Association of Temporal Variations in Staffing With Hospital‐Acquired Pressure Injury in Military Hospitals

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Hospital‐acquired pressure injury (HAPI) remains a common and costly adverse event in patient care units across the United States (Gunningberg, Brudin, & Idvall, 2010). Complications experienced by patients with HAPI, including sepsis, osteomyelitis, and surgical intervention, contribute to longer length of stay and excess costs (Bry, Buescher, & Sandrik, 2012). The costs of treating a patient with a pressure injury worse than Stage 2, as compared to a similar patient without a pressure injury, add an additional $5,904.13 to $21,410.12 per hospital stay (Spetz, Brown, Aydin, & Donaldson, 2013).
Penalties on reimbursement by the Centers for Medicaid and Medicare Services (CMS) for patients who incur preventable conditions have increased hospital leaders’ attention and prompted inquiry into the association between nurse staffing and hospital‐acquired conditions, including HAPI (Aydin, Donaldson, Stotts, Fridman, & Brown, 2014). Preventing pressure injury has been recognized as a nursing function since Florence Nightingale wrote that these injuries are “not the fault of the disease, but of the nursing” (1859, p.8). She added, “By this I do not mean that the nurse is always to blame … bad administrative arrangements often make it impossible to nurse.” Not only the number of staff and their experience levels but the expertise or type of the nursing staff, that is, nursing assistants (NAs), licensed practical nurses (LPNs), and registered nurses (RNs), contribute to patient outcomes (Patrician et al., 2011). The National Quality Forum (2004) considers pressure injury a nursing‐sensitive indicator of quality, but many clinicians claim that pressure injury is a larger health system issue (Lyder & Ayello, 2008). The latter view is plausible, given that staff nurses often have little control over staffing allocations needed to provide the intense level of care necessary to prevent pressure injury in acutely ill patients. Moreover, all shifts must be staffed to the level required to provide appropriate care for all patients, yet great variability exists in shift‐level staffing (West, Patrician, & Loan, 2012), and adverse events have been associated with inadequate staffing at the shift level (Needleman et al., 2011; Patrician et al., 2011). Insufficient turning, repositioning, and personal hygiene for even one inadequately staffed shift during a hospital stay has implications for the development of HAPI. The purpose of this study was to explore the connection between the occurrence of HAPI and nurse staffing measured at different points in time prior to HAPI development in acute care military hospitals.
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