Nurse understaffing and increased workload associated with multiple organ failure


By Lisa Rappaport

(Reuters Health) - Lower nurse staffing levels and increased nurse workload are associated with a greater proportion of patients with multiple organ failure, a Finnish study suggests.

Researchers examined data on 10,230 patients treated at a single tertiary teaching hospital in Finland from 2008 to 2017. Overall, the rate of multiple organ failure was 177 per 1,000 ICU days, and most cases (85.64%) occurred within 48 hours of ICU admission.

Across the entire study population, the mean daily Therapeutic Intervention Scoring System (TISS), a measure of nursing workload, was 31.57 (SD 11.70) and the mean daily highest Intensive Care Nurse Scoring System (ICNSS) score, a measure of patient needs, was 29.27 (SD 5.17).

Patients with multiple organ failure had significantly higher mean daily TISS (32.48 v 28.78) and mean ICNSS scores (32.46 v 28.84). In addition, patients who developed multiple organ failure more than 48 hours after ICU admission had significantly higher mean TISS (43.51 v 30.63) and ICNSS (35.82 v 31.90) scores than patients who developed multiple organ failure within 48 hours.

The mean daily lowest nurse-to-patient ratio was 1.19 during the study, and the highest ICNSS index 0.99. Overall, 22.64% of shifts were understaffed based on nurse-to-patient ratios and 44.64% of shifts were understaffed based on patient needs.

"This study indicates that nurse staffing in the ICU may be an important factor in the number of patients who develop (multiple organ failure)," said Michelle Butler, executive dean of the Faculty of Science and Health at Dublin City University, in Ireland.

"Further research is needed to examine its applicability to other ICUs, to provide stronger evidence, to explore the mechanisms involved, and to provide clearer guidance on the ideal staffing, both in terms of nurse to patient ratios, and the ideal mix of nursing staff in the ICU," Butler, who wasn't involved in the study, said by email.

The single center data may not be generalizable to other hospitals, the study team notes in the Journal of Advanced Nursing. Lead author Miia Jansson of the University of Oulu in Finland didn't respond to requests for comment.

The study also didn't examine the relationship between nurse education and training levels and patient outcomes. And, it didn't look at other factors that could impact outcomes such as the contributions of other medical staff or the presence of students or trainees.

"Nurses comprise the largest component of the hospital labor force, and evidence suggests that more educated nurses in adequate numbers lead to better performance," said Patricia Davidson, dean of the Johns Hopkins School of Nursing in Baltimore.

A growing body of literature underscores that nursing staffing is critical in optimizing patient outcomes, and multiple organ failure, also called multiple organ dysfunction syndrome, is an important predictor of adverse health outcomes in the ICU, Davidson, who wasn't involved in the study, said by email.

"Early recognition is critical to instituting appropriate therapies such as respiratory and hemodynamic support as well as treating causes such as sepsis with definitive therapies," Davidson added. "It is not a long stretch to think that nurses caring for multiple patients, particularly those of high acuity, are challenged to juggle multiple tasks and priorities."

SOURCE: Journal of Advanced Nursing, online June 2, 2020.

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