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OBJECTIVE: There is growing evidence that low nurse staffing jeopardizes quality of patient care. The objective of the study was to determine whether low staffing level increases the infection risk in critical care. DESIGN: Observational, single-center, prospective cohort study. SETTING: Medical intensive care unit of the University of Geneva Hospitals, Switzerland. PATIENTS: All patients admitted over a 4-yr period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Study variables included all infections acquired in critical care, daily nurse-to-patient ratio, demographic characteristics, admission diagnosis and severity score, comorbidities, daily individual exposure to invasive devices, and selected drugs. Of a cohort of 1,883 patients totaling 10,637 patient-days, 415 (22%) developed at least one healthcare-associated infection while in critical care. Overall infection rate was 64.5 episodes per 1000 patient-days. Infected patients experienced higher mortality with a longer duration of stay both in critical care and in the hospital than noninfected patients (all p < .001). Median 24-hr nurse-to-patient ratio was 1.9. Controlling for exposure to central venous catheter, mechanical ventilation, urinary catheter, and antibiotics, we found that higher staffing level was associated with a >30% infection risk reduction (incidence rate ratio, 0.69; 95% confidence interval, 0.50-0.95). We estimated that 26.7% of all infections could be avoided if the nurse-to-patient ratio was maintained >2.2. CONCLUSIONS: Staffing is a key determinant of healthcare-associated infection in critically ill patients. Assuming causality, a substantial proportion of all infections could be avoided if nurse staffing were to be maintained at a higher level. [ABSTRACT FROM AUTHOR]

Purpose of Review: There is growing concern that changes in nurse workforce and hospital-restructuring interventions negatively impact on patient outcomes. This review focuses on the association between understaffing and health-care-associated infections., Recent Findings: There is a large number of studies showing that overcrowding, understaffing or a misbalance between workload and resources are important determinants of nosocomial infections and cross-transmission of microorganisms. Importantly, not only the number of staff but also the level of their training affects outcomes. The nurse workforce is ageing, mainly due to fewer individuals' engaging in a nursing career. This phenomenon, combined with cost-driven downsizing, contributes to a nursing shortage, and this tendency is not expected to revert unless important system changes are implemented. The causal pathway between understaffing and infection is complex, and factors might include lack of time to comply with infection control recommendations, job dissatisfaction, job-related burnout, absenteeism and a high staff turnover., Summary: The evidence that cost-driven downsizing and changes in staffing patterns causes harm to patients cannot be ignored, and should not be considered as an inevitable outcome. More research is needed to better define the optimal patient-to-nurse ratio in various hospital settings and to estimate the economical impact of the nursing shortage. All quality-improvement interventions should carefully take into account systems and processes to be successful, as the issue of staffing is essentially a structural problem.

Objective: To determine whether changes have occurred at our center in the incidence, patterns of organ dysfunctions, prognostic factors, and case-fatality rate of bacteremic sepsis., Design: Retrospective comparative study (1984-1988 vs. 1994-1997)., Setting: University hospital surgical intensive care unit., Patients: A total of 372 critically ill patients with sepsis and positive blood cultures., Intervention: None., Measurements and Main Results: In the 1984-1988 study, 176 patients developed bacteremic sepsis (3.2 per 100 admissions), with a fatality rate of 35% at 28 days, whereas in the 1994-1997 study, 196 patients had bacteremic sepsis (4.3 per 100 admissions), with a 28-day fatality rate of 37%. The frequency of primary bacteremia increased from 21% to 47% (p <.001), paralleled by an increase in the proportional frequency of Gram-positive microorganisms. In 1984-1988, 69% (n = 120) of patients had at least one organ dysfunction, compared with 80% (n = 156) in 1994-1997 (p =.02). The prevalence of pulmonary and cardiac dysfunction increased. The case- fatality rate of septic shock remained high (69% vs. 68%). For both cohorts, the two strongest predictors of mortality remained the Acute Physiology and Chronic Health Evaluation II score at the onset of sepsis and the number of evolving organ dysfunctions., Conclusion: The fatality rate of bacteremic sepsis remained constant over the study period, despite an increased incidence of bacteremia and associated organ dysfunction. Continued efforts need to be directed toward the prevention of bacteremic sepsis, given the magnitude and poor prognosis of this syndrome.