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Understaffing and Infections

By Don Sadler

The Centers for Disease Control and Prevention (CDC) estimate that as many as 1.7 million hospital patients each year acquire an infection while being treated for other conditions. More than 98,000 of these patients die as a result of healthcare associated infections (HAIs) — or one out of every 17 patients.

A substantial body of research over the years has pointed to invasive devices and clinical practice as primary causes of these HAIs. However, some studies indicate another contributing factor to HAIs that can’t be overlooked: nurse understaffing and burnout.

Significant Associations

A study published in the May 2019 issue of the Journal of Nursing Administration examined whether HAIs and nurse staffing are associated using unit-level staffing data. Patients were tracked throughout their hospital stays and the unit on each day and shift were identified, which allowed direct measure of each patient’s exposure to staffing levels.

The study found significant associations between HAIs and nurse understaffing. The risk of HAIs at any given time in patients on units with nurse understaffing on both day and night shifts two days prior to infection onset was 15% higher than for patients in units staffed at or above 80% of the unit median.

In addition, the risk of HAIs in patients on units with nurse understaffing on both day and night shifts two days prior to infection onset was 11% higher than for patients in units that were adequately staffed.

“There’s definitely a lot of validity to this study,” says Peter F. Nichol, MD/PhD, associate professor of surgery in the Division of Pediatric Surgery at the University of Wisconsin SMPH. “It lines up with my personal observation that nurse shortages have a significant impact on HAIs and surgical site infections (SSIs) in patients coming out of the OR and on the floor.”

“Understaffing puts an enormous amount of pressure on nurses and creates an unsafe environment for both patients and these essential providers,” adds Hilary Babcock, MD, MPH, past president of the Society for Healthcare Epidemiology of America (SHEA).

More Study Results

Another study published in the American Journal of Infection Control had similar findings. This study found a significant association between patient-nurse staffing and both urinary tract infections (UTIs) and SSIs.

Overall, 16 patients out of every 1,000 acquired some type of infection while hospitalized. UTIs were the most common (8.6 per 1,000 patients), followed by SSIs (4.2 per 1,000 patients) and gastrointestinal infections (2.5 per 1,000 patients).

The study found a significant association between staffing and UTIs, where each additional patient assigned to a nurse was associated with an increase of nearly one infection per 1,000 patients. A similar finding was reported for SSIs.

In the study population, this would translate to about 1,350 additional infections for each patient added to a nurse’s workload.

“Our study and other research make it clear that as you increase the number of patients nurses have to care for, more patients are at risk for infection and infection-related outcomes such as morbidity and mortality,” says study co-author Jeannie P. Cimiotti, PhD, RN, FAAN, associate professor at the Nell Hodgson Woodruff School of Nursing at Emory University.

The Impact of Burnout

In addition to staffing shortages, Cimiotti and her team also measured the impact of nurse burnout on patient infections. More than one-third of all nurses in the study reported high levels of job burnout and this burnout was highly associated with both UTIs and SSIs.

“In other words, a 10% increase in a hospital’s composition of high-burnout nurses is associated with an increase of nearly one UTI and two SSIs per 1,000 patients,” Cimiotti explains. “So burnout contributes even more to increased patient infection rates than understaffing. This makes sense because increased workloads result in more burnout – it’s difficult to separate the two.”

Importantly, the researchers found that lowering nurse burnout reduces infection rates and the associated costs of infection across the range of burnout levels. “This is most pronounced when burnout is reduced by 30 percent,” says Cimiotti.

When this occurs, UTIs can be reduced by more than 4,000 infections and SSIs by more than 2,200 infections, the study found. This translates to annual hospital cost savings of between $28 million and $69 million.

“The takeaway is clear: Differences in nurse workloads across hospitals are strongly associated with transmission of infections,” says Cimiotti.

A Multi-Factorial Problem

Both Nichol and Cimiotti acknowledge that HAIs are a multi-factorial problem with many different potential causes. “Hospitals have done a number of things the past few years to try to drive down the rates of infection, but we’ve also seen high rates of nurse turnover,” says Nichol.

Of course, the nursing shortage has been well-publicized for years. According to the American Association of Colleges of Nursing, the number of nurses leaving the field each year has doubled over the past decade — from around 40,000 in 2010 to a projected 80,000 this year.

With more than half of nurses now 50 years of age or over, it’s projected that one million nurses will retire over the next decade. The Bureau of Labor Statistics projects the need for an additional 203,700 new nurses each year through 2026 to fill newly created positions and replace these retiring nurses.

Given these statistics, the solution to remaining fully staffed and helping nurses avoid burnout in order to reduce HAIs lies in creating a culture where nurses are appreciated, says Nichol.

“Many hospitals tend to pay lip service to this,” he says. “There’s no question that we need to double down when it comes to making sure nurses feel valued.”

Nichol recommends that hospitals “flatten the hierarchy” so nurses have more input when it comes to policies and procedures that affect the way they do their jobs. “With a vertical hierarchy it’s hard for those who see what needs to be done to get their voice heard and help bring about change.”

“The charge nurse who runs the OR is just as important as the surgeon because he or she has to coordinate and keep everything running smoothly,” Nichol adds. “But the charge nurse usually doesn’t have a seat at the decision-making table.”

Cimiotti concurs.

“It’s important to create a climate where everyone is respected. Unfortunately, we don’t see this in every hospital, which is disappointing to say the least,” Cimiotti says. “It doesn’t cost anything to create an environment where everyone’s input and opinion is valued.”

Patient Monitoring Innovations

Babcock says recent innovations that have improved patient monitoring can also help.

“Infection prevention and control training is a critical part of the solution,” she says. “Training provides frontline personnel with the information and skills they need to successfully apply best practices for safe care.”

“As the research has shown, when frontline providers have the resources they need, there are measurable improvements in the prevention of HAIs,” Babcock adds.

SHEA has released a new online training program, Prevention Course in Healthcare-Associated Infection Knowledge and Control (

“This course is designed to train frontline health care personnel in best practices to prevent and control HAIs and pathogens that can spread in the health care setting,” says Babcock.



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