Variability of nursing complexity within medically homogeneous diagnosis-related groups: A retrospective analysis of pediatric electronic health records

Background: This study examined variability in nursing complexity among pediatric patients within the same Diagnosis-related group (DRG) and assessed whether exceeding DRG-specific length-of-stay (LOS) thresholds was associated with higher nursing complexity. Methods: A retrospective study analyzed electronic health records of pediatric inpatients admitted in 2022 to a tertiary hospital, focusing on the 20 most frequent DRGs. Nursing complexity was assessed using nursing diagnoses (NDs) recorded within 24 h of admission and nursing actions (NAs) documented during hospitalization. Group differences were assessed using independent-samples t-tests and Mann-Whitney U tests. Blockwise multivariable logistic regression estimated associations with LOS threshold exceedance: the first model included ND count adjusted for age, sex, DRG weight, and comorbidities, while the second additionally incorporated NA count. Results: Among 1204 patients, 4247 NDs and 22014 NAs were recorded. NDs ranged 1-14 and NAs 5-59, with marked intra- and inter-DRG variability. Patients exceeding LOS thresholds (2.6%) had higher ND and NA counts (mean 6.29 vs 3.45 and median 27 vs 17, respectively; both p < 0.001). In the fully adjusted model, each additional ND increased the odds of LOS threshold exceedance by 25% (OR = 1.25, 95% CI 1.09-1.43, p = 0.001), and each additional NA by 9% (OR = 1.09, 95% CI 1.05-1.14, p < 0.001). Conclusions: Nursing complexity varies within and across DRGs and is higher among patients exceeding LOS thresholds. Implications to practice: Standardized nursing data may complement DRG classifications to better reflect nursing complexity and inform future reimbursement models.