Download PDF
J Pediatr Intensive Care
DOI: 10.1055/s-0043-1769118
Original Article

The Association of Bedside Nurse Staffing on Patient Outcomes and Throughput in a Pediatric Cardiac Intensive Care Unit

Michael P. Fundora 
1   Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
,
Jiayi Liu
2   Department of Business Information Technology, Pamplin College of Business, Virginia Tech, Blacksburg, Virginia, United States
,
Diwas KC
3   Goizueta Business School, Emory University, Atlanta, Georgia, United States
,
Christina Calamaro
4   Children's Healthcare of Atlanta, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, United States
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Health care throughput is the progression of patients from admission to discharge, limited by bed occupancy and hospital capacity. This study examines heart center throughput, cascading effects of limited beds, transfer delays, and nursing staffing on outcomes utilizing elective surgery cancellation during the initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic wave. This study was a retrospective single-center study of staffing, adverse events, and transfers. The study period was January 1, 2018 to December 31, 2020 with the SARS-CoV-2 period March to May 2020. There were 2,589 patients, median age 5 months (6 days–4 years), 1,543 (60%) surgical and 1,046 (40%) medical. Mortality was 3.9% (n = 101), median stay 5 days (3–11 days), median 1:1 nurse staffing 40% (33–48%), median occupancy 54% (43–65%) for step-down unit, and 81% (74–85%) for cardiac intensive care unit. Every 10% increase in step-down unit occupancy had a 0.5-day increase in cardiac intensive care unit stay (p = 0.044), 2.1% increase in 2-day readmission (p = 0.023), and 2.6% mortality increase (p < 0.001). Every 10% increase in cardiac intensive care unit occupancy had 3.4% increase in surgical delay (p = 0.016), 6.5% increase in transfer delay (p = 0.020), and a 15% increase in total reported adverse events (p < 0.01). Elective surgery cancellation is associated with reduced high occupancy days (23–10%, p < 0.001), increased 1:1 nursing (34–55%, p < 0.001), decreased transfer delays (19–4%, p = 0.008), and decreased mortality (3.7–1.5%, p = 0.044). In conclusion, Elective surgery cancellation was associated with increased 1:1 nursing and decreased mortality. Increased cardiac step-down unit occupancy was associated with longer cardiac intensive care unit stay, increased transfer, and surgical delays.

Keywords

staffing - workload - CICU - resource utilization - bed occupancy

Ethical Standards

Procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975.




Publication History

Received: 13 February 2023

Accepted: 29 April 2023

Article published online:
26 May 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Walker C, Kappus K, Hall N. Strategies for improving patient throughput in an acute care setting resulting in improved outcomes: a systematic review. Nurs Econ 2016; 34 (06) 277-288
    PubMedGoogle Scholar
  • 2 Diercks DB, Roe MT, Chen AY. et al. Prolonged emergency department stays of non-ST-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association guidelines for management and increased adverse events. Ann Emerg Med 2007; 50 (05) 489-496
    CrossrefPubMedGoogle Scholar
  • 3 Fee C, Weber EJ, Maak CA, Bacchetti P. Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg Med 2007; 50 (05) 501-509 , 509.e1
    CrossrefPubMedGoogle Scholar
  • 4 Timm NL, Ho ML, Luria JW. Pediatric emergency department overcrowding and impact on patient flow outcomes. Acad Emerg Med 2008; 15 (09) 832-837
    CrossrefPubMedGoogle Scholar
  • 5 Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: a multicenter investigation. J Hosp Med 2016; 11 (11) 757-762
    CrossrefPubMedGoogle Scholar
  • 6 Johnson DW, Schmidt UH, Bittner EA, Christensen B, Levi R, Pino RM. Delay of transfer from the intensive care unit: a prospective observational study of incidence, causes, and financial impact. Crit Care 2013; 17 (04) R128
    CrossrefPubMedGoogle Scholar
  • 7 Cesta T. Managing length of stay using patient flow–part 1. Hosp Case Manag 2013; 21 (02) 19-22
    PubMedGoogle Scholar
  • 8 Fundora MP, Liu J, Calamaro C, Mahle WT, Kc D. The association of workload and outcomes in the pediatric cardiac ICU. Pediatr Crit Care Med 2021; 22 (08) 683-691
    CrossrefPubMedGoogle Scholar
  • 9 Weissman JS, Rothschild JM, Bendavid E. et al. Hospital workload and adverse events. Med Care 2007; 45 (05) 448-455
    CrossrefPubMedGoogle Scholar
  • 10 Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002; 288 (16) 1987-1993
    CrossrefPubMedGoogle Scholar
  • 11 Holden RJ, Scanlon MC, Patel NR. et al. A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. BMJ Qual Saf 2011; 20 (01) 15-24
    CrossrefPubMedGoogle Scholar
  • 12 Magalhães Ade, Coasta Dda, Riboldi Cde O, Mergen T, Barbosa Ada S, Moura Gde. Association between workload of the nursing staff and patient safety outcomes. Rev Esc Enferm USP 2017; 51 DOI: 10.1590/S1980-220X2016021203255.
    CrossrefPubMedGoogle Scholar
  • 13 Fergusson NA, Ahkioon S, Nagarajan M. et al. Association of intensive care unit occupancy during admission and inpatient mortality: a retrospective cohort study. Can J Anaesth 2020; 67 (02) 213-224
    CrossrefPubMedGoogle Scholar
  • 14 Kc DS, Terwiesch C. An econometric analysis of patient flows in the cardiac intensive care unit. Manuf Serv Oper Manag 2011; 14: 50-65
    CrossrefPubMedGoogle Scholar
  • 15 Surgeons ACo. COVID-19: Elective Case Triage Guidelines for Surgical Care. Accessed June 28, 2022 at: https://www.facs.org/for-medical-professionals/covid-19/clinical-guidance/elective-case/
    PubMed
  • 16 Services CfMM. CMS Releases Recommendations on Adult Elective Surgeries, Non-Essential Medical, Surgical, and Dental Procedures During COVID-19 Response (March 18, 2020). Accessed June 28, 2022 at: https://www.cms.gov/newsroom/press-releases/cms-releases-recommendations-adult-elective-surgeries-non-essential-medical-surgical-and-denta
    PubMed
  • 17 O'Brien SM, Jacobs JP, Pasquali SK. et al. The Society of Thoracic Surgeons congenital heart surgery database mortality risk model: part 1-statistical methodology. Ann Thorac Surg 2015; 100 (03) 1054-1062
    CrossrefPubMedGoogle Scholar
  • 18 Jensen K. Leadership for Smooth Patient Flow: Improved Outcomes, Improved Service, Improved Bottom Line. 1st ed.. Chicago, IL: Health Administration Press; 2008
    Google Scholar
  • 19 Jung M, Park H, Kang D. et al. The effect of bed-to-nurse ratio on hospital mortality of critically ill children on mechanical ventilation: a nationwide population-based study. Ann Intensive Care 2020; 10 (01) 159
    CrossrefPubMedGoogle Scholar
  • 20 Rae PJL, Pearce S, Greaves PJ, Dall'Ora C, Griffiths P, Endacott R. Outcomes sensitive to critical care nurse staffing levels: a systematic review. Intensive Crit Care Nurs 2021; 67: 103110
    CrossrefPubMedGoogle Scholar
  • 21 Carayon P, Gürses AP. A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units. Intensive Crit Care Nurs 2005; 21 (05) 284-301
    CrossrefPubMedGoogle Scholar
  • 22 West E, Barron DN, Harrison D, Rafferty AM, Rowan K, Sanderson C. Nurse staffing, medical staffing and mortality in intensive care: an observational study. Int J Nurs Stud 2014; 51 (05) 781-794
    CrossrefPubMedGoogle Scholar
  • 23 Neuraz A, Guérin C, Payet C. et al. Patient mortality is associated with staff resources and workload in the ICU: a multicenter observational study. Crit Care Med 2015; 43 (08) 1587-1594
    CrossrefPubMedGoogle Scholar
  • 24 Hessels AJ, Paliwal M, Weaver SH, Siddiqui D, Wurmser TA. Impact of patient safety culture on missed nursing care and adverse patient events. J Nurs Care Qual 2019; 34 (04) 287-294
    CrossrefPubMedGoogle Scholar
  • 25 Burlison JD, Quillivan RR, Kath LM. et al. A multilevel analysis of US hospital patient safety culture relationships with perceptions of voluntary event reporting. J Patient Saf 2020; 16 (03) 187-193
    CrossrefPubMedGoogle Scholar
  • 26 Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 2002; 346 (22) 1715-1722
    CrossrefPubMedGoogle Scholar
  • 27 Dang D, Johantgen ME, Pronovost PJ, Jenckes MW, Bass EB. Postoperative complications: does intensive care unit staff nursing make a difference?. Heart Lung 2002; 31 (03) 219-228
    CrossrefPubMedGoogle Scholar
  • 28 Oster NV, Patterson DG, Skillman SM, Frogner BK. COVID-19 and the Rural Health Workforce: The Impact of Federal Pandemic Funding to Address Workforce Needs. Center for Health Workforce Studies, University of Washington; , Mar 2022
    Google Scholar
  • 29 Association AN. Nurse Staffing Crisis (July 18, 2022). Accessed July 28, 2022 at: https://www.nursingworld.org/practice-policy/nurse-staffing/nurse-staffing-crisis/
    PubMed
  • 30 Nurses AAoC-C. American Association of Critical-care Nursing standards for establishing and sustaining healthy work environments: a journey to excellence. Am J Crit Care 2005; 14: 187
    CrossrefPubMedGoogle Scholar
  • 31 Statistics BoL. Wages and salaries cost per hour worked for civilian workers in registered nurse occupations. Accessed June 28, 2022 at: https://beta.bls.gov/dataViewer/view/timeseries/CMU102000012N000D
    PubMed