1. Nurse Working Conditions and Patient Safety: The Outcomes of ICU Working Conditions Study Investigators: Pat Stone, Andy Dick, Teresa Horan, Elaine Larson, Cathy Mooney-Kane, and Jack Zwanziger ps2024@columbia.edu Funded by AHRQ R01 HS013114 Supported by the CDC

2. Working Conditions and Patient Safety Growing concern that poor working conditions in the health care sector is contributing to decreasing patient safety (IOM, 2004). An acute nursing shortage that will not be as cyclic as past shortages due to –Aging workforce –Aging population and increased demand for nursing services –Poor working conditions resulting in difficulty recruiting and retaining qualified nursing personnel

3. Healthcare Associated Infections (HAI): Important Patient Safety Issue HAI rates have risen over the last 30 years –2 million cases annually –500,000 occur in ICU –Commonly associated with insertion of a device 6 th leading cause of death Estimated to cost hospitals $5.9 billion per year Increasing numbers of HAI are resistant to one or more antibiotics

4. Purpose Examine the factors related to ICU nurse working conditions and Patient safety outcomes

5. Administrative Processes: Nurse Working Conditions Organizational Climate Staffing Overtime Wages Patient Characteristics Severity of Illness Comorbidities Demographics Socio-economics Patient Outcomes CLBSI VAP CAUTI Decubitus Ulcer 30-day Mortality Structures of Care Hospital Size Teaching Status ICU Type Nursing Case-mix Conceptual Framework Structures of Care Profit Margin Magnet Status Covariates Independent Variables Dependent Variables

6. Recruitment Through infection control professionals –Invitations sent to CDC NNIS hospitals –APIC listserve Eligibility –ICU must have conducted device related HAI surveillance for part of 2002 according to NNIS definitions

7. Data Collection Procedures Patient characteristics –Medicare files Structure of Care –AHA data –Public files Administrative Processes related to Nurse Working Conditions –Nurse survey –Payroll –Patient census Patient Outcomes –CDC infection data –AHRQ PSI

8. Design/Statistical Analysis Cross sectional analysis All data provided for 2002 Variables computed on a monthly basis –Except organizational climate If patient’s stay covered more than 1 month, patient assigned to period with the longest stay Multivariate logistic regressions for each safety outcome

9. Sample 15,846 patients 51 ICUs 31 hospitals 1,095 RNs

10. Summary of Results Increased staffing significantly (p <0.05) related to safety outcomes –CLBSI (OR=.32), VAP (OR=.21), 30-day mortality (OR=. 81) and decubitus ulcer (OR=.69) Patients in ICUs staffed with higher proportions had a 3 to 5 fold increase in CAUTI and 2 fold increase in decubiti

11. Summary of Results (cont) Organizational climate related to CLBSI and CAUTI –Patients in ICUs with positive organizational climate 39% decreased odds of CAUTI OR=0.61, CI 95% 0.44-0.83 –Conflicting results with CLBSI OR=1.19, CI 95% 1.05-1.36 Mixed results with profit margin No independent effect of Magnet status

12. Discussion First study to link nurse working conditions with CDC infection surveillance data. Comprehensive examination with unique data sources. The administrative processes related to nurse working conditions were associated with patient safety outcomes.

13. Strengths and Limitations Unique data set Large national sample Generalizability? –ICU specific –Over represented by large teaching hospitals –Hospitals were part of the CDC network

14. Clinical Application A systems approach, including improving nurse working conditions, can improve patient safety. Substitutes for overtime and a flexible, qualified workforce is needed.

15. Other Analyses, Nurse and System Outcomes Organizational climate related to –Occupational injuries –Stone & Gershon (2007). Organizational climate related to –Nurses’ intention to leave position –Increasing wages alone, without attention to organizational climate insufficient –Stone et al., (2007).

16. That’s it, time to go… Special thanks to all the infection control professionals, staff nurses and hospitals that participated in this project

17. Next Research Steps Prevention of Nosocomial Infections and Cost- Effectiveness Analysis (P-NICE) –Describe and determine effectiveness of infection control staffing and interventions –Estimate long term outcomes of HAI –Estimate cost-effectiveness of infection control staffing and interventions Funded by NIH Exploratory Study Using Queueing Theory to Improve Nurse Staffing Effectiveness –Can queueing theory be used to inform nurse staffing decisions? Funded by AHRQ