A longitudinal study on the variation of patient turnover and patient-to-nurse ratio: Descriptive analysis of a Swiss University Hospital (Preprint)

Background: Variations in patient demand increase the challenge of balancing high-quality nursing skill mixes against budgetary constraints. Developing staffing guidelines that allow high-quality care at minimal cost requires first exploring the dynamic changes in nursing workload over the course of a day. Objective: Accordingly, this longitudinal study analyzed nursing care supply and demand in 30-minute increments over a period of 3 years. We assessed 5 care factors: patient count (care demand), nurse count (care supply), the patient-to-nurse ratio for each nurse group, extreme supply-demand mismatches, and patient turnover (ie, number of admissions, discharges, and transfers). Methods: Our retrospective analysis of data from the Inselspital University Hospital Bern, Switzerland included all inpatients and nurses working in their units from January 1, 2015 to December 31, 2017. Two data sources were used. The nurse staffing system (tacs) provided information about nurses and all the care they provided to patients, their working time, and admission, discharge, and transfer dates and times. The medical discharge data included patient demographics, further admission and discharge details, and diagnoses. Based on several identifiers, these two data sources were linked. Results: Our final dataset included more than 58 million data points for 128,484 patients and 4633 nurses across 70 units. Compared with patient turnover, fluctuations in the number of nurses were less pronounced. The differences mainly coincided with shifts (night, morning, evening). While the percentage of shifts with extreme staffing fluctuations ranged from fewer than 3% (mornings) to 30% (evenings and nights), the percentage within "normal" ranges ranged from fewer than 50% to more than 80%. Patient turnover occurred throughout the measurement period but was lowest at night. Conclusions: Based on measurements of patient-to-nurse ratio and patient turnover at 30-minute intervals, our findings indicate that the patient count, which varies considerably throughout the day, is the key driver of changes in the patient-to-nurse ratio. This demand-side variability challenges the supply-side mandate to provide safe and reliable care. Detecting and describing patterns in variability such as these are key to appropriate staffing planning. This descriptive analysis was a first step towards identifying time-related variables to be considered for a predictive nurse staffing model.