Nurse StaffingSince staffing to peak patient load is no longer possible, hospitals staff to average patient census levels. The result of this staffing approach is frequent understaffing with attendant deterioration in quality and safety. Attempts to dynamically respond (i.e. staff up) to changes in patient census have been shown to be unsuccessful. For details of a study of patient flow variability and nurse staffing funded by the Robert Wood Johnson Foundation, click here. Addressing flow variability is the only solution to minimize nurse-to-patient staffing variability as Litvak and Laskowski-Jones discuss here. |
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Inpatient Mortality Inpatient mortality risk has been shown to be significantly associated with nurse staffing levels and hospital overcrowding, both of which are compromised by unnecessary variability in patient flow. In a study published in JAMA, Aiken, et. al. showed that mortality increases by 7% as the surgical unit nurse-to-patient ratio decreases from 1:4 to 1:5. Mortality continues to increase by 7% until the ratio reaches 1:7, after which it starts to increase exponentially. For more details, click here. In another study published in NEJM in March 2011, Needleman, et. al. found that mortality risk increases by 2% for every understaffed shift that a patient is exposed to. In addition, the authors found that increased ADT activity has an even greater effect on mortality (4%) than patient census levels. For more details, check here. Sprivulus et. al. found a linear relationship between mortality and hospital and ED overcrowding. Click here for more details. |
Readmissions Unmanaged variability in pateint flow increases readmission risk. Baker et. al. from Johns Hopkins Hospital studied unplanned readmissions to the neurosciences ICU and found that readmissions risk increased dramatically for patients discharged as a result of increased admissions to the ICU. This study shows that expediting discharges is not the right way to manage peaks in admissions; unnecessary peaks in scheduled admissions need to be addressed directly. |
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Rapid Response Teams Rapid response teams may save lives, but many more lives could be saved by providing the right care at the right place and time. One of the main drivers of rapid response team launches is patient placement in inappropriate units, which in turn is a result of artificial variability in patient flow. Click here to read a JAMA commentary by Litvak and Pronovost. |
Safety Occurence of adverse events is often associated with patient flow variability, especially periods of unanticipated peak patient demand. Increased patient volume has been shown to be related to increase in patient harm - one study that established this link was published in the American Journal of Medical Quality in 2008. Click here to read Dr. Ellis M. Knight's experience prior to, and after, implementation of IHO Variability MethodologyTM A study by Jayawardhana, et. al. published in JONA in September 2011 linked higher NQF safe practice adoption with higher nurse hours per patient day. Maintaining higher nurse staffing levels is only possible by managing the variability in patient flow. |
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Boarding and Diversion Artificial variability in patient flow is a major cause of boarding and diversion of patients in the ED as well as in other parts of a hospital such as the post anesthesia care unit and ICUs. McManus et. al. studied the demand for a pediatric ICU and found a very high correlation between scheduled admissions and diversion from the ICU. For more details, click here. ICU bed availability has been shown to have significant association with ICU admision and patient goals of care for patients experiencing sudden clinical deterioration. Click here for the study by Stelfox et. al. |
