1. Nurse Staffing and Quality of Care for Hospitalized Children Barbara A. Mark Ph.D., R.N. FAAN University of North Carolina at Chapel Hill David W. Harless PhD Virginia Commonwealth University Wallace F. Berman MD Duke University Funded by AHRQ: Grant number 2R01HS10153

2. Background u Support for the nurse staffing – patient safety/quality/outcomes relationships in hospitalized patients; u Dimensions of the problem for hospitalized children: –$1 billion in excess charges –Adverse safety events u Unique needs of pediatric population –Low marginal reserve capacity –Dependence on adult caregivers –Inability to voice concerns about their care

3. Study Purpose u To examine the impact of nurse staffing on pediatric quality of care: –In-hospital mortality –Medication reactions/errors [MR/Es] –Other complications

4. Sample u Pediatric discharges (< 14 years old) u 178 general acute care hospitals in California u 2.3 million discharges u Panel data from 1996 – 2001 u Total observations: 890 u Children’s specialty hospitals excluded

5. Sources of Data u California OSHPD –Patient discharge abstracts –Hospital annual disclosure report u Area Resource Files u AHA Annual Survey u InterStudy HMO Profiler u Thomson-Medstat risk adjustment

6. Variables u Nurse staffing: RN, LPN, Aide (FTEs/1000 severity adjusted patient days) u Hospital characteristics: beds; peds in- patient days; presence of PICU/NICU; ownership; teaching status; percent Medicaid discharges u Population characteristics: Unemployment; income; infant mortality; HMO penetration

7. Analysis u Dynamic Poisson panel model for count data –Controls for unobserved heterogeneity –Includes lagged value of dependent variable –Includes initial value of dependent variable u Staffing levels in natural logs u Model includes interactions in staffing levels

8. Marginal Effects: Mortality  RN staffing not significant  0.162 (-0.084, 0.407)  LPN staffing not significant  0.012 (-0.033, 0.057)  Aide staffing significant  -0.045 (-0.091, 0.000)  Dynamic effects not significant

9. Marginal Effects: MR/Es  RN staffing significant  - 0.423 (-0.668, -0.178)  LPN staffing not significant  0.018 (-0.031, 0.067)  Aide staffing not significant  - 0.014 (-0.061, 0.034)  Dynamic effect (initial value) significant (+)

10. Marginal Effects: Other Complications  RN staffing significant  -0.360 (-0.515, -0.205)  LPN staffing significant  -0.074 (-0.106, -0.042)  Aide staffing significant  0.065 (0.033 0.097)  Dynamic effects significant (+)

11. Implications u Effects of nurse staffing differed across outcomes u Lack of effects for mortality u Need to investigate quantity and quality of nurses work u Need to better understand nurse work processes before mandating minimum nurse staffing ratios

12. For further information: bmark@email.unc.edu