ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy

Abstract.

Objective: To determine if having a night-time nurse-to-patient ratio (NNPR) of one nurse caring for one or two patients (>1:2) versus one nurse caring for three or more patients (<1:2) in the intensive care unit (ICU) is associated with clinical and economic outcomes following esophageal resection. Design: Statewide observational cohort study. Hospital discharge data was linked to a prospective survey of ICU organizational characteristics. Multivariate analysis adjusting for case-mix, hospital and surgeon volume was used to determine the association of NNPR with in-hospital mortality, length of stay (LOS), hospital cost and specific postoperative complications. Setting: Non-federal acute care hospitals (n=35) in Maryland that performed esophageal resection. Patients and participants: Adult patients who had esophageal resection in Maryland, 1994 to 1998 (n=366 patients). Measurements and results: Two hundred twenty-five patients at nine hospitals had a NNPR >1:2;128 patients in 23 hospitals had a NNPR <1:2. No significant association between NNPR and in-hospital mortality was seen. A 39% increase in median in-hospital LOS (4.3 days; 95%CI, (2, 5 days); p<0.001), and a 32% increase in costs ($4,810; 95% CI, ($2,094, $7,952) was associated with a NNPR <1:2. Pneumonia (OR 2.4; 95% CI (1.2, 4.7); p=0.012), reintubation (OR 2.6; 95% CI(1.4, 4.5); p=0.001), and septicemia (OR 3.6; 95% CI(1.1, 12.5); p=0.04), were specific complications associated with a NNPR <1:2. Conclusions: A nurse caring for more than two ICU patients at night increases the risk of several postoperative pulmonary and infectious complications and was associated with increased resource use in patients undergoing esophageal resection.