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More RN Staffing Means Fewer Sepsis Deaths

Centers for Disease Control and Prevention (CDC) notes that one in three patients who die in the hospital has sepsis.

According to a recent study published in the JAMA Health Forum, higher levels of RN staffing are linked to a lower likelihood of Medicare age patients dying from sepsis in hospitals. An estimated 1.7 million cases of sepsis occur each year and 270,000 are killed annually. Even more concerning, the Centers for Disease Control and Prevention (CDC) notes that one in three patients who die in the hospital has sepsis. Not all of those deaths occur because of sepsis, but it’s a contributing factor in nearly all cases.

The CDC also cites that the vast majority of infections causing sepsis, approximately 87% of them, begin outside the hospital. The difference between life and death, then, depends on early identification of sepsis with immediate and proper treatment. RNs play a significant role in that process as they have more regular interaction with patients and more opportunities to notice the symptoms of sepsis which include:

—Rapid breathing and heart rate

—Shortness of breath

—Confusion or disorientation

—Extreme pain or discomfort

—Fever, shivering, or feeling very cold

—Clammy or sweaty skin

Three sources of data were analyzed in a recent study from the Nell Hodgson Woodruff School of Nursing at Emory University: 

—The 2018 American Hospital Association (AHA) Annual Survey on hospital size, teaching and technology status, and nurse staffing

—2018 patient characteristics from the Medicare Provider Analysis and Review (MedPAR) file on all Medicare fee-for-service acute care hospitalizations

—2018 hospital performance on the SEP-1 bundle for timely and effective sepsis care from the CMS Hospital Compare

SEP-1 refers to the Severe Sepsis and Septic Shock Management Bundle, and represents how many patients received appropriate care for severe sepsis or septic shock. “The care bundle includes serum lactate levels, collection of blood cultures, and the delivery of broad-spectrum antimicrobial therapy within 3 hours of sepsis onset for individuals with severe sepsis,” the study noted. “Treatment with intravenous fluids within 3 hours of onset, initiation of vasopressors within 5 hours, and repeated volume assessments within 6 hours are additionally required for patients with a diagnosis of septic shock.”

The analysis included 1,958 general acute care hospitals across the U.S., but did not include federal hospitals or those that did not report data on SEP-1 scores or nursing staff. The 702,140 patients studied were Medicare beneficiaries aged 65-99 and were admitted with a primary diagnosis of sepsis. Their average age was 78, and 5% had been transferred in from a different acute care hospital. Nearly half (46%) were admitted to an ICU, and 12% received palliative care. 

Approximately two thirds of the patients (67%) had severe sepsis without any other major complications or comorbidities while 18% had severe sepsis with a major complication or comorbidity, fluid and electrolyte disorders, chronic pulmonary disease, congestive heart failure, or kidney failure. Just over a quarter (26%) of the patients died within 60 days of admission. 

Not surprisingly, higher SEP-1 scores were linked to lower death rates. Every 10% increase in SEP-1 scoring was associated with a 2% lower risk of death within 60 days of admission, once adjusted for characteristics of both the patient and the hospital. 

Higher levels of RN staffing, however, were linked to better chances of survival. Each additional hour of RN staffing per day of a single patient’s stay was linked to a 3% lower chance of death within two months of admission. Death within 60 days was 16% lower if an intensivist was on staff, again once adjusted for differences in the hospitals and patients.  

The researchers then calculated how many deaths could be avoided if hospitals increased their RN staffing levels. They found that “if all hospitals were staffed at 6 registered nurse hours per patient day or higher, there could be 1,266 fewer deaths.” Interestingly, “if all hospitals were staffed at 9 registered nurse hours per patient day or higher, there could be 6,360 avoided patient deaths.”

Overall, the researchers noted that SEP-1 compliance scores were low across the nation, with many patients continuing to die despite advances in identifying and treating sepsis. 

The study noted that “findings suggest that nurse workload is an overlooked and underused aspect of the treatment bundle for patients with a diagnosis of sepsis,” and “recognizing sepsis early is essential, and the effect of interprofessional teamwork cannot be overlooked. It has been reported that nurse-physician communication and collaboration are necessary components to improve sepsis care.”

The study’s authors noted that nurse-physician communication is linked to a 4% decrease in a patient’s risk of developing sepsis from a catheter. Other research has found that each reduction in the ratio of nurses to patients resulted in a small uptick in sepsis. Interestingly, an increase in hospitalist or physician staffing was linked to an increase in sepsis incidence whereas the presence of intensivists reduced sepsis incidence.

“These findings highlight the important relationships that exist between nurses and physicians and the likelihood that nurses might report findings to one group of physicians (such as intensivists) over another (such as a hospitalist or physician), and it supports the importance of communication between all clinicians.” 

The study also reported that rapid identification of sepsis frequently relies on nurses to initiate sepsis protocols, yet 58% of physician directors and 48% of nurse managers have cited nurse staffing as the main cause of delays in treating sepsis. 

The authors previously published an article noting that ”each additional patient added to a nurse’s workload was associated with a 12% increase in the likelihood of in-hospital death, a 7% increase in 60-day mortality and 60-day readmission, and longer lengths of stay in patients with sepsis.” The authors concluded that when evaluating ways to reduce a patient's risk of sepsis, severe sepsis, and death from sepsis, “it is imperative that we include the workload of nurses and other clinicians and promote a care environment that fosters interprofessional communication.”

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