Nursing Quality Indicators: Case Study

RTT1 Task 1
Shirley Krussel
Western Governor 's University

December 12, 2014
RTT1 Task 1
The National Database of Nursing Quality Indicators (NDNQI) established by the American Nurses Association (ANA), provides reports on how care, specifically provided by nurses, affects patient outcomes. Based on these reports, the ANA has developed a national set of nursing sensitive indicators that measure the process of care, the structure of care, and patient- focused outcomes in a health care setting. NDNQI 's aim is to help nurses plan and implement patient safety and quality improvements through evidence-based care (Montalvo, 2007).
Nursing-sensitive Indicators
In this case study of Mr. J’s hospital stay, actual and potential issues are presented. Mr. J is an elderly Jewish man with mild dementia who fell at home and fractured his hip. In the scenario presented he is restrained in bed, taking pain medications but is oriented, and the daughter reports a red area
on his back to the CNA helping Mr. J to the bathroom. Some of the indicators that would help the nurse identify issues that affect Mr. J’s outcomes are history of a fall, use of pain medication, alertness and orientation, decreased mobility secondary to restraint use and age, and skill mix of staff. Understanding the implications of these indicators can help the nurse plan, structure and improve patient safety and quality of care.
Quality Patient Care Nursing sensitive indicators help hospitals determine the relationship between patient outcomes and nursing care. Analyzing data on NSI’s can be used for quality improvement purposes and to support evidence-based decision-making.
Nursing hours per patient is a NSI that impacts patient outcomes. Eighty percent of respondents to a public opinion survey in 2005 said that the quality of nursing care is a very or somewhat important consideration in choosing a hospital (Robert Wood Johnson Foundation [RWJF], 2006, p. 1). There is a strong relationship between nurse/patient ratios and patient safety. Higher registered nurse staffing has been associated with improved quality of care.
Neonatal intensive care units (NICUs) care for the most critically ill infants. A stay in the NICU is one of the most expensive types of hospitalization and requires a high amount of nursing resources. Understaffing is associated with an increased incidence of nosocomial infection. In the NICU population, infection is associated with poor neurodevelopmental and growth outcomes, increased mortality, and longer hospital stay. A study in New York hospitals found that higher nurse hours per patient was associated with significantly lower infection rates (Cimiotti, Haas, Salman, & Larson, 2006). California has mandatory nurse-to-patient staffing requirements but very little is known about the adequacy of NICU staffing. Definitions of infant acuity levels do not exist.
Medicaid is the principal payer for the hospital care of more than one-third of preterm and low birth weight infants (Russell et al., 2007). Under the Affordable Care Act, the Center for Medicare and Medicaid Innovation to improve quality of care has already modified reimbursement for hospital-acquired infections (HAIs). Analysis of nurse-to-patient ratios in the NICU and the relationship to HAIs, poor outcomes, and prolonged stays is needed to assess staffing decisions and improve patient outcomes.
System Resources, Referrals, or Colleagues A problem that created an ethical issue in this scenario is that the Mr. J received a non-kosher meal. The nursing supervisor’s response, “just keep quiet”, sets the tone for how staff members will respond to other errors. Disclosure to the patient, family, physician and administration would have been more honest and respectful. Having the family find out later creates distrust of the system. As the supervisor, I would have notified the kitchen supervisor, also. However others needed to be informed—the patient, family and physician as well as administration. Using an incident reporting system would have alerted others that there is a problem within the system. Since this appears to be an ongoing issue, a task force to look at the hows and whys of this issue would be a good next step. I would include nursing and dietary staff, and members of the community--perhaps the local rabbi and a patient or family member. A good mix of people on a committee brings a better variety of problem solving ideas. Involving the Jewish community indicates that the hospital wants to improve customer satisfaction.

References
Cimiotti, J.
P., Haas, J., Salman, L., & Larson, E. L. (2006, August). Impact of staffing on bloodstream infections in the neonatal intensive care unit. JAMA Pediatrics, 160(8), 832-836. http://dx.doi.org/10.1001/archpedi.160.8.832
Montalvo, I. (2007, September). The National Database of Nursing Quality Indicators (NDNQI). The Online Journal of Issues in Nursing, 12(3). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.html
Robert Wood Johnson Foundation. (2006). Americans’ view of nursing care (2). Retrieved from https://folio.iupui.edu/bitstream/handle/10244/524/Research_Highlight_2_0604.pdf?sequence=2
Russell, R. B., Green, N. S., Steiner, C. A., Meikle, S., Howse, J. L., Poschman, K., ... Petrini, J. R. (2007, July 1). Cost of hospitilization for preterm and low birth weight infants in the United States. Pediatrics, 120(1), e1-e9.
http://dx.doi.org/10.1542/peds.2006-2386)