Abstract
OBJECTIVES: To determine the association between nurse staffing and postsurgical outcomes for older black adults, including 30-day mortality and failure to rescue. DESIGN: A cross-sectional study of University of Pennsylvania Multi-State Nursing Care and Patient Safety Survey data, linked to 2006-2007 administrative patient discharge data from four states (CA, PA, NJ, FL), American Hospital Association Annual Survey data, and a U.S. Census-derived measure of socioeconomic status (SES). Risk-adjusted logistic regression models with correction for clustering were used for the analysis. SETTING: Five hundred ninety-nine adult nonfederal acute care hospitals in California, Pennsylvania, New Jersey, and Florida PARTICIPANTS: Five hundred forty-eight thousand three hundred ninety-seven individuals ages 65 and older undergoing general, orthopedic, or vascular surgery (94% white, 6% black). MEASUREMENTS: Thirty-day mortality and failure to rescue (death after a complication). RESULTS: In models adjusting for sex and age, 30-day mortality was significantly higher for black than white participants (odds ratio (OR) = 1.42, 95% confidence interval (CI) = 1.32-1.52). In fully adjusted models that accounted for SES, surgery type, and comorbidities, as well as hospital characteristics, including nurse staffing, the odds of 30-day mortality were not significantly different for black and white participants. In the fully adjusted models, one additional patient in the average nurse's workload was associated with higher odds of 30-day mortality for all patients (OR = 1.03, 95% CI = 1.01-1.05). A significant interaction was found between race and nurse staffing for 30-day mortality, such that blacks experienced higher odds of death with each additional patient per nurse (OR = 1.10, 95% CI = 1.03-1.18) compared to whites (OR = 1.03, 95% CI = 1.01-1.06). Similar patterns were detected in failure-to-rescue models. CONCLUSION: Older surgical patients experience poorer postsurgical outcomes, including mortality and failure to rescue, when cared for by nurses with higher workloads. The effect of nurse staffing inadequacies is more significant in older black individuals.