SCCM Resource Library-What’s the Right RaNge? Patient-to-RN Ratios in the ICU

Video Transcription

Thank you for joining this talk on the right range of patient-to-RN ratios in the ICU. I'm Darlene Penoyer, Director for the Center for Nursing Research at Orlando Health and  your speaker for this session. So I'll start with a question. The right range for who? The nurse? What ratio would they need to deliver competent and effective care to the patients?  Or the patient? What do they need to restore health or function? Or is it both? Are we talking about the range that is ideal or practical?  Most of you listening to this presentation would likely say that for the most part, critical  care nursing assignments are usually two patients per nurse, unless the patient is unstable or have multiple devices like CRRT.  So what is the right dose of nursing for patient care? Well, I would say it depends. How sick is your patient? Or what are their needs? Is it a stable ICU patient that's monitored?  Are they in resuscitation and unstable or immediate post-op with monitoring devices? Or how good is your nurse? What kind of experience or knowledge or skills do they have?  So there are other things that might influence the right ratio for nurses to patients. How much help do they have from other ancillary caregivers?  Are there nursing assistants or other personnel available to help? Are you in the middle of a pandemic or situation where resources are limited? How many nurses do you have?  Right now there's a big nursing shortage. So the reality is sometimes you have to compromise. Are the nurses embedded in the ICU and organizational culture?  Are they full-time or in the float pool, travelers or temporary agency nurses? And what about the work environment?  Is there psychological safety to speak up with issues, support from bedside nurses by  collaborative environment with the ICU team of interprofessionals? All these things should be taken into this equation of nurse to patient ratios.  So not all nurses are created equally. They bring various characteristics to their work. So patients are also not equal in their needs.  Even the sickest of the sick have a spectrum of illness severity. How many gadgets are attached to them? How many measurements do nurses have to make on them and how often?  And what about the documentation that is needed? This can take up to 50% of their time. So what does the literature say?  I'm going to present a summary of some of the work that's been done in this area. The most cited nurse characteristics that impact mortality are the nurse's education level,  their work environment, nursing staffing and skill mix, and experience. In general care settings, nursing characteristics that impact outcomes usually show that patient  outcomes, including mortality, are better with better nurse staffing. Studies have shown that post-op patients have a reduced risk of mortality with better staffing.  Another study shows by increasing a nurse workload by one patient in the general med surge area increases 30-day mortality by 7%.  In a study on septic patients, each additional patient the nurse was assigned to was associated  with a 12% higher odds for inpatient mortality, a 7% higher odds for 60-day mortality in readmissions and longer length of stay.  And in a European study called RN Forecasts, they found that nurses having a baccalaureate  degree in nursing increases patient satisfaction and nurse perception of the quality and safety of care. So what about in the critical care setting?  Kelly et al. conducted a multi-state, cross-sectional study of nurse survey data over two years using Medicare claims.  They examined the effect of critical care nursing on mortality after adjusting for patient, hospital, and physician characteristics in 303 hospitals in four states.  Their sample size was over 55,000 older adults on mechanical ventilation. Their results showed that in hospitals with better nurse work environments had 11% lower  odds of 30-day mortality. So their work environment is important to the support of nurses in their work.  And for every 10% increase in the proportion of ICU nurses with a baccalaureate degree in nursing was associated with a 2% reduction in 30-day mortality.  So if 75% of nurse workforce has a BSN, this could possibly result in 10% lower mortality  when compared to those units with only a 25% proportion of nurses educated at the baccalaureate level.  The staffing ratios were pretty consistent across hospitals that were studied, so nurse staffing was not associated with mortality. So what about nursing outcomes?  In a recent systematic review in critical care, they included over 5,000 studies related to staffing and ICU nurse outcomes.  There were mixed relationships and rigor found across those studies. However, the significant findings on the impact that low nurse staffing had on nurse outcomes  were increased burnout, fatigue, emotional exhaustion, depersonalization, and stress. Most of these signs are associated with burnout and may lead to nurses leaving the profession  and going to a less stressful environment. In another systematic review in 2019 by Wyongdale et al., they found that nurse-to-patient ratio  was a contributing factor to nurse outcomes, including job dissatisfaction, emotional exhaustion  and burnout, needle stick injuries, the nurse's perception of the quality of care, and the safety of patients in the care they left undone.  They concluded that staffing alone is not enough to ensure quality of care, and other things to take in consideration are the skill mix or members of the care team, patient acuity  on how sick the patient is, and the nurse's education and their work environment. And finally, many studies have been conducted by Dr. Linda Aiken and colleagues about the  impact of nurse staffing and education on outcomes. In this large study in Europe of 300 hospitals, the group studied the impact of nurse staffing  and education on 30-day inpatient mortality that was risk-adjusted, and they surveyed more than 26,000 nurses.  They found that increases in workload of a nurse by one patient increased the likelihood  of inpatient mortality by 7%, and for every 10% increase in the nurses with BSNs was associated with a decrease in mortality by 7%.  They postulated from this data that inpatients in hospitals that would have a 60% nurses with BSNs and caring for an average of six patients would have almost a 30% lower mortality  than those hospitals that had 30% BSNs with assignment of eight patients, and that staffing cuts to save money might adversely affect patient outcomes, and to hire more nurses  with BSN. When cost-cutting strategies face organizations, since nursing salaries are the highest contributor  to budget, it is easier to reduce costs by cutting the number of nurses and is more difficult to improve efficiencies in care.  This has resulted in poor care by trying to save money. Over time, studies in Europe and the United States have found consistent results as these,  including other complications of care. There are also external forces driving nurse staffing. With these kind of data coming in from these studies, the Institute of Medicine pushed  for more BSN nurses at the bedside for 80% by 2020. At the time of that future of nursing report, it was about 49% on average, so hospitals started hiring more BSN nurses.  While this goal was not reached, progress is being made. In 2018, there were 57% of nurses with baccalaureate degrees and more graduating than associate degree graduates.  Many hospitals are also seeking magnet designation, and higher percentage of baccalaureate nurses is one of their criteria.  There's also been a push for staffing mandates in the United States and elsewhere. While this has gained some traction, only two states in the United States have mandates.  So what about these mandates? Only California came out in 2004 with staffing mandates, and in critical care is designated at two to one, or fewer if indicated.  Massachusetts also came up with mandated ratios in 2016, and that the ICU nurse should have  a two to one ratio or less, and the determination is made by using an acuity tool by the staff nurses on the unit.  Other states have not gone this far, but rather to have hospital committees to address staffing concerns and policies, and some are publicly reporting on their staffing levels.  That sounds great, but what are you going to do when you don't have enough nurses? And what are the outcomes of these models?  Australia also has staffing mandates that were implemented in 2018 based on the type of hospital.  Matthew McHugh with Linda Aiken and colleagues did a before and after study comparing hospitals  with and without mandated nurse staffing pre- and post-implementation in 2016 and 2018. They found that mortality was lower with lower ratios.  Readmissions were increased in higher ratio hospitals, but not with lower ratios. Length of stay decreased in both hospital types, but more pronounced in the intervention hospitals.  At intervention hospitals, and staffing improvements by one patient per nurse have reductions in mortality, readmissions, and length of stay.  They also translated this into costs avoided due to fewer readmissions and shorter length of stay, with more than twice the cost of additional nurse staffing in the program.  They concluded that minimal nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with a good return on investment.  In another systematic review by Twigg and colleagues last year of 22 studies about mandated ratios in California and Australia showed that in terms of patient outcomes, ED wait  times were less when staffed to recommended ratios. There were no changes in falls, pressure ulcers, or restraints use.  There were some increases in infections with mandated ratios in California and no difference in post-op sepsis.  There were mixed results on decreases in failure to rescue and no changes in complications and mortality.  They summarized by saying nurse-related outcomes improved following the implementation of mandated minimum-to-nurse-patient ratios.  However, findings related to patient outcomes were inconclusive. Their review supports improvements in nurse staffing levels, which has the associated  benefit of improving nurse-to-patient outcomes. However, the ability to determine the number of nurses required over time remains problematic.  The data to determine how many hours RNs are needed in order to provide safe and quality of care is yet to be determined.  So I'm going to introduce another way of looking at the right RN dose with the Synergy Model. The American Association of Critical Care Nurses Synergy Model for Patient Care says  that the effect of two or more agents working together to produce an effect that is greater than the sum of its parts, so essentially 1 plus 1 is 3.  This model is based on Virginia Henderson's definition of nursing, and Dr. Martha Curley, one of our SCCM nurses, was lead author on a book on this model.  This model says that the nurse's abilities or their competencies should match the needs and characteristics of the patient, and when this occurs, synergy can be achieved.  It's a match game. The model focuses on the interaction between the patient, nurse, and system to produce favorable outcomes. So here's a list of the patient needs in the model.  In critical care, patients are more vulnerable to harm, are more unstable, are complex, and require a lot of resources.  The ability of patients and family to take part in care is limited and limited decision-making by the patient.  Their outcomes are less predictable, so they are at the highest needs of all patients. The matching of nurse competencies to meet those needs are also high.  Nurses need to use critical thinking skills and many observations to care for ICU patients. They're often advocating on the patient's behalf as they are less able to act on their  own. Collaboration with the interdisciplinary team of caregivers is essential with the intensivist-led  model, so one can see that operating to the top of licenses on nurses needed to best benefit the patient and have synergistic relationships.  So this is a balancing act of the nurse having the right degree of competencies to meet the complex needs of critically ill patients. So a nurse is not a nurse is not a nurse.  You need the right kind of nurse to achieve the best outcomes for patients according to the synergy model. So if to achieve this isn't hard enough, then came COVID.  With this pandemic, the revenue of hospitals went down with the limitations of hospitalizations and with it went the nurses.  The ICU nurses in particular were in high demand and were part of the great resignation. Many took early retirement or were let go.  With the demand for acute care nurses and critical care nurses in particular, they had options to do travel nursing and make tons of money quickly.  Some of them were also novices to nursing. This impacted hospitals in a very palpable way, such that our highest costs were for travel nurses to meet the staffing voids.  We are left with many novice nurses on the front line with little or no critical care education.  So with this tip the scale for synergistic options of care, with the experienced nurses exiting the workforce and novice nurses who were focusing on tasks and temporary staff  coming and going, this reduced mentorship and support for nurses at the front line. During COVID, hospitals were flooded with an influx of very critically ill patients  who had high mortality and we had to learn how to care for them in real time. So what did we do? Most hospitals have had to scramble to staff critical care units.  Some have had to have higher nurse to patient ratios as we had to do with what we had. We added non-nurses to help assist with care and non-critical care nurses under the direction  of a critical care nurse to care for patients. Most have had to hire travel nurses or pool nurses to staff units.  These have come to extraordinary costs for hospitals when they are already suffering from financial blows from the pandemic, not to mention the stress that this has had on  all healthcare workers and increased burnout. We are all hoping that this comes to some sort of sense of normalcy soon.  So what are leaders left with to address nurse staffing to meet patient needs? There are some things we are doing at our hospital and others around the United States.  Most everyone is fighting for the same pool of nurses, so retention is of utmost importance to stop the bleed of nurses and we're doing fancy recruitment strategies to meet staffing  deficits. This includes giving bonuses, increasing wages and incentives such as tuition reimbursement and vacation time.  We're moving to more of an apprenticeship model for students in nursing education where we bring them in the hospital earlier in the program and allow them to get some experience  under the tutelage of a registered nurse. We're also having dedicated education units by hospital-based faculty that we're putting into place.  We're also bringing resources to the nurse by licensed practical nurses and nursing techs and other assistive personnel like paramedics.  Many places are also hiring well-being coaches and developing resources to reduce burnout.  Training for leadership to improve work environment is essential in being incorporated in lots of programs and being nimble with flexible thinking to support nursing staff.  Some are hiring experienced nurses in pool positions with flexible hours to combat those long hours they can no longer do.  So everyone I know is pulling out all the stops to fortify and retain nursing talent and this is not going away anytime soon.  So in summary, when making decisions about the right RN to patient ratios, use these things.  First, use your brain to determine the best match of the nurse's abilities for the patient needs beyond a ratio level like 2 to 1.  While this method is easier for assignments and financial planners, it doesn't make the mark for many patients and nurses.  Use resources to bring help to the front line for the nurse to practice at the top of license. Use the evidence. Hire more BSN nurses and provide a healthy work environment.  And finally, use surveillance for outcomes and use that data to evaluate how you're doing so you can make some thoughtful decisions about staffing.  So here we are back to the original question. What is the right patient to nurse ratio in the ICU? Well, as I've described it, it depends still. There is no magic number.  How sick are your patients? Their acuity and their needs matter. How experienced are your nurses and what level of education do they have, particularly in critical care?  What support does the nurse have at the bedside? Do they have assistive personnel? What support do they have for documentation in the medical record?  Is it easy for them to use as it takes up to 50% of their time sometimes to document? And how ingrained are they in the ICU culture? Is there collaborative practice?  What kind of work environment are they in? Is it healthy? Is it psychologically safe and supportive of the nurses?  So if you think about ratio math, if nursing ratios using the concepts of synergy, where the nurse's abilities meet the patient's needs, are combined with a healthy work environment  with the proper education, this may yield the best possible outcomes. So I want to thank you for attending this session on the right patient to nurse ratios in the ICU.

Video Summary

In this talk, the speaker discusses the right range of patient-to-RN ratios in the ICU. They emphasize that the appropriate ratio depends on multiple factors, including the nurse's abilities and the patient's needs. The speaker highlights that critical care nursing assignments usually involve two patients per nurse, unless the patient is unstable or has multiple devices. They discuss various aspects that influence the ideal ratio, such as the nurse's experience, the availability of ancillary caregivers, and the work environment. The speaker also presents research findings on the impact of nursing characteristics on patient outcomes, including mortality. They discuss the importance of nurse education level, work environment, staffing, and experience. The speaker explains the synergy model, which focuses on matching nurse competencies to patient needs to achieve favorable outcomes. They also discuss the challenges faced during the COVID-19 pandemic, and how hospitals have worked to address nurse staffing deficits. In conclusion, the speaker emphasizes the need for thoughtful decisions about nurse staffing based on patient acuity, nurse education and experience, and a healthy work environment.

Asset Subtitle

Administration, Quality and Patient Safety, 2022

Asset Caption

A foundational aspect of high-quality critical care is the use of multidisciplinary healthcare teams that leverage the specialized training of each respective discipline. Evidence continues to demonstrate that the use of multidisciplinary critical care teams improves clinical outcomes. The level of healthcare professional staffing in the ICU correlates to patient outcomes and medical errors. It is clear that medical errors are independently associated with worse outcomes. However, the optimal practitioner-to-patient ratio needed to derive the benefits of this team-based approach and optimize safety is unknown. This session will feature a multidisciplinary panel who will communicate the synthesis of current evidence on optimization of healthcare professional-to-patient ratio for each discipline to educate ICU clinicians unfamiliar with these data and to spur the implementation of evidence-based healthcare professional-to-patient ratios in their ICUs.

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Area Quality and Patient Safety

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Workforce

Tag Evidence Based Medicine

Year 2022

Keywords

patient-to-RN ratios

ICU

nurse's abilities

patient's needs

critical care nursing assignments

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