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Weekend nursing ratios hit stroke mortality

Nurse staffing levels - not specialist stroke physician availability - key to safe seven day working

Mark Gould

Friday, 22 August 2014

Mortality outcomes after stroke are associated with the intensity of weekend staffing by registered nurses but not seven day a week ward rounds by stroke specialist physicians, according to new research*.

As the NHS moves to delivering a true seven day a week service, Dr Ben Bray, clinical fellow at King's College London and a quality improvement fellow at the Royal College of Physicians and colleagues examined data on over 56,000 patients in 103 stroke units in England. Writing in PLOS Medicine they found that weekend nursing ratios were strongly associated with mortality outcomes, not only for patients admitted at a weekend but also for those admitted on a week day.

Patients admitted to a stroke unit with 1.5 registered nurses for every 10 beds had an estimated adjusted 30-day mortality risk of 15.2%, compared to 11.2% for patients admitted to a unit with 3.0 nurses per 10 beds – equivalent to one excess death per 25 admissions. But of the patients admitted to a stroke unit, patient mortality risk did not differ whether stroke specialist physician rounds were seven days per week or fewer than seven days per week. Many stroke units in the UK are already carrying out five-day consultant ward rounds.

Dr Bray and colleagues wrote that "in a perfect world", a patient admitted to hospital on a weekend or during the night should have as good an outcome as a patient admitted during regular working hours. But several observational studies have reported that admission on weekends is associated with a higher mortality rate than admission on weekdays.

This “weekend effect” has led to calls for increased medical and nursing staff to be available in hospitals during the weekend and overnight to ensure that the healthcare provided at these times is of equal quality to that provided during regular working hours. In the UK, for example, “seven-day working” has been identified as a policy and service improvement priority for the National Health Service.

They say that few studies have actually tested the relationship between patient outcomes and weekend physician or nurse staffing levels. It could be that patients who are admitted to hospital on the weekend have poor outcomes because they are generally more ill than those admitted on weekdays. Before any health system introduces potentially expensive increases in weekend staffing levels, better evidence that this intervention will improve patient outcomes is needed.

The researchers said their findings show that the provision of stroke specialist physician rounds seven days/week in stroke units in England did not influence the (weak) association between weekend admission for stroke and death recorded in this study, but mortality outcomes after stroke were associated with the intensity of weekend staffing by registered nurses.

"The accuracy of these findings may be affected by the measure used to judge the level of acute care available in each stroke unit and by residual confounding. For example, patients admitted to units with lower nursing levels may have shared other unknown characteristics that increased their risk of dying after stroke. Moreover, this study considered the impact of staffing levels on mortality only and did not consider other relevant outcomes such as long-term disability. Despite these limitations, these findings support the provision of higher weekend ratios of registered nurses to beds in stroke units, but given the high costs of increasing weekend staffing levels, it is important that controlled trials of different models of physician and nursing staffing are undertaken as soon as possible."

* Bray B D, et al. Associations between Stroke Mortality and Weekend Working by Stroke Specialist Physicians and Registered Nurses: Prospective Multicentre Cohort Study. PLOS Medicine. Published: August 19, 2014. DOI: 10.1371/journal.pmed.1001705

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