Elsevier

Journal of Critical Care

Volume 41, October 2017, Pages 209-215
Journal of Critical Care

Pulmonary
Association between advanced practice nursing and 30-day mortality in mechanically ventilated critically ill patients: A retrospective cohort study

https://doi.org/10.1016/j.jcrc.2017.05.025Get rights and content

Highlights

  • Advanced practice nursing was significantly associated with reduction in mortality in mechanically ventilated patients.

  • Advanced practice nursing may be important for improved patient outcomes in the Japanese adult ICU.

  • This study has important implication for health care decision makers and policy makers.

Abstract

Purpose

Little is known about the association between advanced practice nursing and mortality. The aim of this study was to evaluate whether the presence of advanced practice nurses (APN), that is, certified nurse (CN) and certified nurse specialist (CNS) in intensive care, is associated with 30-day mortality for mechanically ventilated critically ill patients.

Materials and methods

Using a Japanese national in-patient database, we identified 45,620 patients who were admitted to an intensive care unit (ICU) and received mechanical ventilation within 2 days of hospital admission between 1 April 2014 and 31 March 2015. We assessed the association between the number of CN/CNSs per 10 adult ICU beds and 30-day mortality.

Results

We examined 8955 patients in 134 hospitals without CN/CNSs and 36,665 in 284 hospitals with CN/CNSs. Overall, the number of CN/CNSs per 10 adult ICU beds ranged from 0 to 7.5. In the multivariable analysis, the number of CN/CNSs per 10 adult ICU beds was significantly associated with a reduction in 30-day mortality (adjusted odds ratio 0.97; 95% confidence interval, 0.94–1.00; P = 0.023).

Conclusions

Our findings show that APNs may play an important role in improving patient outcome in the adult ICU.

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.

Section snippets

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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