Paul G. Shekelle, MD, PhD
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Acknowledgment: The author thanks Robert Kane, MD; Eileen Lake, PhD, RN; Aneesa Motala, BA; Sydne Newberry, PhD; and Roberta Shanman, MLS.
Financial Support: From the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services (contract HHSA-290-2007-10062I).
Potential Conflicts of Interest: Consultancy: ECRI Institute; Employment: Veterans Affairs; Grants/grants pending: Agency for Healthcare Research and Quality, Veterans Affairs, Centers for Medicare & Medicaid Services, National Institute of Nursing Research, Office of the National Coordinator; Royalties: UpToDate. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2574.
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Author Contributions: Conception and design: P.G. Shekelle.
Analysis and interpretation of the data: P.G. Shekelle.
Drafting of the article: P.G. Shekelle.
Critical revision of the article for important intellectual content: P.G. Shekelle.
Final approval of the article: P.G. Shekelle.
Obtaining of funding: P.G. Shekelle.
Administrative, technical, or logistic support: P.G. Shekelle.
Collection and assembly of data: P.G. Shekelle.
A small percentage of patients die during hospitalization or shortly thereafter, and it is widely believed that more or better nursing care could prevent some of these deaths. The author systematically reviewed the evidence about nurse staffing ratios and in-hospital death through September 2012. From 550 titles, 87 articles were reviewed and 15 new studies that augmented the 2 existing reviews were selected. The strongest evidence supporting a causal relationship between higher nurse staffing levels and decreased inpatient mortality comes from a longitudinal study in a single hospital that carefully accounted for nurse staffing and patient comorbid conditions and a meta-analysis that found a “dose–response relationship” in observational studies of nurse staffing and death. No studies reported any serious harms associated with an increase in nurse staffing. Limiting any stronger conclusions is the lack of an evaluation of an intervention to increase nurse staffing ratios. The formal costs of increasing the nurse–patient ratio cannot be calculated because there has been no evaluation of an intentional change in nurse staffing to improve patient outcomes.
Hospital organization, nursing organization, and patient outcomes.
From reference 8, with permission.
Pooled odds ratio of quartiles of nurse staffing levels.
Odds ratios are based on pooled analysis consistent across the studies (heterogeneity not significant). From reference 27, with permission. RN = registered nurse.
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Shekelle PG. Nurse–Patient Ratios as a Patient Safety Strategy: A Systematic Review. Ann Intern Med. 2013;158:404–409. doi: 10.7326/0003-4819-158-5-201303051-00007
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Published: Ann Intern Med. 2013;158(5_Part_2):404-409.
Healthcare Delivery and Policy, Hospital Medicine.
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