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Original research
Hospital nurse staffing and sepsis protocol compliance and outcomes among patients with sepsis in the USA: a multistate cross-sectional analysis
  1. Andrew M Dierkes1,
  2. Linda H Aiken2,
  3. Douglas M Sloane2,
  4. Jeannie P Cimiotti3,
  5. Kathryn A Riman4,
  6. Matthew D McHugh2
  1. 1Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
  2. 2Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
  3. 3Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia, USA
  4. 4Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Andrew M Dierkes; amd323{at}pitt.edu

Abstract

Objectives Sepsis is a serious inflammatory response to infection with a high death rate. Timely and effective treatment may improve sepsis outcomes resulting in mandatory sepsis care protocol adherence reporting. How the impact of patient-to-nurse staffing compares to sepsis protocol compliance and patient outcomes is not well understood. This study aimed to determine the association between hospital sepsis protocol compliance, patient-to-nurse staffing ratios and patient outcomes.

Design A cross-sectional study examining hospital nurse staffing, sepsis protocol compliance and sepsis patient outcomes, using linked data from nurse (2015–2016, 2020) and hospital (2017) surveys, and Centers for Medicare and Medicaid Services Hospital Compare (2017) and corresponding MedPAR patient claims.

Setting 537 hospitals across six US states (California, Florida, Pennsylvania, New York, Illinois and New Jersey).

Participants 252 699 Medicare inpatients with sepsis present on admission.

Measures The explanatory variables are nurse staffing and SEP-1 compliance. Outcomes are mortality (within 30 and 60 days of index admission), readmissions (within 7, 30, and 60 days of discharge), admission to the intensive care unit (ICU) and lengths of stay (LOS).

Results Sepsis protocol compliance and nurse staffing vary widely across hospitals. Each additional patient per nurse was associated with increased odds of 30-day and 60-day mortality (9% (OR 1.09, 95% CI 1.05 to 1.13) and 10% (1.10, 95% CI 1.07 to 1.14)), 7-day, 30-day and 60-day readmission (8% (OR 1.08, 95% CI 1.05 to 1.11, p<0.001), 7% (OR 1.07, 95% CI 1.05 to 1.10, p<0.001), 7% (OR 1.07, 95% CI 1.05 to 1.10, p<0.001)), ICU admission (12% (OR 1.12, 95% CI 1.03 to 1.22, p=0.007)) and increased relative risk of longer LOS (10% (OR 1.10, 95% CI 1.08 to 1.12, p<0.001)). Each 10% increase in sepsis protocol compliance was associated with shorter LOS (2% ([OR 0.98, 95% CI 0.97 to 0.99, p<0.001)) only.

Conclusions Outcomes are more strongly associated with improved nurse staffing than with increased compliance with sepsis protocols.

  • health policy
  • organisation of health services
  • quality in health care

Data availability statement

Data may be obtained from a third party and are not publicly available. American Hospital Association (AHA) Annual Survey The AHA data is third-party data and cannot be shared by the investigators. However, those files may be licensed from the American Hospital Association via online request form (https://www.ahadata.com/aha-annual-survey-database).MedPAR patient claims may be acquired for a fee through a data use agreement with the Centers for Medicare and Medicaid Services (CMS) (https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/LimitedDataSets/MEDPARLDSHospitalNational). As a condition of the institutional review board (IRB) approved protocol (University of Pennsylvania IRB), the investigators cannot provide hospital identifiers. Nor can they share individual nurse survey data, identified or not, as a condition of research participant consent.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Data availability statement

Data may be obtained from a third party and are not publicly available. American Hospital Association (AHA) Annual Survey The AHA data is third-party data and cannot be shared by the investigators. However, those files may be licensed from the American Hospital Association via online request form (https://www.ahadata.com/aha-annual-survey-database).MedPAR patient claims may be acquired for a fee through a data use agreement with the Centers for Medicare and Medicaid Services (CMS) (https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/LimitedDataSets/MEDPARLDSHospitalNational). As a condition of the institutional review board (IRB) approved protocol (University of Pennsylvania IRB), the investigators cannot provide hospital identifiers. Nor can they share individual nurse survey data, identified or not, as a condition of research participant consent.

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Footnotes

  • Twitter @LindaAiken_Penn, @matthewdmchugh

  • Contributors AMD contributed to study design, interpreted results, drafted and revised the manuscript; LHA developed the idea for the study, raised funding, collected survey data, contributed to study design, interpreted results, revised manuscript; DS contributed to study design, interpreted results, drafted and revised the manuscript; JC interpreted results, drafted and revised the manuscript; KAR interpreted results, drafted and revised the manuscript; MDM raised funding, contributed to study design, reviewed the manuscript. LHA: Guarantor.

  • Funding This work was supported by the National Council of State Boards of Nursing (NCSBN) (Aiken, PI); National Institute of Nursing Research, National Institutes of Health grant numbers R01NR014855 (Aiken, PI), T32NR007104 (Aiken, Lake, McHugh, MPIs) and T32HL007820 (Kahn, PI); and Agency for Healthcare Research and Quality grant number R01HS026232 (Cimiotti, PI).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.