylvania Each additional patient per nurse on medical–surgical units beyond the baseline number was associated with a 4% decrease in the odds of survival until discharge (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93 - 0.99). And for patients treated in hospitals with poor work environments, compared with better environments, there was a 22% decrease in the odds of survival (OR, 0.78; 95% CI, 0.64 - 0.95). Fewer patients per nurse can lead to earlier detection of telltale signs, she told Medscape Medical News. "No cardiac arrest in a hospital should ever be a surprise. Patients are telling us for about 48 hours that something is changing." http://www.medscape.com/viewarticle/845217?nlid=81669_2822&src=wnl_edit_medp_nurs&uac=230769AK&s pon=24http://www.medscape.com/viewarticle/845217?nlid=81669_2822&src=wnl_edit_medp_nurs&uac=230769AK&s pon=24

4. So what do we know about RN staffing in LTC?

5. IOM Improving Quality of Care in Nursing Homes - 1986 Recommended Resident Assessment System NHs obligated to provide residents with full range of services; requires sufficient staff-both numbers and types of professionals- to meet needs of resident Identified one of the major factors affecting QoC and QoL in NHs was the number and quality of nursing staff in relationship to facility’s requirements Poor working conditions combined with heavy workloads and inadequate training were factors that contribute to poor quality of care and high turnover “..there is little doubt that qualified nursing personnel are one of the most important factors affecting high quality of care.” (page 101).

6. So what happened? IOM report Nursing Home Reform Act of 1987 Federal law mandated ◦ a licensed nurse (charge nurse) on each shift ◦RN on duty at least 8 consecutive hours per day, seven days a week ◦RN designated as Director of Nursing on FT basis Above was considered the minimum staffing for a nursing home but it soon became the standard

7. Nursing Home Reform Act of 1987 “Quality of nursing home care has proven to be one of the most politically volatile-yet socially critical- issues confronting the American public. The issue strikes at the core of individual concern about possible functional impairment and potential loss of impairment and potential loss of independence…complicated by the likelihood of personal impoverishment.” (page 129)

8. Recommendation of expert panel in 2000 Looked at past--1997 OSCAR staffing data for 14,140 facilities RN minutes per resident day – 43 (.73 hr) LPN minutes per resident day – 41 (.69 hr) NA minutes per resident day – 126 (2.1 hr) Total minutes for resident day – 210 (3.52 hr) Wide variation seen among homes and state to state Recommended RN mprd – 69 (1.15 hr)LPN mprd – 42 (.70 hr) NA mprd – 139 (2.7 hr) Total minutes for resident day – 273 minutes (4.55 hr)

9. 2001 IOM report Improving the Quality of Long-Term Care ◦Report showed abundant evidence of quality of care problems in some nursing homes and problems were related in part to inadequate staffing levels Inadequate staffing led to poor feeding of residents and inadequate nutritional intake, low rates of skin care, risk of dehydration, poor oral care, declining functional status Workload demands for productivity were in conflict with need to provide individualized care Ratio of professional nurses to other nursing staff are predictors of high quality care in nursing homes

10. Current State of Nursing Home Care High resident acuity Emphasis to reduce hospitalizations and ED visits More short-stay with planned discharges home Emphasis on advanced care planning and end of life care for long stay residents

11. RNs Influence Resident Outcomes Fewer pressure ulcers, weight loss, catheter use, UTIs, aggressive behaviors, hospitalizations, medication use. Improved ADLs, mental health, pain management, QOL and QOC measures.

12. Nursing Home Safety (2014 OIG) An estimated 22% of Medicare SNF residents experienced adverse events during their SNF stays…..” “Over half of residents who experienced harm went to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011.” “An additional 11% of residents experienced events during their SNF stays that resulted in temporary harm.” “Physician reviewers determined 59% of adverse events and temporary harm events were clearly or likely preventable.”

13. TTL TRANSJANUARYTTL TRANSFEBRUARYTTL TRANSMARCHTTL TRANSAPRIL NH HOME 1 SBAR usage ON TRANSFERS 1 100% 2 50% 540%5 20% POT AVOID HOSP TRANSFER 10% 100% 60% 100% NH HOME 2 SBAR usage ON TRANSFERS 2 50% 2 100% 1 2 50% POT AVOID HOSP TRANSFER 100% 0% 100% NH HOME 3 SBAR usage ON TRANSFERS 5 60% 6 16% 9 44% 5 0% POT AVOID HOSP TRANSFER 80% 67% 78% 100% NH HOME 4 SBAR usage ON TRANSFERS 17 18% 15 7% 6 16% 14 14% POT AVOID HOSP TRANSFER 70% 73% 67% 50% NH HOME 5 SBAR usage ON TRANSFERS 10 20% 11 63% 10 60% 4 50% POT AVOID HOSP TRANSFER 50% 27% 60% 50% NH HOME 6 SBAR usage ON TRANSFERS 8 20% 6 67% 5 60% 5 40% POT AVOID HOSP TRANSFER 50% 20% NH HOME 7 SBAR usage ON TRANSFERS 3 100% 5 3 67% 5 100% POT AVOID HOSP TRANSFER 33% 20% 67% 20% NH HOME 8 SBAR usage ON TRANSFERS 4 25% 6 33% 2 50% 6 33% POT AVOID HOSP TRANSFER 50% 67% 50%67% NH HOME 9 SBAR usage ON TRANSFERS 11 36% 20 30% 9 56% 12 17% POT AVOID HOSP TRANSFER 36% 45% 56% 58% NH HOME 10 SBAR usage ON TRANSFERS 4 0% 5 80% 12 42% 6 16% POT AVOID HOSP TRANSFER 25% 60% 83% 50% NH HOME 11 SBAR usage ON TRANSFERS 14 71% 16 69% 15 100% 17 70% POT AVOID HOSP TRANSFER 93% 44% 53% 76% NH HOME 12 SBAR usage ON TRANSFERS 7 43% 18 44% 16 25% 14 64% POT AVOID HOSP TRANSFER 71% 61% 68% 21% NH HOME 13 SBAR usage ON TRANSFERS 5 60% 7 100% 10 50% 7 71% POT AVOID HOSP TRANSFER 80% 71% 70% 57% NH HOME 14 SBAR usage ON TRANSFERS 0 No transfers 4 100% 1 0% 1 100% POT AVOID HOSP TRANSFER No transfers 25% 100% NH HOME 15 SBAR usage ON TRANSFERS 15 40% 9 44% 5 67% 2 50% POT AVOID HOSP TRANSFER 67% 78% 67% 50% NH HOME 16 SBAR usage ON TRANSFERS 10 30% 9 44% 9 33% 6 17% POT AVOID HOSP TRANSFER 30% 33% 44% 67%

14. Nursing Home Safety (2014 OIG) 26% of events related to healthcare acquired infections 37% of events related to basic nursing care 37% of events related to medications

15. Current State of Nursing Home Nursing Care to Manage Safety LPNs are the predominant licensed nurse in NH; comprising approximately 67% of workforce (AHCA, 2012) RN staffing in NHs remains relatively unchanged despite rising acuity ( Seblega, 2010) RN and LPN roles in NHs are often interchangeable (Corazzini 2013) ; including conducting medication reconciliation. (Vogelsmeier, 2011; 2014)

16. Challenges to Nursing Home Safety Elderly have complex conditions Multiple medications Fragmented systems Limited resources Undefined roles (Often) focused on regulation and tasks to meet regulations Leads to risk for Harm

17. Nurses and Medication Reconciliation No one provider coordinates care Physicians and pharmacists remote Nurses are most proximal to the resident and family

18. How Nurses Differed in Medication Reconciliation Practices RNs are more likely to… Raise questions Collaborate Stay vigilant with with follow up Focus on safety

19. How Nurses Differ in Medication Reconciliation Practices LPNs are more likely to…. Make assumptions Work in isolation Focus on task

20. Increased access to staffing data ◦CMS 5 star program started in 2009; gave us access to staffing information; limitations are data is self- reported and is look at 2 week period during annual survey visit

21. Staffing MO NURSING MISSOURI AVERAGENATIONAL AVERAGE HOME 1HOME 2HOME 3 Total number of residents721479474.787.5 Total number of licensed nurse staff hours per resident per day 42 minutes58 minutes48 minutes1 hour and 22 minutes1 hour and 40 minutes RN hours per resident per day20 minutes24 minutes29 minutes36 minutes50 minutes LPN/LVN hours per resident per day 21 minutes33 minutes19 minutes46 minutes50 minutes CNA hours per resident per day2 hours and 6 minutes2 hours and 22 minutes2 hours and 20 minutes2 hours and 33 minutes2 hours and 27 minutes Total hours per resident per day 167 minutes (2 hours and 47 minutes) 199 minutes (3 hours and 32 minutes) 188 minutes (3 hours and 13 minutes) 235 minutes (3 hours and 55 minutes) 247 minutes (4 hours and 7 minutes) Physical therapy staff hours per resident per day 1 minute2 minutes 4 minutes6 minutes Source: www.nursinghomecompare.gov Obtained 4/30/2015 So how far have we come with staffing in nursing homes???

22. DON EDUCATIONAL PREPARATION American Nurses Association recommends that nurses in administrative position at the managerial level or above be minimally prepared with a masters degree Prelicensure education focuses on clinical content, not management or leadership 2004 National Nursing Home Survey: ◦56% of NH DONs were prepared in diploma or associate degree programs ◦43% had some type of bachelors degree ◦30% has bachelors in nursing ◦5% had masters level in nursing

23. DON EDUCATIONAL PREPARATION LTC DONs limited educational preparation taken together with their high level of accountability creates the accountability-preparation gap

24. Source: Annals of Long Term Care, V23#4, 2015

25. Nursing scope of practice in MO RN definition Missouri Revised Statutes (15) "Professional nursing", the performance for compensation of any act which requires substantial specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social and nursing sciences, including, but not limited to: (a) Responsibility for the teaching of health care and the prevention of illness to the patient and his or her family; (b) Assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes; (c) The administration of medications and treatments as prescribed by a person licensed by a state regulatory board to prescribe medications and treatments; (d) The coordination and assistance in the delivery of a plan of health care with all members of a health team; (e) The teaching and supervision of other persons in the performance of any of the foregoing; (16) A "registered professional nurse" or "registered nurse", a person licensed pursuant to the provisions of this chapter to engage in the practice of professional nursing;

26. Nursing scope of practice in MO LPN definition Missouri Revised Statutes 335.016 (14) "Practical nursing", the performance for compensation of selected acts for the promotion of health and in the care of persons who are ill, injured, or experiencing alterations in normal health processes. Such performance requires substantial specialized skill, judgment and knowledge. All such nursing care shall be given under the direction of a person licensed by a state regulatory board to prescribe medications and treatments or under the direction of a registered professional nurse. For the purposes of this chapter, the term "direction" shall mean guidance or supervision provided by a person licensed by a state regulatory board to prescribe medications and treatments or a registered professional nurse, including, but not limited to, oral, written, or otherwise communicated orders or directives for patient care. When practical nursing care is delivered pursuant to the direction of a person licensed by a state regulatory board to prescribe medications and treatments or under the direction of a registered professional nurse, such care may be delivered by a licensed practical nurse without direct physical oversight;

28. LPN Scope of Practice and Quality of Nursing Home Care (2013) Nurse Practice Acts (NPA) have variation in scopes of practice about patient assessment 1. Some states say that LPNs may engage in assessment of patients 2. Some states say that LPNs may engage in focused assessments only 3. Some states say that LPNs may not engage in any type of assessment 4. Some states say nothing about the topic

31. LPN Scope of Practice and Quality of Nursing Home Care (2013) 6 quality measures (QM) were also examined: weight loss, decline in ADLS, UTI, moderate to severe pain, indwelling catheters, restraints) Of the 4 NPA-based predictors (see slide 4), all were associated with at least one QM Example-NHs in states where LPN scope of practice include data collection had on average, higher facility level prevalence of residents with modern to severe pain There was also found interaction effects when professional nursing supervision was higher

32. LPN Scope of Practice and Quality of Nursing Home Care (2013) IMPORTANT FINDINGS “Without RN-level clinical expertise, it was found that care decisions made in response to LPN-focused assessments might actually lead to detrimental care…” “With more availability of RN-level clinical supervision and expertise, however, LPN contributions to assessments related to better care were also found..” Above example of “effective collaboration”

33. LPN Scope of Practice and Quality of Nursing Home Care (2013) “ When guidance about the content and scope of practice is not clear, nurses, both RNs and LPNs, will be vulnerable to ownership entities operationalizing the licensed nurse function and scope, which may prioritize short-term financial performance over longer-term promotion of clinical or public health outcomes.”

34. What does research show about RN hours in nursing homes?

35. Published in 2005 in AJN Studied 82 nursing homes in 1996 & 1997; data on 1.376 residents who were at risk of developing pressure ulcer More RN direct care time per resident day was associated with 1. fewer pressure ulcers, hospitalizations and UTIs; 2. less weight loss, catheterization and deterioration in ability to perform ADLS; 3. greater use of oral stand medical nutritional supplements

36. What does research show about RN hours in nursing homes? There is an clear association between nursing home staffing levels and quality indicators Castle reviewed 59 studies in 2008 40% of the quality indicators were positively and significantly associate with staffing levels Examples of quality indicators: ◦Number of deficiency citations, pressure ulcer incidence, physical restraint use, nursing staffing turnover, drug error rates, hospitalization rates, ADL dependency, catheter use, UTI, weight loss, mortality, number of lawsuits

37. What does research show about RN hours in nursing homes? Kim, Harrington and Greene (2009) studied 411 nursing homes in CA 201 NHs consistently met the minimum standards for total nursing staff over 5 year period 210 NHs consistently failed to meet the minimum standards for total nursing staff > 5 years The standard of total Nursing HPRD in CA is 3.2; classified citations as total and serious (level G and higher) As RN to LPN staffing ratios increased, both total & serious deficiencies decreased In NHs that did not meet minimum standards, a higher RN to total nursing staff ratio had negative relationship to total deficiencies In NHs that did meet minimum standards, a higher RN to total nursing staff ratio had a significant negative relationship only to serious deficiencies

38. Lets talk about role of LPNs in your home What are LPNs allowed to do in your nursing home? What were they educated to do? Who is their supervisor (under the direction of a person licensed by a state regulatory board) when there is no RN in the building? What decisions are they making and has anyone assessed that they are capable of making those decisions? LPNs were not trained to be Charge nurses; lack of that skill leads to turnover among aides! When adverse events happen do you assess what the proportion of RN to LPN was? Falsehood of a “experienced LPN is better than some RNs I know”.

39. Turnover in nursing homes has negative impact on outcomes Turnover results in working under budget Resident needs are not met when working under budget Mistakes happen and errors are increased New staff are not adequately prepared to work with residents and co-workers; on the job training does not work unless you have a preceptor program that is committed to retaining new staff Pay overtime to fill in shifts which wears out existing staff

40. Turnover is expansive “Rule-of-Thumb” Estimates of Direct-Care Turnover Costs The most commonly used, conservative rule-of-thumb for estimating the per worker cost of turnover in the overall U.S. economy puts the comprehensive cost of replacing a lost employee at 25% of his or her annual compensation amount. Applying this rule, the Employment Policy Foundation (December 2002) calculates that “[f]or the typical full-time employee who earns $38,481 and receives $50,025 in total compensation, the total cost of turnover would amount to $12,506 per employee.” The 25% rule-of-thumb applied to US Bureau of Labor Statistics estimates of the annual wages of direct-care workers suggests a total cost of turnover per employee in the range of $4,200 to $5,200. (Source: The Cost of Frontline Turnover in Long-Term Care, 2004)

41. What does the future hold? ANA, the Coalition of Geriatric Nursing Organizations and Consumer Voice advocated for passage of Put a Registered Nurse in the Nursing Home bill (H.R. 952), sponsored by Rep. Jan Schakowsky (D-IL), at a Capitol Hill briefing for congressional staff.Put a Registered Nurse in the Nursing Home bill (H.R. 952) Spokespersons said the current RN on-duty requirement of eight hours per day is inadequate to ensure patient safety, the highest quality of care and maximum well-being for residents as the intensity and complexity of nursing home residents’ care needs continue to increase.

42. Conclusion at last! Differences exist between RNs and LPNs. They are not interchangeable Acknowledging the differences is important given the complexity of care requirements of frail residents

43. REFERENCES Available by contacting flesnerm@Missouri.edu QUESTIONS?