Original article
Quality of patient care in the critical care unit in relation to nurse patient ratio: A descriptive study

https://doi.org/10.1016/j.iccn.2016.01.002Get rights and content

Summary

Background

Intensive care is one of the most resource-intensive forms of medical care due to severely ill patients that are cared for in units with high staffing levels. Nursing's impact on the health of patients has shown that the number of nurses per patient and nurse education effects patient outcome. However, there are a lack of studies investigating highly specialised nurses in intensive care and their relation to patient outcome.

Method

This is a retrospective study of critical care registry data (all patients >15 years) in general critical care units at seven university hospitals.

Results

Patient care and complications in relation to nurse/patient ratio showed that unplanned extubations occurred in 3–5.7% of cases. A difference between hospital patients’ length of time on ventilation was found with the hospitals with the least amount of patients and with 0.5–0.6 specialist-nurse/patient a longer time on ventilation was noted. The length of ICU stay showed differences between the hospitals and nurse/patient ratios, with higher nurse/patient ratio with the longer length of ICU stay.

Conclusion

Despite similarities between hospitals in relation to SAPS III on admission to critical care, there was a difference in nurse/patient ratios ranging from 1:1 to 0.5:1 and mean time on both invasive and noninvasive ventilation.

Introduction

Intensive care is one of the most resource-intensive forms of medical care. This is due to patients’ severity of illness, who typically have several life-threatening conditions and are cared for in units with high staffing levels (both in amount and competence) within a high-tech environment. Critical care units in Sweden care for approximately 50,000 patients each year and in addition approximately 45,000 patients are cared for in close proximity to the ICU (post-operative recovery room and cardiac-intensive care). Critical care consumes about 1/10 of the cost of somatic care with a daily cost 35–50,000 Skr depending on the degree of specialisation (Swedish Society of Anesthesia and Intensive care, SFAI). In order to reduce the lack of knowledge of intensive care long-term outcomes and the impact on patients, a national quality register has collected data since 2001 (www.icuregswe.org). The goal of the registry is to collect and publish optimal medical and nursing-related outcomes as measured by indicators such as mortality, complications, quality of life and functional status after intensive care. Among these indicators, only the frequency of ventilator associated pneumonia (VAP) and catheter-related sepsis coincides for intensive care patients with scientifically approved nursing indicators for nursing care (Kurtzman and Corrigan, 2007, Montalvo, 2007). To date, there is a lack of data that describes how these indicators are a useful measure of Swedish intensive care from the nursing perspective. However, there are quality reports from SFAI suggesting that Sweden has a standardised mortality rate that is low compared to international reports. One possible explanation is that Sweden has a greater amount of staff with higher levels of competence among both physicians and nurses compared to other countries. In Sweden, nursing studies is part of higher education. For nurses there are three years of education (bachelor degree) to become a registered nurse (180 ECTS credits) plus an additional one-year (60 ECTS) for advanced level (Master degree) to become a specialist nurse in critical care. Swedish intensive care units employ both registered nurses with or without specialisation in intensive care to provide basic nursing care, pharmacological, medical and ventilator support alongside nursing assistants. Nursing's impact on the health of patients by hospital has been debated in the scientific literature (Aiken et al., 2013, Aiken et al., 2014b, Neuraz et al., 2015). Aiken et al. (2013) have shown that the number of nurses per patient and nurse education to bachelor level, affect the frequency of complications measured by mortality, infections and higher patient satisfaction with more nurses (Kendall-Gallagher et al., 2011). In a related study regarding intensive care, McGahan et al. (2012) concluded that the education level of basic level nurses did not affect mortality and morbidity in ICU patients (McGahan et al., 2012). However, there is a scarcity of literature that discusses how the number and level of higher education among specialised nurses per patient affect quality of intensive care nursing. Therefore, we aimed to investigate in a national study if the number of specialist nurses plays a role in relation to direct patient care. Specifically this study will identify and discuss the direct result of care such as patient time on non invasive and invasive breathing support during intensive care in order to evaluate the specialist nurse role for the quality of patient care in general critical care units.

Section snippets

Objectives and setting

This is a retrospective survey of critical care from registry data of all patients (>15 years) receiving care in general critical care units at University hospitals and is included in SIR during the years 2010–2014. Comparisons between seven general ICU University Hospitals will be performed.

In Sweden there are three hospital types; university hospitals (teaching hospitals that provide highly specialised care), County hospitals (provide general and to some extent specialised care) and local

Discussion

The hospitals included in the study all reported that they employed nurses with specialist training at masters level in critical care. However, there were differences in ratio ranging from 1:1 to 0:5 specialist nurse per patient with complements of 0.5 nursing assistants per patient. Whether or not this difference is due to local organisations of management or just the fact that there is a lack of nurses with specialisation in critical care was not investigated here but should be a focus for

Acknowledgements

We are grateful to the heads of each critical care unit for giving us access to the study locations.
Funding

The authors have no sources of funding to declare.
Conflict of interest

The authors have no conflict of interest to declare.

References (22)

  • D. Kendall-Gallagher et al.

    Nurse specialty certification, inpatient mortality, and failure to rescue

    J Nurs Scholarsh

    (2011)
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