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Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities.

ABSTRACT: Higher numbers of registered nurses (RNs) per patient have been associated with improved patient outcomes in acute-care facilities. Variation in and associations of patient care staffing levels and hemodialysis facility characteristics have not been examined previously.Cross-sectional study using Poisson regression to examine associations between patient care staffing levels and hemodialysis facility characteristics.4,800 US hemodialysis facilities in the 2009 Centers for Medicare & Medicaid (CMS) End-Stage Renal Disease Annual Facility Survey (CMS-2744 form).Facility characteristics, including profit status, freestanding status, chain affiliation, and geographic region, adjusted for facility size, capacity, functional type, and urbanicity.Patient care staffing levels, including ratios of RNs, licensed practical nurses (LPNs), patient care technicians (PCTs), composite staff (RN + LPN + PCT), social workers, and dietitians to in-center hemodialysis patients.After adjusting for background facility characteristics, ratios of RNs and LPNs to patients were 35% (P < 0.001) and 42% (P < 0.001) lower, respectively, but the PCT to patient ratio was 16% (P < 0.001) higher in for-profit than nonprofit facilities (rate ratios of 0.65 [95% CI, 0.63-0.68], 0.58 [95% CI, 0.51-0.65], and 1.16 [95% CI, 1.12-1.19], respectively). Regionally, compared to the Northeast, the adjusted RN to patient ratio was 14% (P < 0.001) lower in the Midwest, 25% (P < 0.001) lower in the South, and 18% (P < 0.001) lower in the West. Even after additional adjustments, the large for-profit chains had significantly lower RN and LPN to patient ratios than the largest nonprofit chain, but a significantly higher PCT to patient ratio. Overall composite staffing levels also were lower in for-profit and chain-affiliated facilities. The patterns hold when hospital-based units were excluded.Nursing hours were not available. Two part-time staff were counted as one full-time equivalent, which may not always be accurate.The significant variation in patient care staffing levels and its associations with facility characteristics warrants inclusion in future large-scale hemodialysis outcomes studies. End-stage renal disease networks and hemodialysis facilities should attend to quality assurance and performance improvement initiatives that maximize licensed nurse staffing levels in hemodialysis facilities.

SUBMITTER: Yoder LA

PROVIDER: S-EPMC3840051 | biostudies-literature | 2013 Dec

REPOSITORIES: biostudies-literature

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Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities.

Yoder Laura A G LA Xin Wenjun W Norris Keith C KC Yan Guofen G

American journal of kidney diseases : the official journal of the National Kidney Foundation 20130628 6

<h4>Background</h4>Higher numbers of registered nurses (RNs) per patient have been associated with improved patient outcomes in acute-care facilities. Variation in and associations of patient care staffing levels and hemodialysis facility characteristics have not been examined previously.<h4>Study design</h4>Cross-sectional study using Poisson regression to examine associations between patient care staffing levels and hemodialysis facility characteristics.<h4>Setting & participants</h4>4,800 US ...[more]

PMID: 23810689

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Project description:Rationale & objectiveTechnicians caring for patients receiving dialysis play a critical, frontline role in the care of patients receiving dialysis in the United States. We sought to provide a comprehensive description and identify correlates of US in-center hemodialysis facility patient care technician staffing patterns.Study designThis was an ecological study.Setting & participantsUS facilities providing hemodialysis and reporting patient care technician staffing, identified using the US Renal Data System.ExposuresGeography, year, and facility characteristics, including aggregated patient characteristics.OutcomesThe study outcome was facility-reported patient-to-patient care technician ratio.Analytical approachWe examined patient-to-patient care technician ratios by US state and over time and also estimated the differences in patient-to-patient care technician ratios associated with facility characteristics, using robust regression with adjustment for facility-level covariates.ResultsThe median patient-to-patient care technician ratio among 6,862 US facilities in 2019 was 9.9 (25th-75th percentiles, 8.2-12.0). Median 2019 patient-to-patient care technician ratios varied substantially by US state and region. There was an overall decline (from 10.6 to 9.9) in median patient-to-patient care technician ratios from 2004 to 2019, whereas the percentage of positions that were unfilled increased (from 2.8% to 3.5%). After adjustment, large dialysis organization status (β, -0.42; 95% CI, -0.61 to -0.23) and larger facility size (β, -0.51; 95% CI, -0.68 to -0.33) were associated with lower patient-to-patient care technician ratios. Higher patient-to-registered nurse (β, 0.80; 95% CI, 0.65-0.94) and patient-to-social worker (β, 0.53; 95% CI, 0.37-0.70) ratios, presence of licensed vocational nurses or licensed practical nurses at the clinic (β, 0.83; 95% CI, 0.53-1.12), and location in a poverty area (β, 0.29; 95% CI, 0.13-0.44) were all associated with higher patient-to-patient care technician ratios. Aggregated patient characteristics of patients treated at the facilities were generally not associated with patient-to-patient care technician ratio after adjustment.LimitationsLimited causal inference and potential shifts in staffing after 2019.ConclusionsUS dialysis facilities vary considerably in their patient care technician staffing by geography, over time, and by various facility characteristics. Further investigation of US patient care technician staffing is warranted and could lead to better, more stable dialysis staffing, improved staff and patient satisfaction, and higher quality of care.

Project description:Potentially inappropriate antipsychotic use in long-term care (LTC) facilities has been the focus of significant policy and clinical attention over the past 20 years. However, most initiatives aimed at reducing the use of these medications have overlooked assisted living (AL) settings.We sought to compare the prevalence of antipsychotic use (including potentially inappropriate use) among older AL and LTC residents and to explore the resident and facility-level factors associated with use in these two populations.We performed cross-sectional analyses of 1089 residents (mean age 85 years; 77% female) from 59 AL facilities and 1000 residents (mean age 85 years; 66% female) from 54 LTC facilities, in Alberta, Canada. Research nurses completed comprehensive resident assessments at baseline (2006-2007). Facility-level factors were assessed using standardized administrator interviews. Generalized linear models were used to estimate odds ratios for associations, accounting for clustering by facility.Over a quarter of residents in AL (26.4%) and LTC (31.8%) were using antipsychotics (p = 0.006). Prevalence of potentially inappropriate use was similar in AL and LTC (23.4 vs. 26.8%, p = 0.09). However, among users, the proportion of antipsychotic use deemed potentially inappropriate was significantly higher in AL than LTC (AL: 231/287 = 80.5%; LTC: 224/318 = 70.4%; p = 0.004). In both settings, comparable findings regarding associations between resident characteristics (including dementia, psychiatric disorders, frailty, behavioral symptoms, and antidepressant use) and antipsychotic use were observed. Few facility characteristics were associated with overall antipsychotic use, but having a pharmacist on staff (AL), or an affiliated physician (LTC) was associated with a lower likelihood of potentially inappropriate antipsychotic use.Our findings illustrate the importance of including AL settings in clinical and policy initiatives aimed at reducing inappropriate antipsychotic use among older vulnerable residents.

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Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities.

Publications

Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities.

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