Nurse Shortage Linked to NICU Infection Rates

(Medpage Today) Neonatal intensive care units (NICUs) are widely understaffed, potentially increasing the risk of infection in critically ill babies, researchers reported.

In a retrospective study, hospitals understaffed nearly one-third of their NICU infants and more than 90% of their high-acuity NICU infants in 2009, relative to staffing guidelines, Jeannette Rogowski, PhD, of the University of Medicine and Dentistry of New Jersey in Piscataway, and colleagues reported online in JAMA Pediatrics.

In addition, infection rates for very low birth weight infants were 16.5% in 2008 and 13.9% in 2009, with higher levels of nurse understaffing associated with 40% higher odds of infant infection.

“Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants,” they wrote.

National guidelines specify nurse-to-patient staffing levels that are typically based on acuity. For instance, the lowest-acuity infants have a recommended nurse-to-patient ratio of 1 to 3 or 4, but the highest-acuity infants have ratios of greater than one nurse per patient.

But studies have shown shortfalls in NICU nurse staffing, which have been associated with higher rates of nosocomial infections, particularly among infants with very low birth weights.

The researchers conducted a retrospective cohort study using 67 NICUs from the Vermont Oxford Network, with data on 5,771 very low birth weight babies from 2008 and 5,630 very low weight babies from 2009.

Nurse understaffing was assessed based on survey data in 3008 (4,046 nurses and 10,394 infant assignments) and 2009 (3,645 nurses and 8,804 infant assignments).

Overall, they found widespread understaffing of NICUs across the U.S. compared with national guidelines, with about a third of NICU infants being understaffed, and each infant had about 0.4 nurses on average.

Relative to the guidelines, hospitals understaffed 32% of their NICU infants in 2009 and 48% in 2008, and understaffing varied by acuity. Hospitals understaffed 85% of high-acuity infants in 2008 and and 92% in 2009, they reported.

In order to meet minimum staffing guidelines, hospitals would need, on average, an additional 0.11 nurses per infant overall and 0.39 nurses per high-acuity infant at 2009 levels, Rogowski and colleagues wrote.

In multivariate analyses, NICU nurse understaffing was associated with increases in infection risk among very low birth weight infants. For example, a 1-standard deviation increase in nurse understaffing per infant was associated with a higher risk of infection in 2008 (adjusted odds ratio 1.39, 95% CI 1.19 to 1.62, P<0.001) and in 2009 (aOR 1.39, 95% CI 1.18 to 1.63, P<0.001).

The study was limited because it may not represent all hospitals with a NICU; nor does it take into consideration other factors that may be important in NICU staffing decisions, such as non-nursing personnel, the researchers wrote.

Still, they concluded that the findings suggest that the “most vulnerable hospitalized patients, unstable newborns requiring complex critical care, do not receive recommended levels of nursing care.”

They also pointed out that widespread understaffing was found in a hospital sample that was disproportionately recognized for its nursing excellence. The overall registered nurse staffing in sample hospitals was higher than in U.S. hospitals with a NICU in general (10.4 versus 9.4 hours/patient day, P<0.05).

“Staffing levels in all U.S. NICUs may be lower than those observed here,” they said. “Sample NICUs may have better trained nurses than other hospitals, and this training composition may influence nurse staffing. However, the guidelines indicate that a specialized staff is the minimum expectation.”