Associations Between Daily Nurse Staffing Levels and Daily Hospitalizations and ED Visits in Nursing Homes

Objectives: Although many prior studies have shown that high average levels of nurse staffing in nursing homes are associated with fewer hospitalizations, some studies have not, suggesting that the average nursing level may mask a more complex relationship. This study examines this issue by investigating the associations of daily staffing patterns and daily hospitalizations and emergency department (ED) visits. Design: Retrospective analyses of national Payroll Based Journal (PBJ) staffing data merged with the Minimum Data Set. Setting and Participants: A total of 15,718 nursing homes nationally reporting PBJ data during 2017e2019, their staff, and residents. Methods: We estimated facility-day-level models as conditional facility fixed-effect Poisson regressions with robust standard errors. The dependent variables were daily numbers of hospitalization and ED visits and the independent variables of interest were the number of registered nurse (RN), licensed practical nurse (LPN), and certified nurse assistant (CNA) hours on the same and prior days. Results: The daily number of hospital transfers averaged 0.28 (SD 0.21). Daily total direct-care staffing hours averaged 288.7 (SD 188.2), with RNs accounting for 35.0, LPNs for 68.7, and CNAs for 185.0. Higher staffing was associated with more hospitalizations on the concurrent day. Higher staffing on the day prior was associated with fewer hospitalizations. The effect size was larger for RNs and LPNs (same day similar to 2%; prior day - approximately -0.7% to -0.9%) than for CNAs (same day <1%; prior day < similar to 0.5%). ED visits not leading to hospitalizations, and analyses for subsamples exhibited similar findings. Conclusions and Implications: Our findings suggest that staff can address developing problems and prevent admissions the next day and identify emergent problems and hospitalize the same day. They also underscore the complex array of nursing home factors involved in hospitalization and ED visits, including the influence of daily staffing variation, suggesting the need for further research to better understand the associations between staffing and appropriate resident transfers to the hospital or the ED, and the potential implications for quality metrics in these domains.