《柳叶刀杂志》：护士数量和学历可影响患者的死亡率

　　本文在线发表于2014年2月26日的《柳叶刀杂志》官方网站：
　　Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study
　　九个欧洲国家的护士数量和学历与院内死亡率的关系：一项回顾性观察性研究
　　Background
　　Austerity measures and health—system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures.
　　背景：财政紧缩措施和医疗系统改革使医院面临财政开支危机，可对患者的转归产生负面影响。RN4CAST旨在探究如何进行关于护理服务的决策，这是医院营运开销中最大的一环。我们希望了解9个参与RN4CAST研究的欧洲国家中，患者/护士比例和护士的学历是否与常规手术后的院内死亡率有关。
Methods
For this observational study, we obtained discharge data for 422 730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26 516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics.
　　方法：回顾性观察性研究，涉及9个欧洲国家300家医院共计422 730名50岁以上进行常规手术的患者。主要研究终点为30天院内死亡率。参与研究的护士有26 516名。（其余略）
Findings
An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031—1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886—0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients.
　　结果：随着护士的工作量增加一位患者，那么住院患者的30天内死亡的可能性将增加7%（比值比1·068）。如果拥有本科学位的护士增加10%，那么该指标将降低7%（比值比0·929）。如果一家医院的本科学位护士比例达60%且每名护士平均仅负责六位患者，那么该院的院内死亡率将降低30%（与本科护士比例30%、平均负责八位患者的医院相比）。
Interpretation
Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths.
　　结论：如果通过降低护士数量的方式以节约开支，那么患者的转归将受到负面影响。如果强调护士需要拥有本科学历，那么将有助降低可预防的院内死亡。