Nursing Excellence Improves Outcome for High-Risk Infants

Joe Barber Jr, PhD

April 24, 2012

April 24, 2012 — Very low-birth-weight (VLBW) infants born in hospitals with the recognition of nursing excellence (RNE) designation have better outcomes for certain measures of morbidity and mortality, according to the findings of a cross-sectional cohort study.

Eileen T. Lake, PhD, RN, from the University of Pennsylvania in Philadelphia, and colleagues published their findings in the April 25 issue of JAMA.

The authors noted the importance of nursing care in neonatal intensive care units (NICUs). "To intervene before the onset of life-threatening problems, nurses must make complex assessments, implement highly intensive therapies, and make immediate adjustments dependent on infant response," the authors write. "Nurse handling of an infant and recognition and response to subtle cues that an infant is distressed may support infant hemodynamic stability and reduce the likelihood of intraventricular hemorrhage."

The authors included 72,235 VLBW infants weighing 501 to 1500 g born in 1 of 558 Vermont Oxford Network hospital NICUs between January 1, 2007, and December 31, 2008. After adjustment for the higher risk profile of infants born in RNE hospitals, infants born in these hospitals had significantly lower risks for 7-day mortality (7.0% vs 7.4% for those born in RNE hospitals vs non-RNE hospitals, respectively; adjusted odds ratio [OR], 0.87; 95% confidence interval [CI], 0.76 - 0.99; P = .04); infection (16.7% vs 18.3% respectively; adjusted OR, 0.86; 95% CI, 0.75 - 0.99; P = .04); and severe intraventricular hemorrhage (7.2% vs 7.4%, respectively; adjusted OR, 0.88; 95% CI, 0.78 - 1.00; P = .045).

The authors excluded outborn infants, infants with incomplete infant characteristics, and those with missing death data. The authors performed logistic regression using RNE status, patient risk adjusters, and NICU- and hospital-level covariates as the independent variables.

Compared with non-RNE hospitals, RNE hospitals included a higher percentage of not-for-profit institutions (87% vs 71%), had more registered nurse hours (hours per patient-day: 10.5 vs 9.3), were twice as likely to be teaching hospitals (55% vs 27%), and served a larger volume of VLBW infants (93 vs 74). When jointly considering the 5 outcomes of 7-day mortality, 28-day mortality, infection, severe intraventricular hemorrhage, and in-hospital mortality, the researchers found that infants born in RNE hospitals had a lower risk for a poor outcome than those born in non-RNE hospitals (adjusted OR, 0.88; 95% CI, 0.83 - 0.94; P < .001).

The limitations of the study included its cross-sectional design, the fact that the Vermont Oxford Network is not fully representative of US hospitals with NICUs, and the exclusion of outborn infants.

The authors indicated that their findings suggest an association between RNE designation and quality of care. "The better outcomes observed in VLBW infants in RNE hospitals may reflect higher-quality NICU and obstetric care," the authors write. "Thus, RNE status may serve as a marker for an institution-wide commitment to optimizing outcomes."

Systems of Quality Improvement Should Extend Beyond Hospitals

In a linked commentary, Wanda D. Barfield, MD, MPH, from the Centers for Disease Control and Prevention, in Atlanta, Georgia, writes that despite its benefits, quality nursing and medical care in the NICU alone is not sufficient to improve neonatal survival. "Other systems that could be assessed for quality include the provision of maternal, preconception, and interconception care, as well the provision of risk-appropriate prenatal and intrapartum care; antenatal and neonatal transport systems; laboratory, radiology, and medical record systems; staffing; family support; and public health programs," writes Dr. Barfield. "Systems for quality improvement ideally should extend beyond individual hospitals and networks of hospitals."

The study was supported by a Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative grant and the National Institute of Nursing Research, National Institutes of Health. Dr. Lake received an honorarium for remarks at the 2010 American Nurses Credentialing Center Research Symposium. A coauthor holds an equity interest in ArboMetric Inc, a company that sells efficiency measurement systems and consulting services to hospitals and insurers. Another coauthor is the chief executive and scientific officer of the Vermont Oxford Network. The remaining authors and commentator have disclosed no relevant financial relationships.

JAMA. 2012;307:1709-1716.



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