NICU Nurse Staffing and Nosocomial Infections Linked

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By Jennifer Larson, contributor 

March 19, 2013 - Some of the most fragile hospital patients are the tiniest premature babies in a neonatal intensive care unit (NICU).  Their hospital stays are also among the most expensive because they require high levels of resources, including intensive nursing care. However, many hospitals may need to reassess whether they are providing adequate nurse staffing for these tiny patients.

A new study in JAMA Pediatrics suggests that understaffing of NICU nurses is associated with higher nosocomial infection rates in very low birth weight infants--and that staffing shortages are a widespread problem.

The team of researchers, led by Jeannette Rogowski, PhD, analyzed 2008 and 2009 data from 67 U.S. NICUs from the Vermont Oxford Network, a nonprofit collaboration that currently includes more than 900 NICUs around the world. They looked at very low birth weight (VLBW) infants who stayed in the NICU for at least three days and registered nurse assignments for the infants. Then they measured the staffing relative to a set of acuity-based national guidelines that were established in 1992 by the American Academy of Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG); the guidelines have since been revised and affirmed by the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN).

What the researchers found was sobering. Not only did hospitals understaff 32 percent of their NICU infants, but 92 percent of their high-acuity infants were understaffed.  “To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.39 of a nurse per high-acuity infant,” wrote Rogowski, a professor in the school of public health at the University of Medicine and Dentistry of New Jersey (UMDNJ), and her co-authors.

“We were stunned when we found that,” said co-author Eileen Lake, PhD, RN, FAAN, a faculty chair and associate director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. “The most complex infants, with the most sophisticated technological devices supporting them and the most complex treatments, were the ones who were left short.”

The guidelines set out five categories of infants so that nursing resources could be appropriately deployed. The first three levels allow for a range within the nurse-to-patient ratio. But category 4, which denotes multisystem support, and category 5, which means “unstable, requiring complex care,” require more nursing resources.

For the purposes of the study, the authors allowed for compliance to the guidelines to be defined as meeting the minimum threshold within the ratios. The authors noted, “For acuity level 5, where the guidelines indicate more than 1 nurse per infant, the threshold was set to 1.1 nurses per infant.” Thus, the authors referred to this as “a conservative estimate of understaffing.”

Then they examined the correlation with nosocomial infections, also referred to as healthcare-associated infections (HAIs).

"Because the babies are so premature, they have central line catheters. Even to stay alive, they need the fluids and medicines and nutrition, and that's a major source of infection,” said Lake. “The babies have very fragile skin and no defenses, and these catheters--and the nurses are the ones who maintain them and keep them clean. And that's why we suspected there was a relationship." 

They found that higher levels of understaffing were, in fact, associated with a greater likelihood of the infants developing an infection. 

“With staffing according to national guidelines, it is likely that infection rates would have been lower,” said Rogowski. 

Also concerning to the authors was the fact that many of the hospitals in their study are hospitals known for their commitment to nursing.  Of the participating hospitals, 40 percent have received the prestigious Magnet designation from the American Nurses Credential Center (ANCC). They wrote, “The widespread understaffing is noteworthy in a hospital sample that was disproportionately recognized for nursing excellence.”

“So that makes it even more concerning that we found that falling short of the guidelines was pervasive,” said Lake. “We think that bodes poorly for the infants in the rest of the country.”

However, Rogowski and Lake both noted that hospitals didn’t have access to the definitions for the guidelines that might have made it easier for them to classify infants based on the acuity scale and staff accordingly. “Previously, for nurse staffing, definitions for the national guidelines in NICUs that have existed since 1992 were not available,” the researchers wrote. “Definitions that have high inter-rater reliability are now available to guide such efforts. The guidelines can be reevaluated now that such a reliable acuity classification is available.” 

The definitions are one of the most useful outcomes of the study. They “create a feasible approach that NICUs can use in staffing their units,” explained Rogowski. 

The researchers hope that hospital administrators and NICU managers use this as an opportunity to assess their staffing decisions to make sure they are devoting the necessary nursing care to the infants who so desperately need it. 

Said Rogowski, “NICUs should assess their staffing in light of the national guidelines.”


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