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71. Does Staffing Matter? The Effects of Nurse Staffing on Rates of Pressure Ulcer Development

E Hickey, CHQOER, Bedford VAMC; D Berlowitz, CHQOER, Bedford VAMC; E Czarnowski, CHQOER, Bedford VAMC; G Young, MDRC, Boston VAMC

Objectives: Consumers and health care professionals have voiced concerns about the potential effects of decreases in nursing staffing and changes in staffing mix on the quality of nursing home care. We examine the relationship of various components of staffing (staffing levels, staff turnover rates, changes in staffing patterns, and adherence to staffing guidelines) to an important quality outcome measure, risk-adjusted rates of pressure ulcer development.

Methods: Staffing data for this study was obtained through structured interviews with nurse administrators at 35 VA nursing homes. Staffing levels were determined by calculating the number of Patient Care Hours provided at each of these nursing homes. Patient Care Hours are the average number of hours of nursing care available daily for each nursing home patient. We determined each nursing home’s adherence to staffing guidelines by comparing its staffing levels to the minimum staffing standards recommended by a recent national expert panel. In addition, we calculated the per cent of staff turnover at each of the thirty-five nursing homes. Staff turnover is the percent of staff members that resigned or transferred from the nursing home in FY 99 and were replaced. Finally, we examined changes in staffing patterns defined as a decrease in total number of staff (resignation or transfer without replacement) and/or replacement of professional staff (RNs) with licensed practical nurses and/or nurse assistants. Our outcome, risk-adjusted pressure ulcer rates was calculated from the Patient Assessment Files. Rates were adjusted for case mix using a validated model that considers baseline patient characteristics such as functional status and terminal illness.

Results: Patient care hours at VA nursing homes ranged from 2.1 to 4.9 hours per resident. There was no monotonic association between these staffing levels and risk-adjusted rates of pressure ulcer development. However, among the five nursing homes adherent to staffing guidelines, three were among the best performing with an observed rate at least 3% lower than the expected rate of pressure ulcer development. Only five of thirty nursing homes not adherent to staffing guidelines achieved similar levels of performance (p=. 07). Seven of the thirty-five nursing homes had a staff turnover rate of 10% or greater but this was not associated with a higher rate of pressure ulcer development. Ten of the 35 nursing homes had a change in staffing pattern within the past year. Such a change was associated with a 2.1% higher rate of pressure ulcer development (p = .004).

Conclusions: We conclude that good care may be provided across a range of staffing levels but adherence to recommended staffing levels more likely results in best outcomes. However, once staffing levels are changing, it appears as if it may be difficult to maintain quality.

Impact: The association of changes in staffing patterns to poor outcomes has important implications as VA restructures its care delivery systems. Close monitoring of outcomes of care as they relate to organizational change may be an important means of assuring consistent, high quality care.