More COVID-19 patients died in understaffed hospitals, new data show

tired nurse


A new study in the International Journal of Nursing Studies suggests chronically understaffed US hospitals had higher rates of COVID-19 patient deaths early in the pandemic.

"Our study found that individuals' likelihood of surviving was related to hospitals' investments in nursing services prior to the pandemic—in terms of hiring sufficient numbers of RNs [registered nurses], employing nurses with bachelor's educational preparation, and sustaining favorable work environments," said Karen Lasater, PhD, RN, the lead author of the study, in a press release from the University of Pennsylvania School of Nursing. 

Almost a fourth died during hospitalization

The study was based on outcomes seen among 87,000 Medicare enrollees (ages 65 to 99) hospitalized with COVID-19 from April through December 2020 in 237 general acute-care hospitals in New York and Illinois. 

The authors looked at patient-to-RN staffing ratios, proportion of bachelors-qualified RNs, and nurse work environments in the pre-pandemic period (December 2019 to February 2020) and during the pandemic (April to June 2021) to predict in-hospital and 30-day mortality.

About half of hospitals (48.5%) had more than 250 beds, and the greatest percentage of hospitals were non-teaching hospitals (43%), the authors said. 

Overall, the average age of patients was 78 years, and 31.5 % died within 30 days of admission, with 23% of those patients dying during the hospitalization. Mortality was highest in April 2020 (36.1 % in-hospital mortality; 44.6% 30-day mortality) and dropped in July, then steadily rose through December 2020.

4:1 patient-to-nurse ratio would have saved lives

The average patient-to-RN staffing ratio on an adult medical-surgical unit in the study was 5.6 patients per nurse. Patient-to-RN staff ratios were highly linked to mortality: Each additional patient in the nurses' workload pre-pandemic was associated with 20% higher odds of in-hospital mortality (odds ratio [OR], 1.20; 95 % confidence interval [CI], 1.12 to 1.28) and a 15% higher odds of 30-day mortality (OR, 1.15; 95 % CI, 1.09 to 1.21).

Using a model, the authors predicted if all the study hospitals staffed not more than 4 patients per RN, 3,460 in-hospital COVID-19 deaths could have been prevented during the 9-month study period in the two study states—a 17% reduction in mortality.

The authors also estimated that 631 deaths could have been prevented if all hospitals employed a workforce comprising a minimum of 80% of RNs with a bachelor's of science degree in nursing.

Our team’s work shows that U.S. hospitals were already chronically understaffed prior to the pandemic and staffing worsened during the pandemic.

"It is in the public's interest to establish state and federal policies that guarantee a minimum safe standard of hospital nurse staffing at all times," said Lasater. "Our team’s work shows that U.S. hospitals were already chronically understaffed prior to the pandemic and staffing worsened during the pandemic."

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