safety
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The frequency of pressure ulcers increases significantly when staffing agency nurses and overtime nurse hours increased at hospitals, according to researchers who cautioned skilled nursing providers who pursue similar staffing strategies.
The average use of agency nurses and overtime nurse hours surpassed safe thresholds for pressure ulcers by 140% and 63.6%, respectively, a study by researchers at The George Washington University found. They linked their findings to a 6.44% increase in pressure ulcers relative to agency nurse hours and a 2.09% increase related to added overtime hours.
Similar to hospitals, the internal configuration of nursing hours in long-term care facilities has changed dramatically through the years, study author Patricia Pittman told McKnight’s Long-Term Care News on Wednesday. The increased use of temporary nurses and nurses working extra hours were vital and needed options across healthcare during the pandemic. But there have been tradeoffs.
“Both overtime and agency nurse staffing hours have a beneficial effect on patient safety — up until a certain point,” explained Pittman, director of the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University. “When you pass what we call the breaking point, it starts to plummet. Think about it as an intervention or as a medication — if you take a certain amount of a drug, it’s good for you. You take too much, it’s not.”
She added that the lower occurrence of pressure ulcers in overtime staff could be simply attributed to some states, including California, Maine, Alaska, Connecticut and Texas, prohibiting the use of mandatory overtime.
Quality in question
Other research also has pointed to quality implications resulting from nursing homes’ dependence on staffing agency nurses.
A January study involving more than 80,000 US nursing home touchpoints found a link between the use of staffing agency nurses and lower quality ratings in the Centers for Medicare & Medicaid Services Five-Star system.
In fact, the use of agency registered nurses, licensed practical nurses and certified nursing assistants decreased a facility’s chance of attaining higher star ratings by 4%, 5% and 4%, respectively, researchers discovered.
The author of that study, Texas State University health services researcher Rohit Pradhan, told McKnight’s on Wednesday that while his research did not examine the prevalence of pressure ulcers, a 2024 analysis by researchers at the University of California, San Francisco, did. That study found that increasing CNAs hours through staffing agencies — from 0% to 100% — was associated with an approximate 19% increase in pressure ulcers.
John Bowblis, PhD, professor and research fellow at the Scripps Gerontology Center of Miami University, has extensively studied nursing home agency use, including its rise during the pandemic.
While agency staff may influence patient outcomes, he questioned if the new hospital-based study was truly able to discern whether it was agency or lower overall staffing levels in the included hospitals that increased pressure injury risk.
He noted that nursing homes often rely on agencies to bring their staffing up to standards dictated by state regulations — rather than hiring some temporary workers but not enough to reach previous coverage levels.
Even so, he noted that it would be important for nursing homes to consider the potential risk for lower quality care when bringing on new or rotating staff. He told McKnight’s it’s critical for facilities to identify whether the agency staff they hire are showing up for a paycheck or willing to be part of a caregiving team that buys into systems and standards.
He recommended using any agency staff consistently on the same unit and ensuring they know which residents need special attention.
“It really comes down to, has the facility found a way to manage agency staff use in a proper method, in a way that allows them to be successfully used,” he said. “Onboarding agency staff is important … but it’s less about knowing what the policies and procedures are and more about knowing which residents need a specific turing and repositioning plan implemented, knowing which residents need to be repositioned in a specific area.”
The root cause
While there is currently limited data on the fiscal ramifications of pressure ulcers in post-acute and long-term care, it’s estimated that hospital-acquired pressure ulcers cost approximately $26.8 billion annually.
For nursing homes to avert such outcomes, Pittman recommends providers get familiar with their own data.
“If we were doing research in long-term care, I would start with an examination of how agency nurse hours and overtime hours affect pressure ulcers,” she said. “It would behoove [providers] to look at this in their own facilities. It’s not hard. They have the data and should use it to inform their decisions about the extent to which they want to rely on agency and overtime.”
Pittman also said long-term care providers should use the recommendations she issued to hospital leaders to help lower the prevalence of pressure ulcers as they supplement their staffing needs.
Segmenting nurse hours to determine which demographics may be driving certain outcomes is a critical step in uncovering the source of the problem, she noted.
“Just as with hospitals, long-term care providers should be [dissecting] their nurse hours … by CNA, LPN, RN, etc., but also by education level and employment status, such as overtime, agency and regular hires,” she said. “That’s really important.”