PulmonaryAssociation between advanced practice nursing and 30-day mortality in mechanically ventilated critically ill patients: A retrospective cohort study
Introduction
Hospital nurses are required to provide high-quality care and patient safety [1], [2]. In particular, intensive care units (ICUs) require a higher nurse-to-bed ratio than do non-ICUs because ICU patients generally have a higher severity of illness. ICU patients need intensive treatment, continuous and advanced monitoring, and requiring specialized medical equipment [3], [4].
Previous studies have shown that staffing strategies targeting higher level of nurse care, including staffing with more highly educated nurses and lower patient-to-nurse ratios, were associated with better patient outcomes [5], [6], [7], [8], [9]. Several ICU studies have shown that better ICU nurse staffing (defined as lower patient-to-nurse ratio) is associated with better patient outcomes [10], [11], [12], [13], [14], [15], [16]. Another study suggested that better nurse work environments and higher level of nurse education were both associated with reduction in 30-day mortality in mechanically ventilated patients in ICUs [17].
According to the International Council of Nurses, advanced practice nurses (APNs) are: “registered nurses who have acquired the expert knowledge base, complex decision making skills, and clinical competencies for expanded practice” [18]. In the United States, APNs include nurse anesthetists, nurse midwifes, nurse practitioners, and clinical nurse specialists.
In Japan, there are three types of licensed nurse: registered nurse (RN), licensed practical nurse (LPN), and midwife. There is no licensing of midlevel medical providers, but two types of credentialed APN are recognized: certified nurse (CN) and certified nurse specialist (CNS). The Japan Nurse Association (JNA) introduced CN and CNS certification in intensive care in 1999 and 2005, respectively [19].
A recent systematic review suggested that in the United States, the presence of clinical nurse specialists in acute care settings may have reduced both length of stay and medical costs for hospitalized patients [20]; however, to our knowledge, no studies have examined the association between advanced practice nursing and patient mortality.
In the present study, we used data from a national inpatient database to evaluate the association between APNs (CNs and CNSs in intensive care) and mortality in adult ICUs in Japan.
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Data sources
Patient data were obtained from the Japanese Diagnosis Procedure Combination (DPC) system database [21]. The DPC database contains inpatient administrative claims and discharge data from acute care hospitals, which accounts for approximately 50% of all acute care inpatient data in Japan (academic hospitals are obliged to participate in the database, but the participation of community hospitals is voluntary).
The database includes the following information: hospital unique identifier; patient
Results
A total of 45,620 patients from 418 hospitals met the inclusion criteria during the study period. Among these, 8955 patients (19.6%) were admitted to hospitals without CNs or CNSs and 36,665 patients (80.4%) were admitted to hospitals with CNs or CNSs. There were 489 ICU CNs (58.6% of all ICU CNs) and 94 CNSs (70.1% of all ICU CNSs).
Table 1 shows the characteristics of the study patients, overall and stratified according to the presence or absence of CN/CNSs. The group without CN/CNS was more
Discussion
We examined the association of advanced practice nursing with 30-day mortality and found that higher number of CN/CNSs per 10 adult ICU beds was significantly associated with lower 30-day mortality for mechanical ventilated clinically ill patients in Japan. After adjustment for potentially confounding patient and hospital characteristics, each additional CN/CNS per 10 adult ICU beds was associated with an approximate 3% reduction in mortality.
Previous US studies have examined the association
Conclusions
In conclusion, the unit presence of greater number of advanced practice nurses was significantly associated with a reduction in 30-day mortality in critical illness requiring mechanical ventilation in critical care settings throughout Japan. Our findings show that advanced practice nursing may be important for improved patient outcomes in the ICU.
This study has important implication for other nation's health care decision makers and policy makers who may consider introducing APNs to improve the
Conflict of interests
None.
Role of funding source
This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (grant numbers: H29-Policy-Designated-009, H27-Policy-Strategy-011); and the Japan Agency for Medical Research and Development (AMED) (grant number: 16lk1310001h0001).
The funders had no role in the execution of this study or interpretation of the results.
Acknowledgements
Not applicable.
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