But costs put damper on raising RN staffing levels
New research highlighting the relationship between registerednurse staffing levels and hospital readmission rates is drawing praise from professional associations and experts.
But even as hospitals recognize the impact nurses have on patients’ post-discharge utilization, payment barriers often keep them from beefing up staffing levels.
“We’re in an era of cost containment, so there is a desire to staff as tightly as possible,” said Marianne Weiss, associate professor of nursing at Marquette University, Milwaukee, and lead author of the study. “Increasing nurse staffing levels can have a positive impact on costs down the road, but that financial incentive goes to the payer. As health reform goes forward, we want to see if we can put that money in the right place.”
For the study, which appeared in the journal Health Services Research, Weiss and her colleagues used electronic medicalrecord data, billing data and questionnaires from nearly 1,900 patients treated at four hospitals during the first seven months of 2008. They analyzed how nurse staffing levels affected discharge readiness, postdischarge emergency visits and preventable hospital readmissions.
“We looked at discharge teaching because it affects how ready patients are to go home, and that, of course, affects readmissions,” Weiss added.
Discharge teaching encompasses everything nurses do to prepare patients and their families to manage their care, including educating patients about disease red flags, medication adherence and physician followup. And when nurses are pressed for time, that discharge teaching often gets shortchanged, the researchers said.
Specifically, they found that while higher non-overtime RN staffing levels lowered the odds of readmissions, higher overtime staffing levels increased the likelihood that patients would visit the emergency department soon after discharge.
“We’re pleased to see another unit-level study like this one,” said Katie Brewer, senior policy analyst for the American Nurses Association. “While we have robust data on the impact of staffing on patient care on the facility level, unit-level research makes a stronger case.”
Brewer agreed that most hospitals view staffing as something that goes in the cost column on their balance sheets. The challenge, she says, is to make the business case that appropriate levels of nurse staffing can improve patient care and prevent later costs.
“Staffing can be a value-added aspect, especially as we move into an era of valuebased purchasing and accountable care organizations and we get paid for better outcomes,” Brewer said. According to Dr. Karen Joynt, a fellow in cardiology at 773-bed Brigham and Women’s Hospital, Boston, and a fellow in health policy at the Harvard School of Public Health, readmission rates are affected by many factors, making it difficult to draw conclusions about cause and effect. Hospitals that have low nurse staffing levels are likely to be financially strained and could be resource-poor in other areas as well, she said.
Joynt co-authored a recent study in the journal Circulation: Cardiovascular Quality and Outcomes about hospital readmission rates for heart failure, which found that patients discharged from hospitals with low levels of nurse staffing had higher readmission rates than hospitals with higher staffing levels.
While Joynt agreed that discharge teaching improves patients’ readiness, she also argued that policies that focus on reducing readmissions—particularly those policies that include penalties— could target cash-strapped hospitals that serve vulnerable populations.
“It’s important going forward to really be mindful of how these policies might impact a number of different health disparities,” Joynt said.