Discussion: Impact of Nursing Understaffing on Patient Health Case Study
Discussion: Impact of Nursing Understaffing on Patient Health Case Study
Discussion: Impact of Nursing Understaffing on Patient Health Case Study ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Impact of Nursing Understaffing on Patient Health Case Study Compare this case study to your nursing practice and give a similar example from your nursing experience in which you might have run into on staffing or a similar situation (During nursing school rotations). v Other universitys information is not acceptable to use to support/validate your central ideas. They are not peer research based articles(This includes blogs or ATI). Please include research articles no older than 5 yrs from todays date. Please follow the citations guidelines. PLEASE WATCH THE LINK PROVIDED to do the case study https://drive.google.com/file/d/1Zg3FmoO4cHkqBRRhp There are 3 files attached for you to get more information about the research, make sure to cite the PDF file. The video is from website https://learn.westcoastuniversity.edu/bbcswebdav/p (most likely you wont have access to the link, thats why I made a google drive link, just use the west coast university link to reference and cite the paper). Must follow the rubric!!! screen_shot_2020_09_29_at_1.24.42_pm.png screen_shot_2020_09_29_at_1.25.25_pm.png poa130001_444_450.pdf ARTICLE Nurse Staffing and NICU Infection Rates Jeannette A. Rogowski, PhD; Douglas Staiger, PhD; Thelma Patrick, PhD, RN; Jeffrey Horbar, MD; Michael Kenny, MS; Eileen T. Lake, PhD, RN Importance: There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights. Objective: To study the adequacy of NICU nurse staff- ing in the United States using national guidelines and analyze its association with infant outcomes. Design: Retrospective cohort study. Data for 2008 were collected by web survey of staff nurses. Data for 2009 were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010). Setting: Sixty-seven US NICUs from the Vermont Ox- ford Network, a national voluntary network of hospital NICUs. Main Outcomes and Measures: An infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth among VLBW inborn infants. The hypothesis was formulated prior to data collection. Results: Hospitals understaffed 31% of their NICU infants and 68% of high-acuity infants relative to guidelines. To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.34 of a nurse per high-acuity infant. Very low-birth-weight infant infection rates were 16.4% in 2008 and 13.9% in 2009. A 1 standard deviationhigher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios of 1.39 (95% CI, 1.191.62; P ? .001) in 2008 and 1.40 (95% CI, 1.19-1.65; P? .001) in 2009. Discussion: Impact of Nursing Understaffing on Patient Health Case Study Exposures: We measured nurse understaffing relative Conclusions and Relevance: Substantial NICU nurse understaffing relative to national guidelines is widespread. Understaffing is associated with an increased risk for VLBW nosocomial infection. Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants. to acuity-based guidelines using 2008 survey data (4046 nurses and 10 394 infant assignments) and data for 4 complete shifts (3645 nurses and 8804 infant assignments) in 2009-2010. JAMA Pediatr. 2013;167(5):444-450. Published online March 18, 2013. doi:10.1001/jamapediatrics.2013.18 Participants: All inborn very low-birth-weight (VLBW) infants, with a NICU stay of at least 3 days, discharged from the NICUs in 2008 (n = 5771) and 2009 (n=5630). All staff-registered nurses with infant assignments. N EONATAL INTENSIVE CARE units (NICUs) care for the most critically ill infants. Neonatal intensive care unit stays are among the most expensive hospitalizations1 and require high levels of nursing resources. Very little is known about the adequacy of staffing in US NICUs. Acuity-based staffing For editorial comment see page 485 Author Affiliations are listed at the end of this article. guidelines for neonatal nursing2 were recently reaffirmed by national medical and nursing bodies,3,4 although definitions of infant acuity levels do not exist. It is not JAMA PEDIATR/ VOL 167 (NO. 5), MAY 2013 444 known how well the guidelines are followed or how guideline adherence relates to infant outcomes. The guidelines specify ranges of nurse to patient ratios across infant acuity levels, as well as requisite nurse training and experience. For instance, infants with the lowest acuity levels have a recommended nurse to patient ratio of 1 to 3 or 4. In contrast, the highest acuity infants have recommended ratios of 1 or more nurses per patient. Furthermore, the guidelines also address the level of education and experience of the nurses, noting that registered nurses in the NICU should have specialty certification or advanced training. They also should be experienced in caring for unstable WWW.JAMAPEDS.COM ©2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ by Jennifer Grossner on 09/28/2015 Author Aff Departmen and Policy, Health, Uni and Dentist Piscataway, Rogowski); Economics Hanover, N National Bu Research, C Massachuse College of N University, Patrick); D Pediatrics, Vermont (M Oxford Net Burlington, Center for H and Policy Nursing, D Sociology, L Institute of University Philadelphi Table 1. Definitions for Infant Acuity Levels Level Care Provided per Newborn Requirement According to Guideline3,4 1 Continuing care 2 Intermediate care 3 Intensive care 4 Multisystem support 5 Unstable, requiring complex critical care Definition Infant only requiring PO or NG feedings, occasional enteral medications, basic monitoring (may or may not have a hep lock for medications). Discussion: Impact of Nursing Understaffing on Patient Health Case Study Stable infant with established management plan, not requiring significant support Eg, room air, supplemental oxygen or low-flow nasal cannula, several medications Infant is stabilized, although requires frequent treatment and monitoring to assure maintenance of stability Eg, ventilator, CPAP, high-flow nasal cannula, multiple intravenous needs via central or peripheral line Infant requires continuous monitoring and interventions Eg, conventional ventilation, stable on HFV, continuous drug infusions, several intravenous fluid changes via central line Infant is medically unstable and vulnerable, requiring many simultaneous interventions Eg, ECMO, HFV, nitric oxide, frequent administration of fluids, medication Abbreviations: CPAP, continuous positive airway pressure; ECMO, extracorporeal circulation membrane oxygenation; HFV, high-frequency ventilation; NG, nasogastric; PO, by mouth. neonates with multi-organ system problems and in specialized care technology.3(p32) One patient outcome that has been directly linked to nurse staffing in critical care is infection.5,6 Most NICU infants have central venous lines. Nurse understaffing could result in lapses in aseptic technique that increase infants risk for infection.7,8 A study of 2 New York NICUs found that higher nurse staffing was associated with significantly lower infection risk in one NICU but not the other.9 Several other single-site NICU studies have shown that infection spread is associated with nurse staffing.10-13 A large British study found no association between nurse staffing and infection among all NICU infants.14 However, another British study in 6 NICUs showed that more than half of shifts fell short of British guidelines and that understaffing led to delays in essential treatment and reduced clinical care.15 The Affordable Care Act established the Center for Medicare and Medicaid Innovation to improve quality and reduce costs in health care through improvements in health system delivery and payment innovation. Discussion: Impact of Nursing Understaffing on Patient Health Case Study The Centers for Medicare and Medicaid Services has already reformed payments for hospital-associated infections under Medicaid. For hospitals to respond effectively to these incentives, they must have access to evidence about the health systems factors, such as nurse staffing, that contribute to adverse patient outcomes such as infection. We developed definitions for the national NICU staffing guidelines and studied guideline adherence and its association with hospital-associated infection in very lowbirth-weight (VLBW) infants. We hypothesized that nurse understaffing would be positively associated with nosocomial infection. Very low-birth-weight infants are the highest-risk pediatric population, accounting for half of infant deaths in the United States each year.16 They are highly susceptible to infection due to an underdeveloped immune system, more transparent and penetrable skin barrier, and high prevalence of central lines.17-19 Hospital-associated infections in this population have been associated with poor neurodevelopmental and growth outcomes in early childhood, increased mortality, and lon- ger hospital stay.20-22 Medicaid is the largest payer for the care of these infants.23 METHODS STUDY DESIGN AND DATA This retrospective cohort study was conducted in the Vermont Oxford Network (VON), a national voluntary hospital network dedicated to improving the quality and safety of NICU care. The VON database contains detailed uniform clinical and treatment information on all VLBW infants. By 2008, the US network comprised 578 hospitals, which included approximately 65% of NICUs and 80% of all VLBW infants. This study included 67 VON hospitals with inborn infants in 2008 and 2009, with nurse staffing data from 2 data collections. The 2008 data were collected by web survey of staff nurses and included 4046 nurses assigned to 10 394 infants (response rate, 77%). Nurses reported on their last shift the infant assignment including infants acuity levels and whether infants were coassigned. The 2009 data were collected on 4 complete shifts. Data were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010): 1 day shift and 3 shifts that were randomized to day, night, and weekend shifts (3645 nurses assigned to 8804 infants). Discussion: Impact of Nursing Understaffing on Patient Health Case Study For simplicity, these data are referred to as the 2009 data. Interrater reliability of the acuity levels was measured for 258 infants in 9 hospitals in 2009. This project was approved by the institutional review boards of the University of Medicine and Dentistry of New Jersey, the University of Pennsylvania, the University of Vermont, Ohio State University, Dartmouth College, and the study hospitals. VARIABLES Definition of Infant Acuity Levels The national guidelines that have existed since 1992 comprise 5 categories of infants. Infant acuity definitions were developed to represent mutually exclusive categories of infant need for nursing resources (Table 1). An expert panel that included a neonatologist, a perinatal nurse specialist, and a representative from the National Association of Neonatal Nurses JAMA PEDIATR/ VOL 167 (NO. 5), MAY 2013 445 WWW.JAMAPEDS.COM ©2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ by Jennifer Grossner on 09/28/2015 Table 2. Characteristics of the NICUs and Infants No. (%) Variable NICUs No. of NICUs NICU levels A B C Annual volume of VLBW admissions, mean (SD) VLBW infants (eligible for nosocomial infection) No. of VBLW infants Nosocomial infection Birth weight, mean (SD), g Gestational age, mean (SD), wk 1-min Apgar score, mean (SD) Small for gestational age Multiple birth Congenital malformation Vaginal delivery Had prenatal care Male Race/ethnicity, % Non-Hispanic white Non-Hispanic black Other a 2008 2009 67 67 7 (10) 41 (61) 19 (28) 108 (63) 9 (13) 40 (60) 18 (27) 105 (64) 5713 938 (16.4) 1077 (277) 28.4 (2.8) 5.5 (2.5) 1134 (19.9) 1701 (29.8) 200 (3.5) 1631 (28.5) 5468 (95.7) 2878 (50.4) 5558 775 (13.9) 1072 (278) 28.4 (2.8) 5.4 (2.4) 1118 (20.1) 1600 (28.8) 209 (3.8) 1526 (27.5) 5341 (96.1) 2770 (49.8) 2905 (50.8) 1641 (28.7) 1167 (20.4) 2757 (49.6) 1702 (30.6) 1099 (19.8) Abbreviations: NICU, neonatal intensive care unit; VLBW, very low birth weight. a All other races/ethnicities, including Hispanic. developed the definitions. These were refined through focus groups and feedback from a broad range of neonatal nurses. Nurse Staffing Measures Guidelines for the nurse to patient ratio by acuity level were available from medical and nursing specialty societies.3(p29)4(p 33) Nurse to patient ratios by acuity were calculated for all infants in each NICU (adjusted for coassignments). Compliance was defined as meeting the minimum threshold. For 3 acuity levels (1, 2, and 3), the guideline specifies a range, and the maximum number of infants per nurse was used as the threshold. For acuity level 5, where the guideline indicates 1 or more nurses per infant, the threshold was set to 1 nurse per infant. When another nurse was coassigned, we assumed that the additional nurse was entirely available to care for the infant. This approach created a conservative estimate of understaffing. Discussion: Impact of Nursing Understaffing on Patient Health Case Study There were few coassignments (3.3% in 2008 and 1.5% in 2009). Two measures of understaffing were created: the percentage of infants staffed below guidelines and the mean fraction of a nurse per infant needed to meet guidelines. Because the 2009 data were based on a census of all infants and nurses on a shift and the 2008 data were based on a nurse survey, the latter data were subject to measurement error. In the survey, nurses reported caring for 6% more infants and a slightly higher average infant acuity level, and there was more variation across nurses in patient load. Thus, survey-based measures are expected to be biased toward larger understaffing compared with complete shift data. The results based on the 2009 data were emphasized. Infant characteristics, infection rates, and NICU-level measures were obtained from the VON database using standardized definitions. The VON risk-adjustment model24 included gestational age in weeks (and its square); small for gestational age; 1-minute Apgar score; race and ethnicity (non-Hispanic black, non-Hispanic white, or other [including Hispanic]); sex; multiple birth; presence of a major birth defect; vaginal delivery; and whether the mother received prenatal care. This model had an area under the receiver operating characteristic curve of 0.76. Risk-adjusted infection rates for all sites were computed for both years. Nosocomial infection was defined as an infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth for 3 culture-proven infections: coagulase-negative staphylococcus, the most common bacterial infection in the NICU; other bacterial infections; and fungal infections. In 2009, very few infants (0.12%) were transferred, contracted an infection, and were readmitted to the birth hospital where the infection was attributed. Two NICU-level variables were included, consistent with prior research24-26: volume (measured as the log of the mean number of VLBW admissions) and level according to VON classification (A: restriction on ventilation, no surgery; B: major surgery; and C: cardiac surgery, corresponding to high level II and level III units in the American Academy of Pediatrics classification). Discussion: Impact of Nursing Understaffing on Patient Health Case Study Hospital characteristics to describe the sample were derived from the American Hospital Association Annual Survey of Hospitals.27,28 DATA ANALYSIS We estimated a logistic regression of infection on understaffing in each year, controlling for risk adjusters and NICU-level covariates. We estimated random-effect models by the maximum likelihood method, which adjusted for clustering of infants within hospitals. Predicted values were generated from these regressions. Interrater reliability was computed using the Kappa statistic. Estimations were performed in Stata version 10.1 (StataCorp), with a P value of .05 in 2-tailed tests. JAMA PEDIATR/ VOL 167 (NO. 5), MAY 2013 446 WWW.JAMAPEDS.COM ©2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ by Jennifer Grossner on 09/28/2015 Table 3. Recommended Staffing Ratios, Infant Acuity Distribution, and Nurse Understaffing Relative to Guidelines3,4 Mean (SD) a Acuity Level Recommended nurse to patient ratios according to guidelines Infants by acuity level, % 2008 2009 Infants who were understaffed, % 2008 2009 Fraction of a nurse/patient needed to achieve minimum recommended nurse to patient ratio 2008 2009 Overall 1 2 3 4 5 NA 1:3-4 1:2-3 1:1-2 1:1 ?1:1 100 100 32 33 28 33 28 26 8 6 47 (20) 31 (19) 34 (21) 20 (19) 46 (22) 29 (21) 53 (23) 37 (26) 89 (15) 77 (33) 63 (30) 42 (40) .19 (.11) .11 (.08) .10 (.08) .04 (.05) .15 (.09) .07 (.06) .23 (.11) .13 (.10) .52 (.19) .39 (.22) .37 (.24) .20 (.22) 4 2 Abbreviation: NA, not available. a Statistics were calculated from 4046 nurses assigned to 10 394 infants in 2008 and 3645 nurses assigned to 8804 infants in 2009-2010. RESULTS HOSPITAL AND INFANT CHARACTERISTICS Our sample comprised mostly higher level NICUs (87% were levels B and C) compared with the VON (66% were levels B and C and 34% were level A). Compared with the universe of US hospitals with a NICU, our sample contained more teaching hospitals (26% in the United States vs 51% in the study sample) and somewhat more not-forprofit hospitals (71% in the United States vs 85%), as well as larger units (a mean of 22 beds in the United States vs 33). Discussion: Impact of Nursing Understaffing on Patient Health Case Study Many of the participating hospitals had achieved recognition for nursing excellence through Magnet accreditation (40% vs 19% in the United States).29 Infants in our sample had mean birth weights of 1077 g in 2008 and 1072 g in 2009, as well as a mean gestational age of 28.4 weeks in both years. The racial and ethnic composition of the sample was approximately half non-Hispanic white, 30% non-Hispanic black, and 20% other (Table 2). INFECTION RATES The percentages of VLBW infants with hospitalassociated infection were 16.4% in 2008 and 13.9% in 2009. This decline was consistent with a secular trend in nosocomial infections among VLBW infants, as reported by Horbar and colleagues.30 The infection rates ranged from the 25th percentile of 10.0% in 2008 and 8.8% in 2009 to the 75th percentile of 20.3% in 2008 and 16.4% in 2009. INFANT ACUITY DEFINITIONS The infant acuity definitions developed for neonatal intensive care nursing are listed in Table 1. The definitions specify feeding, ventilation, medication, monitoring, and other differences across acuity levels. The classification had high interrater reliability (? = 0.79). In 2009, there were few infants in the 2 highest acuity lev- els (8%), with most in the 2 lowest levels (66%). The proportions of the highest acuity infants were slightly greater in 2008 (12%). COMPLIANCE WITH GUIDELINES On average, each infant had 0.4 of a nurse (in the 2008 data, 4046 nurses were assigned to 10 394 infants; in the 2009-2010 data, 3645 nurses were assigned to 8804 infants). Relative to the guidelines, on average, hospitals understaffed 47% of all NICU infants in 2008 and 31% in 2009 (Table 3). Hospitals understaffed 80% of highacuity infants (levels 4 and 5) in 2008 and 68% in 2009. Higher infant acuity was associated with more understaffing. For example, in 2009, 20% of acuity level 1 infants and 68% of high-acuity infants (levels 4 and 5) were understaffed. To meet guidelines, an additional 0.11 of a nurse per infant overall and an additional 0.34 of a nurse per high acuity infant (ie, levels 4 and 5) would have been needed in 2009. In 2008, the understaffing was higher.Discussion: Impact of Nursing Understaffing on Patient Health Case Study.3 There was very little overstaffing. Hospitals overstaffed 4% and 6% of their infants in 2008 and 2009, respectively. The overstaffing provided a very small offset (0.01 and 0.02 of nurse per infant in 2008 and 2009, respectively) to counterbalance understaffing. In 2009, 55% of units understaffed at least 25% of their infants and 16% understaffed at least 50% of their infants. Five units had no understaffing in 2009. MULTIVARIATE REGRESSION RESULTS As shown in Table 4, a 1 standard deviation increase in the amount of a nurse per infant needed to meet guidelines (0.11 of a nurse in 2008 and 0.08 of a nurse in 2009) was associated with higher odds of infection in 2008 (adjusted odds ratio, 1.39; 95% CI, 1.19-1.62; P ? .001) and 2009 (adjusted odds ratio, 1.40; 95% CI, 1.19-1.65; P ? .001). The odds ratios for understaffing translate into predicted infection rates as displayed in the Figure. This represents the predicted risk for infection associated with JAMA PEDIATR/ VOL 167 (NO. 5), MAY 2013 447 WWW.JAMAPEDS.COM ©2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ by Jennifer Grossner on 09/28/2015 Table 4. Risk for VLBW Infant Infection Associated With Nurse Understaffing and NICU Variables Odds Ratio (95% CI) a Understaffing amount b NICU level A B C Natural log of annual volume of VLBW admissions 2008 2009 1.39 (1.19-1.62) 1.40 (1.19-1.65) 1.33 (0.65-2.70) 0. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10
Discussion: Impact of Nursing Understaffing on Patient Health Case Study
Discussion: Impact of Nursing Understaffing on Patient Health Case Study ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Impact of Nursing Understaffing on Patient Health Case Study Compare this case study to your nursing practice and give a similar example from your nursing experience in which you might have run into on staffing or a similar situation (During nursing school rotations). v Other universitys information is not acceptable to use to support/validate your central ideas. They are not peer research based articles(This includes blogs or ATI). Please include research articles no older than 5 yrs from todays date. Please follow the citations guidelines. PLEASE WATCH THE LINK PROVIDED to do the case study https://drive.google.com/file/d/1Zg3FmoO4cHkqBRRhp There are 3 files attached for you to get more information about the research, make sure to cite the PDF file. The video is from website https://learn.westcoastuniversity.edu/bbcswebdav/p (most likely you wont have access to the link, thats why I made a google drive link, just use the west coast university link to reference and cite the paper). Must follow the rubric!!! screen_shot_2020_09_29_at_1.24.42_pm.png screen_shot_2020_09_29_at_1.25.25_pm.png poa130001_444_450.pdf ARTICLE Nurse Staffing and NICU Infection Rates Jeannette A. Rogowski, PhD; Douglas Staiger, PhD; Thelma Patrick, PhD, RN; Jeffrey Horbar, MD; Michael Kenny, MS; Eileen T. Lake, PhD, RN Importance: There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights. Objective: To study the adequacy of NICU nurse staff- ing in the United States using national guidelines and analyze its association with infant outcomes. Design: Retrospective cohort study. Data for 2008 were collected by web survey of staff nurses. Data for 2009 were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010). Setting: Sixty-seven US NICUs from the Vermont Ox- ford Network, a national voluntary network of hospital NICUs. Main Outcomes and Measures: An infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth among VLBW inborn infants. The hypothesis was formulated prior to data collection. Results: Hospitals understaffed 31% of their NICU infants and 68% of high-acuity infants relative to guidelines. To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.34 of a nurse per high-acuity infant. Very low-birth-weight infant infection rates were 16.4% in 2008 and 13.9% in 2009. A 1 standard deviationhigher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios of 1.39 (95% CI, 1.191.62; P ? .001) in 2008 and 1.40 (95% CI, 1.19-1.65; P? .001) in 2009. Discussion: Impact of Nursing Understaffing on Patient Health Case Study Exposures: We measured nurse understaffing relative Conclusions and Relevance: Substantial NICU nurse understaffing relative to national guidelines is widespread. Understaffing is associated with an increased risk for VLBW nosocomial infection. Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants. to acuity-based guidelines using 2008 survey data (4046 nurses and 10 394 infant assignments) and data for 4 complete shifts (3645 nurses and 8804 infant assignments) in 2009-2010. JAMA Pediatr. 2013;167(5):444-450. Published online March 18, 2013. doi:10.1001/jamapediatrics.2013.18 Participants: All inborn very low-birth-weight (VLBW) infants, with a NICU stay of at least 3 days, discharged from the NICUs in 2008 (n = 5771) and 2009 (n=5630). All staff-registered nurses with infant assignments. N EONATAL INTENSIVE CARE units (NICUs) care for the most critically ill infants. Neonatal intensive care unit stays are among the most expensive hospitalizations1 and require high levels of nursing resources. Very little is known about the adequacy of staffing in US NICUs. Acuity-based staffing For editorial comment see page 485 Author Affiliations are listed at the end of this article. guidelines for neonatal nursing2 were recently reaffirmed by national medical and nursing bodies,3,4 although definitions of infant acuity levels do not exist. It is not JAMA PEDIATR/ VOL 167 (NO. 5), MAY 2013 444 known how well the guidelines are followed or how guideline adherence relates to infant outcomes. The guidelines specify ranges of nurse to patient ratios across infant acuity levels, as well as requisite nurse training and experience. For instance, infants with the lowest acuity levels have a recommended nurse to patient ratio of 1 to 3 or 4. In contrast, the highest acuity infants have recommended ratios of 1 or more nurses per patient. Furthermore, the guidelines also address the level of education and experience of the nurses, noting that registered nurses in the NICU should have specialty certification or advanced training. They also should be experienced in caring for unstable WWW.JAMAPEDS.COM ©2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ by Jennifer Grossner on 09/28/2015 Author Aff Departmen and Policy, Health, Uni and Dentist Piscataway, Rogowski); Economics Hanover, N National Bu Research, C Massachuse College of N University, Patrick); D Pediatrics, Vermont (M Oxford Net Burlington, Center for H and Policy Nursing, D Sociology, L Institute of University Philadelphi Table 1. Definitions for Infant Acuity Levels Level Care Provided per Newborn Requirement According to Guideline3,4 1 Continuing care 2 Intermediate care 3 Intensive care 4 Multisystem support 5 Unstable, requiring complex critical care Definition Infant only requiring PO or NG feedings, occasional enteral medications, basic monitoring (may or may not have a hep lock for medications). Discussion: Impact of Nursing Understaffing on Patient Health Case Study Stable infant with established management plan, not requiring significant support Eg, room air, supplemental oxygen or low-flow nasal cannula, several medications Infant is stabilized, although requires frequent treatment and monitoring to assure maintenance of stability Eg, ventilator, CPAP, high-flow nasal cannula, multiple intravenous needs via central or peripheral line Infant requires continuous monitoring and interventions Eg, conventional ventilation, stable on HFV, continuous drug infusions, several intravenous fluid changes via central line Infant is medically unstable and vulnerable, requiring many simultaneous interventions Eg, ECMO, HFV, nitric oxide, frequent administration of fluids, medication Abbreviations: CPAP, continuous positive airway pressure; ECMO, extracorporeal circulation membrane oxygenation; HFV, high-frequency ventilation; NG, nasogastric; PO, by mouth. neonates with multi-organ system problems and in specialized care technology.3(p32) One patient outcome that has been directly linked to nurse staffing in critical care is infection.5,6 Most NICU infants have central venous lines. Nurse understaffing could result in lapses in aseptic technique that increase infants risk for infection.7,8 A study of 2 New York NICUs found that higher nurse staffing was associated with significantly lower infection risk in one NICU but not the other.9 Several other single-site NICU studies have shown that infection spread is associated with nurse staffing.10-13 A large British study found no association between nurse staffing and infection among all NICU infants.14 However, another British study in 6 NICUs showed that more than half of shifts fell short of British guidelines and that understaffing led to delays in essential treatment and reduced clinical care.15 The Affordable Care Act established the Center for Medicare and Medicaid Innovation to improve quality and reduce costs in health care through improvements in health system delivery and payment innovation. Discussion: Impact of Nursing Understaffing on Patient Health Case Study The Centers for Medicare and Medicaid Services has already reformed payments for hospital-associated infections under Medicaid. For hospitals to respond effectively to these incentives, they must have access to evidence about the health systems factors, such as nurse staffing, that contribute to adverse patient outcomes such as infection. We developed definitions for the national NICU staffing guidelines and studied guideline adherence and its association with hospital-associated infection in very lowbirth-weight (VLBW) infants. We hypothesized that nurse understaffing would be positively associated with nosocomial infection. Very low-birth-weight infants are the highest-risk pediatric population, accounting for half of infant deaths in the United States each year.16 They are highly susceptible to infection due to an underdeveloped immune system, more transparent and penetrable skin barrier, and high prevalence of central lines.17-19 Hospital-associated infections in this population have been associated with poor neurodevelopmental and growth outcomes in early childhood, increased mortality, and lon- ger hospital stay.20-22 Medicaid is the largest payer for the care of these infants.23 METHODS STUDY DESIGN AND DATA This retrospective cohort study was conducted in the Vermont Oxford Network (VON), a national voluntary hospital network dedicated to improving the quality and safety of NICU care. The VON database contains detailed uniform clinical and treatment information on all VLBW infants. By 2008, the US network comprised 578 hospitals, which included approximately 65% of NICUs and 80% of all VLBW infants. This study included 67 VON hospitals with inborn infants in 2008 and 2009, with nurse staffing data from 2 data collections. The 2008 data were collected by web survey of staff nurses and included 4046 nurses assigned to 10 394 infants (response rate, 77%). Nurses reported on their last shift the infant assignment including infants acuity levels and whether infants were coassigned. The 2009 data were collected on 4 complete shifts. Data were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010): 1 day shift and 3 shifts that were randomized to day, night, and weekend shifts (3645 nurses assigned to 8804 infants). Discussion: Impact of Nursing Understaffing on Patient Health Case Study For simplicity, these data are referred to as the 2009 data. Interrater reliability of the acuity levels was measured for 258 infants in 9 hospitals in 2009. This project was approved by the institutional review boards of the University of Medicine and Dentistry of New Jersey, the University of Pennsylvania, the University of Vermont, Ohio State University, Dartmouth College, and the study hospitals. VARIABLES Definition of Infant Acuity Levels The national guidelines that have existed since 1992 comprise 5 categories of infants. Infant acuity definitions were developed to represent mutually exclusive categories of infant need for nursing resources (Table 1). An expert panel that included a neonatologist, a perinatal nurse specialist, and a representative from the National Association of Neonatal Nurses JAMA PEDIATR/ VOL 167 (NO. 5), MAY 2013 445 WWW.JAMAPEDS.COM ©2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ by Jennifer Grossner on 09/28/2015 Table 2. Characteristics of the NICUs and Infants No. (%) Variable NICUs No. of NICUs NICU levels A B C Annual volume of VLBW admissions, mean (SD) VLBW infants (eligible for nosocomial infection) No. of VBLW infants Nosocomial infection Birth weight, mean (SD), g Gestational age, mean (SD), wk 1-min Apgar score, mean (SD) Small for gestational age Multiple birth Congenital malformation Vaginal delivery Had prenatal care Male Race/ethnicity, % Non-Hispanic white Non-Hispanic black Other a 2008 2009 67 67 7 (10) 41 (61) 19 (28) 108 (63) 9 (13) 40 (60) 18 (27) 105 (64) 5713 938 (16.4) 1077 (277) 28.4 (2.8) 5.5 (2.5) 1134 (19.9) 1701 (29.8) 200 (3.5) 1631 (28.5) 5468 (95.7) 2878 (50.4) 5558 775 (13.9) 1072 (278) 28.4 (2.8) 5.4 (2.4) 1118 (20.1) 1600 (28.8) 209 (3.8) 1526 (27.5) 5341 (96.1) 2770 (49.8) 2905 (50.8) 1641 (28.7) 1167 (20.4) 2757 (49.6) 1702 (30.6) 1099 (19.8) Abbreviations: NICU, neonatal intensive care unit; VLBW, very low birth weight. a All other races/ethnicities, including Hispanic. developed the definitions. These were refined through focus groups and feedback from a broad range of neonatal nurses. Nurse Staffing Measures Guidelines for the nurse to patient ratio by acuity level were available from medical and nursing specialty societies.3(p29)4(p 33) Nurse to patient ratios by acuity were calculated for all infants in each NICU (adjusted for coassignments). Compliance was defined as meeting the minimum threshold. For 3 acuity levels (1, 2, and 3), the guideline specifies a range, and the maximum number of infants per nurse was used as the threshold. For acuity level 5, where the guideline indicates 1 or more nurses per infant, the threshold was set to 1 nurse per infant. When another nurse was coassigned, we assumed that the additional nurse was entirely available to care for the infant. This approach created a conservative estimate of understaffing. Discussion: Impact of Nursing Understaffing on Patient Health Case Study There were few coassignments (3.3% in 2008 and 1.5% in 2009). Two measures of understaffing were created: the percentage of infants staffed below guidelines and the mean fraction of a nurse per infant needed to meet guidelines. Because the 2009 data were based on a census of all infants and nurses on a shift and the 2008 data were based on a nurse survey, the latter data were subject to measurement error. In the survey, nurses reported caring for 6% more infants and a slightly higher average infant acuity level, and there was more variation across nurses in patient load. Thus, survey-based measures are expected to be biased toward larger understaffing compared with complete shift data. The results based on the 2009 data were emphasized. Infant characteristics, infection rates, and NICU-level measures were obtained from the VON database using standardized definitions. The VON risk-adjustment model24 included gestational age in weeks (and its square); small for gestational age; 1-minute Apgar score; race and ethnicity (non-Hispanic black, non-Hispanic white, or other [including Hispanic]); sex; multiple birth; presence of a major birth defect; vaginal delivery; and whether the mother received prenatal care. This model had an area under the receiver operating characteristic curve of 0.76. Risk-adjusted infection rates for all sites were computed for both years. Nosocomial infection was defined as an infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth for 3 culture-proven infections: coagulase-negative staphylococcus, the most common bacterial infection in the NICU; other bacterial infections; and fungal infections. In 2009, very few infants (0.12%) were transferred, contracted an infection, and were readmitted to the birth hospital where the infection was attributed. Two NICU-level variables were included, consistent with prior research24-26: volume (measured as the log of the mean number of VLBW admissions) and level according to VON classification (A: restriction on ventilation, no surgery; B: major surgery; and C: cardiac surgery, corresponding to high level II and level III units in the American Academy of Pediatrics classification). Discussion: Impact of Nursing Understaffing on Patient Health Case Study Hospital characteristics to describe the sample were derived from the American Hospital Association Annual Survey of Hospitals.27,28 DATA ANALYSIS We estimated a logistic regression of infection on understaffing in each year, controlling for risk adjusters and NICU-level covariates. We estimated random-effect models by the maximum likelihood method, which adjusted for clustering of infants within hospitals. Predicted values were generated from these regressions. Interrater reliability was computed using the Kappa statistic. Estimations were performed in Stata version 10.1 (StataCorp), with a P value of .05 in 2-tailed tests. JAMA PEDIATR/ VOL 167 (NO. 5), MAY 2013 446 WWW.JAMAPEDS.COM ©2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ by Jennifer Grossner on 09/28/2015 Table 3. Recommended Staffing Ratios, Infant Acuity Distribution, and Nurse Understaffing Relative to Guidelines3,4 Mean (SD) a Acuity Level Recommended nurse to patient ratios according to guidelines Infants by acuity level, % 2008 2009 Infants who were understaffed, % 2008 2009 Fraction of a nurse/patient needed to achieve minimum recommended nurse to patient ratio 2008 2009 Overall 1 2 3 4 5 NA 1:3-4 1:2-3 1:1-2 1:1 ?1:1 100 100 32 33 28 33 28 26 8 6 47 (20) 31 (19) 34 (21) 20 (19) 46 (22) 29 (21) 53 (23) 37 (26) 89 (15) 77 (33) 63 (30) 42 (40) .19 (.11) .11 (.08) .10 (.08) .04 (.05) .15 (.09) .07 (.06) .23 (.11) .13 (.10) .52 (.19) .39 (.22) .37 (.24) .20 (.22) 4 2 Abbreviation: NA, not available. a Statistics were calculated from 4046 nurses assigned to 10 394 infants in 2008 and 3645 nurses assigned to 8804 infants in 2009-2010. RESULTS HOSPITAL AND INFANT CHARACTERISTICS Our sample comprised mostly higher level NICUs (87% were levels B and C) compared with the VON (66% were levels B and C and 34% were level A). Compared with the universe of US hospitals with a NICU, our sample contained more teaching hospitals (26% in the United States vs 51% in the study sample) and somewhat more not-forprofit hospitals (71% in the United States vs 85%), as well as larger units (a mean of 22 beds in the United States vs 33). Discussion: Impact of Nursing Understaffing on Patient Health Case Study Many of the participating hospitals had achieved recognition for nursing excellence through Magnet accreditation (40% vs 19% in the United States).29 Infants in our sample had mean birth weights of 1077 g in 2008 and 1072 g in 2009, as well as a mean gestational age of 28.4 weeks in both years. The racial and ethnic composition of the sample was approximately half non-Hispanic white, 30% non-Hispanic black, and 20% other (Table 2). INFECTION RATES The percentages of VLBW infants with hospitalassociated infection were 16.4% in 2008 and 13.9% in 2009. This decline was consistent with a secular trend in nosocomial infections among VLBW infants, as reported by Horbar and colleagues.30 The infection rates ranged from the 25th percentile of 10.0% in 2008 and 8.8% in 2009 to the 75th percentile of 20.3% in 2008 and 16.4% in 2009. INFANT ACUITY DEFINITIONS The infant acuity definitions developed for neonatal intensive care nursing are listed in Table 1. The definitions specify feeding, ventilation, medication, monitoring, and other differences across acuity levels. The classification had high interrater reliability (? = 0.79). In 2009, there were few infants in the 2 highest acuity lev- els (8%), with most in the 2 lowest levels (66%). The proportions of the highest acuity infants were slightly greater in 2008 (12%). COMPLIANCE WITH GUIDELINES On average, each infant had 0.4 of a nurse (in the 2008 data, 4046 nurses were assigned to 10 394 infants; in the 2009-2010 data, 3645 nurses were assigned to 8804 infants). Relative to the guidelines, on average, hospitals understaffed 47% of all NICU infants in 2008 and 31% in 2009 (Table 3). Hospitals understaffed 80% of highacuity infants (levels 4 and 5) in 2008 and 68% in 2009. Higher infant acuity was associated with more understaffing. For example, in 2009, 20% of acuity level 1 infants and 68% of high-acuity infants (levels 4 and 5) were understaffed. To meet guidelines, an additional 0.11 of a nurse per infant overall and an additional 0.34 of a nurse per high acuity infant (ie, levels 4 and 5) would have been needed in 2009. In 2008, the understaffing was higher.Discussion: Impact of Nursing Understaffing on Patient Health Case Study.3 There was very little overstaffing. Hospitals overstaffed 4% and 6% of their infants in 2008 and 2009, respectively. The overstaffing provided a very small offset (0.01 and 0.02 of nurse per infant in 2008 and 2009, respectively) to counterbalance understaffing. In 2009, 55% of units understaffed at least 25% of their infants and 16% understaffed at least 50% of their infants. Five units had no understaffing in 2009. MULTIVARIATE REGRESSION RESULTS As shown in Table 4, a 1 standard deviation increase in the amount of a nurse per infant needed to meet guidelines (0.11 of a nurse in 2008 and 0.08 of a nurse in 2009) was associated with higher odds of infection in 2008 (adjusted odds ratio, 1.39; 95% CI, 1.19-1.62; P ? .001) and 2009 (adjusted odds ratio, 1.40; 95% CI, 1.19-1.65; P ? .001). The odds ratios for understaffing translate into predicted infection rates as displayed in the Figure. This represents the predicted risk for infection associated with JAMA PEDIATR/ VOL 167 (NO. 5), MAY 2013 447 WWW.JAMAPEDS.COM ©2013 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ by Jennifer Grossner on 09/28/2015 Table 4. Risk for VLBW Infant Infection Associated With Nurse Understaffing and NICU Variables Odds Ratio (95% CI) a Understaffing amount b NICU level A B C Natural log of annual volume of VLBW admissions 2008 2009 1.39 (1.19-1.62) 1.40 (1.19-1.65) 1.33 (0.65-2.70) 0. Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10
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