The association between nurse staffing and quality of care in emergency departments: A systematic review

Background: The relationship between nurse staffing, skill-mix and quality of care has been well-established in medical and surgical settings, however, there is relatively limited evidence of this relationship in emergency departments. Those that have been published identified that lower nurse staffing levels in emergency departments are generally associated with worse outcomes with the conclusion that the evidence in emergency settings was, at best, weak. Methods: We searched thirteen electronic databases for potentially eligible papers published in English up to December 2023. Studies were included if they reported on patient outcomes associated with nurse staffing within emergency departments. Observational, cross-sectional, prospective, retrospective, interrupted time-series designs, difference-in-difference, randomised control trials or quasi-experimental studies and controlled before and after studies study designs were considered for inclusion. Team members independently screened titles and abstracts. Data was synthesised using a narrative approach. Results: We identified 16 papers for inclusion; the majority of the studies (n = 10/16) were observational. The evidence reviewed identified that poorer staffing levels within emergency departments are associated with increased patient wait times, a higher proportion of patients who leave without being seen and an increased length of stay. Lower levels of nurse staffing are also associated with an increase in time to medications and therapeutic interventions, and increased risk of cardiac arrest within the emergency department. Conclusion: Overall, there remains limited high-quality empirical evidence addressing the association between emergency department nurse staffing and patient outcomes. However, it is evident that lower levels of nurse staffing are associated with adverse events that can result in delays to the provision of care and serious outcomes for patients. There is a need for longitudinal studies coupled with research that considers the relationship with skill-mix, other staffing grades and patient outcomes as well as a wider range of geographical settings. Tweetable abstract: Lower levels of nurse staffing in emergency departments are associated with delays in patients receiving treatments and poor quality care including an increase in leaving without being seen, delay in accessing treatments and medications and cardiac arrest

Evaluation of the pilot implementation of the Framework for Safe Nurse Staffing and Skill-Mix in Emergency Care Settings - Report 2

Arising from efforts to introduce a systematic approach to the determination of safe and appropriate nurse staffing levels in the Irish healthcare system, where historical need and legacy issues were often key determinants in staffing decisions, the Department of Health published a policy document titled: A Framework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Care Settings in Ireland (Department of Health 2018) (henceforth referred to as the Framework). Based on the research undertaken by a research team from University College Cork, the University of Southampton, University of Technology Sydney, and National University of Ireland Galway (Drennan at al. 2018), this report outlined a number of recommendations to ensure staffing levels in medical and surgical wards in acute hospitals were safe and effective in the delivery of care. In a continuation of this evidence-based approach, the Department of Health made the decision to extend the model to develop a framework for emergency care settings; this resulted in the publication of a draft document titled: A Pilot to Implement the Framework for Safe Nurse Staffing and Skill Mix in Emergency Care Settings (Department of Health, 2018). This document outlined a number of recommendations to ensure the safe staffing of emergency care settings. Central among these recommendations was the introduction of a systematic approach to the determination of staffing levels, the adjustment of skill mix to ensure that care was delivered by 85% RN and 15% HCA, and to ensure that the CNM 2 role was 100% supervisory. The research in this report provides data on the implementation of the recommendations of the Draft Framework in three emergency departments (EDs) and one injury unit (IU). Exploring the extent to which changes in staffing within the selected departments have had an impact on patientsâ experience within the emergency care setting, as well as on the experience of the nursing and healthcare assistant workforce and on organisational factors, this report outlines the methods and results of the programme of research examining the impact of introducing a pilot safe staffing framework to emergency care settings

IL-1α/IL-1R1 expression in chronic obstructive pulmonary disease and mechanistic relevance to smoke-induced neutrophilia in mice.

BACKGROUND: Cigarette smoking is the main risk factor for the development of chronic obstructive pulmonary disease (COPD), a major cause of morbidity and mortality worldwide. Despite this, the cellular and molecular mechanisms that contribute to COPD pathogenesis are still poorly understood. METHODOLOGY AND PRINCIPAL FINDINGS: The objective of this study was to assess IL-1 α and β expression in COPD patients and to investigate their respective roles in perpetuating cigarette smoke-induced inflammation. Functional studies were pursued in smoke-exposed mice using gene-deficient animals, as well as blocking antibodies for IL-1α and β. Here, we demonstrate an underappreciated role for IL-1α expression in COPD. While a strong correlation existed between IL-1α and β levels in patients during stable disease and periods of exacerbation, neutrophilic inflammation was shown to be IL-1α-dependent, and IL-1β- and caspase-1-independent in a murine model of cigarette smoke exposure. As IL-1α was predominantly expressed by hematopoietic cells in COPD patients and in mice exposed to cigarette smoke, studies pursued in bone marrow chimeric mice demonstrated that the crosstalk between IL-1α+ hematopoietic cells and the IL-1R1+ epithelial cells regulates smoke-induced inflammation. IL-1α/IL-1R1-dependent activation of the airway epithelium also led to exacerbated inflammatory responses in H1N1 influenza virus infected smoke-exposed mice, a previously reported model of COPD exacerbation. CONCLUSIONS AND SIGNIFICANCE: This study provides compelling evidence that IL-1α is central to the initiation of smoke-induced neutrophilic inflammation and suggests that IL-1α/IL-1R1 targeted therapies may be relevant for limiting inflammation and exacerbations in COPD