RN Reductions May Lead to More Deaths, Longer Stays
Hospital leaders should focus on improving their work environments to retain RNs.
Hospitals that cut their proportion of RNs by just 10%, even while maintaining total nurse staffing hours, may face higher risks of avoidable deaths, readmissions and longer lengths of stay, along with decreased patient satisfaction.
“Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care,” in Medical Care, reports that substituting lower-wage nursing staff for RNs may reduce costs initially, but those gains will likely be erased by adverse patient outcomes, RN turnover and poor performance on value-based purchasing metrics.
Conducted at University of Pennsylvania School of Nursing, the study examined data for 6.5 million Medicare patients at 2,676 U.S. hospitals during 2019. The analysis shows that a 10% decrease in RN staffing is associated with 10,947 avoidable deaths and 5,207 extra readmissions per year, resulting in about $68.5 million in additional Medicare costs.
A related article in Becker’s Clinical Leadership adds that the findings come as many hospitals have embraced “team-based” nursing models in which LPNs return to bedside care, freeing RNs to focus on tasks that require their full licensing.
However, senior study author Linda Aiken, professor of nursing at the University of Pennsylvania, notes that the public has no way of assessing adequate RN staffing, and only two states (California and Oregon) have minimum RN staffing requirements. “Rather than replacing RNs with less-qualified staff, hospital leaders should focus on improving their work environments to retain RNs,” Aiken adds in the article.
AACN provides guidance to improve processes that affect RN staffing levels in a range of adult critical-care settings. “AACN Standards for Appropriate Staffing in Adult Critical Care” offers “specific actions that support nurses and units in addressing nurse burnout, moral distress and the nurse shortage as a whole.”
Defeating Difficult IVs: Using Ultrasound Is a Critical Skill
Ultrasound-guided IV is a valuable skill for nurses treating patients with DIVA.
Using ultrasound for difficult intravenous access (DIVA) can improve outcomes and reduce patient discomfort while also enabling ICU nurses to provide high-quality care, manage their time effectively and boost job satisfaction.
“Experiences and Perceptions of Critical Care Nurses on the Use of Point-of-Care Ultrasound (POCUS) to Establish Peripheral Venous Access in Patients With Difficult Intravenous Access: A Qualitative Study,” in BMJ Open, draws on interviews with nine nurses from six ICUs in Norway and Sweden in 2022. Their comments led to a central theme: “POCUS simplifies a complicated procedure,” which they support with five subthemes:
- Sharing the experience: By situating the ultrasound machine for shared viewing, the nurse and patient can watch together, a practice that satisfies the patient’s need for information while also distracting them from potential discomfort.
- Seeing inside the body: Visualizing the needle and relevant anatomical structures improves first-pass success rates and leads to more comfortable IV placements. In addition, POCUS helps nurses select the vein, location and appropriate peripheral intravenous catheter (PIVC) size to deliver medication.
- Establishing DIVA independently: Having the ability to place difficult IVs themselves, without an anesthesiologist, helps nurses reduce patient delays to optimize time and workflow.
- Using POCUS to increase action readiness: The nurses express feeling more empowered and confident to assist colleagues with difficult PIVC insertions. They view the skill as an important asset for their department as well as others.
- Appreciating an expanded role as critical care nurses: Learning to use ultrasound technology increases their job satisfaction and competence, giving them a new role that colleagues can rely on.
The study notes that because of its modest sample size, careful interpretation is warranted, yet the consistent responses from nurses bolster the conclusion that ultrasound-guided IV is a valuable skill for treating patients with DIVA.
Extubation Readiness Assessed Twice Daily Shortens ICU Stays
Study results support the benefits of intubated patients being awake.
Implementing twice-daily rounds to assess intubated patients’ ability to breathe on their own can reduce their ICU stays by 20%, or about 15 hours on average, without significantly impacting mortality.
“Twice Daily Extubation Readiness Assessment to Promote Timely Extubation, ICU Delirium Prevention and LOS Reduction,” in American Journal of Respiratory and Critical Care Medicine, also notes that support from the respiratory care team is crucial for success because more frequent assessments require workflow adjustments on their part.
In the study, care teams at a 38-bed adult ICU in Southern California used A-F bundle protocol and increased patient assessments from once to twice daily (one per 12-hour shift). The length-of-stay (LOS) results over three months were compared with those from three months before the study. Along with the LOS reductions for intubated patients, the study revealed the median LOS for all ICU patients dropped by 38%, or about 24 hours per patient.
In a related article in Healio, study co-author Julie-Kathryn Graham, San Diego State University School of Nursing, says that while clinicians often encourage rest and sedation for patients on ventilators, the study supports the benefits of patients being awake.
“The importance of using evidence to guide practice is underscored here,” Graham says in the article. “Optimal weaning improves functional status, prevents delirium and protects patients [from] potential harms of extended stays in acute care.”
She notes that future studies should focus on sustaining practices such as twice-daily assessments, noting that consistency depends on interdisciplinary team members having a shared understanding of the intervention’s value.
“This requires structures to be in place to support decision-making and accountability,” Graham adds. “Additionally, an organizational culture that supports transformational, collaborative, unit-driven change taps into the intellectual capital of all members of the team, providing opportunities for boundless innovation.”
AACN offers many ABCDEF resources, including CSI projects, journal articles, NTI sessions, blogs and webinars.
Modified ICU Sepsis Alert Shows Predictive Power
The modified alerts effectively identified sepsis in critically ill medical patients.
An intensive care sepsis alert designed with modified criteria for systemic inflammatory response syndrome proved effective in predictive power, offering enhanced accuracy and the possibility of reducing alert fatigue.
“Evaluation of an Intensive Care Unit Sepsis Alert in Critically Ill Medical Patients,” in American Journal of Critical Care, notes that alerts designed to identify those ICU patients with the highest sepsis risk had a positive predictive value of 72% across 128 alerts. The modified alerts were “effective for identifying sepsis in critically ill medical patients,” adds the retrospective evaluation.
The evaluation involved the cases of 713 adult patients at a tertiary referral center from January-February 2020 who had at least one sepsis alert during their stay. The modified alert required patients to meet at least two criteria (white blood cell count, body temperature, heart rate and respiratory rate), and at least one had to be white blood cell count or body temperature to trigger a sepsis alert.
Using the new criteria, only seven of the 713 patients did not have a sepsis alert and still received a sepsis diagnosis. The alert produced a negative predictive value of 99%, sensitivity of 92.9% and specificity of 95.1%.
AACN’s resources to prevent sepsis include tele-ICU surveillance, as described in a blog that outlines objectives, the nurse’s role and integrated artificial intelligence predictive tools. Dedicated screening nurses on light-duty work remotely to evaluate patients triaged by an algorithm, thus saving bedside nurses from excessive alerts.
The blog adds that tele-ICU nurses screened hundreds of patients per week, with a decrease in risk-adjusted mortality, in a pilot project that expanded from covering 100 beds to 800 without requiring additional staff. “By decreasing alert fatigue, interruptions and cognitive burden for bedside staff, the program helped our system achieve its patient safety goals.”
AACN also offers a dedicated webpage that includes understanding sepsis guidelines, being prepared, a sepsis micro-credential and many other clinical resources.
Combination PIVC Securement for Pediatric Patients Reduces Failures, Costs
The trial included 383 inpatients and a likely need for at least 24 hours with a PIVC.
Peripheral intravenous catheters (PIVCs) secured with integrated securement dressings and tissue adhesive produced the fewest failures for children admitted through emergency care in a clinical trial with three methods.
In “Novel Peripheral Intravenous Catheter Securement for Children and Catheter Failure Reduction: A Randomized Clinical Trial,” in JAMA Pediatrics, the low failure rate using the additional measures compared with the alternative approaches means fewer reinsertions or escalations and lower direct costs. “Further research should focus on implementation in inpatient units where prolonged dwell and reliable intravenous access is most needed,” the trial notes.
The Australian trial, conducted from 2020 to 2022, included 383 patients, ages 6 months to 8 years (with a median age of 36 months) and an anticipated need for at least 24 hours with a PIVC during hospitalization; 134 received standard care (bordered polyurethane), 118 received integrated securement dressing, and 131 received integrated securement dressing and tissue adhesive. The latter group had the lowest failure rate (12%), with integrated securement dressing (21%) and standard care (34%) failing more frequently.
Reducing failures improves the pediatric patient’s experience through reduced pain associated with reinsertions and lowers median costs when including the economic burden due to failures, the trial adds. “The experience is often traumatic relating to poor first experience of hospital for children and with incomplete treatment,” adds study author Brooke Charters, Metro South Hospital, Australia, in a related article in MedPage Today.
An editorial in JAMA Pediatrics, cited by MedPage Today, notes the need to adopt practices that take advantage of scientific advancement in this area: “What is most urgently needed now is guidance for how hospitals around the world can make implementing this practice change minimally burdensome to adopt and sustain in routine care.”
Improved Predictive Tools for Brain Injury
The review indicates advantages and limitations of various prognostication techniques.
Neuroprognostic markers are evolving rapidly as new ways to assess the brain’s structural and functional integrity after brain injury are being discovered.
In “Coma Prognostication After Acute Brain Injury: A Review,” in JAMA Neurology, intensive care clinicians attempting to estimate the chances of a patient’s recovery without much certainty may gain insight from emerging markers that have yet to be paired with evidence-based guidelines.
“Further research to establish best practices and standards for emerging prognostic markers, to develop accessible methods for implementation, and to further establish the efficacy and cost-effectiveness of these techniques will be critical for their clinical translation,” the review notes.
In evaluating both conventional and emerging classification schemes, and functional and structural markers, the review indicates the advantages and limitations of various prognostication techniques and their clinical applications. “Recognizing that the complex task of predicting consciousness recovery will likely never be made with certainty, clinicians should continue to approach these sensitive determinations with compassion and humility.”
The review encourages combining multiple prognostic markers to enhance predictive value, and it offers an overview of the science involved in the functional and structural markers that might be added to the ICU toolbox. For example, some physiological markers “suggest that consciousness may be possible in another subset of patients previously presumed unaware.”
Clinicians should consider individual patient data and goals of care for false positives that could lead to withdrawal of life-sustaining treatment. In addition, the review notes that “techniques used to acquire and analyze emerging prognostic marker data have been variable, the equipment necessary for these techniques is often not widely available, and insurance may not provide necessary coverage.”
Above and Beyond: A Nurse Who Made History
Maj. Katie Lunning, the first Air National Guard flight nurse to receive the Distinguished Flying Cross Medal, epitomizes service and bravery. In this nurse story, she reflects on her role as an ICU nurse manager and her conflict zone deployments.