In 2012 Medicare spent $556 billion on healthcare with inpatient hospital costs comprising 25% of this spending and these costs are projected to grow by more than 4 percent annually in the coming years. Medicare generally pays hospitals a set fee (DRG or diagnostic related group) for a each inpatient admission and diagnosis, so hospitals have significant financial incentives to reduce the length of stay of a given patient. Bundling of care forces hospitals to accommodate these financial pressures by moving patients through hospital care and treatment faster than ever (Wachter et al. N Engl J Med. 1996;335:514-517). This increased throughput however been shown to not be without risk.
New research from Dr. Needleman of Harvard Medical School demonstrates the risk of death among hospital patients increased when nurses had a high turnover of patients during their shifts (N Engl J Med 2011; 364:1037-1045). This research is consistent with other groups which have consistently demonstrated the benefit of addditional nursing care: Increased nursing care for patients from additional registered nurses were associated with lower rates of ‘failure to rescue’ defined as pneumonia, shock or cardiac arrest (Silber et al Anesthesiology 2000;93:152-63 & Needleman et al N Engl J Med 2002; 346(22):1715-22).
Registered nurses oppose the trend towards rapid discharge and shorter hospital stays and as a result have become increasingly dissatisfied with the working conditions in hospitals. They report that they are spending less time taking care of increasingly ill patients and believe that the safety and quality of inpatient care are deteriorating (Buerhaus et al. Nurs Econ 2001;19:198-208). In an article in the August 2012 issue of the American Journal of Infection Control, Dr. Jeannie Cimiotti and colleagues identified a significant association between high patient-to-nurse ratios and nurse burnout resulting in increased urinary tract and surgical site infections. Furthermore, RN’s in general are an aging work force and over the next twenty years a large numbers of RNs are projected to retire which may add to the existing relative nursing shortage (Buerhaus et al. JAMA 2000;283: 2948-54).
Perhaps not suprisingly, risks for patients extend beyond the inpatient admission into the discharge phase. Highlighted in the document (which document? ) is that nearly 20%, or 2.3 million of hospitalized Medicare beneficiaries were readmitted to the hospital after 30 days over a one-year period. These incidents most frequently occur when a patient moves from a hospital or physician’s care to home without proper information or preparation. The risks become greater as patients are released from traditional health care settings quicker and with higher acuity of illness, surgical procedure, or disease. Following discharge from a hospital, it has been reported that 19%-23% of patients suffer an adverse event, most frequently an adverse drug event (Forster et al. J Gen Intern Med. 2005;20:317-323). In a further study, primary care physicians reported being unaware of 62% of the pending test results that returned after discharge, of which 37% were considered actionable. (Roy et al CL, Intern Med. 2005;143(2):121-128).
With Federal financial constraints leading to the increasing work load of our nurses, a higher burn out rate and poorer outcomes for out public, where does this leave the American patient? The Joint Commission recently published a statement on home care highlighting, “home care is a key step toward achieving optimal health outcomes” (Home – The Best Place for Healthcare Joint Commission, 2011).
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Wages for home healthcare workers has been a topic of dispute for a long time running. The question has been whether a home health employee should receive minimum wage and overtime pay if they work over 40 hours a week. This seems reasonable seeing that if the aide worked in a nursing home, they would get minimum wage under the Fair Labor Standards Act.
In 1974 Congress exempted people providing “companionship services” from the act which today has caused over 1.5 million home health workers to be excluded. When those lawmakers made this law three decades ago they did not even consider this field because it was virtually non-existent in that time. But now the industry does exist, it is growing and wants to keep the exemption in place.
This debate occurred both during the Clinton and Bush administrations as the former proposed ending the exemption while the latter reversed that course back to the status quo. And now it’s back as the Labor Department has announced that it intends to re-examine the exemption.
While this is happening, the Direct Care Alliance (representing mostly women who provide care) is lobbying the House and Senate to extend the FLSA to home care and improve training. The industry obviously has taken a strong stance against this legislation saying “clients will have no choice but to choose nursing homes”.
Already 21 states mandate minimum wage by paid to home health workers and another 15 states require overtime payment. But the industry is still butting heads with the nurses who work for them. This is a tough problem to solve because families already struggle with the expenses involved with home care while home aides are one of the lowest paid jobs in America. Let’s all hope that the lawmakers come to successful compromise solution that fits both sides needs in the end.
 Leann Reynolds, president of Homewatch CareGivers, http://newoldage.blogs.nytimes.com/2011/07/20/a-fair-wage-for-home-care-workers/?ref=health
It is well known that nurses play a pivotal role in the success of hospitals around the world. Physician Lewis Thomas put it perfectly in The Youngest Science, when he said: hospitals are “held together, glued together, enabled to function…by the nurses and nobody else” (Thomas, 1983: 66-67). Currently over 1.5 million registered nurses work in hospitals across the United States, yet the recent economic downturn and other unforeseen pressures have created a massive nursing shortage. This has brought up new concerns regarding the decrease in the quality and quantity of nursing care and its effects on patients’ recovery.
Several recent studies have found correlations between decreased nursing care and higher rates of adverse outcomes for patients. Needleman conclusively states that “in a large sample of hospitals from a diverse group of states…we found an association between the proportion of total hours of nursing care provided by registered nurses…and…length of stay and the rates of urinary tract infections, upper gastrointestinal bleeding, hospital-acquired pneumonia, shock or cardiac arrest, and failure to rescue”. Needleman’s conclusion was that as the total hours of nursing care increased, the length of stay and rate of infection decreased.
Similarly, Sochalski finds that there is a causal relationship between quality of care and patient workload. She states: “the attenuation of its effect suggests that workload affects quality of care both directly as well as through its effects on patient safety and unfinished work”.
These findings suggest a compelling reason to limit the duration of time spent in a busy and understaffed hospital to what is medically necessary. One can take advantage of care outside hospitals which guarantees extra nursing help while recovering in a familiar and calming environment.
 “RN (Registered Nurse) Salary Statistics”, http://onlinelpntorn.org/rn-registered-nurse-salary-statistics/
 Jack Needleman, Ph.D., Peter Buerhaus, Ph.D., R.N., Soeren Mattke, M.D., M.P.H., Maureen Stewart, B.A., and Katya Zelevinsky. “Nurse-Staffing Levels and the Quality of Care in Hospitals”. N Engl J Med 2002; 346:1715-1722
 Julie Sochalski, PhD, RN, FAAN. “Is More Better? The Relationship Between Nurse Staffing and the Quality of Nursing Care in Hospitals”. Med Care 2004;42: II-67–II-73