As the Affordable Care Act continues rolling out, preventable readmissions will cost hospitals even more. Medicare currently imposes a 2 percent penalty if patients go back into the hospital within 30 days of discharge. Hospitals wanting to avoid ever-steeper penalties may not have to look beyond nursing stations for a solution.
In addition to jeopardizing the health of patients, readmissions cost Medicare more than $17 billion a year, according to a 2013 analysis of Medicare data by the Robert Wood Johnson Foundation. Hospitals have implemented a number of measures to prevent readmissions, such as starting the discharge process immediately upon first admission, patient education and better organization of the discharge process. But studies also have found higher nurse staffing may help lower the odds of readmissions and increase the likelihood of improved patient outcomes.
Investigators led by Matthew McHugh, PhD, JD, MPH, RN, of the University of Pennsylvania in Philadelphia, used data from the Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program to determine readmission penalties for fiscal year 2013. They found that hospitals with a more favorable nurse-to-patient ratio were 25 percent less likely to incur readmission penalties than comparable hospitals with lower nurse staffing (Health Affairs 2013; 32:1740-1747).
Earlier in the year, McHugh and Chenjuan Ma, PhD, RN, also of the University of Pennsylvania, determined the relationship between certain aspects of hospital nursing (staffing, education and work environment) and 30-day readmissions for Medicare patients with heart failure, heart attacks and pneumonia by analyzing both discharge data and nurse surveys asking about staffing, education and work environment (Medical Care 2013:51:52-59).
Risk of understaffing
Their analysis revealed that nearly 25 percent of heart failure patients, 19.1 percent of heart attack admissions and 17.8 percent of pneumonia admissions were readmitted within 30 days. The odds for readmission for all patients were higher in hospitals with higher nurse-to-patient ratios and in hospitals with poorer work environments.
“Environments where nurses are understaffed and under-resourced and where there is poor support of nurses are linked to poor outcomes and processes of care that we know are associated with bad outcomes,” McHugh says. “Nurses are less able to do the kinds of things that evidence suggests are more likely to promote better outcomes, such as patient education, discharge planning, care coordination and advocating for patients on the post-discharge care they should be getting.”
At the Heart Failure Society of America scientific meeting in September, Therese Prentice, CRNP, formerly the heart failure coordinator for Capital Health System in Mercer County, N.J., and colleagues presented a study that compared readmission rates from before a hospital relocation to the rates after the relocation. Prior to relocation, the newly instituted heart failure program saw a 47 percent reduction in readmission rates over the previous year. However, the investigators found that readmission rates after relocation jumped back up again due to the temporary increase in heart failure patients per nurse.
Once staffing returned to a 1:4 nurse-to-patient ratio, readmissions returned to pre-relocation rates.
Donald Haas, MD, senior author of the research and director for mechanical circulatory support at Abington Memorial Hospital in Abington, Pa., says the research, which is not yet published, highlights the need for adequate nursing staff for heart failure patients. These patients are critically ill and need proper education in order to avoid coming back to the hospital.
“It’s also probably more important to educate the caregivers,” he says. “The average age of heart failure patients is about 72, so they’re getting a lot of support from their children or others who care for them.”
Making an investment
McHugh and Haas say the financial incentives offered by reducing readmissions could offset the cost of hiring more nurses. According to a report by CareerBuilder and EMSI, registered nurses earn an average of $32.04 per hour.
“Investing in nurse staffing benefits all patients because not only would there be gains in readmission reductions, but also in hospital-acquired infections and fewer complications,” McHugh says. “Any one of those wouldn’t pay for itself, but the good thing about focusing on a broad, system-level