Nurse Understaffing in NICU Linked to Increased Infections

Jenni Laidman

March 19, 2013

Understaffing in neonatal intensive care units (NICUs) was associated with an increased risk for hospital-acquired infections among very-low-birthweight (VLBW) infants in a study published online March 18 in JAMA Pediatrics.

Jeannette A. Rogowski, PhD, professor, University of Medicine and Dentistry of New Jersey School of Public Health, Piscataway, and colleagues conducted a retrospective cohort study that measured nurse staffing according to acuity-based guidelines established by the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, and the Association of Women's Health Obstetric and Neonatal Nurses.

The study looked at infection rates among all VLBW infants with a NICU stay of at least 3 days in the 67 NICUs of the Vermont Oxford Network, a national voluntary network of hospital NICUs. The study compared nurse staffing levels to the number of infections in blood or cerebrospinal fluid cultures more than 3 days after birth among 5771 infants discharged in 2008 and 5630 infants discharged in 2009.

The research determined that a 1–standard deviation (SD) higher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios for infection of 1.39 (95% confidence interval [CI], 1.19 - 1.62; P < .001) in 2008 and 1.39 (95% CI, 1.18 - 1.63; P < .001) in 2009. The results were adjusted for gestational age, 1-minute Apgar score, race and ethnicity, sex, multiple birth, presence of a major birth defect, vaginal delivery, and whether the mother received prenatal care.

Infection rates among VLBW infants were 16.6% in 2008 and 13.9% in 2009.

In comparing staffing levels to established guidelines, the researchers found the level of understaffing greatest among high-acuity infants. In 2009, hospitals understaffed 32% of NICU infants and understaffed 92% of high-acuity infants. Meeting minimum staffing requirements would require, on average, an additional 0.11 nurse per infant and an additional 0.39 nurse for each high-acuity infant, the authors report.

"This is a strong study that cautions hospital administrators not to cut back on nurse staffing," Patricia W. Stone, PhD, director, Center for Health Policy, Columbia University, New York, New York, told Medscape Medical News. Dr. Stone was not involved in this research. "It's timely in that the current climate of healthcare is changing. Nurses cost a lot. They're the largest labor force in the hospital. This shows that nurses matter. With the overall emphasis that HHS [US Department of Health and Human Services] has put on decreasing hospital infections, there is a trend for these infection rates to go down. As they go down, we have to remember what brought them down."

A coauthor reports equity interest in ArborMetrix Inc, which sells efficiency measurement systems and consulting services to insurers and hospitals. Another coauthor is chief executive and scientific officer of the Vermont Oxford Network. The remaining authors and Dr. Stone have disclosed no relevant financial relationships.

JAMA Pediatr. Published online March 18, 2013. Abstract