美国宾夕法尼亚大学Matthew D McHugh团队研究了护患比立法对护士配置、病人死亡率、再入院率和住院时间的影响。这一研究成果于2021年5月11日发表在《柳叶刀》杂志上。
大量证据表明，在护士人员配置较好的医院中，患者预后更为有利。旨在实现更好人员配置的一项政策是要求最低护患比，但此类政策很少实施或评估。2016年，澳大利亚昆士兰州在选定的医院实施了最低护患比政策。
为了评估该政策对人员配置水平和患者结局的影响，以及两者间的相关性，研究组进行了一项前瞻性小组研究。比较了昆士兰州27家实施最低护患比政策的干预医院，与28家未实施该政策且出院患者类似的对照医院，在实施前和实施后两年的相关影响。
研究组使用标准化的昆士兰医院入院患者数据，与死亡记录相关联，获取医疗外科患者的个体特征和结果数据，以及17010名政策实施前后研究医院的医疗外科护士。评估干预医院和对照医院患者之间结果的差异变化，并确定护士人员配置变化是否与其相关。
研究组在基线时（2016年）共招募了231902名患者，其中干预医院142986名，对照医院88916名；在政策实施两年后（2018年）共招募257253名患者，其中干预医院160167名，对照医院97086名。
政策实施2年后，对照医院的死亡率与基线水平相差不大，但干预医院死亡率显著低于基线水平。从基线到实施两年后，对照医院的再入院率显著增加，而干预医院则没有。虽然实施后两组的住院时间（LOS）均下降，但干预医院的LOS下降幅度明显大于对照医院。
从基线到实施后，医院的人员配置发生了变化：在36家具有可靠人员配置措施的医院中，有30家（83%）在基线时每位护士的患者人数超过4.5名，实施后减少至21家（58%）。大部分改善发生在干预医院，每名护士减少一名患者的人员配置可有效降低死亡率、再入院率和LOS。除了产生更好的临床结果外，由于再入院次数减少和服务水平缩短而避免的费用是额外护士人员成本的两倍多。
研究结果表明，最低护患比政策是改善护士人员配置和患者结局并获得良好投资回报的可行方法。
附：英文原文
Title: Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals
Author: Matthew D McHugh, Linda H Aiken, Douglas M Sloane, Carol Windsor, Clint Douglas, Patsy Yates
Issue&Volume: 2021-05-11
Abstract:
Background
Substantial evidence indicates that patient outcomes are more favourable in hospitals with better nurse staffing. One policy designed to achieve better staffing is minimum nurse-to-patient ratio mandates, but such policies have rarely been implemented or evaluated. In 2016, Queensland (Australia) implemented minimum nurse-to-patient ratios in selected hospitals. We aimed to assess the effects of this policy on staffing levels and patient outcomes and whether both were associated.
Methods
For this prospective panel study, we compared Queensland hospitals subject to the ratio policy (27 intervention hospitals) and those that discharged similar patients but were not subject to ratios (28 comparison hospitals) at two timepoints: before implementation of ratios (baseline) and 2 years after implementation (post-implementation). We used standardised Queensland Hospital Admitted Patient Data, linked with death records, to obtain data on patient characteristics and outcomes (30-day mortality, 7-day readmissions, and length of stay [LOS]) for medical-surgical patients and survey data from 17010 medical-surgical nurses in the study hospitals before and after policy implementation. Survey data from nurses were used to measure nurse staffing and, after linking with standardised patient data, to estimate the differential change in outcomes between patients in intervention and comparison hospitals, and determine whether nurse staffing changes were related to it.
Findings
We included 231902 patients (142986 in intervention hospitals and 88916 in comparison hospitals) assessed at baseline (2016) and 257253 patients (160167 in intervention hospitals and 97086 in comparison hospitals) assessed in the post-implementation period (2018). After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio [OR] 1·07, 95% CI 0·97–1·17, p=0·18), but were significantly lower than at baseline in intervention hospitals (0·89, 0·84–0·95, p=0·0003). From baseline to post-implementation, readmissions increased in comparison hospitals (1·06, 1·01–1·12, p=0·015), but not in intervention hospitals (1·00, 0·95–1·04, p=0·92). Although LOS decreased in both groups post-implementation, the reduction was more pronounced in intervention hospitals than in comparison hospitals (adjusted incident rate ratio [IRR] 0·95, 95% CI 0·92–0·99, p=0·010). Staffing changed in hospitals from baseline to post-implementation: of the 36 hospitals with reliable staffing measures, 30 (83%) had more than 4·5 patients per nurse at baseline, with the number decreasing to 21 (58%) post-implementation. The majority of change was at intervention hospitals, and staffing improvements by one patient per nurse produced reductions in mortality (OR 0·93, 95% CI 0·86–0·99, p=0·045), readmissions (0·93, 0·89–0·97, p<0·0001), and LOS (IRR 0·97, 0·94–0·99, p=0·035). In addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing.
Interpretation
Minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment.
DOI: 10.1016/S0140-6736(21)00768-6
Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00768-6/fulltext
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