Fran Lowry

March 19, 2010

March 19, 2010 (New Orleans, Louisiana) — Low nurse staffing levels are associated with increased mortality among elderly patients admitted to hospital with hip fractures, new research suggests.

In a retrospective cohort study presented here at the American Association of Orthopaedic Surgeons 2010 Annual Meeting, the risk for death among elderly patients in the hospital with hip fractures increased 22% when the nursing staff was reduced by 1 full-time nurse each day, Peter Schilling, MD, from the University of Michigan Medical Center in Ann Arbor, told meeting delegates.

"It is estimated that nearly 5% of elderly patients admitted with a hip fracture die during their initial hospitalization, and another third die within a year of their injury," he said. "There is very little research on how to reduce the risk of complications in these patients, but there is growing evidence of the importance of nurse staffing levels in reducing morbidity and mortality in this vulnerable population."

To shed more light on this issue, he and his colleagues conducted a retrospective cohort study of 13,343 elderly patients admitted between 2003 and 2006 to 39 Michigan hospitals with a primary diagnosis of hip fracture.

They used regression models to control for patient age, sex, comorbidities, and hospital characteristics, including teaching status, hip fracture volume, income and racial composition of each hospital's zip code, and, finally, seasonal influenza.

The study found a statistically significant association between nurse staffing levels and in-hospital mortality among hip fracture patients.

The odds of in-hospital mortality decreased by 0.16 (P < .003) for every additional full-time-equivalent registered nursing staff per patient-day, even after controlling for covariates.

"This association indicates that the absolute risk of mortality increases by 0.35 percentage points for every 1-unit decrease in full-time-equivalent registered nursing staff per patient-day, or a 16% increase in death," Dr. Schilling said.

He speculated that more nursing attention could decrease occurrences of urinary tract infection, pneumonia, sepsis, and cardiac arrest. "Two of the most common causes of death for hip fracture patients — pulmonary embolism and acute myocardial infarction — are also considered to be the most preventable causes of in-hospital death. If nurses are responsible for a small number of patients, they might be able to identify and deal with impending complications earlier."

Senior author Paul Joseph Dougherty, MD, associate professor and director of the Orthopaedic Surgery Residency Program at the University of Michigan, said that although the study has limitations and does not give a definite answer, "it certainly points to the fact that nurse staffing may be an important factor in preventing complications."

"There's a great deal of concern with cost-cutting measures, but what you may perceive to be excess nursing staff may in fact prevent long-term problems. The problem is, we don't have a precise value for that," he told Medscape Orthopaedics.

More work needs to be done to establish acceptable nursing staffing levels, he said. "This is probably where our efforts should be directed, so that we can make some assumptions for staff, based on the type of patient we are seeing. Hip fracture patients are frail and very vulnerable. They tend to be the oldest patients, and they tend to be the sickest."

Andrew Pollak, MD, head of the Division of Orthopaedic Trauma at the University of Maryland School of Medicine in Baltimore, said the authors should be congratulated for taking on this important topic.

"This study does not definitively show that nurse staffing levels are associated with mortality. But it suggests that there might be a relationship and that further investigation is warranted," said Dr. Pollak, who moderated the session at which the study was presented.

Orthopaedic surgeons need to pay more attention to this issue, he added. "As orthopaedic surgeons, we pay a lot of attention to having enough personnel in the operating room with us to take care of our patients, but it is pretty rare that we will actually go up on the floor in a hospital, or other places in the hospital outside of the operating room, and pay any attention to the number of staff around. We don't really have direct access to that kind of information," he told Medscape Orthopaedics.

"This type of information tells us that we really ought to start thinking about these things when we start to consider where we are going to put our patients, and whether staffing, or the lack of it, could mean a difference in our patients' well-being."

Dr. Schilling, Dr. Dougherty, and Dr. Pollak have disclosed no relevant financial relationships.

American Association of Orthopaedic Surgeons (AAOS) 2010 Annual Meeting: Abstract 125. Presented March 10, 2010


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.