By Debra Wood, RN, contributor
Critical-care nurses expressed no surprise at recent findings from an international study that improved staffing decreases the risk of patients developing ventilator-associated pneumonia.
“If staffing ratios are not in alignment with all of the activities [needed to prevent infection], it makes it more difficult for nurses to stay on top of things,” says Rick Bassett, RN, BSN, CCRN, project manager of VHA’s Transformation of the Intensive Care Unit (TICU) at St. Luke's Regional Medical Center in Boise, Idaho.
Andrea Kline, RN, APN-NP, a pediatric nurse practitioner in the pediatric intensive care unit at Children’s Memorial Hospital in Chicago, also was not surprised, speculating that poorer staffing results in nurses having less time to wash their hands or follow aseptic technique when suctioning.
“In pediatrics we are still sorting out what is different and what is the same as for adults in regard to risk factors for ventilator-associated pneumonia, but certainly nursing ratios would affect kids similarly to adults,” Kline said.
The Swiss study, reported in the journal Critical Care, found that patients were more likely to develop ventilator-associated pneumonia (VAP) six days or more after being placed on the ventilator when there were lower numbers of nurses working on the unit. The study tracked rates and staffing for four years. One fifth of the 936 patients on mechanical ventilation during the study developed VAP.
“This study shows that a low nurse-to-patient ratio increases the risk of late-onset VAP,” said lead author Stéphane Hugonnet, M.D., in a written statement. “It adds also to the growing body of evidence demonstrating that adequate staffing is a key determinant and a prerequisite for adequate care and patient safety.”
VHA Inc., a national health-care provider alliance, began TICU in 2000 to improve critical-care outcomes. Among the goals was reducing VAP rates, which decreased 49 percent from September 2003 to August 2004. Methods initiated and evaluated as part of the initiative have become the standard of care.
“Every single [prevention-program] component is critical to providing the best care to the patient on a ventilator and giving them the best chance of avoiding ventilator-associated pneumonia,” Bassett said.
Among the recommendations is keeping the head of the bed elevated at least 30 degrees, but Bassett explains that goal is more complex than simply raising the bed, explaining the need for a nurse to evaluate the patient’s hemodynamic status.
Other nursing care that contributes to lower VAP rates include giving the least amount of sedation and pain medication to achieve patient goals, screening the patient daily to determine if he or she could come off the ventilator, maintaining tight glycemic control, and providing oral care every two to four hours.
“All of these elements are time intensive,” Bassett said. “As you spread nurses thinner and thinner, they don’t have as much time to focus on these important things.”
Within months of joining TICU in 2005, St. Luke’s MICU/CCU VAP rates dropped from being higher than the national average to zero, and its SICU rate decreased to less than one case per month. The hospital continues to have low to no incidence of VAP. In addition, the hospital has decreased the number of ventilator days per patient, which has helped to lower patients’ VAP risk, says Veronica Hunt, spokesperson for VHA.
The Swiss researchers suggested that nurses could be transferring bacteria between patients or from one site to another on the same person. Because of being rushed, they may not follow good hand washing practices or follow isolation procedures.
“If you are taking care of three patients rather than two patients, the possibility something will happen quickly means you have to react and not wash your hands,” agreed Christine T. Kovner, Ph.D., RN, FAAN, a professor at the College of Nursing at New York University, whose research focus includes nurse staffing & patient safety.
Jeannie P. Cimiotti, DNS, RN, research assistant professor at the University of Pennsylvania School of Nursing in Philadelphia, expressed disappointment in that the study investigators did not evaluate which nursing variables—such as not following hand hygiene, aseptic technique, oral care, or positioning standards—contributed to the increased infection rate, which would have added the profession’s body of knowledge.
“We haven’t been able to find that causal link,” Cimiotti said. “We know its staffing. But what happens when staffing goes bad and the workload increases?”
Kovner thought the Swiss study was well designed and controlled for a lot of factors. She suggested an observational study is needed to determine whether hand washing or some other factor, such as getting interrupted, contributes to the results.
“It’s clear better staffing is related to fewer infections,” Kovner said. “The literature is pretty good that if we have more nurses, we have fewer adverse events, but I don’t know how much people are willing to pay for that.”
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