1. Sofer, Dalia

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For hospitals facing financial trouble, increasing the number of patients seen by each nurse has been one way to control costs. But bottom-line assessments haven't taken into consideration such variables as length of hospital stay and mortality rates. In a recent study, researchers analyzed the cost-effectiveness of various nurse-staffing ratios-ranging from 8:1 to 4:1-from three viewpoints: labor costs alone, labor costs offset by costs associated with length of stay, and total costs incurred by the hospital when mandated 4:1 ratios were accompanied by wage increases.


They found that assigning eight patients to each nurse was always the least expensive option but the one associated with the highest patient mortality rate. And although each decrement in the ratio increased the cost per patient, the mortality rate declined. For example, when considering labor costs alone, changing the ratio of patients per nurse from eight to seven was associated with an increased cost of $46,000 per life saved. Savings from shortened length of stay offset only half of the increase in labor costs. And when the possibility of mandatory wage increases was taken into account, the incremental cost per life saved was $71,000 at five patients per nurse and $136,000 at four patients per nurse.


The increase in cost, the researchers argue, is in line with many other patient safety interventions: testing the U.S. blood supply for HIV, for example, costs $22,000 per life saved; thrombolytic therapy in acute myocardial infarction costs $182,000 per life saved; and cervical cancer screening with Papanicolaou tests costs $432,000 per life saved. Compared with these interventions, the researchers say, a patient-to-nurse ratio of 4:1-which never exceeded $449,000 per life saved-is reasonably priced. So why isn't it perceived as a necessary life-saving intervention?


Another study, published in the American Cancer Society journal Cancer, echoes these findings: of 1,302 bladder carcinoma patients who underwent cystectomy in 133 hospitals, those treated at hospitals that perform higher numbers of such procedures (high-volume hospitals) were 76% less likely to die than those receiving care at low-volume hospitals; the majority of deaths occurred more than a week after surgery, often a result of postoperative complications. Patients at high-volume hospitals fared better, not because of the number of beds or the annual occupancy rates; after adjustment for confounding variables, higher registered nurse-patient ratios were shown to reduce the mortality rate by more than 50%. Interestingly, low-volume hospitals with high nurse-patient ratios had lower mortality rates than poorly staffed low-volume hospitals, thus confirming the life-saving benefits of high nurse-patient ratios.


Rothberg MB, et al. Med Care 2005;43(8): 785-91

FIGURE. Lower patien... - Click to enlarge in new windowFIGURE. Lower patient-to-nurse ratios mean more time for patient education. In this photo from the National Cancer Institute, a nurse, right, teaches a woman with cancer and her husband how to administer chemotherapy.

Elting LS, et al. Cancer 2005; 104(5):975-84.