Impact of Critical Care Nursing on 30-day Mortality of Mechanically Ventilated Older Adults

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1 Impact of Critical Care Nursing on 30-day Mortality of Mechanically Ventilated Older Adults Deena M. Kelly PhD RN Post-doctoral Fellow Department of Critical Care University of Pittsburgh School of Medicine

2 Background & Significance 5.6 million US adult ICU admissions annually Mean ICU admissions per life: % mortality 600,000 hospital deaths (1/5 of US) $67 billion per year 0.56 to 0.67% of GDP Kersten CCM 2004 Angus CCM 2004

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4 Purpose To understand how aspects of critical care nursing are associated with 30- day mortality of mechanically ventilated ICU patients Staffing Work environment Education

5 Study Design & Sample Observational, cross-sectional design Secondary analysis of 3 linked datasets Multi-State Nursing Care and Patient Safety Survey American Hospital Association Annual Survey Medicare claims data (MedPAR) 55,159 mechanically ventilated ICU patients in 303 non-federal acute care hospitals Aiken et al., Medical Care, 2011

6 Primary exposures Staffing- mean patients per ICU nurse Education- proportion of ICU nurses with a BSN or higher Work Environment (PES-NWI) Staffing and Resource Adequacy i.e. Enough staff to get the work done Nurse Participation in Hospital Affairs i.e. Opportunity for staff nurses to participate in policy decisions Nursing Foundations for Quality of Care i.e. Active staff development or continuing education programs for nurses Collegial Nurse/Physician Relations i.e. Physicians and nurses have good working relationships Nurse Manager Ability, Leadership & Support i.e. A supervisory staff that is supportive of nurses

7 Statistical Analysis Descriptive & bivariate models Logistic regression with robust variance estimators Adjusted models accounted for: hospital structural characteristics presence of intensivist patient characteristics & comorbidities clustering of patients in hospitals

8 Patient characteristics n=55,159 Age, mean(sd) 77.9 (7.0) Race, no. (%) White (82.2) Black 5554 (10.1) Other 4249 (7.7) Female, no. (%) (50.9) Emergent Admission, no. (%) (76.3) Top Three Primary Diagnoses, no. (%) Respiratory Failure (23.0) Sepsis 7681 (13.9) Neurologic disorder 7033 (12.8) Thirty Day Mortality (48)

9 Hospital Characteristics n=303 Mean ICU beds, mean (SD) 39.1 (30.3) Total Number of Hospital Beds, no. (%) 250 beds or less 100 (33) (50.2) > (16.8) Teaching Status, no. (%) None 143 (47.2) Minor (resident to bed ratio less than 1:4) 123 (40.6) Major (resident to bed ratio 1:4 or greater) 37 (12.2) High technology Hospital, no. (%) 204 (67.3) Intensivist Present 99 (32.7) Absent 111 (36.6) Missing 93 (31)

10 Hospital level critical care nursing characteristics Mean (SD) Range Average number of ICU nurses per hospital 10.6 (7.3) 5 69 Number of patients per ICU nurse 2.15 (0.37) Proportion of ICU nurses with a BSN or higher 0.50 (0.20) ICU Nurse Work Environment, composite score 2.73 (0.30) Better, no. (%) 72 (23.8) Mixed, no. (%) 147 (48.5) Poor, no. (%) 84 (27.7)

11 Critical Care Nursing and 30- day mortality Unadjusted Adjusted OR p OR p Nurse Staffing Nurse Education ^ Nurse Work Environment (poor is referent category) Better Mixed

12 Conclusions Patients receiving care in hospitals with better ICU nurse work environments and higher educated ICU nursing staff experienced significantly lower odds of death

13 Limitations Cross-sectional, four state study Unit of analysis Medicare claims Risk adjustment Unmeasured confounding

14 Implications Optimal care environments Emphasis on quality of environment and ICU nurse education and less on quantity of providers

15 Acknowledgments Co-authors Linda H. Aiken PhD, RN Douglas P. Sloane PhD Ann Kutney-Lee PhD, RN Matthew D. McHugh PhD, RN, JD, CRNP, MPH At the Center for Health Outcomes and Policy Research, University of Pennsylvania Many thanks Jeremy M. Kahn MD MS Pitt CRISMA Faculty and fellows Tim Cheney at the University of Pennsylvania Funding R01-NR004513(Aiken) T32-NR (Aiken) T32 -HL007820(Pinsky)

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