1. My Busy SUMR
By Egor Buharin
Mentored by Matthew D McHugh, PhD, JD, MPH, RN, CRNP

2. Interesting Situation
∗ Continuation of former research and new projects
∗ October, 2010 – Center for Health Outcomes and
Policy Research (CHOPR)
∗ Flurry of projects

3. Visual Diagrams – Impact of Nurse
Residency Programs

4. Visual Representation of research

5. Diagrams

6. Projects
∗ End-of-Life Care: statistical programming
∗ California’s Nurse-to-Patient Mandate
∗ United Arab Emirates – several thousand nurse and
patient surveys.

7. End of Life
∗ Set the scene.
∗ 2,423,995 people died in the U.S. Of these, estimated that 765,651 died in the
hospital – 32 percent (2007)
∗ Among the elderly, 31 percent of deaths occurred in the hospital
∗ Approximately 75% of 65+ people have at least one chronic condition
∗ Chronically ill patients often spend their last days in a hospital – society
∗ 50 percent of the conscious patients who die in the hospital have moderate-to-
severe pain at least half the time. – New England Journal of Medicine
∗ Passive euthanasia – legal
∗ Hospice
• The Costs of End-of-Life Hospitalizations, 2007 - Yafu Zhao, M.S. and William Encinosa, Ph.D
• AHRQ - Preventing Disability in the Elderly With Chronic Disease

9. +50,000,000 observation

10. Dartmouth – End of Life Trend
Report
44 page report: Dartmouth Institute for
Health Policy and Clinical Practice
∗ 67 to 99 years
∗ full Part A and Part B entitlement throughout the last two years
of life
∗ Persons enrolled in managed care organizations were excluded
from the analysis.
∗ Patients with surgical admissions only were excluded (a patient
∗ whose only hospital admission was for bypass surgery could only
be assigned to
∗ the hospital where the surgery was performed)
∗ based on the first qualifying
∗ ICD-9-CM diagnosis code encountered on the claim closest to
death

11. Experience
My Struggles My Supports
∗ I don’t know what I
don’t know ∗ Medicare Data
∗ Learning STATA ∗ Researchers’
∗ Learning SAS assistance
∗ Identify all readmissions
associated with the ∗ Resources (forums
patients that passed and textbooks)
during the years of
collected data
∗ Combine patient data
with hospital data

12. Lessons Learned / Experience Gained
∗ Beauty of tutorials
∗ Frustration of poor organization / lack of
standardization
∗ Importance of efficiency
∗ Value of programmer comments

13. Background: California’s Nurse
Mandate
 Claims that a lower patient-to-nurse ratio promotes better
patient outcomes
 1999 – Legislation signed into law
 2002 – Final ratios hospitals would face are released
 2004 – Mandate implemented

14. California’s Nurse to Patient Mandate
∗ Linda H. Aiken, PhD, RN; Sean P. Clarke, PhD, RN; Douglas M.
Sloane…
∗ Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and
Job Dissatisfaction
∗ each additional patient per nurse was associated with a 7% increase in the
likelihood of dying within 30 days of admission
∗ 7% increase in the odds of failure-to-rescue.
∗ 23% increase in the odds of burnout and a 15% increase in the odds of job
dissatisfaction.
Policy

15. Propelled Research: 2056
∗ Magnet Hospitals
∗ Hospital or department closings (not significant)
∗ Public reporting: Nurse to Patient Ratios – increased
competitiveness among hospitals
∗ Lower percentage of skilled nurses (BSN trained): paper

16. California’s Nurse-to-Patient
Mandate
∗ California hospitals on average followed
the trend of hospitals nationally by increasing their
nursing skill mix, and they primarily used more highly skilled registered
nurses to meet the staffing mandate
∗ staffing mandate resulted in roughly an
additional half-hour of nursing per adjusted
patient day beyond what would have been expected
in the absence of the policy
∗ Lower Medicare Mortality Among a Set of Hospitals
Known for Good Nursing Care – Magnet Hospital
have 9.4 fewer deaths per 1000 patients
∗ My part; literary reviews

17. Tremendous Gain
∗ Inside the head of a researcher
∗ Discuss inherent problems
∗ Search for solutions
∗ Be part of the developmental processes

18. United Arab Emirates
∗ Established as a country in 1973
∗ 30% of world’s cranes in Dubai – 2008
∗ The UAE is classified as a high-income developing economy by
the International Monetary Fund.
∗ A high per-capita nominal GDP of US$47,407 for the last fiscal
year.

19. Dubai
∗ Monday, May 10th, 2010
∗ Dr. Lauren Arnold - consultant to the
UAE Ministry of Health and Executive
Director of the newly formed UAE
Council on Nursing
∗ Operates out of the Office of Her
Royal Highness Princess Haya

20. ∗ Ghada Sherry. Ghada is Head of practice Development Section,
Federal Department of Nursing, Ministry of Health
∗ Deputy Minister
∗ Dr. Fatima Rafai, Chief Nurse of UAE
∗ Dr. Linda Aiken
∗ Dr. Hanif Al Qassimi, Minister of Health for United Arab Emirates
∗ Dr. Lauren Arnold

21. The Surveys
∗ 30 general hospitals of over 100 beds in the UAE
∗ EU research protocol surveying nurses and patients
∗ Grant from Emirates Foundation and the Ministry
∗ Nursing survey - 8 pages, 15 questions each.

22. Intent
∗ Use empirical data to sculpt a modern healthcare
system
∗ Very malleable – as oppose to the healthcare system
of the United States
∗ Create a international model

23. Coding
∗ First – skim through packets searching for excessive
mistakes.
∗ Interesting findings from first glance: Nurses were
eager to vent.
∗ Physical and verbal abuse from patients, patients’
families, and superiors – Very Dissatisfied

24. Technical Lessons
∗ Properly construct survey
∗ Typos
∗ Leave no room to wiggle
∗ BASIC
∗ Importance of automated coding
∗ Countless work-hours
∗ Time consuming labor

25. Appreciation
∗ Matthew D McHugh, PhD, JD, MPH, RN, CRNP
∗ All personnel and faculty that make SUMR possible
∗ SUMR Scholars