More permanent nurses could save lives and reduce healthcare costs

More permanent nurses could save lives and reduce healthcare costs

Employing too few permanent nurses on hospital wards is linked to longer hospital stays, readmissions, patient deaths and ultimately more lives and costs money, finds a long-term study published online in the journalBMJ quality and safety.

Rebalancing is cost-effective, saving an estimated £4728 for every healthy year of life gained per patient.

Immediate understaffing - or deliberate, through cost-cutting - of nurses risks harming hospital patients and contributes to nursing recruitment and retention problems, researchers say.

Much of the existing research on the effects of nurse:patient ratios is cross-sectional and thus has limited use in determining causal factors, they add.

To determine whether investing in increased staffing levels to offset under-tables would be cost effective, assess the associations between nurse and healthcare assistants and the risk of patient deaths, readmissions, and length of stay in adult acute inpatient units.

They relied on data provided by four NHS hospital trusts with different staffing levels, sizes, teaching status, of different local populations in England. Three of the trusts provided acute inpatient services predominantly from single hospital sites and the fourth provided inpatient services at four sites within a city.

Data were derived from electronic health records and staffing rosters and were derived from April 2015 to March 2020 for a total of 626,313 patients across 185 different acute care care records.

Two main nursing team roles were included in the study: Registered Nurses (RNS) who have completed university training and are registered with the professional regulator; and care support workers (such as healthcare assistants) who do not have this training and who are largely unregulated.

The incremental cost-effectiveness of eliminating the underemployment of these two roles was estimated from the costs and consequences of transitioning the observed staffing shortages, averaged over the study period to the planned staffing levels.

The patients spent an average of 8 days in the ward. During the first 5 days of their hospital stay, patients received a daily average of just over 5 hours of care from RNs and just under 3 hours of care from nursing staff.

The calculations showed that patients on wards that were understaffed by RNs were more likely to die (5% vs. 4% for patients with adequate RN staffing), to be readmitted (15% vs. 14%), and to stay in the hospital longer (8 days vs. 5 days), with similar figures for inadequate nursing staffing levels.

Patients experiencing underintervention received an average of 1 hour 9 minutes/day of care in the first 5 days, while those not experiencing underintervention received an average of 3 hours 22 minutes of care above the ward average.

During the study period, 31,885 patients died. Each day a patient experienced RN understaffing (understaffing on the ward) for the first 5 days of their stay. The risks of death and readmission within 30 days increased by 8% and 1%, respectively. When everyone was understaffed 5 days after entry, length of stay increased by 69%.

Days of care maintenance were also associated with similar increases in the risks of death and length of stay within 30 days: 7% and 61%, respectively. However, the risk of readmission within 30 days fell by 0.6%.

The total estimated cost of care for the 626,313 adults included in the study was £2,613,385,125 or £4173 per admission.

The researchers calculated that eliminating disruption to both care roles would cost an additional £197 per patient entry to avoid 6,527 of the 31,885 deaths during the study period and achieve 44,483 years of life in good health.

This equates to the additional employees of £2,778 per healthy year of life and £2,685 when reduced sick leave and averted readmissions are taken into account. However, reducing length of stay savings of £4,728 per additional life year has an overall cost saving from increasing staffing levels.

If the agency's staff were used to be understaffed instead, the staff costs for each additional healthy year of life were higher, ranging from £7320 to £14,639.

"The results give no indication that it makes rational economic sense to correct the effort to correct the most favorable staff employment only for the most acute patients. Not only is this logistically difficult for patients whose acuity occurs (occurring on a general ward), it also offers much fewer benefits at a significantly higher cost per unit improvement in the result of the unit," explains the researchers.

“Steps to address low staffing for the general (lower acuity) population of patients are also likely to benefit to the extent they are in the same units, while the opposite is unlikely if interventions target high battery patients in high battery units,” they add.

This is an observational study and as such no firm conclusions can be drawn regarding cause and effect. And the researchers acknowledge that the data comes only from hospitals in England's NHS and may not be applicable further. Understaffing was assessed relative to ward norms rather than a validated assessment of staffing needs.

However, the researchers conclude: "In examining alternative policy strategies, this study shows the importance of prioritizing investment in RNs employed on wards over support staff, and that there are no linkages to employing enough RNs, as the use of temporary staff is more expensive and less effective."

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