Increased nurse staffing and intensivist hours in hospital critical care and step-down units are associated with notably lower sepsis rates, according to a study of Massachusetts hospitals, “Factors Associated With the Rate of Sepsis After Surgery,” published in Critical Care Nurse.
Researchers of the same study found greater physician staffing and hospitalist hours were associated with higher postoperative sepsis rates.
As the leading cause of death at U.S. hospitals, the authors write that sepsis is a serious problem. One in three patients who die in hospitals have sepsis, according to the CDC. And an estimated 50% of those who survive sepsis are left with serious complications, including organ damage and limb loss, according to the study.
About the Study
Nurse researchers studied data from the Massachusetts Hospital Association. To analyze the relationship between nurse staffing and sepsis rates they used a sample of 53 hospitals with intensive or critical care units and med-surg units and 25 hospitals with stepdown units.
They also examined the relationship between physician staffing and sepsis rates using a sample of 54 hospitals with physicians and medical residents, 42 with hospitalists and 33 with intensivists. Hospitalists are physicians working in hospitals, while intensivists can be physicians, physician assistants, or nurse practitioners.
The findings revealed that sepsis rates ranged from nine or fewer cases per 1,000 discharges when nurses on stepdown units cared for an average 2.29 patients, but increased to 11 or more cases per 1,000 discharges when nurses each cared for an average 3.61 patients, according to a news release on the study.
“… adding one more patient to the nurse’s care in a step-down unit increased the risk that two or more patients per 1000 discharges would become septic,” the study authors wrote.
A higher ratio of patients to nurses also was associated with an increased risk for a common sepsis contributor, catheter-associated urinary tract infections, or CAUTIs. Higher CAUTI rates and greater numbers of step-down patients assigned to each RN explained more than half of the variance in sepsis rates.
In their analysis of physician staffing, the authors found that higher intensivist hours were associated with a lower rate of sepsis. When intensivist hours were 0.12 per patient day, sepsis rates ranged from nine or fewer cases per 1,000 discharges. But when intensivist hours were 0.05 per patient day, sepsis rates were 11 or more per 1,000 discharges.
Higher rates of sepsis could be attributed to CAUTI, wound dehiscence after surgery, greater hospitalist hours, and greater physician hours.
The authors wrote that it is unclear why greater physician staffing is associated with higher rates of not only sepsis but also sepsis contributors, but communication and collaboration might be a factor.
Enter Nurse Intuition
These findings indicate staffing influences sepsis rates, but not causally or solely, said study co-author Jane Flanagan, PhD, RN, ANP-BC, AHN-BC, an associate professor at Boston College, Chestnut Hill, Massachusetts.
“Beyond staffing numbers, different roles may contribute to better collaboration and communication between nurses and the providers to whom they would report their concerns for early signs of sepsis,” Flanagan said.
A growing body of evidence in recent years suggests nurses’ intuition, sometimes called “nurse worry,” might have an important role in early sepsis recognition.
“As a former ICU nurse, I remember many times when being attuned to subtle changes in the patient’s behavior made a difference,” Flanagan said. “By the time it is a big cue like a sudden drop in blood pressure, you are running against the clock. To pick up on those subtle cues, you need to know your patient, and by that, I mean the little things aside from the machines and medications.”
Flanagan referred to knowing individual patient’s behaviors, likes, dislikes, and more. Does a patient like visitors or seem to get upset after they arrive? For those that can talk, do they need to be in charge or are they passive? Do they use humor to ease their fear? Are they scared and quiet or scared and a bit cantankerous?
Even subtle changes are cues that something is different, and sepsis is a risk.
“A person who is usually quiet becoming fussy or picking at the tubes is concerning,” she said. “If you are new and inexperienced, you should ask a colleague who is more experienced. If you are experienced, you verify what you think with another nurse. But in all cases, you have to first know the person well enough to pick up on the subtle change. Secondly, take the time to assess, and lastly, have someone verify what you think.”
Staffing impacts nurses’ ability to stay in tune with their patients.
“Limiting the number of critically ill patients assigned to a nurse increases the ability of nurses to recognize the subtle initial symptoms of change in a patient’s condition that precede sepsis,” said study author Judith Shindul-Rothschild, PhD, RN, research professor, Boston College, Chestnut Hill, Massachusetts.
Empirically, it has been demonstrated by numerous studies that when nurses have a lower number of patients to care for, patient outcomes improve. What remains unanswered is exactly what is the specific number of critically ill patients per nurse that is appropriate, according to Shindul-Rothschild.
The findings also raise concerns about communication and collaboration, which could be vital in reducing sepsis rates.
CAUTI and wound dehiscence after surgery, both of which are correlated with higher rates of sepsis, were associated with greater physician and hospitalist hours but not with greater intensivist hours.
Take these courses related to sepsis and communication:
Sepsis: A Review for the Healthcare Team
(2 contact hrs)
Sepsis is a complex, multifactorial condition that results in high healthcare costs and significant morbidity and mortality. The definitions of sepsis, septic shock, and organ dysfunction were established in 1991. Over the past 20 years, more research has been conducted on sepsis pathophysiology and management, and several new antibiotics have been approved. A new guideline was released in 2016 that reexamines sepsis and associated definitions and provides updated recommendations for managing patients with sepsis. Interprofessional healthcare teams have been shown to improve patient outcomes and are essential in caring for critically ill patients. It is therefore important for each member of the team to understand sepsis and collaborate to provide the best care. This program will review sepsis guidelines, comment on updates from previous guidelines, and provide information regarding the management of sepsis from different aspects of the healthcare team.
Effective Nursing Communication
(.5 contact hr)
From accepting an order over the telephone to handing off a patient to another department, every healthcare professional faces situations each day involving potential miscommunication. Healthcare professionals must understand and adopt safety practices to ensure the smooth functioning of the healthcare team and the safety of their patients. This course discusses the importance of accurate and timely communication. It reviews unacceptable medical abbreviations and a standardized process for handoff communication.