Preventing Hospital Acquired Infections among Elderly ICU Patients Reduces Death Risk, Saves Money

Elderly patients who develop hospital-acquired infections (HAIs) while in intensive care units (ICU) are approximately 35 percent more likely to die within five years than other patients, according to a new study co-authored by INQRI grantee Patricia Stone.

The most common HAIs are bloodstream infections caused by central lines and pneumonia caused by ventilators, reports Advanced Healthcare Network for Nurses. Decreasing the incidents of these two HAIs alone could increase the odds that ICU patients survive, and reduce health care costs by more than $150,000, according to Stone’s study.

Stone and her colleagues examined outcomes for 17,537 Medicare patients over a five year period and found that while 57 percent of all the elderly ICU patients had died, nearly 80 percent of patients who developed HAIs during their ICU stays died.

"Any death from preventable infections is one too many," Stone tells Advanced. "We've known for decades what works to prevent infections and save lives. Now, our study shows just how much money can be saved by investing in prevention."

The paper, "A decade of investment in infection prevention: A cost-effectiveness analysis," was published in the January 2015 issue of the American Journal of Infection Control and was funded by the National Institute of Nursing Research.

Reducing central line infections was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.

Patricia Stone’s INQRI-funded project: “The Impacts of Nurse Staffing, Skill Mix, and Experience on Quality and Costs in Long-Term Care” examined whether there is a causal relationship between nursing input and patient outcomes in long-term care (LTC) facilities.

The full Advanced article is available here.

When It Comes to Cost and Quality of Hospital Care, Nurse Tenure and Teamwork Count

This post originally appeared on the Robert Wood Johnson Foundation Human Capital Blog.

The largest study to examine the relationship between nurse staffing and patient care reveals that patients get the best care when they are treated in hospital units staffed by teams of nurses who have extensive experience in their current jobs. The study, conducted by an interdisciplinary team including Patricia Stone, PhD, RN, FAAN, Centennial Professor of Health Policy at the Columbia University School of Nursing and Ciaran Phibbs, PhD, research economist at the Health Economics Resource Center at the Palo Alto Veterans Administration Health Care System, was funded by the Interdisciplinary Nursing Quality Research Initiative (INQRI).

The research team reviewed more than 900,000 patient admissions over four years (from 2003 through 2006) at hospitals in the Veterans Administration Health Care System. They analyzed nurses’ payroll records and patients’ medical records to see how nurse staffing affected patients’ length of stay. Longer hospital stays tend to be associated with delays and errors in care delivery, so shorter stays indicate better care. Shorter stays also reduce the cost of care.

Researchers found that a one-year increase in the average tenure of registered nurses (RNs) on a hospital unit was associated with a 1.3 percent decrease in the average length of stay.

The study also found that patients’ length of stay was longer when a member of a team of experienced RNs was missing or a new member was added to the team. Stone, one of the principal investigators, notes that “when the same team of nurses works together over the years, the nurses develop a rhythm and routine that lead to more efficient care.”

The researchers note that their findings suggest that hospital executives should consider policies that will help them retain experienced nurses and that encourage nurses to remain on their current units.

The paper, “Human Capital and Productivity in a Team Environment for the Healthcare Sector” was published in the April 2014 issue of American Economics Journal: Applied Economics.

The Robert Wood Johnson Foundation created INQRI to generate, disseminate, and translate research to understand how nurses contribute to and can improve patient care quality.

Nurses' Experience and Teamwork Contribute to Better Patient Care

A new study partially funded through the INQRI program reveals that nurse tenure and good team work improve the quality of hospital care and reduce costs. The research team, led by INQRI grantee Patricia Stone, found that patients received the best care when treated by nurses who have extensive experience in their current job. The study is in the current issue of the American Economics Journal: Applied Economics.

Stone and her team reviewed more than 900,000 patient admissions over four years at Veterans Administration Healthcare System hospitals. It is the largest study of its kind to link nurse staffing to patient outcomes, according to a statement by Columbia University Medical Center. Stone, centennial professor of health policy at Columbia Nursing, and her co-authors analyzed payroll records for individual nurses and medical records for individual patients to examine how changes in nurse staffing impacted length of stay.

"Reducing length of stay is the holy grail of hospital management because it means patients are getting higher quality, more cost-effective care," Stone said in the statement. "When the same team of nurses works together over the years, the nurses develop a rhythm and routines that lead to more efficient care. Hospitals need to keep this in mind when making staffing decisions–disrupting the balance of a team can make quality go down and costs go up."

Stone’s earlier INQRI-funded project: “The Impacts of Nurse Staffing, Skill Mix, and Experience on Quality and Costs in Long-Term Care” examined whether there is a causal relationship between nursing input and patient outcomes in long-term care facilities.

Interdisciplinary Team Approach Needed to Battle HAIs Effectively

Nurse-led, interdisciplinary team-based approaches are needed to effectively prevent hospital-acquired infections (HAIs), according to a new study led by former INQRI grantee Patricia Stone. Neither nurses alone, nor the presence of infection-prevention policies, are enough to keep HAI rates down, HealthLeaders Media reports.

The study was published by Columbia School of Nursing, where Stone is Centennial Professor of Health Policy, and is featured in the American Journal of Infection Control. Among the findings:

• Central line-associated bloodstream infections (CLABSI): 92 percent of ICUs had a policy for an insertion checklist, but only 52 percent of the health care professionals were seen to adhere to that policy;
• Ventilator-associated pneumonia: 74 percent of ICUs had a ventilator bundle checklist, but only 52 percent of those treating patients adhered to it; and
• Catheter-associated urinary tract infection: 27 percent of ICUs had a policy for a nurse-assisted catheter insertion, but only 22 percent were seen to observe that practice.

"Some of these things are really [linked to] nursing," Stone tells HealthLeaders. “But just because HAIs are a nursing-sensitive outcome, doesn't mean that nurses alone bear the responsibility for them. It takes a team, it takes top leadership, it takes everyone on the same page. It's not just a nursing problem."

However, nurse leaders can and should take the lead on making sure that an interdisciplinary team is adhering to infection prevention policies, and establishing such policies when needed. This can include ensuring that nurses have carts for central line insertion and resources like portable bladder ultrasounds. Strong policies, interdisciplinary checks and balances, and leadership are all needed to battle HAIs, according to the study.

Reducing CLABIs was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.

Patricia Stone’s INQRI-funded project: “The Impacts of Nurse Staffing, Skill Mix, and Experience on Quality and Costs in Long-Term Care” examined whether there is a causal relationship between nursing input and patient outcomes in long-term care (LTC) facilities.

INQRI In the News

New guidelines from the Joint Commission highlight the key role of nurses in preventing central line-associated bloodstream infections (CLABSIs), Infection Control Today reports. "Nurses are on the front lines and can take advantage of their constant contact with patients and other caregivers to explain infection control techniques and help health facilities develop and enforce standards of care that have been proven effective against CLABSI," said INQRI grantee Patricia Stone, PhD, MPH, RN.  She is also quoted in Long-Term Living,  Advanced Healthcare Network for Nurses, and Becker’s ASC Review.  

The health care system must ready itself for the influx of newly insured patients resulting from the Affordable Care Act, and advancing the role of nurses may be one way of addressing a potential physician shortage, according to an MSNBC.com article. The Institute of Medicine’s "Future of Nursing Report" is quoted in the article: “Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training, and competence.”

A Reuters Health article profiles the INQRI-funded study "Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics" and quotes co-lead investigator Joanne Spetz. "It appears there are cost savings when those nurse practitioners are allowed to operate autonomously in the retail clinic settings," Spetz told Reuters Health.

Joint Commission Guidelines for Preventing Bloodstream Infections Emphasize Role of Nurses

Guidelines and a toolkit released this week by the Joint Commission highlight the key role nurses play in preventing central line-associated bloodstream infections (CLABSIs). CLABSIs are among the most deadly and costly hospital-associated infections, accounting for 31,000 deaths annually and costing the health system an estimated $9 billion. Studies funded by INQRI revealed that nurses can play a key role in preventing these infections.

Patricia Stone, PhD, MPH, RN, FAAN, a principal investigator for an INQRI-funded study on the impact of nurse staffing, skill mix, and experience on quality and costs in long-term care, contributed to the new guidelines.  Stone is the Centennial Professor of Health Policy in Nursing at Columbia University School of Nursing.

An INQRI-funded study published last year in Critical Care Medicine found that a nurse-led intervention combining a “bundle” of evidence-based practices with a comprehensive safety program dramatically reduced the mean rate of infections. The study was conducted by David Thompson, DSNc, MSN, RN, and Jill Marsteller PhD, MPP, associate professors at Johns Hopkins University in the School of Medicine and Bloomberg School of Public Health, respectively, and by J. Bryan Sexton, PhD, now at the Duke University Health System Patient Safety Center.

“It’s important to note that this was a nurse-led intervention,” Marsteller said. “The units’ success in reducing infections not only demonstrates the effectiveness of the intervention, but also confirms that nurses can have and should play a central role in quality improvement interventions.”