Department of Emergency Medicine, University of California, San Diego, CA, USA.
Acad Emerg Med. 2010 May;17(5):545-52. doi: 10.1111/j.1553-2712.2010.00727.x.
The objective was to evaluate the effect of mandated nurse-patient ratios (NPRs) on emergency department (ED) patient flow.
Two institutions implemented an electronic tracking system embedded within the electronic medical record (EMR) of two EDs (an academic urban, teaching medical center-Hospital A; and a suburban community hospital-Hospital B), with a combined census of 60,000/year, to monitor real-time NPRs and patient acuity, such that compliance with state-mandated ratios could be prospectively monitored. Data were queried for a 1-year period after implementation and included patient wait times (WTs), ED care time (EDCT), patient acuity, ED census, and NPR status for each nurse, patient, and the ED overall. Median WT and EDCT with interquartile ranges (IQRs) were analyzed to determine the effect of NPR status of each patient, nurse, and the ED overall. To control for factors that could affect the "within the mandated ratio" and the "outside of the mandated ratio" status, including patient volume and acuity, log-linear regression models were used controlling for specified factors for each hospital facility and combined.
There were a total of 30,404 (50.9%) patients who waited in the waiting room prior to being placed in an ED bed (53.8% at Hospital A and 46.4% at Hospital B). Patients who waited at Hospital A waited a median duration of 55 minutes (IQR = 15-128 minutes), compared with 32 minutes (IQR = 12-67 minutes) at Hospital B with a combined median WT of 44 minutes (IQR = 13-101 minutes). In the log-linear regression analysis, WTs were 17% (95% confidence interval [CI] = 10% to 25%, p < 0.001) longer at Hospital A and 13% (95% CI = 3% to 24%, p = 0.008) longer at Hospital B (combined 16% [95% CI = 10% to 22%, p < 0.001] longer at both sites) when the ED overall was out-of-ratio compared to in-ratio. There were a total of 45,660 patients discharged from both EDs during the study period, from which EDCT data were collected (26,894 in Hospital A and 18,766 in Hospital B). Median EDCT was 184 minutes (IQR = 97-311 minutes) at Hospital A, compared to 120 minutes (IQR = 63-208 minutes) at Hospital B, for a combined median EDCT of 153 minutes (IQR = 81-269 minutes). In the log-linear regression analysis, the EDCT for patients whose nurse was out-of-ratio were 34% (95% CI = 30% to 38%, p < 0.001) longer at Hospital A and 42% (95% CI = 37% to 48%, p < 0.001) longer at Hospital B (combined 37% [95% CI = 34% to 41%, p < 0.001] longer at both sites) when compared to patients whose nurse was in-ratio.
In these two EDs, throughput measures of WT and EDCT were shorter when the ED nurse staffing were within state-mandated levels, after controlling for ED census and patient acuity.
评估强制性护士患者比例（NPR）对急诊部（ED）患者流量的影响。
两家机构在两个 ED（一个是城市学术性教学医疗中心-医院 A；另一个是郊区社区医院-医院 B）的电子病历（EMR）中嵌入了一个电子跟踪系统，每年的总人数为 60,000 人，以实时监测 NPR 和患者的严重程度，从而可以前瞻性地监测符合州规定的比例。在实施后对数据进行了为期一年的查询，包括患者等待时间（WT）、ED 护理时间（EDCT）、患者严重程度、ED 人数和每位护士、患者和 ED 的 NPR 状态。分析中位数 WT 和 IQR 的 EDCT 以确定每个患者、护士和 ED 整体的 NPR 状态的影响。为了控制可能影响“在规定比例内”和“在规定比例外”状态的因素，包括患者量和严重程度，使用对数线性回归模型对每个医院设施和综合设施进行了特定因素的控制。
共有 30404 名（50.9%）患者在被安置在 ED 病床之前在等候室等候（医院 A 为 53.8%，医院 B 为 46.4%）。在医院 A 等待的患者中位数等待时间为 55 分钟（IQR = 15-128 分钟），而在医院 B 等待的患者中位数等待时间为 32 分钟（IQR = 12-67 分钟），合并中位数 WT 为 44 分钟（IQR = 13-101 分钟）。在对数线性回归分析中，当 ED 整体处于比例之外时，WT 在医院 A 中长 17%（95%置信区间[CI] = 10%至 25%，p <0.001），在医院 B 中长 13%（95% CI = 3%至 24%，p = 0.008）（两者相加，在两个地点的 WT 长 16%[95% CI = 10%至 22%，p <0.001]）。在研究期间，共有 45660 名患者从两个 ED 出院，从中收集了 EDCT 数据（医院 A 有 26894 名，医院 B 有 18766 名）。医院 A 的 EDCT 中位数为 184 分钟（IQR = 97-311 分钟），而医院 B 的 EDCT 中位数为 120 分钟（IQR = 63-208 分钟），合并 EDCT 的中位数为 153 分钟（IQR = 81-269 分钟）。在对数线性回归分析中，当护士比例失调时，患者的 EDCT 长 34%（95% CI = 30%至 38%，p <0.001），在医院 B 中长 42%（95% CI = 37%至 48%，p <0.001）（两者相加，在两个地点的 EDCT 长 37%[95% CI = 34%至 41%，p <0.001]）。
在这两个 ED 中，在控制 ED 人数和患者严重程度后，当 ED 护士人员配备符合州规定水平时，WT 和 EDCT 等通过措施更短。
