The Relationship between Nursing Specialty Certification and Surgical Site Infection Rates in Acute Care Hospitals

There is limited research examining whether nursing specialty certification improves patient outcomes. Researchers have not studied the relationship between specialty certified nurses and one of the most common complications of surgical care, surgical site infections (SSI). Urban [1] estimated that costs per SSI vary from $400 for superficial SSI to $30,000 per SSI of serious organ or space infections. Other costs are more difficult to translate into financial terms, such as pain, distress, functional impairment, and mortality.

Our study purpose is to examine the relationship between nursing specialty certification rates and SSI rates in US acute care hospitals using merged data from the National Database of Nursing Quality Indicators® (NDNQI®) and the National Healthcare Safety Network (NHSN). Our study rationale is that identification of specialty certification as a factor that reduces SSI would be supportive of promoting specialty certification among nurses caring for surgical patients globally, which is consistent with the language and intent of the Institute of Medicine ‘Future of Nursing’ [2] report. Specific aims are:

1. Examine the relationship between the percent of perioperative area nurses holding specialty certification (CAPA, CPAN, CNOR/CRNFA) and hospital surgical site infection rates.
2. Examine the relationship between the percent of surgical intensive care unit, surgical unit, and medical-surgical combined unit nurses holding specialty certification (any national specialty certification) and hospital surgical site infection rates.
3. Examine the relationship between the number of wound and ostomy certified nurses and hospital surgical site infection rates.
4. Explore whether the perceived autonomy of specialty certified nurses moderates the relationship between specialty certification rates and hospital surgical site infection rates.
5. Explore whether the processes of decision making and nurse – physician relations mediates the relationship between specialty certification rates and hospital surgical site infection rates.

 Our study methodology is a retrospective, secondary analysis of merged data from NDNQI and NHSN. All NDNQI hospitals in the US that submitted quarterly administrative staffing data and annual RN survey data for the year 2014 are being invited to participate in the study by downloading their NHSN SSI csv files to NDNQI.

 Variable selection for our study is informed by Donabedian’s framework in which the structure and processes of care influence the outcomes of care [3,4]. Structure refers to setting attributes in which patient care takes place. Process is how things work in a hospital or unit and what is done for/to patients. Patient outcomes are results of care and include adverse outcome measures. Our main study structure variables are specialty certification rates (number of wound and ostomy certified nurses at the hospital level; percent of specialty certified nurses in perioperative areas; percent of specialty certified nurses in surgical intensive care units; percent of specialty certified nurses in surgical units; and percent of specialty certified nurses in medical-surgical combined units) and nurse autonomy. Our study process variables process variables are decision making and nurse – physician relations. Our study outcome variable is SSI. We also will control for a range of hospital structure characteristics [e.g., Magnet status, bed size, ownership, teaching status, case mix index, mean American Society of Anesthesiologists (ASA) score] and unit-type structure characteristics (e.g., staffing, skill mix, education, experience).

 Analysis includes generalized linear regression models at the hospital level. We will fit each model using a Poisson-based count of SSIs and the log of total number of operations performed as the exposure, and include specialty certification predictors and all control variables. Poisson-based models account for the zero-truncated, and often skewed SSI data.

Preliminary findings will be presented in the poster.

 At the completion of our study, it is our expectation that we will have beginning evidence about whether increasing nursing specialty certification rates in acute care hospitals should be a part of SSI prevention strategies globally. The study is expected to have a potentially important impact for both of promoting specialty certification among nurses caring for surgical patients and decreasing costly surgical site infections among patients in acute care settings.