Not Enough Nurses in Neonatal Intensive Care Units

March 19, 2013 -- A new study reveals that the health of critically ill newborns is endangered by insufficient nurse staffing.  The national study finds that very few neonatal intensive care units (NICUs) provide sufficient numbers of nurses to meet guidelines and that the most vulnerable babies are also the most understaffed. The study published in the current issue of JAMA-Pediatrics and funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative and the National Institute of Nursing Research, suggests that the health of premature infants would be improved by increasing adherence to national guidelines.

Staffing guidelines developed by the American Academy of Pediatrics (AAP), and affirmed by the Association of Women’s Health, Obstetric and Neonatal Nurses, recommend a nurse-to-patient ratio of one nurse for every three to four infants for the lowest risk babies and a ratio of more than one nurse per baby for the most complex cases. 

The new study found that nurse understaffing was associated with higher rates of infections, which 13.9 percent of these infants suffered. Premature infants are extremely susceptible to infections because they have underdeveloped immune systems, skin that is more easily penetrated and frequently need to have central venous lines inserted to administer nutrition or medication. For very low birth weight (VLBW) infants (i.e., less than 3.2 pounds at birth), hospital-acquired infections are associated with mortality and longer hospital stays as well as poor neurological developmental and physical growth as they enter early childhood. 

The study examined nurse staffing levels in 2008 and 2009 for NICU infants in 67 hospitals that are part of the Vermont Oxford Network (VON). VON is a voluntary hospital network dedicated to improving the quality and safety of care for newborns and their families. The team also examined the rate of hospital-acquired infections in blood or cerebrospinal fluid among VLBW infants in the NICU at the study hospitals during that time period. These infections may result from commonly used central venous lines which administer medication or fluids and are maintained by nurses. 

Compared with the AAP guidelines, on average, the hospitals understaffed about one third of all NICU infants. More than half the hospitals understaffed one in four babies. The highest risk infants were more frequently understaffed (i.e., 9 out of every 10 babies). 

Eileen T. Lake, PhD, RN, FAAN, nursing professor and associate director of the Center for Health Outcomes and Policy Research at the School of Nursing at the University of Pennsylvania and Jeannette A. Rogowski, PhD, university professor in Health Economics in the School of Public Health at the University of Medicine and Dentistry of New Jersey led the research team, which included Douglas Staiger, PhD, Department of Economics, Dartmouth College; Jeffrey Horbar, MD, Department of Pediatrics, University of Vermont; Mike Kenny, MS, University of Vermont; and Thelma Patrick, PhD, RN, Ohio State University College of Nursing.

“Hospitals in this study had better overall nurse staffing than most hospitals with a NICU in the U.S., and yet, the understaffing levels are striking, suggesting that most hospitals are falling even further short of the accepted guidelines for staffing critically ill infants,” said Lake.

“This is the first time that anyone has measured adherence to guidelines in the NICU,” said Rogowski.  “Policy-makers should be concerned about the quality of care for these vulnerable babies that account for half of infant deaths each year.”  

Medicaid, the largest payer for premature infant hospitalization, recently announced that it will reduce hospital payments related to infection. This may erode the quality of care for these vulnerable babies if payment cuts translate into nurse staffing reductions.
 
The Interdisciplinary Nursing Quality Research Initiative is funded by the Robert Wood Johnson Foundation. To learn more, visit www.inqri.org and follow @INQRIProgram on Twitter.