The association between nursing factors and patient mortality in the Veterans Health Administration: the view from the nursing unit level.
BACKGROUND
Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units.


OBJECTIVE
To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA).


METHODS
A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals.


METHODS
We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission.


METHODS
In-hospital mortality.


RESULTS
: Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality.


CONCLUSIONS
Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.
Sales
Anne
A
Faculty of Nursing, University of Alberta, Edmonton, AB, Canada. anne.sales@ualberta.ca
Sharp
Nancy
N
Li
Yu-Fang
YF
Lowy
Elliott
E
Greiner
Gwendolyn
G
Liu
Chuan-Fen
CF
Alt-White
Anna
A
Rick
Cathy
C
Sochalski
Julie
J
Mitchell
Pamela H
PH
Rosenthal
Gary
G
Stetler
Cheryl
C
Cournoyer
Paulette
P
Needleman
Jack
J
D000368:Aged; D002983:Clinical Competence / Q000706:statistics & numerical data; D003953:Diagnosis-Related Groups / Q000706:statistics & numerical data; D004508:Education, Nursing, Baccalaureate / Q000706:statistics & numerical data; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000401:mortality; D017052:Hospital Mortality; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D015999:Multivariate Analysis; D009741:Nursing Staff, Hospital / Q000193:education / Q000600:supply & distribution*; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D011014:Pneumonia / Q000401:mortality; D011336:Probability; D012189:Retrospective Studies; D012306:Risk; D018805:Sepsis / Q000401:mortality; D012769:Shock / Q000401:mortality; D016019:Survival Analysis; D014481:United States; D020246:Venous Thrombosis / Q000401:mortality; D000078329:Workforce