Yesterday I ended a piece on medical safety with a reference to a well known British
agony auntie advice columnist who will not go into hospital unless she’s at the point of death, primarily because of the lack of training (and lack of professionalism) of the staff she saw in her last visit where she contracted a severe nosocomial infection. One issue that she included was the relative lack of RNs who were involved in patient contact.
Another issue, detailed well in this article from March 2004, has been the impact on patient safety of overwork for nurses. The story cites a malpractice case where 2 nurses had over 40 patients to look after, and at least one terrible diagnosis fell through the cracks to terrible effect for that patient’s future. Consequently several states, notably California, have mandated nurse to patient ratios (usually 1 to 6), and the initial news seems to be that it is improving patient care. However, a new article by the Univ of Pennsylvania team (lead author is Ann Rogers, but nursing staffing guru Linda Aitken is a co-author) suggests that increased work weeks, increased shift lengths and unexpected but forced overtime is also bad for patient care and increases error rates. As the article is behind Health Affairs’ fire wall, I’ve quoted a chunk of their findings and recommendations:
"Our analysis showed that work duration, overtime, and number of hours worked per week had significant effects on errors. The likelihood of making an error increased with longer work hours and was three times higher when nurses worked shifts lasting of 12.5 hours or more (odds ratio =3.29, p =.001). Working overtime increased the odds of making at least one error, regardless of how long the shift was originally scheduled (OR = 2.06, p = .0005). Our data also suggest that there is a trend for increasing risks when nurses work overtime after longer shifts (OR = 1.34, 1.53, and 3.26 for scheduled eight-hour, eight-to-twelve-hour, and twelve-hour shifts, respectively), with the risks being significantly elevated for overtime following a twelve-hour shift (p = .005). Although the effects of working prolonged shifts were clearly associated with errors, there was no interaction between scheduled shift duration and overtime (p = .17). Finally, working more than forty hours per week and more than fifty hours per week significantly increased the risk of making an error. Results were somewhat similar for near errors."
The article concludes with a recommendation, which is similar to that made by the IOM last year:
"Hospital staff nurses’ long hours may have adverse effects on patient care; we found that both errors and near errors are more likely to occur when hospital staff nurses work twelve or more hours. Because more than three-fourths of the shifts scheduled for twelve hours exceeded that time frame, routine use of twelve-hour shifts should be curtailed, and overtime–especially that associated with twelve-hour shifts–should be eliminated".
But there is a huge YABBUT behind all these numbers, and that YABBUT is the severe shortage of nurses (and allied staff) in the US.
The average age of a working RN is 43 and by 2010 it will be pushing 50. Admission to nursing schools is slightly up but the number of individuals sitting for the nursing exam is flat, and far too few new nurses are coming into the workforce. Increased demand based on the aging of the population (the 85+ group is doubling between 2000 and 2010, and of course the baby boomers start turning 65 in 2010) means additional demand for health care services. More, sicker patients plus fewer nurses to care for them means this problem will get worse, so the likelihood is more rather than fewer medical errors in the future. This is all well captured in the 2002 JCAHO report, Health care at the Crossroads.
126,000 nursing positions are currently unfilled in hospitals across the country. Some estimates are that by 2020, there will be at least 400,000 fewer nurses available to provide care than will be needed. Turnover rates are at about 20% a year, and it costs nearly an annual salary to replace a nurse.
This is probably the biggest single problem facing hospitals today. So in the words of Valdimir Ilyitch, What is to be done? There seem to be two main strategies. The first is to buy in talent from abroad. This has worked relatively well for physicians–roughly 20% of new residents each year are foreign medical graduates (who tend to stay here). This may not exactly be good news for other countries, many of whom already have bigger nursing shortages than the US. For instance the Pasadena Star-News reports on importing nurses from Mexico, while nurses are being recruited from the Philippines, China and India. While this is all at some cost to the medical care of the people in those countries, as an immigrant myself I would never blame any individual for coming to the US to try to do better for themselves than they can at home. And of course the money sent home to their families often means that one nurse is supporting many people.
The second solution is to replace (the lack of) nurses with technology. Much of the recent hospital investment in IT is moving towards attempting to change the process of a nurse’s workflow. Too much time is spent recording patient information and fetching supplies, rather than directly delivering patient care. If IT systems can directly capture information from medical devices (i.e. blood pressure, pulse, etc) then nurses could spend less time recording that in the chart. If robots can bring supplies direct to the bedside then nurses won’t need to go fetch them and could stay with their patients. Even something as simple as the soon-to-be ubiquitous Vocera "no-hands" communications badge can save nurses’ time from answering the phones and returning pages.
Nonetheless, the nursing shortage is a real challenge for American healthcare (I’m not so convinced about the "physician shortage" by the way!). And it’s a challenge that has a serious negative impact on the quality of care being delivered. However, I have some confidence that in 10 years time, the use of technology will improve the job of the nurse which will eventually cause more Americans to choose nursing as a career, and finding it a rewarding one psychically as well as financially. I hope I’m right, otherwise it will be grim to be old and sick in 20 years time if you can’t afford your own private nurse.
UPDATE: My cautious optimism that IT would help guide us out of the nursing shortage mess did not sit well with The Industry Veteran, who leaves his lair of pharma exclusivity to talk about nursing. But don’t worry, he stays in character with his remarks about doctors! So in an attempt to keep my email box from overflowing with his MD admirers, I’ve hidden his comments in this update!
As far as the nursing shortage, so what else is new? My memory of this subject goes back to the 1950s, and even then, the lack of good nurses was considered a major obstacle to quality care in hospitals. Nurses’ hours are too long, performance suffers, enrollment in nursing programs fails to keep pace, yaddada, yaddada. I must say, Matthew, I don’t share your optimism that more IT will substantially improve the situation. More IT can help, but so can good shoes, meditation, chair massages and a hundred other measures. To extend your analogy, when Comrade Vladimir asked how we might transform the plaintive cry, "What am I to do," into the search for concerted action ("What is to be done?"), he specifically disdained tinkering around the edges and adopting increments that perpetuate the alienating system.Hospitals have always appeared to me as the most caste-ridden social organizations in the country. At the top sits a small group of physicians and senior administrators who earn large incomes and receive extraordinary deference. Everyone else works undesirable hours under problematic conditions, receiving mediocre compensation for jobs that require high skills and induce substantial stress. Want to get more and better nurses, lab techs, radiology techs and the rest? Well if your universal panacea is IT, my universal villains are the f