Researchers evaluating multiple organ failure in the intensive care unit (ICU) found both the proportion of understaffing and increased nurse workload increase the risk that ICU patients will suffer multiple organ failure.
This is an important patient care issue, given multiple organ failure is the most common cause of death among non-cardiac surgery, multiple trauma, and severe burn patients. Trauma center studies looking at multiple organ failure after injury suggest from 24% to 36% of these patients die. Multiple organ failure also is a big strain on ICU resources, prolonging the need for mechanical ventilation and length of ICU stays, according to a study called "The proportion of understaffing and increased nursing workload are associated with multiple organ failure: A cross-sectional study," published in the Journal of Advanced Nursing. It was prior to the pandemic when the paper's authors pointed to a growing awareness of the need for appropriate staffing, increasing demand for critical care services, higher ICU patient complexity, and increasing workloads for nurses and other healthcare providers. The need to look at and address nurse staffing and workload in the ICU might be more acute today.
"The burden for critical care services has risen exponentially in response to the COVID-19 pandemic," corresponding author Miia Jansson, PhD, MHSc, RN, of the University of Oulu, in Finland, said in a Wiley journal press release on the study. "The consequences of increased nursing workload during COVID-19 remains uncertain and need to be investigated in this light."
The Findings
Researchers studied the association between nurse staffing, nursing workload, and prognosis at a tertiary-level teaching hospital in Finland. In the study of 10,230 adult ICU patients, researchers defined multiple organ failure according to the Sequential Organ Failure Assessment score, which scores respiratory, cardiovascular, renal, liver coagulation, and central nervous systems. Grading each of the organ systems from 0 to 4, a grade of 3 or higher signifies organ failure. They categorized shifts as understaffed if there was a nurse-to-patient ratio of greater than 1 and an Intensive Care Nursing Score System index greater than 1. The Intensive Care Nursing Score System index is a measure of nurse staffing based on patient need. Researchers also used the Therapeutic Intervention Scoring System, which quantifies type and number of ICU treatments, for measuring nursing workload in this study.
The researchers found multiple organ failure and death were associated with higher nurse workloads. The average daily scores associated with the measures used to look at workload were significantly higher in multiple organ failure patients.
They also found in a subgroup analysis, the average daily scores for workload were significantly higher in late stage multiple organ failure, which means failure occurred more than 48 hours after ICU admission. Understaffing also was more likely to be associated with patients experiencing multiple organ failure. Among their findings, 22.64% of shifts were understaffed according to the nurse-to-patient ratio, while 44.64% were understaffed in relation to patient needs. "In addition, the proportion of understaffing was more common in patients with [multiple organ failure] than those without and in non-survivors than in survivors," the study authors wrote. "The levels of nursing workload and understaffing were at their worst on weekends, while [multiple organ failure] was diagnosed mainly on Mondays."
Implications
[caption id="attachment_77371" align="alignleft" width="224"]
Sarah Delgado, RN[/caption] These findings support previous findings about the relationship between nursing care and patient outcomes, according to Sarah Delgado, MSN, RN, ACNP, Clinical Practice Specialist, Strategic Advocacy Team, American Association of Critical-Care Nurses.
"What is unique about this study is that the authors looked not only at the number of staff and patients on the unit, but they also measured nursing workload, based on the severity of patient illness," Delgado said. "Their findings -- that measure how understaffing based on nurse workload are associated with multiple organ failure -- reinforce that staffing decisions are optimal when driven by the needs of the patient population."
It is also notable that understaffing based on ratio occurred in 22.64% of shifts, while 44.64% of shifts were understaffed based on a score of patient needs. "This difference shows that assessing the adequacy of staffing based on ratios alone may not give a complete picture of how resources and patient needs will align in an intensive care unit," Delgado said. "The condition of critically ill patients fluctuates rapidly so staffing decisions must be nimble and flexible to meet the changing demands for nursing expertise." Delgado said nurses, clinical leaders, and organization administrators need more research and resources to better understand how to create staffing plans that match patients' dynamic needs. It's important, she said, to engage nurses in staffing decisions. "No one understands the nursing care that patients need better than a nurse, so that knowledge has to be part of the decision-making process," Delgado said. "Research such as this study reinforces that appropriate staffing is a key element to a healthy work environment. It has been 15 years since AACN Standards for Establishing and Sustaining Healthy Work Environments was first published. Appropriate staffing was one of the original six standards, and it continues to be a crucial element to healthy work environments." Multiple organ failure and death are among the consequences of high nurse workloads. Studies have found that a reduction in registered nurse workload is associated with reduced mortality and failure to rescue, reduced hospital readmission rates and fewer other adverse events such as medication errors, hospital-associated pressure injuries, and patient falls with injury, according to the AACN Guiding Principles for Appropriate Staffing.
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- ICU Sedation, Central Line Infections, and Early Feeding: Evidence-Based Practice (1.5 contact hrs) Despite progress in managing acute care disease, acute respiratory distress syndrome continues to pose challenges for critical care clinicians. ARDS is associated with injury to the alveolar-capillary membrane of the lungs, which alters oxygenation status and results in a reduced concentration of oxygen in the blood. Prompt recognition of the distinct signs and symptoms of acute lung injury, often a harbinger of ARDS, can set a targeted treatment plan in motion. Likewise, early recognition of the progressively worsening respiratory function seen in ARDS can alert the team that the patient will need special types of mechanical ventilation to preserve and improve oxygenation.
