Professional Development, Continuing Education and Nursing Research Unit, Bambino Gesù Children's Hospital, IRCCS, Roma, Lazio, Italy
Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
BMJ Open. 2024 Jul 4;14(7):e081645. doi: 10.1136/bmjopen-2023-081645.
To describe the associations between patient-to-nurse staffing ratios and rates of mortality, process of care events and vital sign documentation.
Secondary analysis of data from the evaluating processes of care and outcomes of children in hospital (EPOCH) cluster-randomised trial.
22 hospitals caring for children in Canada, Europe and New Zealand.
Eligible hospitalised patients were aged>37 weeks and <18 years.
The primary outcome was all-cause hospital mortality. Secondary outcomes included five events reflecting the process of care, collected for all EPOCH patients; the frequency of documentation for each of eight vital signs on a random sample of patients; four measures describing nursing perceptions of care.
A total of 217 714 patient admissions accounting for 849 798 patient days over the course of the study were analysed. The overall mortality rate was 1.65/1000 patient discharges. The median (IQR) number of patients cared for by an individual nurse was 3.0 (2.8-3.6). Univariate Bayesian models estimating the rate ratio (RR) for the patient-to-nurse ratio and the probability that the RR was less than one found that a higher patient-to-nurse ratio was associated with fewer clinical deterioration events (RR=0.88, 95% credible interval (CrI) 0.77-1.03; P (RR<1)=95%) and late intensive care unit admissions (RR=0.76, 95% CrI 0.53-1.06; P (RR<1)=95%). In adjusted models, a higher patient-to-nurse ratio was associated with lower hospital mortality (OR=0.77, 95% CrI=0.57-1.00; P (OR<1)=98%). Nurses from hospitals with a higher patient-to-nurse ratio had lower ratings for their ability to influence care and reduced documentation of most individual vital signs and of the complete set of vital signs.
The data from this study challenge the assumption that lower patient-to-nurse ratios will improve the safety of paediatric care in contexts where ratios are low. The mechanism of these effects warrants further evaluation including factors, such as nursing skill mix, experience, education, work environment and physician staffing ratios.
EPOCH clinical trial registered on clinical trial.gov NCT01260831; post-results.
描述患者与护士的配置比例与死亡率、护理过程事件和生命体征记录之间的关联。
对来自评估医院患儿护理过程和结局（EPOCH）的聚类随机试验数据进行二次分析。
22 家加拿大、欧洲和新西兰的医院，收治患儿。
符合条件的住院患儿胎龄>37 周且<18 岁。
主要结局为全因住院死亡率。次要结局包括反映护理过程的 5 个事件，收集 EPOCH 所有患儿的数据；对随机样本患儿的 8 项生命体征记录的频率；描述护士对护理感知的 4 项措施。
在研究过程中，共分析了 217714 例患儿住院，共 849798 个患儿日。总死亡率为 1.65/1000 出院患儿。每位护士照顾的患儿中位数（IQR）为 3.0（2.8-3.6）。对患者与护士比例的比率估计（RR）和 RR 小于 1 的概率进行单变量贝叶斯模型估计发现，较高的患者与护士比例与较少的临床恶化事件相关（RR=0.88，95%可信区间（CrI）0.77-1.03；P（RR<1）=95%）和迟发性重症监护病房入院（RR=0.76，95%CrI 0.53-1.06；P（RR<1）=95%）。在调整模型中，较高的患者与护士比例与较低的住院死亡率相关（OR=0.77，95%CrI=0.57-1.00；P（OR<1）=98%）。来自患者与护士比例较高的医院的护士对其影响护理能力的评价较低，并且对大多数单个生命体征和完整生命体征的记录也较少。
这项研究的数据挑战了低患者与护士比例将提高儿科护理安全性的假设，在低比例的情况下尤其如此。这些影响的机制需要进一步评估，包括护理技能组合、经验、教育、工作环境和医生与护士比例等因素。
EPOCH 临床试验在 clinicaltrial.gov 上注册，编号 NCT01260831；结果后。
