Reduced Sepsis Mortality Risk Seen With High Nurse Staffing

Additional hours of care provided by registered nurses to hospitalized patients with sepsis was found to reduce mortality risk and improve compliance to Severe Sepsis and Septic Shock Management Bundle (SEP-1) data collection requirements. Findings were published in JAMA Health Forum.

More than 1.7 million cases of sepsis are diagnosed annually in the United States, with patients facing significant health- and cost-related burdens. For Medicare beneficiaries, the researchers of the present study note that sepsis-related mortality and the costs associated with inpatient and outpatient treatment continue to escalate.

To promote the early recognition and treatment of sepsis, CMS requires that hospitals collect data on SEP-1, in which all components of the measure must be met for hospitals to be considered compliant.

“To meet those criteria, recognizing sepsis early is essential, and communication among clinicians cannot be overlooked. Although the benefit of nurse-driven sepsis treatment tools has been reported, it is nurse-physician communication that has been identified as a necessary component to support the improvement that is needed in sepsis care,” said the study authors. “Some have identified the workload of nurses as the primary mechanism that prevents the rapid initiation of antibiotic treatment to patients with a diagnosis of sepsis and that an adequate number of nurses are necessary to improve SEP-1 bundle compliance.”

They conducted a cross-sectional study of 2018 data from the American Hospital Association Annual Survey, CMS Hospital Compare, and Medicare claims to investigate whether the hours of care provided by registered nurses was associated with mortality in hospitalized Medicare beneficiaries.

The study included participants aged 65 to 99 years with a primary diagnosis of sepsis who were admitted to 1 of 1958 nonfederal, general acute care hospitals that had data on CMS SEP-1 scores and registered nurse workload (indicated by registered nurse hours per patient day [HPPD]). Data were analyzed throughout 2021, with the primary outcome being mortality within 60 days of admission.

A total of 702,140 Medicare beneficiaries (mean [SD] age, 78.2 [8.7] years; 51% women) with a diagnosis of sepsis were examined. Hospitals were associated with a mean SEP-1 score of 56.1 and a mean registered nurse HPPD of 6.2. Large hospitals, or those with more than 500 beds, were indicated to provide more registered nurse HPPD (7.7), as did for-profit hospitals (6.4) and major teaching hospitals (7.4).

“Hospitals that were high technology (HPPD, 7.0), located in metropolitan areas (HPPD, 6.5), and located in the Pacific region of the United States (HPPD, 8.1) all provided more registered nurse HPPD compared with the overall average hours,” added the study authors.

Findings of the multivariable regression model showed that each additional registered nurse HPPD was associated with a significant 3% decrease in the odds of 60-day mortality (odds ratio [OR], 0.97; 95% CI, 0.96-0.99; P < .001) controlling for SEP-1 score and hospital and patient characteristics.

Having an intensivist on staff was also associated with a 16% decrease in the odds of 60-day mortality (OR, 0.84; 95% CI, 0.79-0.89; P < .001) while controlling for SEP-1 score and hospital and patient characteristics.

Additional analyses on projected deaths avoided if all hospitals were staffed at 6 registered nurse HPPD or higher indicated that 1266 fewer deaths may occur. In addition, if this projected trend continued, if all hospitals were staffed at 9 registered nurse HPPD or higher, there could be 6360 avoided patient deaths, according to the findings.

Limitations of the analysis included its cross-sectional design and its inability to determine a causal association between registered nurse HPPD and sepsis-related 60-day mortality.

“As we redefine the sepsis bundle, it is imperative that we include the workload of nurses and other clinicians and promote a care environment that fosters interprofessional communication,” concluded the researchers. “Not doing so will place patients at increased risk of sepsis-related mortality and nonmortality adverse events.”

Reference

Cimiotti JP, Becker ER, Li Y, et al. Association of registered nurse staffing with mortality risk of Medicare beneficiaries hospitalized with sepsis. JAMA Health Forum. 2022;3(5):e221173. doi:10.1001/jamahealthforum.2022.1173