evaluating the difference in outcomes

My Busy SUMR By Egor Buharin

Mentored by Matthew D McHugh, PhD, JD, MPH, RN, CRNP

∗ Continuation of former research and new projects

∗ October, 2010 – Center for Health Outcomes and Policy Research (CHOPR)

∗ Flurry of projects

Interesting Situation

Visual Diagrams – Impact of Nurse Residency Programs

Visual Representation of research

Diagrams

∗ End-of-Life Care: statistical programming ∗ California’s Nurse-to-Patient Mandate

∗ United Arab Emirates – several thousand nurse and

patient surveys.

Projects

∗ Set the scene.

∗ 2,423,995 people died in the U.S. Of these, estimated that 765,651 died in the hospital – 32 percent (2007) ∗ Among the elderly, 31 percent of deaths occurred in the hospital ∗ Approximately 75% of 65+ people have at least one chronic condition

∗ Chronically ill patients often spend their last days in a hospital – society

∗ 50 percent of the conscious patients who die in the hospital have moderate-to-severe pain at least half the time. – New England Journal of Medicine

∗ Passive euthanasia – legal

∗ Hospice

End of Life

• The Costs of End-of-Life Hospitalizations, 2007 - Yafu Zhao, M.S. and William Encinosa, Ph.D • AHRQ - Preventing Disability in the Elderly With Chronic Disease

+50,000,000 observation

∗ 67 to 99 years ∗ full Part A and Part B entitlement throughout the last two years

of life ∗ Persons enrolled in managed care organizations were excluded

from the analysis. ∗ Patients with surgical admissions only were excluded (a patient ∗ whose only hospital admission was for bypass surgery could only

be assigned to ∗ the hospital where the surgery was performed) ∗ based on the first qualifying ∗ ICD-9-CM diagnosis code encountered on the claim closest to

death

Dartmouth – End of Life Trend Report

44 page report: Dartmouth Institute for Health Policy and Clinical Practice

∗ I don’t know what I don’t know

∗ Learning STATA ∗ Learning SAS ∗ Identify all readmissions

associated with the patients that passed during the years of collected data

∗ Combine patient data with hospital data

Experience

∗ Medicare Data ∗ Researchers’

assistance ∗ Resources (forums

and textbooks)

My Struggles My Supports

∗ Beauty of tutorials

∗ Frustration of poor organization / lack of standardization

∗ Importance of efficiency

∗ Value of programmer comments

Lessons Learned / Experience Gained

Claims that a lower patient-to-nurse ratio promotes better patient outcomes

1999 – Legislation signed into law

2002 – Final ratios hospitals would face are released

2004 – Mandate implemented

Background: California’s Nurse Mandate

∗ Linda H. Aiken, PhD, RN; Sean P. Clarke, PhD, RN; Douglas M. Sloane…

∗ Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and

Job Dissatisfaction ∗ each additional patient per nurse was associated with a 7% increase in the

likelihood of dying within 30 days of admission

∗ 7% increase in the odds of failure-to-rescue.

∗ 23% increase in the odds of burnout and a 15% increase in the odds of job dissatisfaction.

Policy

California’s Nurse to Patient Mandate

∗ Magnet Hospitals ∗ Hospital or department closings (not significant)

∗ Public reporting: Nurse to Patient Ratios – increased

competitiveness among hospitals ∗ Lower percentage of skilled nurses (BSN trained): paper

Propelled Research: 2056

∗ California hospitals on average followed

the trend of hospitals nationally by increasing their nursing skill mix, and they primarily used more highly skilled registered nurses to meet the staffing mandate

∗ staffing mandate resulted in roughly an

additional half-hour of nursing per adjusted patient day beyond what would have been expected in the absence of the policy

∗ Lower Medicare Mortality Among a Set of Hospitals Known for Good Nursing Care – Magnet Hospital have 9.4 fewer deaths per 1000 patients

∗ My part; literary reviews

California’s Nurse-to-Patient Mandate

∗ Inside the head of a researcher

∗ Discuss inherent problems

∗ Search for solutions

∗ Be part of the developmental processes

Tremendous Gain

∗ Established as a country in 1973

∗ 30% of world’s cranes in Dubai – 2008

∗ The UAE is classified as a high-income developing economy by the International Monetary Fund.

∗ A high per-capita nominal GDP of US$47,407 for the last fiscal year.

United Arab Emirates

∗ Monday, May 10th, 2010

∗ Dr. Lauren Arnold - consultant to the UAE Ministry of Health and Executive Director of the newly formed UAE Council on Nursing

∗ Operates out of the Office of Her Royal Highness Princess Haya

Dubai

∗ Ghada Sherry. Ghada is Head of practice Development Section,

Federal Department of Nursing, Ministry of Health ∗ Deputy Minister ∗ Dr. Fatima Rafai, Chief Nurse of UAE ∗ Dr. Linda Aiken ∗ Dr. Hanif Al Qassimi, Minister of Health for United Arab Emirates ∗ Dr. Lauren Arnold

∗ 30 general hospitals of over 100 beds in the UAE

∗ EU research protocol surveying nurses and patients

∗ Grant from Emirates Foundation and the Ministry

∗ Nursing survey - 8 pages, 15 questions each.

The Surveys

∗ Use empirical data to sculpt a modern healthcare system

∗ Very malleable – as oppose to the healthcare system of the United States

∗ Create a international model

Intent

∗ First – skim through packets searching for excessive mistakes.

∗ Interesting findings from first glance: Nurses were eager to vent.

∗ Physical and verbal abuse from patients, patients’ families, and superiors – Very Dissatisfied

Coding

∗ Properly construct survey ∗ Typos ∗ Leave no room to wiggle ∗ BASIC

∗ Importance of automated coding ∗ Countless work-hours ∗ Time consuming labor

Technical Lessons

∗ Matthew D McHugh, PhD, JD, MPH, RN, CRNP

∗ All personnel and faculty that make SUMR possible

∗ SUMR Scholars

Appreciation