Effects of Hospital Nurse Staffing on in-hospital Mortality, Pneumonia, Sepsis, and Urinary Tract Infection in Surgical Patients

Yunmi Kim; Sung-Hyun Cho; Kyung Ja June; Soon Ae Shin; Jiyun Kim

doi:10.4040/jkan.2012.42.5.719

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Kim, Cho, June, Shin, and Kim: Effects of Hospital Nurse Staffing on in-hospital Mortality, Pneumonia, Sepsis, and Urinary Tract Infection in Surgical Patients

Original Article

J Korean Acad Nurs 2012;42(5):719-729.

Published online: 12 October 2012

DOI: https://doi.org/10.4040/jkan.2012.42.5.719

Effects of Hospital Nurse Staffing on in-hospital Mortality, Pneumonia, Sepsis, and Urinary Tract Infection in Surgical Patients

Yunmi Kim¹, Sung-Hyun Cho², Kyung Ja June³, Soon Ae Shin⁴, Jiyun Kim⁵

¹Department of Nursing, Eulji University, Seongnam, Korea

²College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, Korea

³Department of Nursing, Soonchunhyang University, Cheonan, Korea

⁴Department of Health Promotion & Management, National Health Insurance Corporation, Seoul, Korea

⁵Department of Nursing, Gachon University, Seongnam, Korea

Address reprint requests to : Kim, Jiyun Department of Nursing, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Seongnam 461-701, Korea. Tel : +82-31-750-8822 Fax: +82-31-750-8859 E-mail: jkim@gachon.ac.kr

Received 6 February 2012 Revised 22 February 2012 Accepted 25 September 2012

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

This study was done to examine relationships between nurse staffing level and postsurgical patient outcomes using inpatient database from the National Health Insurance.

Methods

Records of 111,491 patients who received one of 12 types of surgery between January and December, 2009 were identified and analyzed in this study. Nurse staffing level was measured using adjusted nurse staffing grades from 0 to 7. Patient outcomes were defined as in-hospital mortality, or pneumonia, sepsis, or urinary tract infection after surgery. Logistic regression analyses estimated by Generalized Estimation Model, were used to analyze the association between nurse staffing level and patient outcomes.

Results

An inverse relationship was found between nurse staffing and patient mortality. Compared with patients who were cared for in hospitals with the highest nurse staffing (Grades 0-1), increases in the odds of dying were found in those with Grades 6-7 [OR (odds ratio)= 2.99, 95% CI (confidence interval)= 1.94-4.60], those with Grades 4-5 (OR= 1.78, 95% CI= 1.24-2.57) and those with Grades 2-3 (OR= 1.57, 95% CI= 1.25-1.98). Lower nurse staffing level was also associated with higher number of cases in pneumonia and sepsis.

Conclusion

Policies for providing adequate nurse staffing is required to enhance quality of care and lead to better perioperative patient outcomes.

Keywords: Personnel staffing, Nursing administration research, Outcomes research

References

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Table 1.

Characteristics of Hospitals

Variables	Categories	Hospital (n=182)	Patients (n=111,491)
Variables	Categories	n (%) or M±SD	n (%) or M±SD
Type	Hospital	9 (5.0)	1,137 (1.0)
	General hospital	129 (70.9)	36,972 (33.2)
	Tertiary hospital	44 (24.2)	73,382 (65.8)
Ownership	Medical cooperation	95 (52.2)	38,829 (34.8)
	Educational foundation	57 (31.3)	47,771 (42.9)
	Public	30 (16.5)	24,891 (22.3)
Location	Small city	82 (45.1)	35,636 (32.0)
	Metropolitan	100 (54.9)	75,855 (68.0)
Size (number of beds)		508.6±312.6	−
	50-299	45 (24.7)	6,201 (5.6)
	300-499	60 (33.0)	12,938 (11.6)
	500_-699	37 (20.3)	20,722 (18.6)
	700-999	35 (19.2)	44,497 (39.9)
	≥1000	5 (2.8)	27,133 (24.3)
Physician staffing		27.1±16.8	−
(number/100 beds)	<10	28 (15.4)	3,071 (2.8)
	10-19	55 (30.2)	8,137 (7.3)
	20-29	24 (13.2)	8,373 (7.5)
	30-39	29 (15.9)	23,552 (21.1)
	40-49	32 (17.6)	41,980 (37.7)
	≥50	14 (7.7)	26,378 (23.7)
Adjusted nurse staffing grade	Grade 7	5 (2.8)	764 (0.7)
	Grade 6	22 (12.1)	1,766 (1.6)
	Grade 5	17 (9.3)	1,868 (1.7)
	Grade 4	22 (12.1)	4,280 (3.8)
	Grade 3	58 (31.9)	25,423 (22.8)
	Grade 2	41 (22.5)	34,576 (31.0)
	Grade 1	15 (8.2)	26,807 (24.0)
	Grade 0	2 (1.1)	16,007 (14.4)

Table 2.

Characteristics of Patients (N=111,491)

Variables	Categories	n (%)
Age (year)	20-29	2,454 (2.2)
	30_-39	5,620 (5.0)
	40-49	14,903 (13.4)
	50-59	26,706 (24.0)
	60-69	33,282 (29.9)
	70-85	28,526 (25.6)
Gender	Female	40,857 (36.7)
Health insurance type	Self employees-dependants	11,952 (10.7)
	Self employees_-insured	28,458 (25.5)
	Industrial workers-dependants	49,408 (44.3)
	Industrial workers-insured	21,673 (19.4)
Income	1st quartile	17,972 (16.1)
	2nd quartile	19,015 (17.1)
	3rd quartile	28,360 (25.4)
	4th quartile	46,144 (41.4)
Past history*	Pneumonia	1,110 (1.0)
	Sepsis	1,053 (0.9)
	Urinary tract Infection	2,041 (1.8)
Admission route	Emergency room	33,174 (29.8)
	Outpatient department	78,317 (70.2)
Surgery	Major craniotomy except for trauma	13,142 (11.8)
	Other craniotomy except for trauma	3,177 (2.9)
	Craniotomy for trauma Cardiac valve procedure with/without cardiac catheter	2,544 2,154 (2.3) (1.9)
	Cardiac valve procedure with/without cardiac catheter Coronary bypass with/without cardiac catheter	2,154 2,138 (1.9) (1.9)
	Coronary bypass with/without cardiac catheter	2,138 (1.9)
	Major reconstructive vascular procedure	1,184 (1.1)
	Percutaneous cardiovascular procedure	46,331 (41.6)
	Amputation for circulatory system disorders	1,068 (1.0)
	Rectal resection with/without complication and comorbidity	5,494 (4.9)
	Major small and large bowel procedure	10,727 (9.6)
	Stomach, esophageal and duodenal procedure	17,503 (15.7)
	Pancreas, liver and shunt procedure	6,029 (5.4)
Severity	3_-severe complication and comorbidity	2,152 (1.9)
	2-moderate complication and comorbidity	14,868 (13.3)
	1-minor complication and comorbidity	30,413 (27.3)
	0-No complication and comorbidity	64,058 (57.5)

*Existence of past history is not mutually exclusive. To detect past history of pneumonia, sepsis and unrinary tract infection, related health problems, such as respiratory diseases, inflammatory diseases, and unrologic diseases, patients' claims were tracked.

Table 3.

In_-hospital Mortality, Pneumonia, Sepsis, and Urinary Tract Infection by Nurse Staffing Level (N₌111,491)

Variables	Staffing grade	Death			Pneumonia			Sepsis			Urinary tract infection
		Died	Survived	χ² (p)	Experienced	Not experienced	χ² (p)	Experienced	Not experienced	χ² (p)	Experienced	Not experienced	χ² (p)
		n (%)	n (%)		n (%)	n (%)		n (%)	n (%)		n (%)	n (%)
Total	6-7	180 (7.1)	2,350 (92.9)	286.97	83 (3.3)	2,447 (96.7)	69.40	53 (2.1)	2,477 (97.9)	35.28	155 (6.1)	2,375 (93.9)	'118.59
	4-5	178 (2.9)	5,970 (97.1)	(<.001)	126 (2.0)	6,022 (98.0)	(<.001)	68 (1.1)	6,080 (98.9)	(<.001)	166 (2.7)	5,982 (97.3)	(<.001)
	2-3	1,768 (3.0)	58,231 (97.0)		732 (1.2)	59,267 (98.8)		609 (1.0)	59,390 (99.0)		1,329 (2.2)	5,8670 (97.8)
	0-1	485 (1.1)	42,329 (98.9)		169 (0.4)	42,645 (99.6)		323 (0.8)	42,491 (99.2)		391 (0.9)	42,423 (99.1)
Tertiary	2-3	953 (2.8)	33,170 (97.2)	283.43	392 (1.2)	33,731 (98.8)	156.55	295 (0.9)	33,828 (99.1)	0.59	623 (1.8)	33,500 (98.2)	140.82
hospital	0-1	431 (1.1)	38,828 (98.9)	(<.001)	142 (0.4)	39,117 (98.6)	(<.001)	319 (0.8)	38,940 (99.2)	(.441)	327 (0.8)	38,932 (99.2)	(<.001)
Hospital	6-7	180 (7.1)	2,350 (92.9)	158.66	83 (3.3)	2,447 (96.7)	85.43	53 (2.1)	2,477 (97.9)	54.46	155 (6.1)	2,375 (93.9)	113.61
&	4-5	178 (2.9)	5,970 (97.1)	(<.001)	126 (2.1)	6,022 (97.9)	(<.001)	68 (1.1)	6,080 (98.9)	(<.001)	166 (2.7)	5,982 (97.3)	(<.001)
general	2_-3	815 (3.2)	25,061 (96.9)		340 (1.3)	25,536 (98.7)		314 (1.2)	25,562 (98.8)		706 (2.7)	25,170 (97.3)
hospital	0-1	54 (1.5)	3,501 (98.5)		27 (0.8)	3,528 (99.2)		4 (0.1)	3,551 (99.9)		64 (1.8)	3,491 (98.2)

Table 4.

GEE Logistic Regression on Patient Outcome by Nurse Staffing Level (N=111,491)

Variables	Categories	Death			Pneumonia			Sepsis			Urinary Tract Infection
Variables	Categories	OR	p	95% CI	OR	p	95% CI	OR	p	95% CI	OR	p	95% CI
Age (year)		1.03	<.001	1.02-1.03	1.03	<.001	1.02-1.03	1.01	.023	1.00-1.02	1.02	<.001	1.02-1.03
Men (vs. women)		1.22	.001	1.09-1.37	1.56	<.001	1.32-1.84	1.22	.027	1.02-1.45	0.69	<.001	0.59-0.80
Severity (vs. 0-No CC)	3-severe CC	3.42	<.001	2.19-5.36	7.32	<.001	4.07-13.17	14.77	<.001	9.13-23.87	4.45	<.001	2.50-7.89
	2-moderate CC	3.95	<.001	3.21-4.85	9.25	<.001	6.97-12.26	15.22	<.001	10.62-21.82	3.73	<.001	2.93-4.75
	1-minor CC	2.55	<.001	2.16-3.02	6.54	<.001	5.15-8.30	8.06	<.001	5.71-11.37	2.53	<.001	2.14-2.99
Past history (vs. No)		−	−	−	1.13	.097	0.98_-1.30	1.46	.004	1.13_-1.89	1.65	<.001	1.40_-1.94
Admission route ER (vs. OPD)		6.63	<.001	5.69-7.71	3.43	<.001	2.78-4.23	3.99	<.001	2.92-5.46	2.45	<.001	2.09-2.87
Health insurance	Self employees-dependants	2.64	<.001	2.19-3.18	1.95	<.001	1.40-2.72	1.34	.085	0.96-1.86	1.17	.155	0.94-1.47
type	Self employees-insured	1.28	.004	1.08-1.52	1.40	.005	1.11-1.77	1.07	.598	0.83-1.39	1.04	.709	0.85-1.27
(vs. Industrial workers-insured)	Industrial workers-dependants	1.61	<.001	1.38-1.88	1.38	.018	1.06-1.81	1.24	.077	0.98-1.57	1.01	.918	0.83-1.23
Income	1st quartile	1.34	<.001	1.17-1.54	1.17	.137	0.95-1.43	1.04	.702	0.84-1.30	0.93	.348	0.80-1.08
(vs.4th Quartile)	2nd quartile	1.19	.005	1.05-1.34	1.20	.053	1.00-1.45	1.09	.305	0.93-1.27	1.11	.203	0.95-1.30
	3rd quartile	1.18	.004	1.05-1.32	1.07	.416	0.91-1.27	1.01	.925	0.88-1.15	1.05	.476	0.91-1.22
Type	Hospital	1.28	.474	0.65_-2.50	2.54	.141	0.73_-8.82	1.18	.829	0.26_-5.33	5.74	.033	1.15_-28.55
(vs. Tertiary hospital)	General hospital	1.06	.586	0.86_-1.30	0.92	.689	0.60_-1.41	1.68	.094	0.91_-3.10	1.03	.957	0.41_-2.56
Ownership (vs. Public)	Medical corporation	1.02	.886	0.79-1.32	0.60	.008	0.41-0.88	0.91	.738	0.51-1.61	1.01	.974	0.47-2.20
	Educational foundation	1.27	.023	1.03-1.55	0.67	.061	0.44-1.02	0.84	.571	0.46-1.54	1.29	.588	0.51-3.28
Small city (vs. Metropolitan)		1.07	.886	0.93-1.23	0.93	.675	0.64-1.33	0.99	.941	0.68-1.44	1.22	.475	0.71-2.11
Physician staffing		0.81	.539	0.42-1.57	0.27	.087	0.06-1.21	13.14	.051	0.99-174.81	1 0.15	.041	0.03-0.92
Adjusted nurse staffing grade	6_-7	2.99	<.001	1.94_-4.60	2.79	.010	1.27_-6.10	3.22	.010	1.33_-7.82	1.68	.298	0.63_-4.48
(vs. 0_-1)	4_-5	1.78	.002	1.24_-2.57	2.25	.070	0.94_-5.44	1.86	.086	0.92_-3.78	1.07	.884	0.43_-2.66
	2_-3	1.57	<.001	1.25_-1.98	1.73	.012	1.13_-2.64	1.20	.462	0.74_-1.92	1.34	.465	0.61_-2.91

The results of surgery is not shown in the table; OR=Odds ratio; CI=Confidence Interval; CC=Complication and comorbidity; OPD=Outpatient department.

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