Patient Turnover and Nursing Staff Adequacy

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Patient Turnover and Nursing Staff Adequacy

• Lynn Unruh, PhD, RN, LHRM
• Myron D. Fottler, PhD

AcademyHealth Annual Research Meeting San Diego,
June 6-8, 2004
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Research Problem

• Common hospital nurse staffing measures
• nurses or hours of nursing care
• patients or patient days of care
• Need to also consider intensity of nursing care
• Staffing needs vary with the amount and type of
  care provided for each of those patients

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Research Problem

• An ideal measure of nursing staff adequacy should
  indicate the volume of nurses of a certain skill
  level that is necessary for the given volume of
  patients given the intensity of nursing care
  required for those patients during their stay
• of RNs
• of patient days X intensity of RN care for
  those patient days

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Nursing Care Intensity

• Indicators of nursing care intensity

• Patient turnover

• Patient acuity

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Patient Turnover

• As patient turnover increases
• Nursing care must be delivered in a shorter
  period of time
• Holding patient acuity and total nursing care
  requirements for the patient stay constant
• Admission, transfer, and discharge procedures
  take up an increasing proportion of the patients
  stay

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Patient Turnover

• An available measure for patient turnover is
  patient length of stay
• The number of days a patient is an inpatient in
  the hospital.
• The inverse of patient length of stay produces a
  fraction that ranges between 0 and 1
• Lower amounts indicate lower turnover, and vice
  versa.

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Research Questions

• Does adjusting nurse staffing data for patient
  turnover, as measured by the inverse of patient
  LOS, significantly alter the measurement of nurse
  staffing and changes in nurse staffing?
• What is the trend in nurse staffing when measures
  adjust for both patient turnover and patient
  acuity?

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Sample and Data Sources

• All general, acute-care Pennsylvania hospitals
  1991-2000 (N 166-213)
• Data obtained from
• Pennsylvania Department of Health
• Yearly filled RN, LPN and Nursing Assistant FTEs
• American Hospital Association
• APDC and LOS
• Patient days of care include outpatient care
• Atlas MediQual System
• Patient acuity

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Design

• Assess the trend in the average patient LOS and
  turnover (inverse of length of stay).
• Create a patient turnover index using 1991 as the
  base year, and adjust nurse staffing measures for
  patient turnover using this index
• Compare the standard and new measures using
  paired sample t-tests
• Assess whether the trend over time in nurse
  staffing utilizing the new measure is
  significantly different than the old measure
  using paired sample t-tests
• Analyze the trend in nurse staffing adjusted for
  both patient turnover and acuity

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Results
Average Patient Length of Stay in Pennsylvania
Hospitals, 1991-2000
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Results
Average Patient Turnover in Pennsylvania
Hospitals 1991-2000
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Results
RN/1,000 APDC in Pennsylvania Hospitals 1991-2000
RN/1000APDC 1991 1995 2000
Before Adjustment 2.68 2.88 2.87
After Adjustment 2.69 2.45 2.04
Mean Difference 0 -0.44 -0.83
t Value --- -10.53 -25.05
plt.01, plt.001, plt.0001
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Results
LPN/1,000 APDC in Pennsylvania Hospitals
1991-2000
LPN/1000APDC 1991 1995 2000
Before Adjustment 0.60 0.52 0.43
After Adjustment 0.61 0.44 0.30
Mean Difference 0 -0.08 -0.13
t Value --- -8.04 -14.10
plt.01, plt.001, plt.0001
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Results
NA/1,000 APDC in Pennsylvania Hospitals 1991-2000
NA/1000APDC 1991 1995 2000
Before Adjustment 0.58 0.60 0.65
After Adjustment 0.58 0.50 0.45
Mean Difference 0 -0.08 -0.19
t Value --- -3.92 -13.29
plt.01, plt.001, plt.0001
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Results
Percentage Change in RN/1,000 APDC in
Pennsylvania Hospitals
RN/1000APDC 1991-2 1995-6 1999-00
Before Adjustment 4.19 2.32 -0.73
After Adjustment 5.50 -2.82 -4.23
Mean Difference 0.85 -5.29 -2.20
t Value 0.45 -8.71 -4.40
plt.01, plt.001, plt.0001
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Results
Percentage Change in LPN/1,000 APDC in
Pennsylvania Hospitals
LPN/1000APDC 1991-2 1995-6 1999-00
Before Adjustment 5.13 -1.17 -4.35
After Adjustment 5.66 -7.63 -7.13
Mean Difference 0.26 -5.30 -2.11
t Value 0.18 -10.08 -4.07
plt.01, plt.001, plt.0001
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Results
Percentage Change in NA/1,000 APDC in
Pennsylvania Hospitals
NA/1000APDC 1991-2 1995-6 1999-00
Before Adjustment 13.61 8.40 9.73
After Adjustment 16.14 3.12 13.33
Mean Difference 1.94 -5.47 -2.26
t Value 1.01 -7.69 -4.30
plt.01, plt.001, plt.0001
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Results
Percentage Change in Nursing Staff/1,000 APDC in
Pennsylvania Hospitals 1991-2000
RN/1000 LPN/1000 NA/1000
Before Adjustment 7.24 -18.70 32.95
After Adjustment -25.88 -43.61 -9.34
Mean Difference -32.25 -24.55 -37.48
t Value -24.75 -10.16 -12.00
plt.01, plt.001, plt.0001
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Results
Nursing Staff/1,000 Adjusted APDC in
Pennsylvania Hospitals 1991-2000
Change 1991-2000 RNs -44 LPNs -65 NAs
-48
APDC adjusted for patient acuity and turnover
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Conclusions

• Unadjusted nurse workload measures fail to
  adequately address the work intensity issue and,
  consequently, significantly underestimate nurse
  workloads
• Perceptions of nurses themselves, the media, and
  others concerning increasing nurse
  workloads/declining staffing ratios are justified
  and supported by our results
• Future research on nurse staffing or nurse
  workload issues should adjust for both patient
  acuity and patient turnover